AAOS commends CMS for this important proposal and, after further analyzing all details in the rule, AAOS will be submitting comments by the October 16 due date.

“AAOS applauds Secretary Price, Administrator Seema Verma, and others at CMS for clearly hearing concerns of orthopaedic surgeons related to these mandatory payment models,” stated AAOS President William J. Maloney, MD. “As we have said before, AAOS strongly supports the efforts of all stakeholders to develop payment models that incentivize care coordination and address rising health care costs. Additionally, appropriate alternative payment models are a necessary component of the current Quality Payment Program. However, imposing mandatory models on surgeons and facilities that lack the familiarity, experience, or infrastructure required has serious unintended consequences. Reducing the geographic area for CJR while still leaving a voluntary option significantly remedies this issue. We thank CMS for their work on this proposed rule and will be commenting officially with a more detailed response.”

“Changing the scope of these models allows CMS to test and evaluate improvements in care processes that will improve quality, reduce costs, and ease burdens on hospitals,” said CMS Administrator Seema Verma. “Stakeholders have asked for more input on the design of these models. These changes make this possible and give CMS maximum flexibility to test other episode-based models that will bring about innovation and provide better care for Medicare beneficiaries.”

For more information on the Comprehensive Care for Joint Replacement Model, please visit: https://innovation.cms.gov/initiatives/cjr.

For more information on the models proposed for rescission, please visit: https://innovation.cms.gov/initiatives/epm

The proposed rule (CMS-5524-P) can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection. Public comments are due by October 16 at 11:59 pm EST.

Your government affairs team is also doing work for the Ambulatory Surgery Center Association and so we are now seeing all their meeting and advocacy update materials.   Assuming that a number of you are partners/investors in ASCs and/or operate in ASCs, I will start sending you the information via Alerts.

Ambulatory Surgery Center Association 2017 Webinar Series

Cordially,

Kathleen Conaboy

I hope you recall that, at the Governor’s request, the 2017 Legislature passed AB 474.  (See page 17 of our NVOS End of 2017 Session Report; the link to the bill is live.)  This bill is designed to help curb the opioid misuse and abuse epidemic; details are outlined in the report.    Note that the bill was effective upon the Governor’s signature for the purpose of promulgating regulations; all other provisions – including many that will impact your daily interactions with your patients and your practice protocols– are effective on January 1, 2018.

PLEASE INCLUDE YOUR PRACTICE ADMINISTRATORS IN A REVIEW OF THIS BILL, SPECIFICALLY SECTIONS 51- 58; this is where you will find the steps that you must take and document in the patient record.

Progress in preparing for implementation:

The Governor’s office worked closely with organized medicine throughout the development of this legislation to assure that the bill is both practical and implementable.  They were also very cognizant of our repeated requests not to interfere with the  doctor-patient relationship.

In late June, the Governor’s chief health policy advisor, Elyse Monroy, called a meeting of the medical licensing boards and several of the specialty societies to talk about educating physicians and other prescribers about the requirements of the bill.  We attended, along with the boards from Pharmacy, Nursing, NBME, and the Board of Osteopathic Medicine.

• Because each of the boards will issue its own regulations – but Pharmacy’s regulations will impact all prescribers — the boards agreed to coordinate; their legal counsel will meet collectively and work through overlapping issues.  Specifically, Pharmacy is responsible to outline processes for generating the PDMP reports that will go to the licensing boards to alert them about potential overprescribing by physicians.   The licensing boards will each determine their own processes for dealing with infractions.
  • Based on the bill, licensing boards will no longer need to wait for a formal complaint against a physician before taking action about potential overprescribing; if the prescriber appears to be an “outlier”, the board will be in contact to ask for details.  There will, of course, be variables for oncology and palliative care, as well as for pain management.
  • If there is an actual infraction, Pharmacy may pull a DEA license AFTER the prescriber’s licensing board has taken action.
• There will be refinements to the PDMP, which can already track patients who are doctor shopping.  New processes will allow the PDMP to review a physician’s prescribing pattern per patient.
• Each prescriber will be required to take 2 hours of CME within your licensure renewal cycle,  up from the current 1 hour requirement.
• Prescriptions must include the ICD-10 code; your DEA number; and the number of days for which the prescription is written, if the patient consumes the maximum dosage as prescribed.

