• Vol. 77, May 2021 DC E-Newsletter

    • May 25, 2021

    Special Announcement

    Congress Passes Legislation to Prevent 2% Medicare Payment Cut

    On April 13, the U.S. House of Representatives overwhelmingly approved — by a vote of 384 to 38 — legislation passed by the U.S. Senate in March that would delay the 2% Medicare payment sequester cuts for the rest of the year, extending the three-month moratorium of the sequester that was included in the Consolidated Appropriations Act, 2021 (P.L. 116-260). Endorsed by the Congress of Neurological Surgeons (CNS) and the American Association of Neurological Surgeons (AANS), the amended bill, H.R. 1868, forestalled cuts totaling $18 billion scheduled to resume April 1. On April 14, President Joseph R. Biden Jr. signed the bill into law (P.L. 117-7). In late March, the Centers for Medicare & Medicaid Services (CMS) announced it would hold Medicare claims “for a short period” starting April 1 so providers would not face the 2% Medicare sequester cuts before lawmakers had a chance to take final action on the moratorium extension.

    Absent Congressional action, additional Medicare payment sequester cuts will occur on Jan. 1, 2022. These reductions were triggered under a “pay-as-you-go” law when Congress passed the $1.9 trillion American Rescue Plan Act (P.L. 117-2). The Statutory Pay-As-You-Go Act (P.L. 111-139) requires across-the-board sequestration cuts to Medicare if certain legislation affecting mandatory spending or revenues increases net deficits.

    The CNS and the AANS continue to advocate for additional legislation to prevent these and other Medicare payment cuts. To this end, the groups recently led a coalition effort urging Congress to provide an additional $3 billion in funding for the Medicare Physician Fee Schedule in 2022. The neurosurgical societies, along with the CNS/AANS Joint Section on Disorders of the Spine and Peripheral Nerves, have also committed funds to support the Surgical Care Coalition, which will continue its communications and advocacy initiative to demonstrate the value of surgical care and to prevent steep Medicare cuts.

    Click here to read the letter to Congress.


    CMS Begins Recouping COVID-19 Payments

    CMS recently began automatic recoupment of COVID-19 Accelerated and Advance Payments, which were an advance of up to three months of Medicare payments to help physician practices during the COVID-19 pandemic. Organized medicine strongly advocated for improved repayment terms, which Congress and CMS adopted in 2020. Under the revised repayment terms, neurosurgeons should be aware that:

    • These funds are loans that are required to be repaid;
    • Repayment begins one year from when the Medicare advance payment is received, rather than 120 days under the original terms;
    • The per claim recoupment amount was reduced from 100% to 25% for the first 11 months, and then 50% for an additional six months;
    • If there is an outstanding balance after the 17-month recoupment time frame, the Medicare Administrative Contractor (MAC) will issue a demand letter requiring repayment subject to an interest rate of 4%, a decrease from the original interest rate of 10.25%; and
    • Physicians may repay the Medicare advance payment in full at any time by contacting their MAC.

    The American Medical Association (AMA) is very interested in feedback about the recoupment of Medicare advance payments. Please share your feedback via AMA.Advocacy@ama-assn.org.

    2021 COVID-19 MIPS Relief Now Available

    For the 2021 Merit-Based Incentive Payment System (MIPS) performance year, CMS will once again use its Extreme and Uncontrollable Circumstances Policy to allow clinicians, groups and Alternative Payment Model (APM) entities to submit an application requesting reweighting of MIPS performance categories due to the current COVID-19 public health emergency. CMS recently posted instructions for submitting this application on the Quality Payment Program (QPP) website. The Extreme and Uncontrollable Circumstances Exception Application deadline for performance year 2021 is Dec. 31. 

