• Volume 44, May/June 2016 CNS DC E-Newsletter

    • Jun 01, 2016

    Special Announcement

    CMS Proposes Major Overhaul of Medicare Physician Payment System
    On April 27, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a proposal to overhaul the way Medicare pays physicians. The proposed rule implements key elements of the Medicare Access and CHIP Reauthorization Act (MACRA). This legislation repealed Medicare's sustainable growth rate (SGR) formula and replaced it with a new payment system. Through a single framework called the "Quality Payment Program," the new payment paradigm has two paths — the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs). The new program consolidates components of three existing Medicare penalty programs — Physician Quality Reporting System (PQRS)Electronic Health Record (EHR) and Value-Based Payment Modifier (VM) — and creates an opportunity for neurosurgeons to earn quality improvement bonus payments.

    Initially, most neurosurgeons will likely participate in the Quality Payment Program through MIPS, which will allocate payments based on performance in four categories: quality, Advancing Care Information (formerly EHR meaningful use), clinical practice improvement activities and cost/resource use. CMS would begin measuring performance for physicians through MIPS in 2017, with payments based on those measures starting in 2019. Neurosurgeons participating to a sufficient extent in risk-based APMs would be exempt from MIPS reporting requirements and qualify for financial bonuses in addition to any shared-savings earned through the APMs.

    On June 7, 2016, AANS/CNS Washington Office staff met with senior staff from CMS, including acting administrator Andy Slavitt, to discuss a number of topics related to the proposed rule. Members of the AANS/CNS Neurosurgery Quality Council (NQC) and Washington Office staff developed a detailed comment letter, which was submitted on June 27, 2016. In the letter, organized neurosurgery expressed serious concerns with the new proposed payment rules and urged CMS to make substantial change before finalizing the payment overhaul. 

    In a release coinciding with the submission of comments, AANS president, Frederick A. Boop, MD, chair of the department of neurosurgery at the University of Tennessee remarked, “MACRA presents an unprecedented opportunity to fix the currently broken and burdensome Medicare quality programs, which have little meaningful impact on quality and have been extremely disruptive to physician practices.”

    CNS president, Russell R. Lonser, MD, chair of the department of neurosurgery at The Ohio State University, stated, “CMS should seize this moment and make substantial changes to the proposed rule to ensure that the new quality payment program is patient-centered, flexible and meaningful for physicians and patients alike.” Dr. Lonser added, “The AANS and CNS recognize the enormity of the task to overhaul the Medicare physician payment system. Nevertheless, it is essential that CMS establish the programmatic building blocks that will ensure the quality payment program’s success into the future.”

    Copies of the press release and letters neurosurgery-supported are available by clicking the links below:

    In the coming weeks and months, the AANS and CNS will be publishing a variety of educational materials to ensure that neurosurgeons are “MACRA ready” and can thrive under the new quality payment program.

    Click here for more information from CMS. Stay tuned for more details from the AANS and CNS.

    Legislative Affairs

    Congress Holds Hearing on MACRA Implementation
    On May 11, 2016, the House Ways and Means Health Subcommittee held a hearing entitled “Implementation of Medicare Access & CHIP Reauthorization Act of 2015 (MACRA).” Centers for Medicare & Medicaid Services (CMS) Acting Administrator, Andy Slavitt, testified before the House Ways and Means Health Subcommittee on implementation of MACRA, legislation that repealed the sustainable growth rate (SGR) formula and reformed Medicare physician reimbursement payments.

    Neurosurgery Advocates for Pediatric Trauma Care
    On May 24, 2016, the AANS, CNS, AANS/CNS Joint Section on Neurotrauma and Critical Care and the AANS/CNS Joint Section on Pediatric Neurosurgery participated in a “Day on the Hill.” Additionally, we participated at a Congressional briefing convened to highlight the challenges facing pediatric trauma patients and the need to find bipartisan solutions to ensure adequate trauma care for children. P. David Adelson, MD, director of Barrow Neurological Institute at Phoenix’s Children’s Hospital and chief of pediatric neurosurgery at Phoenix’s Children’s Hospital, represented the AANS and CNS. Throughout the day, he met with several members of Congress and joined with other pediatric experts in raising awareness about the number one killer of children in the U.S. Also, as part of this effort, Reps. Richard Hudson (R-N.C.) and G.K. Butterfield (D-N.C.) announced the establishment of the Pediatric Trauma Caucus.

