Summer 2017 Rumblings

Page 1

Summer 2017

www.pasg.org

PSG

INSIDE

President’s Message

2017 PSG Annual Meeting

The Train Has Left the Station

Legislative Update

By Ralph D. McKibbin, MD, FACP, FACG, AGAF I recently had discussions with gastroenterologists from several Pennsylvania practices who are still trying to decide how they will handle the reporting for MACRA/MIPS. There can be no delay. The time for indecision has passed. It is not too late to hop aboard. Clinicians who decide not to participate in 2017 are assured a -4% penalty in 2019. The penalty rises to -5% in 2020, -7% in 2021, and -9% in 2022. One year ago, the Centers for Medicare and Medicaid Services (CMS) released the details of how practitioners participating in Medicare will be reimbursed beginning in the year 2019. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) enacted in 2015, repealed the Medicare sustainable growth rate formula (SGR) and created this new reimbursement system. The good news is that in 2017 and 2018 and until December of 2019 there will be a 0.5% annual increase as part of the update for Medicare fee for service providers. The bad news is that beginning in 2017, we must choose how we will be evaluated on performance measures and activities under the merit-based incentive payment system (MIPS) or as part of an advanced alternative payment model (APM). The

adjustments to your payment in 2019 will be based on how you report the data this year. For GI, CMS estimates there are about 12,600 eligible clinicians that would be subject to MIPS. This includes physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists working in gastroenterology practices. 83% of Medicare enrolled gastroenterology clinicians are expected to be MIPS eligible clinicians. In its original estimates, CMS estimated that roughly 62% would be eligible for a bonus but 38% would be subject to payment cuts. This estimate was likely based on earlier Physician Quality Reporting System (PQRS) data. Approximately 15,000 gastroenterologists were eligible to participate in PQRS in 2014. Of those, approximately one-third received a downward PQRS payment adjustment in 2016. The recent relaxation of reporting requirements has created an opportunity to avoid additional payment cuts. These numbers have been revised and an estimated 95.6% of eligible GI participants can avoid a payment cut. You must participate, however, to avoid the cuts. Report as little as one quality measure for one patient to yield three points or one improvement activity and avoid a penalty continued on page 11

Pennsylvania’s Medical Marijuana Law Clinically Integrated Networks Membership Application & Benefits PRESIDENT Ralph D. McKibbin, MD Blair Gastroenterology Associates 810 Valley View Blvd. Altoona, PA 16602-6342 (814) 946-5469 (Phone) ralphmckibbin@hotmail.com PRESIDENT-ELECT Richard E. Moses, DO, JD Phila. Gastroenterology Consultants, Ltd. 700 Cottman Ave., Suite 201 Philadelphia, PA 19111 (215) 742-9900 (Phone) remoses@mosesmedlaw.com SECRETARY Ravi Ghanta, MD Digestive Disease Associates 1011 Reed Ave., Suite 300 Wyomissing, PA 19610 (610) 374-4401 (Phone) rghanta@hotmail.com TREASURER David L. Diehl, MD Geisinger Medical Center Mc21-11, 100 N. Academy Ave. Danville, PA 17822 (570) 271-6439 (Phone) dldiehl@geisinger.edu ADMINISTRATIVE OFFICE ASSOCIATION EXECUTIVE Robbi-Ann M. Cook 777 East Park Drive, P.O. Box 8820 Harrisburg, PA 17105-8820 (717) 558-7750 ext. 1584 gastro@pamedsoc.org