    On April 13, the CNS and the AANS sent a letter thanking CMS for providing much-needed relief for physicians in MIPS by establishing an automatic and flexible Extreme and Uncontrollable Circumstances Hardship Exemption policy for the 2020 MIPS performance year due to the COVID-19 Public Health Emergency. The letter urges additional action to provide greater transparency in MIPS and asks that CMS release the 2018, 2019 and 2020 MIPS cost measures benchmarks and make cost measure benchmarks and patient attribution information available on a rolling, real-time basis during the 2021 performance year and thereafter.

    Click here for more information about these flexibilities.

    Legislative Affairs

    Neurosurgery Requests Congressional Oversight of Medicare Quality Programs

    While the CNS and the AANS are firmly behind efforts to improve the quality of care delivered to our patients, Medicare’s Quality Payment Program is an abject failure. The flawed MIPS perpetuates a complicated, one-size-fits-all approach, with meaningless quality measures that do nothing to improve quality or increase the value of care. Furthermore, few if any APMs are available for specialty physicians — including neurosurgeons — further thwarting efforts to achieve the program’s goals.

    The neurosurgical societies are calling on policymakers to minimize the complexity, streamline and reduce the reporting burdens of the MIPS and APM programs. To this end, the CNS and the AANS joined the Alliance of Specialty Medicine in urging the Senate Finance Committee and the House Energy and Commerce and Ways and Means Committees to convene oversight hearings to examine the implementation of physician-focused value-based care initiatives authorized under the Medicare Access and CHIP Reauthorization Act of 2015.

    Click here to read the Alliance of Specialty Medicine letter.

    Neurosurgery Endorses Senate Telehealth Expansion Legislation

    On April 27, the CNS and the AANS endorsed the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act. Introduced by Sen. Brian Schatz (D-Hawaii) and 50 bipartisan U.S. Senators, S. 1512 would build on recent progress and permanently expand access to telehealth services, removing outdated restrictions for providing remote health care services. In their letter, the groups noted that “Americans have benefited significantly from this expansion of telehealth and have come to rely on its availability.” The CNS and the AANS called on Congress “to expand access to telehealth services permanently so that telehealth remains an option for all Medicare beneficiaries both now and after the pandemic.”  

    Click here to read the letter.

    Neurosurgery Joins Alliance in Urging Congress to Fund Additional GME Slots

    On April 21, the CNS and the AANS joined the Alliance of Specialty Medicine in supporting the Resident Physician Shortage Reduction Act (S. 834/H.R. 2256). Introduced in the Senate by Sens. Robert Menendez (D-N.J.), John N. Boozman, OD, (R-Ark.) and Charles E. Schumer (D-N.Y.), and in the House by Reps. Terri A. Sewell (D-Ark.), John M. Katko (R-N.Y.), Thomas R. Suozzi (D-N.Y.) and Rodney L. Davis (R-Ill.), this legislation would provide 14,000 new Medicare-funded graduate medical education (GME) slots over seven years. The bill builds on the GME provisions included in the Consolidated Appropriations Act, 2021 (P.L. 116-260), which provided 1,000 new Medicare-funded GME positions.

    In determining which hospitals would receive slots, CMS would consider the likelihood of a teaching hospital filling positions and would be required to distribute at least 10% of the positions in each of the following categories:

    • Hospitals in rural areas;
    • Hospitals training over their current GME caps;
    • Hospitals in states with new medical schools or new branch campuses; and
    • Hospitals that serve areas designated as health professional shortage areas.

    Click here for the Alliance of Specialty Medicine letter to the House and here for the letter to the Senate.

    Neurosurgery Joins Effort to Ensure Provider Relief Funds are Not Taxable

    On April 19, the CNS and the AANS joined a coalition letter to Reps. Cindy Axne (D-Iowa), Brian Fitzpatrick (R-Pa.) and Neal Dunn, MD, (R-Fla.) supporting the Eliminating the Provider Relief Fund Tax Penalties Act (H.R. 2079). This legislation would remove the negative tax implications for Public Health and Social Services Emergency Fund (Provider Relief Fund). If enacted, the bill would ensure that all Provider Relief Funds are not taxable, while maintaining the tax deductibility of expenses tied to this assistance. Currently, Provider Relief Fund assistance is taxable, resulting in a 21% or more reduction to the benefit for taxpaying providers compared to non-taxpaying providers. 

