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2019 promises to be another busy year in healthcare. The 2018 midterm elections shifted the balance of power in Washington as Democrats now hold the gavel in the U.S. House of Representatives, creating a divided Congress with the Republican-held Senate. MGMA has identified the following legislative and regulatory issues critical for medical practices in the coming year. We will keep members apprised of key developments in these areas and their impact on medical practices and will continue to advocate for policies that enable practices to thrive in their mission to furnish high-quality, cost-effective patient care.

1. HHS doubles down on risk

Despite an anemic pipeline of new voluntary Medicare alternative payment models (APMs) trickling out of the Department of Health and Human Services (HHS), Secretary Alex Azar is planning a new approach to accelerate participation in risk-based APMs. Forgoing incremental implementation, the Secretary is expected to unveil new mandatory models in 2019 and to emphasize performance-based risk as a necessary component of any new APM.

MGMA strongly supports voluntary participation in APMs when it makes financial sense for individual practices and disagrees with the Secretary that the way to expedite the move to value-based care is to mandate participation. We will continue to advocate for new opportunities for practices to participate in voluntary APMs and for development of more physician-led models.

2. Regulatory relief from government burdens

It is expected that Congress and the Administration will continue to work toward reducing the regulatory burden on medical practices participating in government healthcare programs. The Centers for Medicare & Medicaid Services’ (CMS’) “Patients Over Paperwork” initiative is one such example. However, this has translated into only modest relief for practices thus far, as 88% of MGMA members polled reported an increase in overall regulatory burden last year. MGMA will continue to make regulatory relief a top advocacy priority in 2019. Keep up with our efforts at mgma.com/regrelief.

3. Kicking back the Stark Law

 As part of the effort to accelerate payment innovation, HHS leaders pledge to revisit antiquated fraud and abuse rules such as the Stark Law and Anti-Kickback Statute. In 2019, watch for proposed rules that expand exceptions and safe harbors to protect value-based arrangements and benefit providers willing to take on performance-based risk. 

While a push to simplify Medicare compliance rules is welcomed, it is likely that congressional intervention will be necessary to achieve meaningful reform. It remains to be seen if Congress will also prioritize this issue in 2019. 

 4. Surprise! Here is a medical bill you didn’t expect

Medical practices can expect to see a push to curb surprise medical bills, including efforts to empower patients and consumers through improved access to healthcare cost information. The sticker shock of surprise hospital bills continues to make headlines and draw bipartisan attention in Congress, making this issue ripe for legislative action in 2019.

5. A spoonful of new regulations to help drug prices go down

With a new Congress and support from the Administration, reducing Medicare drug prices is on the action list for 2019. For physician-administered drugs, one proposal seeks to curb the price of drugs in Part B by tying prices to a new International Price Index, create new private-sector vendors to supply practices with drugs, and set drug administration cost as a flat fee. CMS is also looking to give Part D drug plans greater flexibility to negotiate drug prices in protected classes. 

6. The stakes are higher in MIPS

Implementation of the Merit-based Incentive Payment System (MIPS) continues to ramp up. In 2019, MIPS performance will determine whether clinicians receive a positive or negative payment adjustment of up to 7% on 2021 Medicare reimbursement. Medicare is accelerating cost accountability for MIPS clinicians by increasing the cost component to 15% of the overall MIPS score and introducing episode-based measures. The performance threshold required to avoid a payment penalty also doubles from 15 to 30 points in 2019. With more on the line this year, it is critical that MGMA members prepare their practices for success. Visit mgma.com/macra for helpful resources. 

7. Data interoperability a priority for feds 

The Office of the National Coordinator for Health Information Technology (ONC) is expected to release regulations to meet requirements of the 21st Century Cures Act and facilitate improved data sharing between healthcare entities. ONC will define and seek to discourage “information blocking,” develop a framework to facilitate data movement between heath information exchange entities, and release specifications for the use of apps to foster data exchange between different providers and between providers and patients. The goal of using apps, a component of MIPS and Stage 3 Meaningful Use, is to permit practices to efficiently and securely move administrative and clinical data via their EHR.    

