American Hospital Association Federal Update November 11, 2014
Overview Election 2014 Ebola Regulatory Update Physician Fee Schedule Final Rule Outpatient Final Rule Veterans Affairs Regulations Rural Advocacy Agenda
Beyond Election Day Louisiana Run-Off December 6 Dan Cassidy (R) Mary Landrieu (D)
Beyond Election Day Alaska Dan Sullivan (R) Mark Begich (D)
Six-year itch? 1950 Truman 1958 Eisenhower 1986 Reagan 1998 Clinton 2006 Bush 2014 Obama House -28-48 -5 +5-30 -12 Senate -6-13 -8 0-6 -7
Beyond 2014 2014 (36) Democrats: 21 Republicans: 15 2016 (34) Democrats: 10 Republicans: 24 2018 (33) Democrats: 28 Republicans: 8
Senate Leadership John Cornyn (R-TX) John Thune (R-SD)
Senate Committees Finance Orrin Hatch (R-UT) HELP Lamar Alexander (R-TN) Budget Jeff Sessions (R-AL) Mike Enzi (R-WY) Appropriations Thad Cochran (R-MS)
House of Representatives Leadership no expected changes Committees Ways and Means Paul Ryan (R-WI) Kevin Brady (R-TX) Budget Tom Price (R-GA) Energy and Commerce Anna Eshoo (D-CA) Frank Pallone (D-NJ)
Congressional Schedule
Lame Duck Prospects Appropriations Appointments (while under Democratic control) Ebola
2015-2016 Outlook GOP sets congressional agenda: Still need 60 But, only need 50 for budget mandating reconciliation process (platform for reforms?) Legacy vs. gridlock
2015-2016 Outlook GOP sets congressional agenda: Still need 60 But, only need 50 for budget mandating reconciliation process (platform for reforms?) Legacy vs. gridlock Appointments Oversight hearings
2015-2016 Outlook GOP Health Care Priorities No consensus Incremental: Repeal medical device tax Change definition of full-time employee Has Democrat support Delay employer mandate Repeal individual mandate Repeal restrictions on physician-owned hospitals
2015-2016 Outlook GOP Health Care Priorities No consensus Incremental: Repeal medical device tax Change definition of full-time employee Has Democrat support Delay employer mandate Repeal individual mandate Repeal restrictions on physician-owned hospitals Comprehensive repeal of ACA GOP alternative
2015-2016 Outlook GOP Health Care Priorities No consensus Incremental: Repeal medical device tax Change definition of full-time employee Has Democrat support Delay employer mandate Repeal individual mandate Repeal restrictions on physician-owned hospitals Comprehensive repeal of ACA GOP alternative Implications of presidential politics
2015-2016 Outlook Likely Scenario Message repeal and replace Legislative incremental
Fiscal Cliffs and Deadlines December 11, 2014 - Federal budget appropriations December 31, 2014 Medicaid physician cliff April 1, 2015 Medicare physician cliff Debt Limit
Need for budget predictability Prospective coding offsets ($8 billion) Site neutral payment policies E&M code/hopd ($10 billion) 66 additional APCs procedures ($9 billion) 12 procedures performed in ASCs ($6 billion) Hospital bad-debt reductions ($20 billion) (Assistance for low income Medicare beneficiaries) GME reductions ($10 billion) CAH: payment reductions and qualification criteria ($2 billion) Post acute care ($70 billion) IPAB expansion ($4.1+ billion) Medicaid: 340B State provider assessments ($22 billion)
Overview Election 2014 Ebola Regulatory Update Physician Fee Schedule Final Rule Outpatient Final Rule Veterans Affairs Regulations Rural Advocacy Agenda
Ebola
Coordination
Helping Hospitals Respond AHA Ebola Preparedness Page www.aha.org/ebola
Helping Hospitals Respond AHA Ebola Preparedness Page www.aha.org/ebola
Overview Election 2014 Ebola Regulatory Update Physician Fee Schedule Final Rule Outpatient Final Rule Veterans Affairs Regulations Rural Advocacy Agenda
PFS Final Rule CY 2015 Transitions the Ambulance Fee Schedule to the new OMB CBSA and RUCA delineations for the purpose of payment calculations Adds several codes to the telehealth list: Psychotherapy/analysis Prolonged E & M; and Annual wellness visit Removes employment requirements for services furnished "incident to" RHC and FQHC visits, effectively allowing them to contract, rather than employ, non-practitioner staff
PFS Final Rule CY 2015 Includes the Interim Final Rule applying to the Medicare EHR incentive program CMS provides certain eligible hospitals and physicians through Nov. 30 to apply for a hardship exception to avoid penalties in FY 2015 (hospitals) and CY 2015 (physicians) Exception only available for those that: Had not attested to meaningful use before FY/CY 2014; Were unable to fully implement 2014 Edition Certified EHR technology; and Could have attested under the flexibility options recently provided by CMS
OPPS Final Rule CY 2015 Outpatient payment update of 2.2% For all services paid under the OPPS, SCH payments continue at 7.1% A single, "packaged payment" for ancillary services when they support a primary service Implementation of Comprehensive APCs Data collection on site-of-service for off-campus provider-based departments Outpatient PPS wage index will be based on the most recent labor market areas that were issued by OMB A physician certification for inpatient hospital admissions only required for long and outlier cases