The boards are collaborating to develop a white paper to educate all prescribers, which will hopefully be released by the end of August.  The document will includes sample forms and checklists that you can use as templates to satisfy the requirements of the bill.

DHHS staff assumed responsibility for putting together a group to work on the patient risk assessments that can be used to satisfy the provisions of the bill.  This effort will be coordinated with the licensing board so physicians input is included.  They are also working with the University of Nevada School of Medicine to develop a CME course that can be offered statewide.

Eventually, all this info needs to make its way into your EMRs, so the checklists and protocols are easily accessible and documentable.  Since Pharmacy has relationships with the EMR vendors, they will coordinate data collection with their vendor.

___________________________________________________________________________________________________________________________

The information below arrived Monday from the AAOS; as you can readily see, Nevada is one of many states grappling with the opioid epidemic.  I am pleased to say that NVOS was at the table during numerous discussion throughout 2016  and that we often cited the AAOS information statement mentioned below as a guide to informing policy.

State Governments, Orthopaedic Societies Respond to Opioid Epidemic

Though many benefit from opioid medications, abuse of prescription opioids is a serious problem, causing nearly 50 deaths a day and thousands of emergency room visits a year. In context, the number of emergencies related to nonmedical use of opioids increased 183% from 2004 to 2011. State governments have responded to this crisis in different ways, with nearly 80 laws passed in 2015-2016. Many of these laws, according to a study published in Practical Pain Management, have resulted “in an increasing proportion of legitimate chronic pain patients unable to fill their prescriptions.”

State laws with specific-mandates that impact orthopaedic surgeons generally fit within three large buckets: continuing medical education (CME) requirements, querying prescription drug monitoring programs, and quantitative limits to prescriptions.

Currently, 15 states have CME requirements for opioid prescribers. Though many of these laws vary, with some impacting only pain management clinics, many impact AAOS members. For instance, the New York law requires prescribers who hold a DEA license to take a three hour course on pain management, palliative care and addiction. The New York State Orthopaedic Society has responded to this mandate by creating a webpage at http://www.nyssos.org/education/pmc.html. The information page helps navigate the requirement for orthopaedic surgeons and steers members towards online modules created by the Boston University School of Medicine Safe and Competent Opioid Prescribing Education (SCOPE) and the New York Chapter American College of Physicians to meet requirements.

At least 26 states have some form of mandatory querying of prescription drug monitoring programs (PDMP) before prescribing an opioid. PDMPs are state electronic databases that track prescriptions of controlled substances, including opioids. These requirements significantly vary by state; Some states require prescribers to check the PDMP before writing the majority of opioid prescriptions; Others mandate checking the PDMP only for certain providers or under certain circumstances, such as when a provider has a reasonable belief of inappropriate use or if the prescription is for chronic pain. Recently, the Texas Orthoapedic Society has created a page for orthopaedic surgeons to advocate for proven, patient-centered solutions at http://www.stateortho.com/txpdmp/. According to the grassroots page, “TOA has indicated to lawmakers that the PDMP is an appropriate tool that physicians will utilize when it is necessary.  However, as TOA has pointed out to lawmakers in a recent hearing, ‘doctor shoppers’ are not going to have a knee replacement surgery or purposely break their arm to access prescription drugs.” The TOA is advocating for policies that utilize data from PDMPs to flag “doctor shoppers” — the practice of visiting numerous physicians to obtain several prescriptions for prescription drugs.

Quantitative limits to opioid prescriptions are becoming a popular solution for politicians desperately seeking answers to the opioid epidemic. With little scientific research on limiting opioid prescriptions to certain-day supplies actually working, state medical societies have sought to mediate a popular idea’s impact to the patient-physician relationship. The Ohio State Medical Association in March 2017 worked with their governor, John Kasich, to announce new rules that will create prescription limits of up to seven days of painkillers for adults and five days for kids and teens with limits only applying to acute pain patients, with exceptions for cancer, hospice or medication-assisted addiction patients. Prescribers in Ohio can override the limits if they provide a specific reason in the patient’s medical record.