8. Cybersecurity continues to be a top practice concern

Medical practices can be a prime target for phishing and other cybersecurity attacks because they possess valuable information assets (patient clinical and financial data) and often have inadequate cybersecurity protections. HHS’ HIPAA enforcement arm is expected to ramp up audits and fines in 2019. Medical practices should protect both their data and business continuity by completing a comprehensive risk assessment, identifying vulnerable areas of the organization, and taking the steps necessary to mitigate risk. Check out MGMA security resources to prepare your practice this year. 

9. Site-of-service payment differentials remain a target

Policymakers will continue the trend toward site-neutral payments with the goal of equalizing Medicare payments for the same services across clinical sites. Medicare expanded this policy through 2018 rulemaking by phasing-in payment reductions for clinic visits at hospital outpatient departments (HOPDs), including HOPDs excpeted from previous site-neutral payment rules. In addition to saving money for patients and the government, site-neutral payments are viewed as a policy lever for increasing market competition, eliminating the incentive for hospitals to purchase freestanding clinics and leveling the playing field. 

10. “Repeal and replace” is out, “Medicare for all” is in 

This shift in power within Congress will recast the role the federal government plays in healthcare in 2019. With “Medicare for all” a key platform for many progressives during the 2018 primaries, the politicized debate over a single-payer health system shows no signs of slowing down and will likely gain steam ahead of 2020 elections.

Passage of any major health reform bill is highly unlikely anytime soon. However, as presidential contenders begin campaigning for the 2020 primaries, universal healthcare will almost certainly become a point of debate.

After receiving responses from 426 medical practices, MGMA released the findings of the 2018 Regulatory Burden Survey on Tuesday at MGMA18 | The Annual Conference. An overwhelming 86% of respondents reported an increase in regulatory burden over the past 12 months. An even larger percentage (94%) said a reduction in regulatory burden would allow more resources to be allocated toward patient care. 

The Quality Payment Program (QPP) ranked as the most burdensome issue with 88% of respondents finding the QPP to be very or extremely burdensome with little clinical benefit. Furthermore, the percentage of medical practices citing the lack of EHR interoperability as very or extremely burdensome increased 12% since last year. 

MGMA will use data from the survey to continue to educate the Administration and Congress and advocate for reduced regulatory burden on medical group practices. Click here for the full survey results.

Effective January 2018, CMS began recognizing medical group practices that use digital health tools to monitor and analyze patient physiological data. CMS opened the door to reimbursement for remote patient monitoring (RPM) services by unbundling CPT code 99091, which is described as the collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored or transmitted by the patient to a qualified healthcare professional. To be reimbursed for RPM services, practices must meet certain billing requirements, such as obtaining and documenting patient consent and spending a minimum of 30 minutes of time on RPM. Additionally, for patients who are new or have not been seen within one year, providers must initiate RPM services in a face-to-face visit. 

To learn more about RPM services and additional Medicare service updates for the 2018 payment year, download MGMA’s analysis of the 2018 Physician Fee Schedule. 

To determine 2018 MIPS eligibility, physician practice leaders must check the participation status for each clinician by inputting his or her national provider identified (NPI) in the MIPS look-up tool. Previously, CMS mailed letters to practices to inform them of their eligibility status, but the agency does not plan to notify medical groups about their eligibility in 2018. Practices should not rely on historic eligibility determinations, as many physicians and medical groups who were required to participate in MIPS in 2017 will be exempt in 2018 under the expanded low-volume threshold. 

MGMA is engaged in discussions with CMS officials about the limitations of the look-up tool and asked the agency to enhance the tool’s functionality by making available eligibility data for all NPIs who have reassigned their billing rights to the group practice, rather than requiring eligibility data to be accessed on an NPI-by-NPI basis.