Rumblings Editor Manish Thapar, MD gastro@pamedsoc.org


2 Join PSG at Nemacolin Woodlands Resort for the 2017 Annual Scientific Meeting By: Vinay Chandrasekhara, MD 2017 PSG Program Chair The PSG is planning an educational, family-friendly Annual Scientific Meeting at the Nemacolin Woodlands Resort from September 8-10. We have been fortunate to attract many expert speakers throughout the state of Pennsylvania who will deliver dynamic lectures on a variety of topics related to the field of gastroenterology. Every year, this meeting attracts a large number of GI providers and allows for a social atmosphere to connect with colleagues. I personally enjoy this meeting because it provides me with relevant updates that impact my practice and allows me to keep current with current issues in Pennsylvania. The program will start on Friday, September 8 with cocktails and hors d’oeuvres. The Saturday session begins at 7:45 am and concludes at 12:30 pm and the Sunday session begins at 7:45 am and concludes at noon. Breakfast is provided both mornings prior to the start of the meeting. In keeping with prior meetings, we will have a GI Fellow Jeopardy tournament from 12:30 – 1:30 pm on Saturday with lunch provided. Attendees are encouraged to stay back for the tournament to see how many questions they can answer correctly! In addition to these sessions, we will also hold our annual FIT poster competition, which allows you to review cutting edge research and interact with our energetic trainees within the state. The scientific sessions are designed so that participants may have time to spend exploring the resort with families and other guests. This year in lieu of a formal evening reception, the PSG will be hosting an early evening reception for registered attendees and their guests on Saturday, September 9. This will be held at the Nemacolin Wildlife Academy from 4-6 pm and will feature animal interactions, which will be fun for the entire family.

Join us for a reception at the Wildlife Adventure Center on Saturday

SEPTEMBER 8-10, 2017 Nemacolin Woodlands Resort | Farmington, PA

2017 Program Topics Include • GERD – Pitfalls and Pearls • New Updates in the management of H pylori • Practical Considerations for IBS • Hereditary polyposis syndromes • NASH • Hepatitis C • Organ Allocation in Pennsylvania • Advances In the Management of refractory IBD • Total Pancreatectomy with Auto Islet Cell Transplantation • Endoscopic closure of leaks and perforations • EUS-guided pancreaticobiliary interventions • Telemedicine in Gastroenterology & Hepatology • Cybersecurity for your GI practice • Patient Engagement • And More!

As you can see, this meeting promises to be an educational, fun-filled weekend. We look forward to seeing at this year’s Annual Scientific Meeting in September at the Nemacolin Woodlands Resort!


3 Legislative Update By Richard E. Moses, DO, JD Chair, PSG Legislative Committee The PSG, in cooperation with the Pennsylvania Medical Society (PAMED) and other state societies, continues to track healthcare bill legislation introduced into the Pennsylvania Congress. The PSG has made access to select bills available to members through on the PSG website: www.pasg.org. This list of bills is periodically updated. Since our last update, Pennsylvania Congress has introduced a few healthcare related bills. Some bills we are watching have moved forward in committee(s). We will touch on some of the major bills of interest to date. From the healthcare standpoint, the past few months have not been as active as earlier this year. There continues to be attention to the opioid crisis.

HB 118: An act amending the act of July 19, 1979 (P.L.130, No.48), known as the Health Care Facilities Act, in licensing of healthcare facilities, providing for Emergency Drug and

Alcohol Detoxification Program. This bill is to encourage existing healthcare facilities to convert beds to provide for supervised detoxification.

HB 125: An act providing for the use of certain

credentialing applications and for credentialing requirements for health insurers; imposing penalties; and conferring powers and imposing duties on the Insurance Department. The bill is intended to streamline the credentialing process for providers.

SB 25: An act amending the act of May 22, 1951 (P.L.317,

No.69), known as The Professional Nursing Law, further providing for definitions for the State Board of Nursing, for dietitian-nutritionist license required, for temporary practice permit, for graduates of schools of other states, territories or Dominion of Canada, for certified registered nurse practitioners, for scope of practice for certified registered nurse practitioners, for prescriptive authority for certified registered nurse practitioners, for Drug Review Committee and for professional liability, and providing for the expiration of the State Board of Nursing’s power to license certified registered nurse practitioners. The bill affords Certified Registered Nurse Practitioners independent practice. The bill passed through Committee with a vote of 40-10. The bill next goes to the Professional Licensure Committee. continued on page 9

