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 Government Affairs Newsletter, June 2013

Supreme Court sides with doctors in dispute over insurer's pay practices
AMA
A decision Monday by the Supreme Court of the United States will allow individual physicians to come together as a group to fight unfair business practices of large health insurance companies. The ruling in Sutter v. Oxford Health Plans, a dispute between the East Coast insurer and New Jersey pediatrician John Sutter, MD, that dates back to 2003, means that thousands of physicians will be able to use class arbitration against an insurer that has underpaid them for more than a decade. Read more.
 
Federal judge lifts ban on public access to Medicare data
Reuters
A federal judge lifted a 33-year-old injunction barring public access to a confidential database of Medicare insurance claims, a decision that could lead to greater scrutiny of how physicians treat patients and charge for their services. Judge Marcia Morales Howard ruled Friday in favor of a motion by Dow Jones, publisher of the Wall Street Journal, that the U.S. District Court for the Middle District of Florida lift an injunction imposed in 1979. Read more.
 
Most Doctors Don’t Meet U.S. Push for Electronic Records
Bloomberg
Fewer than 1 in 10 doctors used electronic records last year to U.S. standards, according to a survey that shows the challenge facing a multibillion-dollar effort to digitize the health system for improved patient care. Only 9.8 percent of 1,820 primary-care and specialty doctors said they had electronic systems that met U.S. rules for "meaningful use," a list of tasks such as tracking referrals or filling prescriptions online. Less than half all those surveyed, or 44 percent, had any system in place, according to the report published by the journal Annals of Internal Medicine. Read more.
 
Hand Society Legislative Update
Bruce M. Leslie, M.D.
Chair, ASSH Government Affairs Committee
Each year the Government Affairs Committee (GAC) sends representatives to Washington D.C to attend the National Orthopaedic Leadership Convention (NOLC). The NOLC is sponsored by the AAOS. Members of the GAC attend seminars about health care and spend one day visiting with our respective legislators on Capitol Hill.  This year the NOLC was scheduled during a time that most of the legislators were out of town. As a result attendees met with staff members.  Typically that would not be the time to travel to Washington, but this year was a bit different. One or two staff members in each of the state’s delegations were willing to engage in frank and meaningful dialogue giving us the impression that our persistence may finally be paying off.  This year’s issues:

1. Sustainable Growth Rate (SGR). The SGR is the method currently used by the Centers for Medicare and Medicaid Services (CMS) in the United States to control spending by Medicare on physician services. It is the SGR that has caused Medicare reimbursement to be effectively flat for the past 15+years.   Every congressional office agrees that the SGR needs to be abandoned. In the past, the issue was how the government was going to offset the $335 billion price tag. The Congressional Budget Office (CBO) has rescored the ten year cost estimate based on savings realized in decreased utilization and revised expenditure forecasts.  As a result, the White House’s Office of Management and Budget (OMB)  has now priced the SGR fix at $138 billion. The decrease in this estimated cost has motivated Congress to act. Even the most reluctant democrats say that this is the year to fix the SGR and take advantage of an unexpected 60% discount. http://www.aaos.org/news/aaosnow/jul12/advocacy2.asp
 
2. In-office Exemption (Stark exemption). In their search for additional healthcare dollars some legislators have proposed elimination of this exemption. This exemption allows doctors to provide x-rays and splints in the office. Eliminating this exemption would make office visits much less convenient for patients and require that patients make multiple trips going from the doctor’s office to the x-ray suite, then back to the doctor’s office and then to the brace maker’s shop. Almost every legislator’s office saw the folly in eliminating the in-office exemption but surprisingly few were willing to champion our cause. Fortunately there is presently no bill to eliminate the in-office exemption, so at the moment this is just chatter.

3. IPAB (Independent Payment Advisory Board). This is the Board established by the Patient Protection and Affordable Care Act (PPACA) that will determine how much health providers will be paid. For those of you who have not been following past newsletters the IPAB adjustment will occur after CMS discounts what doctors will get paid based on the RVU system. In other words doctors will be hit with two reductions. Hospitals and Big Pharma are excluded from IPAB reductions until the year 2020. That means any IPAB reduction will only affect doctors and other medical professionals. The good news is that there is no anticipated IPAB reduction this year.  Some of the smaller and less populated states are looking at IPAB as a way of redistributing moneys away from states that receive more healthcare dollars. In a world with fixed costs, redistribution means when a state gets more money another state must get less money.
http://www.aaos.org/news/aaosnow/jul10/advocacy1.asp
 
4.  Medical Device Payments. For those of you who receive payments from medical device companies you should know that effective August 1, 2013 anything valued over $10 is reported to CMS. This includes travel and meals. Know that the payments are cumulative. If you receive something that is less than $10 in value but over the year the combined value reaches $100 your name will be reported to CMS. Research grants that are not assigned to a specific person are not reported. CME grants are not reported. At the moment the moneys reported to CMS are not reported to the IRS.
 
5. Accountable Care Organizations (ACO’s). Jonathan Blum, the deputy administrator and director of CMS, made it clear that patients can receive their care from any participating Medicare provider. Using his terms: ACO’s are layered on top of basic Medicare rights and one of those rights is the ability of Medicare patients to choose their provider. He did not address, however, the difficulties that patients may encounter when accessing care within an ACO, such as disparate EMR systems, differing practice cultures and the manner in which ACOs may affect primary care referrals to specialists.
 
6. Medicare. Mr. Blum made it very clear that CMS has the ability to look at their numbers geographically and by procedure. They know that the average 30 day hospital re-admission rate is 18%. Of most interest was his statement that there is little apparent correlation between Quality of Care and Cost of Care. This may be intuitively obvious, but it is an amazing statement and underscores CMS’s push to decrease the cost of providing care. It should also underscore the recent articles about variations in the cost of medical procedures across the country.
 
Fun Facts: Percent Medicare spending in 2011

a. Hospitals – 40.19%
b. Physicians – 16.29%
c. Prescription Drugs – 13.85%
d. Skilled Nursing – 7.05%
e. Home Health – 4.52%
 
The bottom line is patient access. Ten thousand new patients are enrolled in Medicare each day! More and more senior physicians are choosing to retire early rather than continue practicing. Medical Schools have increased the number of slots by 10-15%, but there are not enough post-graduate slots to accommodate the new graduates. 
 
 
There will be pressure to open more primary care post-graduate slot than subspecialty slots.
 
 
This means that there will be continued pressure on practicing hand surgeons to see more and more patients at what will probably be a lower reimbursement. Medical groups and the government need to work together to find solutions to this burgeoning problem. Nimble groups may be able find ways to provide appropriate care at a decreased reimbursement in the face of increasing patient demand.