MGMA authored a letter to the Centers for Medicare & Medicaid Services (CMS), which was signed by more than 40 physician organizations, urging the agency to shorten the 2018 Merit-based Incentive Payment System (MIPS) quality data reporting period from 365 to 90 days. Despite being held accountable for data tracking and collection as of Jan. 1, 2018, physicians were not informed of basic eligibility information until early April, and the MIPS website has yet to be updated with key 2018 program information, including final quality measures. MGMA and the coalition also recommended CMS maintain a shorter reporting period in future years to reduce administrative burden and ensure physicians have sufficient time to report after receiving MIPS feedback. MGMA has long championed a 90-day reporting period to give group practices greater flexibility to focus their attention on improving patient care, as opposed to reporting for reporting’s sake. 

Participants in the 2018 CMS study on quality reporting burdens will receive full improvement activity credit for the Merit-based Incentive Payment System (MIPS). The study, which will run from April 2018 to March 2019, will examine challenges group practices and clinicians face when collecting and reporting quality data and make recommendations to eliminate burden and improve quality data collection. Study participants must complete surveys, attend a virtual focus group session, and submit at least three MIPS quality measures in 2018. If you are interested in receiving full MIPS improvement activity credit for helping CMS understand quality reporting burdens, submit a study application by April 30.

A new report from the U.S. Department of Health and Human Services Office of Inspector General (OIG) concluded that nearly one-third of claims did not meet Medicare requirements for telehealth services, resulting in improper payments of around $3.7 million in 2014-2015. Most sampled claims were deemed improper because patients were not located at a rural geographic originating site. OIG recommended the Centers for Medicare & Medicaid Services (CMS) conduct periodic post-payment reviews on telehealth claims, underscoring the importance of billing compliance, particularly with respect to originating site rules. MGMA recommends practices use the Medicare telehealth eligibility analyzer to determine payment eligibility based on location and urges groups who bill Medicare for telehealth services to ensure their claims comply with Medicare requirements.

Overnight, Congress passed a sweeping two-year budget deal signed into law by President Trump today. The Bipartisan Budget Act of 2018 (H.R. 1892) is largely a win for physician practices. The law addresses top MGMA priorities, including reducing burden in the MIPS program, eliminating the unelected Medicare cost-cutting board known as the IPAB, and averting a flawed misvalued-code policy that would have resulted in drastic across-the-board payment cuts in 2019 and 2020. MGMA opposed Congress’ use of a .25 reduction to the Medicare physician payment conversion factor next year as a budgetary offset. Its inclusion is a disappointment in an otherwise favorable bill.

Important to medical groups, the bill will: 

• Increase flexibility and reduce burden in the Quality Payment Program;
• Eliminate the unelected Medicare cost-cutting board known as the IPAB;
• Extend the work Geographic Practice Cost Index (GPCI) floor for two years through 2019;
• Permanently repeal the Medicare therapy payment cap;
• Incorporate new flexibility for Accountable Care Organizations;
• Expand coverage for telehealth services; 
• Decrease requirements in the Meaningful Use Program; and
• Extend Children's Health Insurance Program funding for an additional four years through fiscal year 2027.

MGMA will continue to advocate for Medical Group Practices, and we thank you for your continued grassroots efforts.

MGMA recently commented on proposed policy changes to the Medicare Advantage (MA) and Medicare Part D Prescription Drug Programs. The Association applauded a proposal to publish a list of precluded providers rather than proceeding with burdensome new requirements, opposed by MGMA, that eligible professionals enroll in or validly opt out of Medicare by Jan. 1, 2019 to have their Part D drugs and MA services covered by Medicare. The Association also underscored the growing burden imposed by patient records requests from MA plans, which MGMA members report can be several thousand records annually. Read the full letter. 

A short-term spending deal reached late Monday reopened the federal government and provides temporary funding through Feb. 8. The bill also reauthorizes the Children’s Health Insurance Program (CHIP) for six years and delays several Affordable Care Act-related taxes, including the so-called “Cadillac tax,” which imposes a fee on high-cost employer health insurance plans. Notably absent were extensions of several expired Medicare provisions, including the 1.0 work GPCI floor and therapy caps exceptions. Both provisions have bipartisan support in Congress but have been put on hold for other legislative priorities. The Centers for Medicare & Medicaid Services (CMS) is temporarily holding claims affected by therapy caps but if Congress does not act soon, will “release and process claims accordingly.”