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4 Risk Management

Pennsylvania’s Medical Marijuana Law By Richard E. Moses, DO, JD

The term “medical marijuana” generally refers to using the whole unprocessed marijuana plant or its basic extracts to treat a disease or symptom. Despite controversy for any number of reasons, a growing number of states are legalizing marijuana for medical use. On April 17, 2016, Governor Wolf signed Pennsylvania’s Senate Bill 3 into law, now known as Act 16 of 2016 (the Act or Medical Marijuana Program), thereby allowing the Pennsylvania Department of Health to begin the process of implementing our state’s Medical Marijuana Program. The implementation of the program is expected to take 18-24 months. The Act made Pennsylvania the 24th state with a comprehensive medical marijuana program. The law will protect registered patients and their physicians from criminal and civil penalties, in addition to creating a safe system for access to medical marijuana. Because there are risks to gastroenterologists if the proper protocol and requirements are not followed, this article discusses the program generally and issues as understood to date. Under Act 16, the term “medical marijuana” refers to marijuana obtained for a certified medical use by a Pennsylvania resident with a serious medical condition and is limited by statute in Pennsylvania to the following forms: pill; oil; topical forms including gels, creams, and ointments; a form medically appropriate for administration by vaporization or nebulization, excluding dry leaf or plant form; tincture; and liquid. Patients under a physician’s care who possess a physician’s certification form will be able to obtain medical marijuana for the treatment of certain defined serious conditions from one of the designated state dispensaries The Pennsylvania Department of Health (DOH) has defined the following as serious medical conditions: Crohn’s Disease, Inflammatory Bowel Disease, Amyotrophic Lateral Sclerosis, Autism, Cancer, damage to the nervous tissue of the spinal cord with objective

neurological indication of intractable spasticity, Epilepsy, Glaucoma, HIV/AIDS, Huntington’s Disease, intractable seizures, Multiple Sclerosis, neuropathies, Parkinson’s Disease, PTSD, severe chronic or intractable pain or neuropathic origin or severe chronic or intractable pain in which conventional therapeutic intervention and opiate therapy is contraindicated or ineffective, and Sickle Cell Disease. The U.S. Department of Justice (DOJ) has the authority to enforce civil and criminal federal laws relating to marijuana possession and use, regardless of state law. Growing, distributing, and/or possession of marijuana in any capacity, except through a federally approved research program, is technically a violation of federal law. No state or local law provides a legal defense to a violation of federal law. However, in light of the current DOJ guidance, it is unlikely that federal authorities will bring civil enforcement actions and criminal investigations and prosecutions against growers/processors, dispensaries, physicians, seriously ill individuals and caregivers as long as they are acting pursuant to the Act. An August 29, 2013 memorandum from the DOJ explains the priorities of federal authorities regarding marijuana possession and use, including state medical marijuana laws. (http://www. health.pa.gov/My%20Health/Diseases%20and%20Conditions/M-P/ MedicalMarijuana/Documents/MEMO.pdf) If you are going to be a certifying physician for medical marijuana for your IBD patients, you must be fully educated on Pennsylvania’s Medical Marijuana Law. For more information and the status of the Act, visit: http://www. health.pa.gov/My%20Health/Diseases%20and%20Conditions/M-P/ MedicalMarijuana/Pages/Physicians.aspx#.WWdu3bpFw2y.


5 Clinically Integrated Networks and Gastroenterologists Dennis Olmstead, MPA As healthcare reform continues its serpentine path, gastroenterologists can be certain of one outcome: increasing pressure to demonstrate value. I use the word “demonstrate” because it’s already known that Pennsylvania gastroenterologists take superb care of their patients: office-based procedures are not only safe but high quality, and the care of persons with chronic conditions often results in long periods of remission. Despite these huge advances in quality, voters are alarmed by rising costs and sensationalized media reports of shoddy care. While professional organized medical associations are working to counter this with patient education campaigns and advocacy, that road is long and the outcome uncertain. In the meantime, politicians and regulators continue to respond as they always do with more rules, more requirements, and more meddling.

