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As the COVID-19 Public Health Emergency (PHE) continues to evolve, PAI is working to share feedback with members of Congress and federal regulators on issues that physicians and patients are facing. PAI and Healthsperien will continue to provide real-time policy updates and analysis on issues of interest to physicians. Please visit PAI’s COVID-19 Resources page and the Healthsperien COVID-19 Resource Updates page for up-to-date information.

Provider Relief Fund and PPP Updates

As a reminder, on June 9, the U.S. Department of Health and Human Services (HHS) announced that it is allocating $15 billion in relief funds to Medicaid and CHIP physicians and providers. The deadline to apply for these funds is July 20. To be eligible for this funding, physicians must not have received payments from the first $50 billion Provider Relief Fund General Distribution (this also includes physicians who were eligible for the General Distribution but ultimately rejected their payments), and either have directly billed their state Medicaid/CHIP programs or Medicaid managed care plans for healthcare-related services between January 1, 2018 and May 31, 2020.

The new distribution requires the use of a new portal and a new application. Physicians will have to set up an Optum ID. Please see the Medicaid Distribution Instructions for additional details.

HHS has provided several new updates to existing FAQ guidance for the Provider Relief Fund. The Department has added several new clarifying questions regarding general Relief Fund information, as well as General, Medicaid, and Targeted Distribution FAQs. 

The Small Business Administration has also released updated FAQ guidance for PPP loan recipients. The updated guidance verifies that loans made on or after June 5 will have a five-year maturity date (compared to the two-year maturity date applicable to loans outlaid prior to this date). These changes are pursuant to PPP loan requirement changes made effective through the Paycheck Protection Program Flexibility Act of 2020. More information on updates made to PPP loan requirements and the loan forgiveness process can be found in PAI’s June 2020 COVID-19 Regulatory Update.

CMS Releases 2018 Quality Payment Program Results

On July 7, CMS released the 2018 Quality Payment Program Experience Report. The report covers various data points regarding participation and performance in the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs) tracks of the QPP during the 2018 performance period. Key takeaways from the report’s findings are summarized below.

Small Practice and Rural Practice Performance in MIPS
While the participation rate of small practices (15 or fewer eligible clinicians) increased from 81 percent in 2017 to 88 percent in 2018, CMS notes that this increase could be due to the increase in the low-volume thresholds in 2018.

Additionally, only six percent of all participants participated as individuals, and they had lower mean and median final scores compared to those who participated as part of a group or MIPS APM.

MIPS Payment Adjustments
Eighty-four percent of eligible clinicians in 2018 achieved an exceptional performance score (70-100 points), and 13.39 percent achieved a positive performance score (15.01-69.99 points).

Since payment adjustments within MIPS are subject to budget neutrality rules, the maximum positive payment adjustment for the 2018 performance period (2020 payment period) that exceptional performers will receive is only 1.68 percent. Additionally, those who received a positive performance score will only receive a maximum adjustment of 0.20 percent. The minimal positive payment adjustment experienced (range of 0.20%-1.68%) still indicates that there is marginal reward for participation in the program.

2.01 percent of eligible clinicians received a negative adjustment. The maximum negative payment adjustment experienced was -5.00 percent.

Medicare Shared Savings Program (MSSP) Participation Drives Results
About 360,000 eligible clinicians participated in MIPS through an APM – this excludes those with QP and PQ status. The large majority of these eligible clinicians participated in Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs).

These participants seem to have driven the performance in the quality category, as CMS Web Interface (which is required under MSSP) was the most common submission method for quality measures.

Challenging Quality Measures
Excluding the CMS Web Interface measures, of the top 10 quality category measures that contributed to participants’ quality category score, the most challenging measures for participants seem to be:

  • All-Cause Hospital Readmission – 15.29% average performance rate
  • Diabetes: Hemoglobin A1c Poor Control – 39.3% average performance rate
  • Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents – 48.61% average performance rate

Secretary Azar Comments on Permanency of Telehealth Flexibilities

On July 9, The Hill held a virtual event titled “Health Reimagined: The Future of Healthcare.” The event featured several notable speakers, including HHS Secretary Alex Azar. In his discussion, Secretary Azar stated that telehealth, alongside other virtual healthcare services, “are now an embedded part of the U.S. healthcare system.” He furthermore stated that the administration will do “everything they can through regulation to keep the gains made that keep the patient and doctor relationship, as well as the patient and hospital relationship, in the center.” He also states that the administration will work with Congress to ensure that flexibilities limited by statutory law will be addressed promptly by the U.S. legislature. The Secretary did not provide any further detail as to what specific flexibilities the administration plans to prioritize. 

The Secretary’s remarks come as the Office of Management and Budget continue to hold the CY 2021 Medicare physician fee schedule proposed rule, as well as the CY 2021 hospital outpatient PPS proposed rule, which are expected to potentially address many of the current flexibilities for telehealth, remote patient monitoring (RPM), and communication-technology based services (CTBS), that can be extended through regulatory pathways.

Secretary Azar also took time to discuss the administration’s stance on healthcare reform, in light of the imminent Supreme Court decision that will decide the future of the Affordable Care Act. Notably, while the Secretary confirmed the administration is dedicated to ensuring that affordable health financing (and insurance) is available to individuals with pre-existing conditions, he also alluded to the administration’s negative stance on community rating and stated that healthy individuals should not be paying “unaffordable high premiums.”

Court Upholds Hospital Price Transparency Rule

On June 23, the U.S. District Court for the District of Columbia issued a ruling in The American Hospital Association, et al v. Azar, the case regarding CMS's Final Rule, CY 2020 Hospital Outpatient Prospective Payment System (OPPS) Policy Changes: Hospital Price Transparency Requirements. The Final Rule requires hospitals to annually update and publicly disclose a list of their standard charges for provided hospital items and services, which would include gross charges; payer-specific negotiated charges; de-identified minimum and maximum negotiated charges; and discounted cash prices. The Final Rule also mandates hospitals to publicly disclose negotiated charges and other information for 300 “shoppable” services.

The Plaintiffs’ case challenged how CMS defined the standard charges that a hospital must list publicly and contended that the final rule exceeds the agency’s statutory authority, violates the First Amendment, and is arbitrary and capricious under the Administrative Procedure Act. The judge ultimately ruled that, “It is undisputed that…the amounts paid to hospitals for items and services differ across those various patient groups. The agency’s decision to define ‘standard charges’ based on the different patient groups is thus a reasonable construction that accounts for the “peculiar dynamics of the healthcare industry.” The American Hospital Association confirmed it will appeal this ruling.

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