November 15, 2011 Legislation





The feds have published the final ACO regs.  The regs lowered the onerous number of quality? measures to 33 from 65.  They retained EHR as a quality measure but eliminated meaningful use requirements.  The regs allowed first dollar savings and eliminated year 3 downside risk in Track 1.  They also made Track 1 more like Track 2 by making a fixed 2% minimum saving rate.  Patients will now be assigned to ACOs prospectively initially but the patient may leave at any time so the final census will not be to tend of the fiscal year.  These are improvements over the proposed rules but are they enough to make physicians want to join??

The feds also simultaneously issued waivers for those in ACOs in the fraud and abuse categories allowing sharing of information pre-ACO, waiving anti kickback and self referral laws during and for some time after an ACO is formed, a waiver of shared distributions, and a waiver of some patient inducements for ACOs.  There were also some changes in the antitrust arena to allow ACOs some more flexibility.  Even the IRS got into the act but they kept the charitable purpose.  The non profit entity (hospital) does not have to have control to be sure there is a charitable contribution.  The feds also recognized that physician led ACOs would not have enough money at first so they will pay monies in advance and collect it back later from savings.  

CLASS, the long term health insurance, has been given the heave ho by HHS and the administration due to financial concerns.  Then Obama said he wanted it back.  He did that for political posturing since he originally gave the OK for its removal.

The federal stimulus money has run out for helping states with their Medicaid programs.  This means that almost all states will be drastically cut back on the program and payments to providers.  I hope more physicians stop seeing the patients to show what will happen if the feds cut back on Medicare.

CMS has decided to pay for a one office visit per year aimed a preventing cardiac disease.  It will consist of a face to face meeting with men between 45 and 79 and women ages 55 to 79.  It will include behavioral counseling, blood pressure exam and then is to arrange a follow up appointment which is not paid for by CMS.  This exam must be in a primary care setting and not a cardiologist office, hospital, ASC, Diagnostic testing facilities, rehab facilities or hospices.  This is like the one free Medicare exam per year which is not being italicized since it does not cover any physician exam just talking. 

CMS has changed the revalidation of physicians to 2015.  All physicians are supposed to reenroll in Medicare by that date, unless they are relatively new to practice.  If you or your practice have already received a notice from CMS then you had better comply in a timely fashion or lose your ability to treat Medicare patients.  This might not be bad since the pay for seeing Medicare patients is still scheduled to decrease by 27% starting January.  However CMS has said they will punish physicians less if they read more than one advanced radiological exams on the same patients the same day.  This is especially onerous on the cardiologists who do multiple procedures on the patient at one time.  

Again government sticks its nose into medicine to raise the costs for all.  This time it is in New York.  The Governor just signed a law mandating insurance companies cover up to $45,000 per autistic child per year.  This is expected to raise family premiums by several hundred dollars and employers several tens of thousands of dollars.  This also effects the public sector and will increase state health care costs dramatically.  

The state of Washington has been ordered to reverse its law limiting Medicaid patients to three ED visits per year.  The patients had been told they could be billed for any additional visits.  That is now all gone.

I have just returned from a trip to France and England.  On the return flight I picked up a British Daily Mail newspaper?.  The front page story is that the government has ordered physicians to treat the elderly with respect.  The story talks about how many elderly people are not fed or given personal hygiene care.  The government says this is the physician fault.  I always was under the impression that the hospital employees were responsible for feeding the patient, not the physician.  I must have been wrong.  The same paper decries the use of caesarian sections on demand at a time when finances are so thin that needed medicines will not be purchased by the NHS.  In their Health Section there is an article about how GPs are too busy to give proper care and how patients get to see different physicians each visit which decreases continuity of care.  This is what we have to look forward to in this country.  It boggles the mind that applications to medical school here are up substantially and all the graduates want to be employees.  

The Wall Street Journal had a fascinating article on Greece's medical care.  It is supposed to be a socialistic, government paid program.  The government forgets to pay for some years at a time and if any Greek wants any type of medical care they do as all the central European nations do, pay under the table to the physician.  The pay can be from several Euros for an office visit to 5000 Euros for surgery.  They pay as much in bribes as they pay in taxes and insurance for health.  The public hospitals are so far behind in their payments for supplies and pharmaceuticals that they can't get anymore unless the government pays first.  There is a second tier of care for the wealthy with their own hospitals and physicians as in Britiain.    Top


The government continues to find new ways to have physicians not see Medicare patients.  They have imposed a 3% withhold on payments to physicians, hospitals and health care plans to protect federal revenue from tax cheats.  They do nothing about Medicare fraud.  Assuming the physicians are paying their taxes they get the money back on their taxes.  This would be on top of the SGR. The House has passed a law to rescind the 3% affront but the Senate wants to know how the lost money will be made up.  They must have found out since the bill passed the Senate 95-0.  The President has said he will sign the law.

The SGR has not been removed but has changed.  Now only expect a 27.4 reduction in your Medicare payments not the original 30%.  If it happens still stop seeing Medicare patients or limit them.  There will also be a 50% reduction for repeated scans with a visit.  If you give out pharmaceuticals also expect a decrease from 106% of the average manufacturers price to 103%.  It may be better to have the patient get the meds and bring them to the office or do the infusions at the hospital.

It is possible that MedPAC will get rid of the SGR in time.  If they do they will reduce pay 5.9% per year for three years and then freeze the pay for seven years to specialists and freeze pay to primary care for ten years.  This would be a blow to keeping some offices open and would definitely lead to the dismissal of employees.

Letters have gone out to physicians who do not do e-prescribing that they will get a 1% decrease in pay next year.  This penalty goes up 0.5% per year for several years.  

HHS has botched another deadline.  Under Obamacare they were supposed to have in place by October1 a mechanism for all companies to report any payment over $10 to any physician to be made public.  They aren't close.     Top


Tennessee Erlanger Health is being investigated by the feds for their contracts between the hospital and the Chattanooga Heart Institute.  They paid the Institute about $1.9 million for on call coverage and cardiac test interpretations.  The Institute was a subsidiary of Erlanger's main competitor, Memorial Hospital.  Erlanger got in financial trouble in the past for anti kickback problems when they had to pay $40 million to the feds. 

HHS has issued rules to help hospitals by cutting back some regs.  The hospitals may use PAs and advanced practice RNs instead of physicians in some instances.  Patients could take their own drugs without the supervision of a nurse.  Also no more detailed logs of infection problems but investigations of outbreaks would still need to be investigated.  A major change is that a hospital system now needs only one governing body.  

The NPDB is attempting to streamline some operations.  It will allow disputes of reporting by physicians to be via email as well as supporting documentation.  Then all communication either way can be by email.  

The Joint Commission had removed the term "disruptive behavior" from its lexicon as too vague. In its place is the term  behavior or behaviors that undermine a culture of safety has been inserted.  They also have new rules for California institutions that perform CT scans.  They have to conform to the new laws regarding the dosages of the scans.  Also a new set of standard went into place for influenza immunizations.  They require certain documentation but do not require licensed independent practitioners obtain the vaccine nor do they require the hospitals or other organizations to pay for the LIP vaccines.     Top


DISCLAIMER: Although this article is updated periodically, it reflects the author's point of view at the time of publication. Nothing in this article constitutes legal advice. Readers should consult with their own legal counsel before acting on any of the information presented.