    Click here to read the coalition letter.

    CNS and AANS Support the Safe Step Act

    On April 21, the CNS and the AANS joined the Alliance of Specialty Medicine in supporting the Safe Step Act (H.R. 2163) sponsored by Reps. Raul Ruiz, MD, (D-Calif.), Brad Wenstrup, DPM, (R-Ohio), Lucy McBath (D-Ga.) and Mariannette Miller-Meeks, MD, (R-Iowa). Health insurers often use step therapy — also called “fail first” — to control costs. Step therapy occurs when insurers require patients to fail the first step of treatment — typically a generic or low-cost drug — before moving on to the second step. This legislation would require health plans to establish specific exceptions to medication step-therapy protocols.

    Click here to read the Alliance of Specialty Medicine letter.

    Neurosurgery Urges Congress to Increase NIH Funding for Stroke

    Joining the National Coalition for Heart and Stroke Research and the National Heart, Lung & Blood Institute (NHLBI) Constituent Group, the CNS and the AANS recently signed letters to Sens. Roy Blunt (R-Mo.) and Patty Murray (D-Wash.) and Reps. Rosa DeLauro (D-Conn.) and Tom Cole (R-Okla.) urging Congress to allocate $46.1 billion to the National Institutes of Health (NIH) for FY 2022 — including $3.94 billion for the NHLBI and $2.7 billion to the National Institute of Neurological Disorders and Stroke (NINDS). This funding level would allow the NIH to sustain current activities and investment in promising and critically needed scientific research that will aggressively advance the fight against heart disease and stroke. The NINDS funds will also fund ongoing stroke research conducted under the BRAIN Initiative and new research to improve our understanding of the effects of COVID-19 on the nervous system.

    Click here to read the National Coalition for Heart and Stroke Research letter and here to read the NHLBI Constituency Group letter.

    Members of Congress Urge Funding for MISSION ZERO Program

    Championed by Reps. Kathy Castor (R-Fla.) and Michael Burgess, MD, (R-Texas) and supported by neurosurgery, on April 27, 34 members of Congress sent a letter to House Labor, Health and Human Services, Education, and Related Agencies Subcommittee leaders requesting $11.5 million in FY 2022 funding for the Military and Civilian Partnership for the Trauma Readiness Grant Program. Initially known as MISSION ZERO, the program provides funding to ensure trauma care readiness by integrating military trauma care providers into civilian trauma centers.

    Coding and Reimbursement

    Neurosurgery Reiterates Opposition to Prior Authorization Requirements for Spine Procedures

    On April 7, the CNS and the AANS joined a diverse coalition of 40 state and national health care organizations reiterating their strong opposition to the expansion of prior authorization in Medicare. Despite the demonstrated problems with prior authorization, the CMS has inappropriately expanded its use in Medicare’s fee-for-service program. Last year, CMS established a nationwide prior authorization process to include critical spine services — cervical fusion with disc removal and implanted spinal neurostimulators — provided in hospital outpatient departments. Over the objections of the CNS and the AANS, 50 bipartisan members of Congress and others, the new requirements go live on July 1. The CNS and the AANS are working to delay or halt the new requirements, including meeting with senior Biden Administration officials and key members of Congress.

    Click here to read the coalition letter and here for the CNS and the AANS press release about the coalition letter. 

    Drugs and Devices

    Check Your Open Payments Data Today

    In June, CMS will publish the Open Payments Program Year 2020 data and updates to the 2019 data. Neurosurgeons are encouraged to immediately review and dispute any data errors, keeping in mind the following:

    • Disputes must be initiated by May 15 to be reflected in the June 2021 data publication;
    • CMS does not meditate or facilitate disputes — physicians and teaching hospitals should work directly with reporting entities to resolve disputes; and
    • Registration in the Open Payments system is required to participate in review and dispute activities.