Other than giving up their independence and becoming a salaried employee of a hospital, how else can physicians respond? One option is the formation of “clinically integrated networks” (CINs). While this option has been around for years, it has gained new urgency. Briefly, this is a network of independent physicians relying on clinical protocols that create a high degree of interdependence and cooperation to pursue high value healthcare. While care must be taken to avoid market-dominant business practices, the governance of a CIN allows it to be able to negotiate with insurers on behalf of patients to assure that there are demonstrable links between the cost and the quality of medical services. This may involve value or risk based payment arrangements that ultimately leverage on doctors’ professionalism to control the content of care. For gastroenterologists, CINs should have particular salience. Indications and reimbursement for procedures can be “outsourced” to the CIN, which assumes responsibility for their use in a covered population. Care of persons with chronic conditions can be covered by an episode-based continued on page 11

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6 The Benefits of Your PSG Membership Annual Meeting • Free to members. The non-member meeting physician registration fee is $175 and $100 for physicians’ assistants and nurses. (Pending members who have a completed application on file are entitled to free registration.) • The 2017 Annual Meeting will be held September 8-10 at Nemacolin Woodlands Resort in Farmington, PA. • The PSG Annual Scientific Meeting provides an excellent opportunity to earn CME credits.

Interaction with Other State and National Medical Societies • PSG is a member of the DDNC and is represented at their meetings. • PSG maintains a regular dialogue with the AGA, ACG, and ASGE on national issues that impact Pennsylvania gastroenterologists. • PSG has a seat on the PA Medical Society (PAMED) Specialty Leadership Cabinet and a vote at their House of Delegates. Together, PSG and PAMED advocate for gastrointestinal issues on a state level. • The two PA regional governors for ACG are now members of the PSG Board and we will closely collaborate with them on matters of common interest.

Representation by GI Fellows In Training

• Four FITs sit on the PSG Board. • PSG hosts a FIT poster competition at the annual meeting. Those who submit a poster and attend the meeting receive generous stipends.

Reimbursement and Health Care Issues

• PSG routinely corresponds with carriers to convey gastroenterology concerns and clarify questions. • PSG sends a gastroenterology representative to the PA Medicare Carrier Advisory Committee.

PSG Website The PSG Website (www.pasg.org) has many features that benefit our physician members and their patients. Website features include: • membership information – online join/renew opportunities; • meeting information; • legislative and payor relations updates; • fellows in training details; and • electronic copies of the PSG newsletter, Rumblings.

Rumblings Newsletter • • • •

Contains reimbursement news and updates Alerts members of pending issues and problems relative to gastroenterology Informs members of state and federal legislative issues effecting Pennsylvania gastroenterologists Provides helpful information for GI fellows and new practitioners

If you received this issue of Rumblings as a non-member, PSG invites you to consider membership benefits such as free registration for the PSG Annual Scientific Meeting, representation in physician advocacy activities, and opportunities for dialogue with other GI professionals across Pennsylvania. To learn more about the Society, visit www.pasg.org.

Join us today! A membership application is enclosed.


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9 Legislative Update continued from page 3

PA Prescription Drug Monitoring Program (PDMP): As a reminder, the PSG again calls your

attention to recent launching on August 25, 2016 of the Pennsylvania PDMP (PA PMP AWARxE). Pennsylvania physicians who are licensed, registered, or otherwise lawfully authorized to prescribed controlled substances in the course of professional practice or research in Pennsylvania are required by law to register in PA PMP AWARxE. The link is: https://pennsylvania.pmpaware.net/login.

Prior Authorization

UPDATE

Do you have patients whose care has been delayed because of prior authorization decisions from insurance plans? A bill before the Pennsylvania House of Representatives aims to improve response times by increasing transparency and standardization of the prior authorization process. We need your help in supporting House Bill 1293. The PSG, the Pennsylvania Medical Society and our coalition partners are looking for patients to share their story and continue building support for HB 1293. Here are two ways you can help: • Contact your House member through the Pennsylvania Medical Society’s Voter Voice and ask him/her to support House Bill 1293. • Ask your patients who have experienced delays from prior authorization decisions from health plans to share their story on the Pennsylvania Medical Society website at www.pamedsoc.org/shareyourstory.