    To aid in awareness, the AANS and CNS convened an expert workgroup of prominent pediatric neurosurgeons. Led by Dr. Adelson, the group — which included Douglas L. Brockmeyer, MD; Ann-Christine Duhaime, MD; Gerald A. Grant, MD; Leon E. Moores, MD; and Nathan R. Selden, MD, PhD — developed a background paper titled “Pediatric Trauma in the United States: Challenges of Ensuring Adequate Trauma Care for the Pediatric Patient.”

    House Subcommittee Advances Sports Liability Bill
    On June 8, 2016, the House Energy & Commerce Subcommittee on Health marked up H.R. 921, the Sports Medicine Licensure Clarity Act of 2015. Introduced by Rep. Brett Guthrie (R-Ky.), this legislation aims to preserve the access of athletes and athletic teams to sports medicine professionals who provide high-quality, continuous health care services. The bill stipulates that health care services provided by covered sports medicine professionals who travel to a secondary state with an athlete, athletic team or staff member will be covered by the professional’s medical liability insurance provider. For the purposes of liability, health care services provided by a covered sports medicine professional will be deemed to have been provided in the professional’s primary state of licensure. The bill currently has 168 cosponsors and is pending further action by the full committee.

    Congress Holds Hearing on Concussions in Youth Sports
    On May 11, 2016, the House Energy & Commerce Subcommittee on Oversight and Investigations, chaired by Rep. Tim Murphy (R-Pa.), held a hearing entitled “Concussions in Youth Sports: Evaluating Prevention and Research,” which examined concussions in youth sports, as part of the committee’s broad review of concussions. The hearing followed the committee’s first roundtable discussion held in March 2016. The goal of the review is to bring experts from a wide variety of fields — medical, military, sports leagues and other stakeholders — to advance the understanding of these complex and traumatic brain injuries.

    Neurosurgery Endorses the Ensuring Children’s Access to Specialty Care Act
    On June 7, 2016, organized neurosurgery joined forces with 67 other groups in endorsing H.R. 1859/S.2782, the Ensuring Children’s Access to Specialty Care Act. Sponsored by Rep. Chris Collins (R-N.Y.) in the House and Sen. Roy Blunt (R-Mo.) in the Senate, this legislation would modify the National Health Service Corps (NHSC) loan repayment program to allow pediatric subspecialists working in underserved area to participate. This bill recognizes the serious shortages that exist in pediatric subspecialties and will give the Health Resources and Services Administration (HRSA) the ability to begin to address this in a meaningful way. The House bill currently has 69 cosponsors.

    House Passes Multiple Opioid-Related Bills
    On May 11, 2016, the House passed a bipartisan package of opioid-related bills, including H.R. 4641, legislation to establish an inter-agency task force to review, modify and update best practices for pain management and how pain medication is prescribed. Other bills in this series included:

    • H.R. 3680, the Co-Prescribing to Reduce Overdoses Act;
    • H.R. 4063, the Promoting Responsible Opioid Management and Incorporating Scientific Expertise Act;
    • H.R. 4586, the Lali’s Law;
    • H.R. 4599, the Reducing Unused Medications Act;
    • H.R. 4969, the John Thomas Decker Act;
    • H.R. 4976, the Opioid Review Modernization Act;
    • H.R. 4978, the NAS Healthy Babies Act;
    • H.R. 4981, the Opioid Use Disorder Treatment Expansion and Modernization Act;
    • H.R. 4982, the Examining Opioid Treatment Infrastructure Act;
    • H.R. 5046, the Comprehensive Opioid Abuse Reduction Act;
    • H.R. 5048, the Good Samaritan Assessment Act; and
    • H.R. 5052, the OPEN Act.

    Earlier this year, on March 10, 2016, the U.S. Senate passed S. 524, the Comprehensive Addiction and Recovery Act, or CARA. The bill authorizes the attorney general to provide grants to states, local governments and non-profit groups for programs to strengthen prescription drug monitoring, improve treatment for addicts and expand prevention, education and law enforcement initiatives. A House-Senate conference committee has been appointed to develop a single legislative package.

    If you have questions about these, or other legislative issues, please contact Katie Orrico, director of the AANS/CNS Washington Office, at korrico@neurosurgery.org.

    Coding and Reimbursement 

    Neurosurgery Supports Candidates for Washington State Health Care Panel
    On May 2, 2016, the Washington State Health Care Health Technology Assessment Program (HTAP) issued a notice requesting nominations for the program’s Health Technology Clinical Committee (HTCC). Washington State neurosurgeons Jean-Christophe A. Leveque, MD, and Abhineet Chowdhary, MD, have applied for open positions. On June 1, 2016, the AANS, CNS and Washington State Association of Neurological Surgeons (WSANS) sent a letter of support for Drs. Leveque and Chowdhary. The letter stated, “Given the many issues discussed by this committee related to the nervous system, we believe the process would be greatly enhanced with the addition of neurosurgical expertise on the panel.”