    To register with Open Payments, physicians will need their National Provider Identifier and State License Number. Initial registration is a two-step process:

    1. Register in the CMS Identity Management System; and
    2. Register in the Open Payments system.

    For more information on review and dispute timing and publication, refer to the Review and Dispute Timing and Data Publication Quick Reference Guide.

    Neurosurgery Urges CMS to Limit Mandatory Step Therapy in Medicare

    On April 22, the CNS and the AANS joined a physician coalition letter urging U.S. Department of Health and Human Services Secretary Xavier Becerra to reinstate the step therapy prohibition in Medicare Advantage plans. Specifically, the groups are asking the department to prohibit step therapy for Part B drugs as specified in the original Sept. 17, 2012, memo Prohibition on Imposing Mandatory Step Therapy for Access to Part B Drugs and Services. The letter points out that step therapy policies often result “in delayed treatment, increased disease activity, disability and in some cases irreversible disease progression.” The groups also highlighted that step therapy requirements can also be administratively burdensome on physicians and their staff as they help patients navigate complicated and often opaque coverage determination processes.

    Of Note

    AMA Releases Survey Results on Prior Authorization During COVID-19

    As COVID-19 cases in the U.S. were peaking in late 2020, most physicians reported that health plans continued to impose bureaucratic prior authorization policies that delay access to necessary care and sometimes result in serious harm to patients, according to recent survey results issued by the AMA. Key findings of the report include:

    • Almost 70% of 1,000 practicing physicians reported that health insurers had either reverted to past prior authorizations policies or never relaxed these policies in the first place;
    • More than nine in 10 physicians (94%) reported care delays while waiting for health insurers to authorize necessary care; and
    • Nearly four in five physicians (79%) said patients abandon treatment due to authorization struggles with health insurers.

    The findings of the AMA survey illustrate a critical need to streamline or eliminate low-value prior-authorization requirements to minimize delays or disruptions in care delivery.

    Click here to read the full report.

    AMA Report Tracks Impact of COVID-19 on Physician Practices

    A recent report from the AMA summarizes the impacts of the COVID-19 pandemic on Medicare spending and physician services through the first half of 2020. The report found that spending declined by 57% in April, and though recovered, was still down 8% at the end of the third quarter. Key findings in the AMA report include: 

    • Spending from the start of the pandemic through September was $11.5 billion or 16% below expected;
    • Telehealth accounted for 5.2% of Medicare physician spending from July to September, down from a peak of over 16% of spending in April 2020; and
    • Telehealth continues to be concentrated in a handful of service categories, including established patient office visits, telephone calls and mental health services.

    National Academies Virtual TBI Workshop

    In March and April, the National Academies of Sciences, Engineering and Medicine hosted a virtual workshop series, Accelerating Progress in Traumatic Brain Injury Research and Care.” The experts overseeing this work include neurosurgeons Odette A. Harris, MD, MPH, FAANS and Geoffrey T. Manley, MD, PhD, FAANS. The workshop gathered input from experts and stakeholders to examine the current landscape of traumatic brain injury (TBI) research and identify gaps and opportunities to accelerate research progress and improve care for those affected by TBI. Discussion topics included: 

    • Patient and family experiences with TBI;
    • Provider perspectives on TBI care;
    • Systems issues for TBI care and research;
      Gaps in TBI care systems and needs for improvement; and
    • Actions that could help bring an improved vision of TBI care and research to fruition.

    A workshop report is expected to be released in early 2022. It will identify barriers that are impeding progress, highlight opportunities for collaborative action and provide a roadmap for advancing both research and clinical care over the next decade.

    Click here for additional information about the workshop and this initiative.

    Leapfrog Publishes New Hospital Safety Grades

    The Leapfrog Group recently published its spring 2021 Leapfrog Hospital Safety Grades (formerly known as Hospital Safety Scores). These grades are assigned to more than 2,700 general acute-care hospitals across the nation twice annually. The grades are based on an analysis of 27 patient safety measures.