VA Regulation Interim Final Rule implementing the Veterans Access, Choice, and Accountability Act of 2014 Establishes the Veterans Choice Program that allows qualifying veterans to elect to receive hospital care and medical services from non-va entities and providers Key provisions include: Contracting between VA and non-va providers Payment rate Prompt payment Effective Nov. 4 or Dec. 5
Overview Election 2014 Ebola Regulatory Update Physician Fee Schedule Final Rule Outpatient Final Rule Veterans Affairs Regulations Rural Advocacy Agenda
Rural Advocacy Agenda Maintaining financial viability of rural hospitals R-HoPE Act Medicare Extender Priorities Improving federal regulatory requirements for rural health care facilities 96-hour rule Direct supervision Protecting special rural payment programs 340B Rural hospital threats OIG reports
R-HoPE Act (S.2359) Sponsors Senate John Barrasso (R-WY) Al Franken (D-MN) Tom Harkin (D-IA) Pat Roberts (R-KS) Provisions Extend the outpatient hold harmless Extend and increase the low-volume adjustment Extend rural ambulance payments Extend the billing for the technical component of pathology services Address 96 hour condition of payment Implement enforcement delay of direct supervision
Medicare Extender Priorities Reauthorization of the MDH program Extension of the current Low-Volume Hospital Adjustment Outpatient therapy cap Ambulance add-ons RCH demonstration program Rural Payments Eliminated By Congress: Outpatient hold harmless Section 508 Extension of payment for the technical component of certain physician pathology services
96-Hour Rule Two existing statutory conditions for CAHs Condition of Participation CAHs must provide acute inpatient care for a period that does not exceed, on an annual average basis, 96 hours per patient Condition of Payment a physician must certify that a beneficiary may reasonably be expected to be discharged or transferred to a hospital within 96 hours after admission
96-Hour Rule CMS has not historically enforced the condition of payment, however, if it is enforced, CAHs will no longer receive Medicare payment for medical services requiring a stay longer than 96 hours CMS issued new guidance, Jan. 30, 2014 setting forth additional information regarding this requirement Changes in IPPS final rule for FY 2015
96-Hour Rule Critical Access Hospital Relief Act AHA is working with concerned lawmakers to pass legislation that would remove the 96-hour piece of the physician certification requirement as a condition of payment.
Direct Supervision CMS ended the direct supervision enforcement moratorium for CAHs and small rural hospitals, effective Jan. 1, 2014 CMS will require a minimum of direct supervision for all outpatient therapeutic services furnished in hospitals and CAHs Hospital Outpatient Payment (HOP) Panel CMS encourages hospitals to continue to request changes in supervision levels through the HOP Panel process Since 2012, when the HOP Panel was established, CMS has reduced the level of supervision for 56 outpatient therapeutic services Summary of March & August Meetings 1
Direct Supervision Sens. Moran (R-KS)/Tester (D-MT) Reps. Noem (R-SD)/Peterson(D-MN) Advisory panel to set up an exceptions process for those services that require higher level of supervision Default standard of general supervision Special rule for CAHs based upon their Medicare CoPs Revise the definition of direct supervision to allow for telemedicine, telephone or other technology Hold harmless from civil or criminal action back to 2001
Recent Legislative Activity H.R. 4067 To provide for the extension of the enforcement instruction on supervision requirements for outpatient therapeutic services in critical access and small rural hospitals through 2014 (Rep. Lynn Jenkins - Energy and Commerce Committee)
340B Drug Program
http://www.aha.org/advocacyissues/alliances/340b.shtml
New Challenges 340B Mega-rule Hospital eligibility Patient definition Contract pharmacy Drug diversion GPO exclusion www.aha.org
Rural Hospital Threats 2011 CBO options document $62B in savings if eliminate CAH, MDH, SCH FY2015 Pres. Obama Budget Reduce CAHs payment of 101% of costs to 100% ($-1.69B) Prohibit CAH designation for those CAHs that are less then 10 miles from nearest hospital ($-720M) 2014 Omnibus asks CMS for 10 mile list
OIG Reports Reports on CAHs August 2013 Recommended that CMS seek legislative authority to remove necessary provider CAHs permanent exemption from the distance requirement, thus allowing CMS to reassess these CAHs September 2014 Recommended that CMS seek legislative authority to change formula for calculating beneficiary costs for outpatient services Upcoming report Payment policy for swing bed services Report on RHCs September 2014 -- Recommended that CMS terminate RHCs that no longer meet location criteria and issue regulations to ensure that RHCs determined to be essential providers remain certified as RHCs