In February, New Jersey Governor Chris Christie signed a bill into law that sets a five-day limit on initial prescriptions for pain-killing opioids with little exemptions. Christie declared the law, “the toughest in the country in the fight against heroin and opioid addiction.” Though Governor Christie says, “we are taking action to save lives,” his administration gave little proof of the efficacy of the law while patient groups decried the potentially dangerous approach. The physicians of New Jersey nearly unanimously called the law “cruel” to patients and opposed the “one-size fit all” approach.

Last year, the National Governors Association (NGA) secured 46 Governors (including Gov Sandoval)  in a Compact to Fight Opioid Addiction. To address the growing heroin and opioid situation, the NGA Center for Best Practices developed a road map to help states prevent, respond and treat opioid misuse as well as strengthen law enforcement efforts to address illegal supply chain activity. According to the NGA, “It is designed as a policy development tool, allowing a state to use all or portions of the road map as it applies to their unique situation.” The Compact says that, “Although there has been progress in recent years, inappropriate opioid prescribing continues to fuel one of the deadliest drug epidemics in our nation’s history… [The Compact] sends a clear signal to opioid prescribers and others whose leadership is critical to saving lives.” The compact has three distinctive portions. First, to reduce inappropriate opioid prescribing. Second, changing the public’s understanding of opioids and addiction. Last, creating pathways to recovery for individuals with addictions.

In November 2015, the American Academy of Orthopaedic Surgeons released an information statement titled “Opioid Use, Misuse, and Abuse in Orthopaedic Practice.” The document said, in part, “The AAOS believes that a comprehensive opioid program is necessary to decrease opioid use, misuse, and abuse in the United States. New, effective education programs for physicians, caregivers, and patients; improvements in physician monitoring of opioid prescription use; increased research funding for effective alternative pain management and coping strategies; and support for more effective opioid abuse treatment programs are needed.” To read the statement, visit: http://www.aaos.org/uploadedFiles/PreProduction/About/Opinion_Statements/advistmt/1045%20Opioid%20Use,%20Misuse,%20and%20Abuse%20in%20Practice.pdf

To highlight the potential dangers of opioids, the AAOS created a multimedia public service campaign that was released at the 2017 Annual Meeting. The campaign includes display and radio ads, urging doctors and patients to exercise caution in prescribing and taking opioids. Visit for more information http://orthoInfo.org/PrescriptionSafety.

Despite legislative and other efforts to stem the tide of opioid abuse, the crisis still affects many Americans. The National Safety Council provides toolkits and resources for addressing substance abuse in the home and workplace. To learn more, visit: http://safety.nsc.org/rxemployerkit

__________________________________________________________________________________________________________________________________

There will be much more information to share in the coming weeks and months, but your government affairs team wanted to make sure that this issue is high on your radar screens NOW.   Cordailly, Kathleen

]]> https://www.nevadaortho.org/2017/08/06/7312017-effective-use-of-mat-in-an-opioid-dependent-population/ Sun, 06 Aug 2017 20:57:20 +0000 http://www.nevadaortho.org/?p=1109 Read More

The orthopaedic societies in Florida and New York are collaborating on a project funded by the AAOS State Legislative and Regulatory Issues Committee (SLRI) and are asking for our input.  They are researching the extent of inappropriate rate reductions by PPOs  in workers compensation programs.

Background:

As you know, when a physician contracts to join a health plan network, he or she agrees to accept a discounted rate in return for the plan directing patients into his or her practice through a listing in the health plan’s directory.   However, there is a deceptive  market practice called a “silent PPO” or “rental network.”   Silent PPO/rental networks create agreements with insuring entities, allowing buyers into the silent PPO to access the terms of the lowest discounted rate available. Patients (and other insuring entities who are members of the silent PPO) may then access the lowest discounted rate of the healthcare provider, even though the patient is not directly a member of the plan contracted to the healthcare provider at that rate.  Essentially, the network “shops” around to find the lowest rates a physician has agreed to with any insurer, then “rents” that discounted rate to another entity without the physician’s knowledge or permission. 

 This practice has resulted in physicians experiencing inappropriate rate reductions without their knowledge and frustration felt throughout the workers compensation system.

