PRESIDENT'S MESSAGE

Nothing is Constant but Change

ABOUT THE AUTHOR Dr. Richelle Marasigan is the President of the San Joaquin Medical Society and is a secondgeneration physician who practices family medicine at HT Family Physicians

In medicine, as in life, change is inevitable. The way we practice medicine is always changing, and health care policy is constantly evolving as well. With these changes in practice and policy come changes in the way patients interact with these new changes as well. One example is the unanticipated recent decline in primary care physician (PCP) visits across all populations with the increased accessibility to care due in part to the Affordable Care Act (ACA).

The California Medical Association (CMA) physicians have always been an advocate for health care coverage for all Californians and improved access to care. In 2010, California adopted the Affordable Care Act (ACA) and expanded coverage to more than 5.4 million previously uninsured Californians through the Covered California State Exchange and the Medicaid Expansion for very low-income adults. This led to a drop in rate of uninsured from 17 percent to 7 percent of the total population. During the last few years there have been a number of essential health care reforms brought about by the Affordable Care Act to help reduce financial barriers and focus on prevention and wellness. However, there are still issues that are constantly under debate including: universal coverage, instability in the individual marketplace and rising health care costs.

One particular study showed the number of primary care visits among commercially insured adults decreased 24.2% over 9 years while specialist visits remain largely unchanged. This information is of particular concern due to the fact that consistent primary care has been associated, at a population level, with lower mortality and better health care outcomes as well as less need for emergency care, lower costs of care and better patient satisfaction. There are reasons for the decline in visits including the following:

More patients are seeking medical care online. In the age of telemedicine and the internet patients are technologically savvy and becoming increasingly comfortable with obtaining medical advice online via online consults and internet searches.

Rising deductibles and out-of-pocket costs for care. The decline in PCP visits is the largest in low-income communities. Health care is more difficult to obtain with high out-of-pocket costs, estimated to be increased as much as 32% for problem-based visits and an increase in the percentage of visits that involve a deductible.

Seeking care other places. Patients have also been noted to visit urgent care centers, retail clinics, telemedicine visits, and emergency departments.

Longer appointments that are necessary to address more complex medical problems. The electronic health records have made it possible to provide more preventative services and procedures, like vaccines and wound care.

Physicians now offer more non face-to-face care. Secure messaging and virtual care make it easy to relay followup questions to the PCP and also obtain lab results without having to come in for an appointment. The decline of PCP visits does not necessarily occur with the population of healthy patients who, in all likelihood, are least likely to be affected by missing appointments. Those that are showing the most decline are those with chronic conditions that need to be monitored, such as asthma and diabetes mellitus. The lack of regular visits could lead to serious complications in the future, which would lead to a much greater cost and burden to the system and to the patient. The steady decline in the PCP visit rates across all populations may be the unintended consequence of using cost sharing to reduce unnecessary care in an uncoordinated health care system. Cost-sharing and highdeductibles have been designed to decrease use of unneeded care and require patient investment, however needed care is also being decreased. It will be interesting going forward to see how this will impact health care reform. These are the studies that can help the CMA to pursue their goal to ensure that Californians maintain access to physicians and meaningful, affordable coverage.

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Federal Advocacy Update

What to expect in 2020

While some believe that the 2020 election politics, Presidential impeachment, and escalating tensions with Iran will scuttle Congress’ ability to legislate, there are two bipartisan health care issues extremely important to voters - surprise medical bills and skyrocketing costs of prescription drugs - that might rise above the fray and move to the President’s desk. The question is whether Democrats and Republicans want to compromise to give each other a victory in an important election year.

A BALANCED SOLUTION TO SURPRISE MEDICAL BILLS The early priority will be to protect patients from surprise medical bills. While insurers had the upper hand for the fi rst half of 2019, physicians and hospitals began to tell their story and legislators became concerned that the bills tipped the scales too far in favor of the insurers and did not protect access to physicians and hospitals. CMA effectively educated Congress about the unintended consequences of California’s law and we were key in the fi ght to ensure a more balanced solution that protects patients from surprise bills but establishes a fair process for insurers and physicians to resolve disputes. CMA helped to lead the fi ght with our key California Congressional leaders to stop the Senate HELP and House Energy Commerce (E&C) Committee bills. These bills would have imposed more than 20% payment cuts on non-contracting, as well as contracting physicians, and negatively impacted access to in-network physicians, and on-call physician specialists caring for patients in emergencies. Speaker Pelosi blocked the HELP and E&C bills at the end of session so that the House Ways and Means Committee could weigh-in with a more balanced approach in 2020.

