Top Ten Policy Issues for 2016

MGMA has outlined the top 10 physician group practice policy issues to watch in 2016:

1. Election year 2016: Congressional gridlock and regulatory landslide

Campaigns are well underway for the 2016 elections, which will change the political landscape for the next four years and have a significant impact on health policy. Issues such as rising out-of-pocket healthcare costs and the uncertain future of the Affordable Care Act (ACA) have become presidential debate mainstays, and healthcare is expected to continue to be a key determining factor in the upcoming presidential election. Election politics are already impacting Congress and the Administration, and this trend will continue throughout 2016. Expect gridlock in Washington to increase as the November elections get closer, along with a spike in regulatory activity as the Obama Administration nears its end.

2. Massive post-SGR regulations on horizon

Last year, Congress passed landmark legislation entitled the Medicare Access and CHIP Reauthorization Act (MACRA), which repealed the flawed sustainable growth rate formula, removed the annual threat of payment cuts and set in motion a shift toward value-based reimbursement in Medicare. 2016 will be a critical year for MACRA development, as we await several major rules that will govern the program’s implementation and largely sculpt the future of value-based Medicare reimbursement for medical groups. Beginning in 2019, physicians must choose between participating in a single, new program called the Merit-Based Incentive Payment System (MIPS) that will consolidate and replace the Meaningful Use, PQRS and VBPM Programs, or participate in a CMS-approved alternative payment model. As our number one priority, MGMA will continue to advocate for reducing the complexity and administrative burden of these future Medicare quality initiatives.

3. Meaningful Use modifications bring some relief, yet headaches remain

Following MGMA advocacy, the Centers for Medicare & Medicaid Services (CMS) made significant modifications to EHR Incentive (Meaningful Use) Program reporting requirements late last year, several of which will carry into 2016, including reduced thresholds for the patient use of a web portal and secure messaging objectives. However, 2016 still promises to be a challenging year as medical groups navigate these modified Stage 2 requirements and must report for the entire calendar year. MGMA will continue to push back against Stage 3 implementation in favor of incorporating new, simpler EHR criteria into the future MIPS program, which will take effect one year after Stage 3 is scheduled to begin. In the interim, members can prepare their practices for 2016 with MGMA’s overview of critical 2015-2017 program changes.

4. PQRS success remains critical to avoiding Medicare penalties

Eligible professionals (EPs) continue to face a 2% penalty for failing to satisfactorily report PQRS data in 2016. Groups reporting through the group practice reporting option can submit data through a qualified clinical data registry for the first time this year. Previously, this reporting option was only available to EPs reporting individually. As in previous years, CMS made numerous changes to the PQRS measure sets. MGMA reminds members of the importance of verifying all PQRS measures prior to the start of each new reporting year to ensure that practices are reporting on valid measures. For links to the final 2016 PQRS measures list and more information about the PQRS program, visit MGMA’s PQRS homepage.

5. Value-Based Payment Modifier (VBPM) expands its reach

In the 2016 performance year, smaller practices with nine or fewer EPs now face potential 2% penalties based on cost and quality performance, while practices of 10 or more EPs face the same 4% maximum amount of Medicare reimbursement at risk as last year. The VBPM expands to cover certain non-physician practitioners including physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists for the first time. Notably, group practices are excluded from the VBPM altogether if at least one EP in the group participates in one of five existing Medicare alternative payment models. This exclusion forecasts what is likely to emerge in the new Medicare payment system starting in 2019, under which APM participants will be excluded from MIPS. For more information, read MGMA’s VBPM: How to prepare your practice.

6. Primary care outlook: ACA bonus expires, new billable services added

The Medicare Primary Care Incentive Program, which took effect in 2011 under the ACA and paid an annual 10% bonus to primary care practitioners for certain services, sunset at the end of 2015. Beginning in 2016, CMS will pay separately for advance care planning services involving face-to-face discussion of long-term treatment options. The agency also added six Medicare services to the list of approved Medicare telehealth services for 2016. For more information about changes to Medicare services in 2016, download MGMA’s member-exclusive analysis of the final 2016 PFS.

7. More physician data goes public as Medicare ramps up transparency efforts

CMS continues its gradual approach of adding more information to the Physician Compare website, which is aimed at providing the general public with comparative information about healthcare providers. By the end of 2017, all 2016 PQRS quality data will be posted live to the site. MGMA has repeatedly expressed its concerns regarding incorrect and misleading data to the agency, and encourages practices to visit the website to verify the accuracy of current information. Additionally, CMS plans to release the 2015 Open Payments data in June of 2016 following a 45-day physician review and dispute period. This information is intended to highlight the financial relationships between physicians, teaching hospitals and drug and device manufacturers. For more information, read MGMA’s Open Payments: What you need to know.

8. Healthcare mergers: The race to big draws antitrust scrutiny

Four of the five dominant U.S. health insurance plans have proposed mergers, which would dramatically consolidate their market power and create monopolies in certain areas of the country. Both the Federal Trade Commission (FTC) and the Department of Justice are investigating whether the mergers—Aetna’s acquisition of Humana and Anthem’s acquisition of Cigna—violate the federal antitrust laws by reducing payments to providers and thus threatening access to care and increasing patient expenses. The agencies are expected to render a decision in 2016 regarding whether the planned mergers can move forward. In an effort to preserve its bargaining power, the medical community has been consolidating in a well-documented surge of hospitals merging and absorbing physician practices. The FTC has scrutinized this trend in provider consolidation, arguing as it did in the historic St. Luke’s Hospital decision, that these mergers are only permissible if they demonstrate pro-competitive effects, such as increased efficiencies and care coordination. This increased government scrutiny on both sides of the market sets up 2016 as a pivotal turning point for antitrust issues.

9. Brace for increased government scrutiny on data breaches, other HIPAA violations

With patient data increasingly being transferred and stored electronically, medical groups in 2016 will be impacted by heightened concern of identity theft and data breaches. The federal government is expected to take a more aggressive posture regarding enforcement of HIPAA privacy and security requirements, with several federal agencies now focused on compliance. The Office for Civil Rights is expected to ramp up its enforcement activity in 2016, as is the Office of Inspector General. CMS has similarly indicated that an inadequate security risk assessment is the leading cause for failing a Meaningful Use audit. MGMA members are strongly encouraged to conduct a comprehensive risk assessment and complete review of their organization’s policies and procedures. To assist in that process, access MGMA’s member-benefit HIPAA Security Risk Analysis Toolkit. Also see MGMA’s HIPAA Outpatient Practice Policies and Procedures Toolkit.

10. Fraud and abuse: Renewed RAC contracts, overpayment rules, Stark refinements

Government auditing activities continue in 2016 as CMS obtains new contracts for the recovery audit contractor (RAC) program and we await several compliance-related rules, including the final rule addressing the requirement to report and return overpayments within 60 days. Practices will also encounter some changes to Physician Self-Referral (“Stark”) Law that were finalized in the 2016 Medicare Physician Fee Schedule (PFS), including two new exceptions for timeshare arrangements and assistance to employ non-physician practitioners. For a more detailed explanation of what you need to know related to recent Stark changes, download MGMA’s member-benefit memo, which was prepared by our Washington Counsel.


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