    Click here to see how your hospital(s) fared and for more information about the grading system.


    Neurosurgery Featured in Prior Authorization Article

    On April 8, the CNS and the AANS issued a press release objecting to Medicare’s new prior authorization requirements for cervical fusion and spinal neurostimulators. In the release, CNS/AANS Washington Committee chair, John K. Ratliff, MD, FAANS, noted that neurosurgeons “care for patients who suffer from painful and life-threatening neurologic conditions, and prior authorization is causing unacceptable delays and denials of medical treatments, particularly for debilitating spine disorders.” He added, that “patients cannot afford to wait or jump through unnecessary hoops to get the care they need, so it is imperative that CMS reevaluate the use of prior authorization in Medicare.”

    Subsequently, MedPage Today published an article titled “Doc Groups Object to New Prior Authorization Rules in Medicare.” The piece featured Katie O. Orrico, Esq., director of the CNS/AANS Washington Office. In her comments, Ms. Orrico noted that “without a clear rationale, increased volume is not in itself a justifiable reason for imposing prior authorization — particularly given the severe consequences to patients for delays in care.” She pointed out that “any increase in utilization is likely a result from appropriate changes in clinical practice, such as providing non-opioid pain treatment for spinal disabilities.” Finally, Ms. Orrico went on to state that “given the ‘Patients Over Paperwork’ initiative launched by the previous administration, we are dumbfounded why the agency chose to expand prior authorization in the face of overwhelming evidence ... that the expanded use of this utilization tool is causing significant administrative burden and delays in medically necessary care — to the detriment of patients ... In the context of the current policy related to these spine procedures — these delays could result in patients developing worsening neurological deficits, increased narcotic use, and avoidable patient suffering.”

    Neurosurgery Blog Launches Neurosurgery Match Series

    As impactful as the COVID-19 pandemic has been, the effect on neurosurgical practice has been similarly profound — from shifting outpatient care towards a more remote, telehealth presence to restricting non-urgent surgical case volume. Perhaps the most significant, potentially long-lasting effect of the pandemic on the neurosurgical profession has been with the transition from medical student to resident physician.

    To examine the topic, Neurosurgery Blog launched a series highlighting challenges in the application process experienced by neurosurgical programs, medical students and others in organized neurosurgery due to COVID-19 and relates the innovative responses during this critical time. To date, the following blogs have been published:

    In addition to the neurosurgery match series, Neurosurgery Blog continues to publish items of importance to the neurosurgical community. The blog recently highlighted the COVID-19 public service announcement released by the Congressional Doctors Caucus in a guest blog post by Sen. Roger Marshall, MD, (R-Kan.) titled “Congressional Docs Urge Americans to Take Action and Get the COVID-19 Vaccine.”

    Neurosurgeons Publish Op-Ed on Overlapping Surgeries and COVID-19

    On April 1, The American Spectator published an op-ed titled “Overlapping Surgery: A Safe and Smart Way to Fix COVID-Related Backlogs,” authored by Richard Menger, MD, MPA, and Anthony M. DiGiorgio, DO, MHA. The piece highlights the opportunity to use overlapping surgery to assist with the backlog of neurosurgical cases due to COVID-19. On April 9, Neurosurgery Blog published a cross-post to amplify the message.

    Neurosurgeon Publishes Op-Ed about Specialty Silos

    On April 27, Modern Healthcare published an op-ed titled “It’s time to break down the specialty silos.” Authored by Daniel B. Sciubba, MD, FAANS, the piece focuses on the benefits of multidisciplinary care as an opportunity to offer better and more individualized medical and surgical care, leading to vastly better patient outcomes.

    Join the Conversation on Social Media

    Connect with the CNS/AANS Washington Committee and Washington Office on various social media platforms to keep up with the many health policy activities happening in the nation’s capital and beyond the Beltway.

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