 Please participate in this survey so that AAOS can work with States to:

·         Develop model legislation to establish how a physician’s contract rate is sold, leased, or shared among health plans;

·         Ensure the physician’s right of action against anyone who improperly accesses their price discount; and

·         Provide guidance on how to speak with state Departments of Insurance to enforce current state insurance laws to alleviate this deceptive trade practice.

 This survey is geared toward individual physicians and should take participants an average of 4 minutes to complete.  The survey is at this link below and will be live until July 31, 2017:

https://www.surveymonkey.com/r/YZ28789

Please take a few minutes to assist in this effort.

Thanks!

Kathleen

I assume you are all on this mailing list, but just in case…

Cordially,

Kathleen

State of Nevada Workers’ Compensation Section

Workers’ Compensation Medical Training Classes

The State of Nevada Workers’ Compensation Section Medical Unit will be teaching two classes on Wednesday, July 12, 2017.  Health care providers and their staff are the targeted audience. Due to limited seating for both classes, registration is required.  There is no charge for the WCS trainings and all training materials will be provided.

July 12, 2017  9:30 am – 11:00 am

The C-4 Claim process and Using the Coverage Verification Service. Make sure your health care provider or facility does not get stuck with workers’ comp claims (C-4s) that have nowhere to go. This class details the process for verifying worker’s compensation insurance coverage and how to use available tools to expedite that process.

July 12, 2017   1:30 pm – 4 pm

Medical Billing can be tricky. Some have compared it to rocket science, but we’ll demystify it for you to get workers’ comp bills paid in a timely manner. Third-Party Administrators, and their staff, are encouraged to attend. This class is focused on functional applicability.

Where:

Henderson   – 1301 North Green Valley Parkway, Suite 130, Henderson, Nevada 89015

Carson City,  – 400 W. King Street, Carson City, Nevada 89703 via video conference to the Workers’ Compensation Conference Room

Register:

Henderson – Contact Kristine Garcia at krissi.garcia@business.nv.gov or (702) 486-9103

Carson City – Kimberly Williams at kawilliams@business.nv.gov or  (775) 684-7265

Due to limited seating for both classes, registration is required. If you have further questions, please contact Katherine Godwin, RN at kgodwin@business.nv.gov. There is no charge for the WCS trainings and all training materials will be provided. Should you require any further information, please do not hesitate to contact us.

Pursuant to U.S. Equal Employment Opportunity Commission, Enforcement Guidance: Reasonable Accommodation and Undue Hardship under the Americans with Disabilities Act (ADA), Number 915.002, 10/17/00, persons with disabilities who require special accommodations or assistance are required to notify our offices in writing, via fax, email or to the address listed above. Please submit all requests at least three (3) days before the training.

Here is the end-of-session report compiled by your government affairs team at McDonald Carano.

NVOS End of 2017 Session Report

As you can see from the detail, 2017 was a complicated, fast-moving session with numerous bills that may impact your practice environment.    Please share this report with your practice management staff, as many of the issues impact the business side of your practices.

Because Nevada’s legislature meets only biennially, significant policy and regulatory work takes place during the interim between sessions.    As detailed in this report, a number of the bills passed by the Legislature and signed by the Governor will now precipitate regulatory work.  In addition, there will be a new Advisory Committee on Medicaid Innovation and a study of the possibilities for designing a “Medicaid-like” plan to be offered on the HIX for patients otherwise not eligible for Medicaid.  Finally, the interim Legislative Committee on Health Care will meet and develop its bill draft requests for the 2019 session.

Against this backdrop, political fundraising for races ranging from Congress and the Senate to the Governor, all constitutional officers, all Assembly member and a number of state Senators will commence shortly.    These policy and election activities provide an opportunity to continue to position NVOS with legislators as we work to protect your interests and those of your patients.

Please feel free to contact me if you have any questions about the report.  My number is in the signature line below.