The ways and means committee released a legislative outline at the end of 2019 and they plan to move a full bill in January. The basic framework appears to be an improvement over the other committee bills. It does not set a benchmark payment rate but rather allows it to be determined in an independent dispute resolution (IDR) process and without a monetary threshold for accessing IDR. It also addresses network adequacy. Their proposal would need to be reconciled with the House Energy Commerce/ Senate HELP proposals. CMA will continue to aggressively advocate for a balanced solution that protects physician contracting and access to care. >>

While some believe that the 2020 election politics, Presidential impeachment, and escalating tensions with Iran will scuttle Congress’ ability to legislate, there are two bipartisan health care issues extremely important to voters - surprise medical bills and skyrocketing costs of prescription drugs - that might rise above the fray and move to the President’s desk. The question is whether Democrats and Republicans want to compromise to give each other a victory in an important election year. A BALANCED SOLUTION TO SURPRISE MEDICAL BILLS The early priority will be to protect patients from surprise medical bills. While insurers had the upper hand for the fi rst half of 2019, physicians and hospitals began to tell their story and legislators became concerned that the bills tipped the scales too far in favor of the insurers and did not protect access to physicians and hospitals. CMA effectively educated Congress about the unintended consequences of California’s law and we were key in the fi ght to ensure a more balanced solution that protects patients from surprise bills but establishes a fair process for insurers and physicians to resolve disputes. CMA helped to lead the fi ght with our key California Congressional leaders to stop the Senate HELP and House Energy Commerce (E&C) Committee bills. These bills would have imposed more than 20% payment cuts on non-contracting, as well as contracting physicians, and negatively impacted access to in-network physicians, and on-call physician specialists caring for patients in emergencies. Speaker Pelosi blocked the HELP and E&C bills at the end of session so that the House Ways and Means Committee could weigh-in with a more balanced approach in 2020. THE WAYS AND MEANS COMMITTEE released a legislative outline at the end of 2019 and they plan to move a full bill in January. The basic framework appears to be an improvement over the other committee bills. It does not set a benchmark payment rate but rather allows it to be determined in an independent dispute resolution (IDR) process and without a monetary threshold for accessing IDR. It also addresses network adequacy. Their proposal would need to be reconciled with the House Energy Commerce/Senate HELP proposals. CMA will continue to aggressively advocate for a balanced solution that protects physician contracting and access to care. CURBING PRESCRIPTION DRUG COSTS While Congress faces an even greater challenge on prescription drugs costs, it is a top health care priority for voters. Speaker Pelosi and Democrats will push HR 3 which allows Medicare to negotiate drug prices with the pharmaceutical manufacturers. It focuses on the most expensive and most commonly prescribed drugs and uses 120% of international drug prices as a payment guideline. Republicans have been critical of this approach although President Trump promoted it during the Presidential campaign. Senate Finance Committee leaders have a bipartisan proposal that would limit annual drug price increases to the rate of infl ation. But Senate Republicans are divided These bills would have imposed more than 20% payment cuts on non-contracting, as well as contracting physicians, and negatively impacted access to in-network physicians, and on-call physician specialists caring for patients in emergencies.

Legislature Clarifi es Law Requiring Physicians to Off er Naloxone to Patients

In January, a new law took effect that requires opioid prescribers to also offer prescriptions for opioid-overdose reversal drugs such as naloxone. The California Medical Association (CMA) received numerous calls from physicians regarding the ambiguity of the new requirements.

The California Legislature recently enacted a bill that clarifi es the circumstances under which physicians are required to offer opioid-overdose reversal drugs. Effective September 5, 2019, AB 714 specifi es that the requirement to offer naloxone applies only if the patient is receiving a prescription for an opioid or benzodiazepine medication.

If a patient is receiving such a prescription, the law requires that the prescriber offer naloxone or other similar drug if:

The prescription dosage for the patient is 90 or more morphine milligram equivalents of an opioid medication per day

An opioid medication is prescribed within a year from the date a prescription for benzodiazepine has been dispensed to the patient

The patient presents with an increased risk for opioid overdose, including a patient with a history of opioid overdose, a patient with a history of opioid use disorder, or a patient at risk for returning to a high dose of opioid medication to which the patient is no longer tolerant.

In addition, the law now specifi es that the education physicians must provide patients who are prescribed naloxone or other similar drug must be about opioid overdose prevention and use of the opioid reversal drug. Physicians do not need to provide the education if the patient declines or if the patient has received the education within the past 24 months.

The new law further clarifi es that the requirement to offer naloxone do not apply when the opioid or benzodiazepine medication is being administered in a facility or prescribed to a patient who is terminally ill.

To learn more about prescribing controlled substances, including this new requirement, see CMA health law library document #3201, “Controlled Substances: Prescribing.”

