Published 2/1/2016

Second Look—Advocacy

Quality measures
CMS has released a draft CMS Quality Measure Development Plan (MDP) for comment. The MDP supports the transition to a new Merit-based Incentive Payment System (MIPS) and alternative payment models (APMs) for providers. The MDP arises from the passage earlier this year of the Medicare Access and CHIP Reauthorization Act of 2015, which repealed the Medicare sustainable growth rate formula, replacing it with MIPS and APMs, and phasing out the Physician Quality Reporting System, the Value-based Payment Modifier, and Meaningful Use. According to CMS, the MDP will address gaps in the quality measures identified in those programs, meet the statute's requirements, and serve as a template for developing clinical quality measures to support MIPS and APMs. As stated in the MDP, the agency will apply a positive, negative, or neutral payment adjustment to each MIPS-eligible provider based on a composite performance score to include quality, resource use, clinical practice improvement activities, and meaningful use of EHR technology beginning in 2019. The American Medical Association has expressed concern over the possibility that physicians will be penalized for missing a single requirement or for unavoidable technological glitches. CMS is soliciting stakeholder comments on the draft plan through March 1, 2016; the final MDP will be posted to the CMS website by May 1, 2016 and updated annually or as otherwise appropriate.

Opioid prescribing guideline
The U.S. Centers for Disease Control and Prevention (CDC) released a draft CDC Guideline for Prescribing Opioids for Chronic Pain. Recommendations in the guideline include but are not limited to:

  • Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Providers should only consider adding opioid therapy if expected benefits for both pain and function are anticipated to outweigh risks to the patient.
  • Before starting and periodically during opioid therapy, providers should discuss with patients known risks and realistic benefits of opioid therapy and patient and provider responsibilities for managing therapy.
  • Providers should review the patient's history of controlled substance prescriptions using state prescription drug monitoring program data to determine whether the patient is receiving high opioid dosages or dangerous combinations that put him or her at high risk for overdose.
  • When prescribing opioids for chronic pain, providers should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.

"Vertical consolidation"
A report by the Government Accountability Office (GAO) found that "vertical consolidation"—an arrangement in which a hospital acquires a physician practice and/or has physicians on salary—is linked with more evaluation and management (E/M) visits occurring in a hospital setting. The trend leads to increased costs for Medicare, which pays providers at a higher rate when the same service is performed in a hospital outpatient department (HOPD) compared to a physician's office. Between 2007 and 2013, the number of vertically consolidated hospitals grew from about 1,400 to 1,700, and the number of vertically consolidated physicians nearly doubled, from 96,000 to 182,000. In 2013, the Medicare payment for a midlevel E/M visit was $51 higher when it took place in a hospital. "Such excess payments are inconsistent with Medicare's role as an efficient purchaser of health care," the GAO stated. However, the agency noted, the Centers for Medicare & Medicaid Services "lacks the statutory authority to equalize total payment rates between HOPDs and physician offices and achieve Medicare savings."

These items originally appeared in AAOS Headline News Now, a thrice-weekly enewsletter that keeps AAOS members up to date on clinical, socioeconomic, and political issues, with links to more detailed information.