Cordially,

Kathleen

We have been alerted by AAOS that Nevada is one of nine states to be included in a geographic sampling where CMS has mandated new reporting of postoperative follow-up visits.  The new system takes effect on July 1, 2017.    See the details here:

https://www.aaos.org/AAOSNow/2017/Jun/Managing/managing02/

https://www.karenzupko.com/medicare-sharpens-focus-global-surgical-package/

BACKGROUND:

The Centers for Medicare & Medicaid Services (CMS) has expressed concern that services with 10- and 90-day postoperative periods are not valued accurately, and follow-up visits included in the value of the global services are not consistently being performed. Consequently, as required by the Medicare Access and CHIP Reauthorization Act (MACRA), CMS mandated the reporting of postoperative visits for 293 Current Procedural Terminology (CPT) codes for providers in nine states beginning July 1, 2017.

These postoperative visits should be reported with CPT code 99024, which the CPT book uses to describe “a postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure.”

In the nine states, 99024 reporting will be required on Medicare fee-for-service claims in groups with 10 or more practitioners. Physician or qualified nonphysician practitioners (eg, nurse practitioner, physician assistant) who furnish services to patients are included when enumerating a group’s practitioners. These practitioners do not need to share the same physical address to be considered part of the same practice, but may share a tax identification number. Physicians in teaching hospitals are included in this mandatory reporting requirement.

The place of service designations where reporting must occur include, but are not limited to, inpatient hospital, outpatient hospital, ambulatory surgical center (ASC), intensive care unit, critical care unit, skilled nursing facility, or a physician’s office. This means that inpatient postoperative hospital rounding visits related to the surgical procedure would be reported, a dramatic departure from current practice, wherein many of these encounters are not tracked at all.

In the proposed rule, CMS recommended collection of post-operative data in three ways.

• The first prong would collect claims-based data on the number and level of visits in 10-minute increments from all physicians who perform Global Code (G-code) procedures.
• The second method would be a survey pf physicians.
• The third method would be data collection from the accountable care organizations (ACOs).

The claims-based universal data gathering proposal was deemed extremely burdensome on surgeons and not in line with the intent of the Medicare Access and CHIP Reauthorization Act (MACRA) statute. AAOS commented to CMS explaining these issues as well as joined other surgical specialties in legislative and regulatory advocacy efforts to urge CMS to reverse this proposal.

Subsequently, in the final rule with comments [Regulation No. CMS-1656-FC] (available online at: https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-26515.pdf), CMS finalized three major flexibilities in reporting requirements as follows:

1.    CPT code 99024 can be used to collect data on the number of post-operative visits (as suggested by AAOS and others). Further, at this time, CMS will not require time units or modifiers to distinguish levels of visits to be reported.

2.    Instead of required reporting on all codes, CMS is just collecting data on the number of visits for codes that are reported annually by more than 100 practitioners and with high volume or high allowed charges (furnished more than 10,000 times or have allowed charges of more than $10 million annually as recommended by the RUC (AMA RVS Update Committee) and many other commenters including AAOS).

3.    Instead of collecting data from all physicians who perform global code procedures, CMS has finalized reporting requirements for a geographic sample of practitioners located only in the following states: Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon and Rhode Island.

Moreover, the start date for implementation of such data collection has been postponed from January 1, 2017 to July 1, 2017. At this time, CMS is not implementing the statutory provision that authorizes a 5 percent withhold of payment for the global services until claims are filed for the post-operative care, if required. The proposals regarding the physician survey and data collection in ACO have been finalized as proposed.

“CMS is hopeful that use of the existing CPT code for reporting these services will be significantly less burdensome than the proposal to require time-based reporting using the G-codes,” the agency wrote in a summary. “[W]hile practitioners are encouraged to begin reporting post-operative visits for procedures furnished on or after January 1, 2017, the requirement to report will be effective for services related to global procedures furnished on or after July 1, 2017. To the extent that these data result in proposals to revalue any global packages, that revaluation will be done through notice and comment rulemaking at a future time.”

Since reporting via the 99024 CPT code will only provide information on the number of visits, CMS will explore whether a survey would provide data on the level of visits (needed to value surgical services correctly) as mandated by the MACRA statute.

AAOS will continue to monitor future rule making on this issue.

Thank you to all of you who contacted the Governor to request a veto AB 382.  The Governor received the bill from the Legislature on Thursday and vetoed it Thursday night!!

See the veto letter AB382 VETO and note that NVOS was at the table in support of patients and physicians – good policy!

Cordially,

Kathleen