    Neurosurgery Responds to Washington State HTA Plan for Re-review of Artificial Disc Policy
    On April 18, 2016, the Washington State Health Care Authority (HCA) issued a notice listing technologies to be reviewed by the Washington State HCA Health Technology Clinical Committee (HTCC) in the coming year. Included on the list was a re-review of coverage for cervical and lumbar artificial discs citing new indications and new literature. On May 19, 2016, the AANS, CNS, AANS/CNS Joint Section on Spine and Peripheral Nerves and WSANS sent a letter highlighting new studies that support two-level cervical disc arthroplasty and the cost effectiveness of artificial discs. In addition, the letter urges the agency to include neurosurgeons in the review of the clinical data for the technology. 

    Neurosurgery Maintains Stance on Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis 
    On May 13, 2016, the AANS and CNS submitted a letter to the Centers for Medicare & Medicaid Services (CMS) in response to notice regarding a request from Vertos Medical, Inc. for reconsideration of the current CMS policy not to cover percutaneous image-guided lumbar decompression (PILD) for lumbar spinal stenosis (LSS) except in a clinical trial. On April 13, 2016, CMS issued a reconsideration notice in response to the request. In our letter, we reaffirmed previous concerns about PILD procedures and stated that CMS should not widen the coverage for the procedure until 12 full months of clinical data are available and have been thoroughly reviewed.

    If you have any questions regarding this, or other reimbursement issues, please contact Cathy Hill, AANS/CNS senior manager for regulatory affairs, at chill@neurosurgery.org.

    Quality Improvement

    Hardship Exception Applications Due by July 1 for the Medicare EHR Incentive Program
    Neurosurgeons must apply for Medicare’s Electronic Health Records (EHR) Incentive Program’s hardship exception by July 1, 2016, for eligible professionals (EPs), eligible hospitals and critical access hospitals (CAHs). The Medicare EHR Incentive Program 2017 hardship exception instructions and application for EPs and eligible hospitals are available on the Payment Adjustments & Hardship Information webpage of the EHR Incentive Programs website. Please visit the EHR Incentive Program’s FAQs page for answers to specific hardship exception questions.

    Practices Have Until June 30 to Register for PQRS GPRO
    Time is running out for group practices to register to participate in the 2016 Physician Quality Reporting System (PQRS) Group Practice Reporting Option (GPRO). PQRS GPRO is an option available to groups with two or more eligible professionals (EPs). Alternatively, EPs can participate in PQRS as individuals. The benefit of participating as a group is that billing and reporting staff may report one set of quality measures data on behalf of all EPs within the group, reducing the need to keep track of EPs’ reporting efforts separately. 

    Keep in mind that 2016 marks the first year that CMS will permit group practice reporting through Qualified Clinical Data Registries (QCDRs). Organized neurosurgery’s Quality Outcomes Database (QOD) has been approved as a QCDR and can accommodate both individual and group practice reporting in 2016.

    Regardless of whether you choose to participate in the PQRS as an individual or group practice, all EPs must satisfactorily participate in PQRS in 2016 to avoid a -2.0 percent payment adjustment in 2018. Failure to do so will also result in an additional automatic payment adjustment of -2.0 percent or -4.0 percent in 2018, depending on the group’s size, pursuant to the Value-Based Payment Modifier (VM). 

    New PQRS and Value-Based Payment Modifier Resources Available for Neurosurgeons 
    The Medicare Physician Quality Reporting System (PQRS) is a federal quality reporting program that penalizes physicians who do not satisfactorily submit quality data to the Centers (CMS). PQRS compliance also has implications for a separate Medicare payment adjustment, known as the Value-Based Payment Modifier (VM). Starting in 2017, CMS will begin applying the VM to Medicare physician fee schedule payments for all neurosurgeons. The VM adjusts payments to groups of physicians based on their performance on a composite of quality and cost measures. Given the complexity of these programs, the Washington Office has developed new educational resources for neurosurgeons on participating in the PQRS and participating in the VM.

    If you have any questions regarding these or other quality-related issues, please contact Rachel Groman, Vice President for Clinical Affairs and Quality Improvement at Hart Health Strategies, via email at rgroman@hhs.com.

    Drugs and Devices

    Organized Neurosurgery Participates in FDA Network of Experts Open House
    On May 25, 2016, Maya Babu, MD, MBA — a member of AANS/CNS Drugs and Devices Committee — and Washington Office staff attended an open house for FDA Network of Experts partner organizations. The AANS and CNS have participated in the program since its inception in 2012. The FDA Network of Experts is currently made up of 54 organizations that have contracted with the FDA to provide rapid access to “real world” scientific, engineering and clinical expertise regarding the use of devices.