By law, prescribers must query the system for each patient every time the patient is prescribed a controlled substance (opioid or benzodiazepine) for purposes of establishing a baseline and a thorough medical record. A prescriber shall also query the system if he/she believes or has reason to believe, using sound judgement, that a patient may be abusing or diverting drugs. To make consistent use of the PA PDMP more practicable, prescribers and dispensers may grant access to any delegates under their employment or supervision to query the system on their behalf. Delegates register for their own accounts and enter the email address of their supervising prescriber(s) or pharmacist(s) to request access to the database. As of May 31, 2017, the PA PDMP is requiring new and existing users to verify the last four digits of their Social Security Number. This information is being collected for verification purposes only and is not stored by the PA Department of Health. Further information may be obtained at: http://www.health. pa.gov/Your-Department-of-Health/Offices%20and%20Bureaus/ PaPrescriptionDrugMonitoringProgram/Pages/PDMP-Portal. aspx#.V_qRNCvD-Uk.

Welcome New Members (March 28, 2017 – June 20, 2017) Active Rajih Alkhafaji, MD, Ronald J. Brzana, MD Mitul T. Patel, MD Non-Physician Clinician Robert C. Allison, PA-C

Edmond J. Bouassaf, MD Lance C. DeFrancisco, MD


Take Steps for Crohn’s & Sunday, September 17, 2017 Colitis Central PA 10 am Check In Take Steps for Crohn’s & Colitis Central PA

11 am Walk Starts City Island – Harrisburg, PA

Visit: http://online.ccfa.org/CentralPA To register today! Sunday, September 17, 2017

in For more information, contact Desiree 10AM Heller at Check dheller@crohnscolitisfoundation.org or 484-402-6134 11AM Walk Starts

City Island- Harrisburg PA

http://online.ccfa.org/CentralPA PSG is on Visit: Facebook and Twitter

to register Social media is antoday! important way to network, For more information Heller @ dheller@crohnscolitisfoundation.org or stay current oncontact newsDesiree and new studies, and build your 484-402-6134The world of social media can be overwhelming, reputation and circle of influence. The PSG has social media!

but it is also informative, engaging, and leads to relationship building.

We will be actively tweeting and posting during the 2017 Annual Scientific Meeting so make sure you like our Facebook page www.facebook. com/PaGastroSoc

Follow our Twitter page www.twitter. com/PaGastroSoc prior to the meeting. Our meeting hashtag is #PSG2017 so when you are posting during the meeting, make sure to use that hashtag.


11 President’s Message

Clinically Integrated

continued from page 1

continued from page 5

in 2019. To increase your payments, engaging in 90 days of continuous reporting will qualify for a positive payment bonus.

payment arrangement that reflects care protocols determined by doctors, not bureaucrats. Credentialing is under the control of the CIN, which is ultimately used to develop a high-value network that is patient-friendly. Higher levels of control also mean greater investment in information systems that the CIN can use to achieve a virtuous cycle of continuous improvement that can be shared with politicians, regulators and the public.

You should recognize that even if all providers in a group do not participate, scores will still be attributed to individual providers. Your individual profile will follow you even if you change practices. You should be careful to protect your information. You can review your existing profile at https://www.medicare.gov/ physiciancompare. Resources are available. The American College of Gastroenterology, The American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy have gastroenterology specific materials to guide you in the reporting process. PAMED and our practice management organizations are also geared up to assist us. The easing of reporting requirements has made the reporting for 2017 much simpler. Don’t delay.

The policy implications are enormous. While most accountable care organizations (ACOs) have lost money, physician-led ACOs have had considerable success in controlling costs and increasing quality. While there is less literature on the success of CINs, growing interest in arrangements such as Brandeis is evidence that when physicians are in charge, good things can happen. The Pennsylvania Medical Society is committed to helping physician develop innovative approaches to value-based, patient-centered care. For more information on CINs contact Jaan Sidorov, MD (JSidorov@ patientccc.com) at the Pennsylvania Medical Society’s Care Centered Collaborative.

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