This document, as well as the rest of CMA’s online health law library, is available free to members at cmadocs.org/health-law-library.

Nonmembers can purchase documents for $2 per page.

on this approach. CMA has long-standing policy strongly supporting HR 3. It is a monumental bill that would effectively reduce escalating drug costs for patients. The legislation also produces a Medicare costsavings that could help to permanently fund other process to reduce burdens on physicians and eliminate delays for patients. See CMA talking points attached. Physician Public Service Loan Forgiveness Fix for California and Texas Physicians The fate of CMA’s statutory clarification (HR 4607 Harder D-CA/Cook R-CA) that gives California physicians access to the federal public service loan forgiveness program without being directly employed by a hospital is tied to the massive Higher Education Reauthorization Act which needs to move through Congress soon. CMA is pushing on all fronts to get a fix as soon as possible. These bills would have imposed more than 20% payment cuts on non-contracting, as well as contracting physicians, and negatively impacted access to in-network physicians, and on-call physician specialists caring for patients in emergencies.

important health care programs, such as the teaching health center primary care GME program, and Medicare payment updates to maintain seniors’ access to care.

PUBLIC HEALTH PROTECTIONS The teen e-cigarette epidemic will continue to gain Congressional attention. Unfortunately, there won’t be meaningful action to prevent gun violence.

CMA-SPONSORED BILLS Prior Authorization Reform, Medicare Payment Updates, MACRA Regulatory Relief The Speaker’s grand plan is for a surprise billing solution, the Medicare drug pricing legislation, and an extension for the expiring health care programs to be included in one legislative package and adopted by Congress by May 22, 2020. CMA is working to ensure that the following CMAsponsored issues are included in the package: a Medicare payment update, MACRA regulatory relief, and HR 3107 (Bera, MD D-CA) that reforms the Medicare Advantage prior authorization

REGULATORY ADVOCACY New Medicaid Financing Regulation Reduces the Federal Commitment to States, Providers and Patients

In late November, the Centers for Medicare and Medicaid Services (CMS) released a Medicaid fee-for- service financing rule that dramatically departs from how Republican and Democratic Administrations have allowed states to finance Medicaid programs for decades. In essence, the rule prohibits states from using hospital fees, Medicaid managed care plan taxes, and special funds to draw down federal Medicaid matching funds. At least 34 states employ these funding sources. CMA is assessing how the rule impacts the Prop 56 tobacco tax funding. CMA is concerned that the proposed rule would significantly reduce both state and federal Medicaid (Medi-Cal) funding which would cause substantial state Medicaid budget shortfalls, reduce all provider payments and therefore, participation in the program and exacerbate access to care challenges for patients.

CMA is working with a coalition of California stakeholders, and leading a coalition of state medical associations to oppose the rule.

Knowledge, Quality & Accuracy Matter!

Regulatory Relief and Physician-Led Alternative Payment Models CMA continues to aggressively fi ght for more MACRA regulatory relief and to promote physician-led alternative payment models, such as those in the CMA Medicaid Demonstration project approved but stalled by the Centers for Medicare and Medicaid Services (CMS). California Medicare Geographic Payment Errors – 2020 Claims to be Reconciled In the 2020 Medicare Physician Payment Rule, CMA physician analysts, Edward Bentley, MD and Larry DeGhetaldi, MD found numerous errors in the California geographic payments. While the payment errors they identifi ed in the proposed rule were corrected by the Centers for Medicare and Medicaid Services (CMS), additional mistakes were made by CMS in the fi nal rule. CMS recently acknowledged the errors and concur with the Bentley/DeGhetaldi fi ndings. CMA is working with CMS to make the changes to ensure accurate payments. Noridian (the payment contractor) is holding the affected physician claims while they test and implement the correct payments. If any claims need to be reprocessed, Noridian will begin reprocessing in late January. Physicians do not need to do anything for now. CMA believes this is the least disruptive way to handle the impacted claims. The corrections will impact all California physicians EXCEPT those practicing in Orange, Ventura, Los Angeles, San Francisco, Santa Clara, Alameda, and Contra Costa counties. CMA will provide additional information. The future of health care remains as unsettled and dynamic as ever. March 2020 is the 10th anniversary of the embattled Affordable Care Act (ACA) and there will be historic court cases decided this year that determine its future. Call us (209)491-4960 and let us quote your business needs today!  Revenue Cycle Management  Audits  References available Precisionmedbilling.com  Billing & Collections  Credentialing & Contracting  Practice Management CMA continues to aggressively fi ght for more MACRA regulatory relief and to promote physician-led alternative payment models, such as those in the CMA Medicaid Demonstration project approved but stalled by the Centers for Medicare and Medicaid Services (CMS).