    If you have any questions regarding this, or other drug and device issues, please contact Cathy Hill, AANS/CNS senior manager for regulatory affairs, at chill@neurosurgery.org

    Fraud and Abuse

    AANS and CNS join AMA and others in Letter to CMS on Provider Enrollment
    On April 25, 2016, AANS and CNS joined the American Medical Association (AMA) and 24 other physician specialty societies in a letter to the Centers for Medicare & Medicaid Services (CMS) providing comments on a proposed rule implementing new provisions to the provider enrollment process for Medicare, Medicaid and the Children’s Health Insurance Program (CHIP). Specifically, the letter objects to inappropriately long “look back” periods for disclosable events and reporting of alleged events for which an appeal is pending. In addition, the groups expressed concern about the proposal to extend the maximum re-enrollment bar from three years to 10, and in some cases, up to 20 years. The letter supports the goal of CMS to protect patients, but urges CMS to consider the regulatory burden and cost to physicians.

    Senate Finance Committee Publishes Updated Physician Owned Distributors Report
    On May 10, 2016, the Senate Committee on Finance published an updated version of its 2011 report on Physician Owned Distributors (PODs). According to the report, PODs have been most prevalent for spinal surgery devices, but may be used to market other medical devices.  The document includes concerns about lack of hospital transparency regarding the use of PODs to procure devices and recommends measures to strengthen disclosure requirements and increase enforcement of current law regarding the business arrangements. The Department of Health and Human Services Office of Inspector General (HHS OIG) has also highlighted concerns with PODs and, in 2013, issued a special fraud alert regarding the arrangements followed by a report detailing the prevalence and use of PODs.

    If you have any questions regarding this, or other fraud and abuse issues, please contact Cathy Hill, AANS/CNS senior manager for regulatory affairs, at chill@neurosurgery.org.


    Neurosurgery and Other Societies Send Letter to NEJM Regarding Fusion for Degenerative Spondylolisthesis
    On May 1, 2016, organized neurosurgery led an effort responding to a series of articles published in the New England Journal of Medicine (NEJM) regarding spine fusion. To that end, the AANS, along with the American Academy of Orthopaedic Surgeons (AAOS) and the North American Spine Society (NASS), submitted a letter to the NEJM editor commenting on the articles.

    In our letter, the AANS, AAOS and NASS said:

    Clinical guidelines recommend spinal stenosis without instability, intraoperative destabilization or deformity typically should be treated with decompression alone. Despite the widespread acceptance of these principles, Försth performed an RCT evaluating whether fusion improves outcomes in a mixed population with spinal stenosis. As expected, the study showed no benefit to fusion. Subgroup analysis of a heterogeneous population with degenerative spondylolisthesis also failed to show a significant benefit of fusion; however two-year follow-up was only 56%, and the study was underpowered to detect a clinically important difference in ODI.

    Simultaneously, Ghogawala published a RCT looking specifically at “stable” degenerative spondylolisthesis patients. They excluded patients with >3 mm of motion and therefore examined a population where the necessity of fusion is controversial. Decompression with fusion improved outcomes and resulted in fewer reoperations than decompression alone. Not every patient with degenerative spondylolisthesis requires fusion. However, many patients achieve better outcomes and more durable results as a result of fusion. Neurosurgery and orthopaedic surgery leadership disagree with the conclusion that instrumented fusion does not create any value for patients.

    The letter, which was not published by the journal, went on to point out that:

    Not every patient with degenerative spondylolisthesis requires fusion. However, many patients achieve better outcomes and more durable results as a result of fusion. Neurosurgery and orthopaedic surgery leadership disagree with the conclusion that instrumented fusion does not create any value for patients.

    Subscribe to Neurosurgery Blog Today!
    The mission of Neurosurgery Blog is to investigate and report on how healthcare policy affects patients, physicians and medical practice and to illustrate how the art and science of neurosurgery encompass much more than brain surgery. Over the past few months, Neurosurgery Blog has ramped up its reporting efforts to include multiple guest blog posts from key thought leaders and members of the neurosurgical community. We invite you to visit the blog and subscribe to it, as well as connect with us on our various social media platforms. This will allow you to keep up with the many health-policy activities happening in the nation's capital and beyond the Beltway.

    If you are interested in these communications activities, please contact Alison Dye, AANS/CNS senior manager of communications, at adye@neurosurgery.org.

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