IHA Daily Briefing: Nov. 5

IHA Board Focuses on Key 2019 Issues and Challenges
CMS Releases CY 2019 MACRA QPP Final Rule
CMS Releases Medicare ESRD, DME-POS Final Rule
IL Hospitals Recognized for Surgical Patient Care Efforts

IHA Board Focuses on Key 2019 Issues and Challenges
The IHA Board of Trustees engaged in productive, wide-ranging strategic discussions on key issues and challenges facing the Illinois hospital community in 2019 during its day-and-a-half-long retreat and board meeting late last week.

During the retreat, the Board received a status report from the 18-member Hospital Transformation Task Force, chaired by Dr. James Leonard, President & CEO, the Carle Foundation Hospital and a former IHA Board chair. Dr. Leonard and the Board reviewed recommended principles and framework components for the Hospital Transformation Program, including the allocation of a $263 million funding pool and eligibility/participation criteria, scheduled to go into effect on July 1, 2020. IHA will be providing details and seeking feedback from the membership on this critical issue in the coming weeks and months.

The Board focused heavily on the topic of Medicaid managed care, which continues to be a top concern for IHA and members, including IHA’s strategy to address ongoing claims denials and payment delays by working with the Dept. of Healthcare and Family Services, managed care organizations, the General Assembly, and the Governor’s Office.

The Board also looked at the political landscape for 2019 and its strategic implications on issues such as Medicaid managed care, hospital transformation, the state budget, coverage expansion, and a graduated income tax. Board members engaged in a thorough overview of the work of IHA’s Institute for Innovations in Care and Quality to assist members in improving quality and patient safety through seven major service lines and initiatives, including the Great Lakes Partners for Patients Hospital Improvement and Innovation Network (HIIN) and the Midwest Alliance for Patient Safety (MAPS) patient safety organization.

Following the retreat, at its last regularly scheduled meeting of the year, the Board approved IHA’s 2019 budget, with no dues increase. The Association has been able to reduce aggregate dues by $1 million since 2017 primarily due to increased operational and staffing efficiencies that have been implemented in the past two years. The Board also approved the Association’s strategic priorities for 2019, which have been streamlined to enhance the focus on 20 priorities. Top priorities include: addressing Medicaid managed care challenges, avoiding Medicaid cuts, working on Phase 2 of the Hospital Assessment Program, finalizing recommendations on hospital transformation, advancing IHA’s quality improvement/patient safety initiatives and meeting IHA financial targets.


CMS Releases CY 2019 MACRA QPP Final Rule
On Nov. 1, the Centers for Medicare & Medicaid Services (CMS) issued a display version of the final rule and interim final rule addressing Medicare payment changes for the calendar year (CY) 2019 affecting: the Medicare Physician Fee Schedule (PFS), the Medicare Access and CHIP Reauthorization ACT (MACRA) Quality Payment Program (QPP) and other Medicare Part B services.

Medicare PFS highlights:

  • Deferring until CY 2021 the implementation of the proposal to combine the five current Evaluation and Management (E & M) codes into two codes;
  • Implementing a 0.25 percent increase in the Medicare PFS payment rates, in accordance with the Bipartisan Budget Act of 2018; coupled with other adjustments, (e.g., budget neutrality), the conversion factors for medical and anesthesia services are $36.0391 and $22.2730, respectively;
  • Revisions to the PFS Relative Value Units for Work, Practice Expense and Malpractice; and
  • Reimbursing physicians for “virtual check-ins” (brief appointments conducted using telecommunications technology, e.g. telemedicine).

IHA will inform members if CMS issues a Correction Notice, amending any of the PFS payment factors.

Medicare QPP (Year 3) highlights:

  • Expanding the definition of Merit-based Incentive Payment System (MIPS) eligible clinicians to include additional clinical classifications such as physical, occupational and speech therapists, clinical social workers, clinical psychologists, registered dieticians/nutritionists, and audiologists;
  • Adding a third threshold (a maximum of 200 covered professional services) to the low-volume MIPS-exclusion criteria and providing an opt-in policy that offers eligible clinicians who meet or exceed one or two but not all three conditions of the low-volume threshold, the option to participate in MIPS;
  • Providing the option to use facility-based scoring for facility-based clinicians, eliminating the requirement for them to submit their own data separately;
  • Modifying the MIPS Promoting Interoperability (formerly Advancing Care Information) performance category to support greater electronic health record adaptability and patient access while aligning with the new Promoting Interoperability (PI) program requirements for hospitals. Clinicians would be scored on a smaller set of objectives and measures based on their performance in the PI category;
  • Increasing the range of payment incentives and penalties from the current range of + or – 5 percent to + or – 7 percent;
  • Continuing the Small Practice and Complex Patients bonuses, but now categorizing the small practice bonus points within the Quality performance category;
  • Retaining the option to participate in “virtual groups;”
  • Applying the MIPS payment adjustments to only those services paid under the Medicare PFS, excluding certain Part B services;
  • Increasing the weighting of the Cost performance category from the current 10 percent to 15 percent in 2019; the corresponding 5 percent decrease will be applied to the Quality performance category, reducing its weighting from 50 to 45 percent. The weighting of the Improvement Activities and Promoting Interoperability categories remain at 15 and 25 percent, respectively;
  • A 2019 threshold of 30 points required to avoid a payment penalty in 2021;
  • Streamlining the definitions of MIPS comparable measures in both the Advanced Alternative Payment Models (APMs) and Other Payer Advanced APMs criteria;
  • Increasing flexibility for the All-Payer Combination option and Other Payer Advanced APMs for non-Medicare payers allowing them greater opportunities to participate;
  • Updating the Advanced APM Certified EHR Technology (CEHRT) threshold, requiring that at least 75 percent of eligible clinicians in each APM entity use CEHRT;
  • Extending the 8 percent revenue-based nominal amount standard for Advanced APMs through performance year 2024.

Other Part B Services highlights:

  • Site-Neutral Payments for Off-Campus Hospital Outpatient Departments (HOPDs): Maintaining the current Medicare payment rate of 40 percent of the Medicare Outpatient Prospective Payment System rates for non-excepted, off-campus HOPDs;
  • Part B Drug Payments: Reducing the payment add-on for new Part B drugs from 6 percent of the wholesale acquisition cost to 3 percent;
  • Telehealth: Adding the following two additional codes (G0513 and G0514-Prolonged Preventive Services) to the list of Medicare-covered telehealth services, and adding renal dialysis facilities and mobile stroke units for End-Stage Renal Disease (ESRD) patients as telehealth originating sites;
  • Ambulance Services: Extending the additional payments for ambulance services in rural areas through CY 2022, in accordance with provisions of the Bipartisan Budget Act of 2018; and
  • Therapy Caps: Implementing a provision of the Bipartisan Budget Act of 2018 that repeals the Medicare payment “caps” previously applied to outpatient physical, occupational and speech therapy services.

Additional information can be found on the PFS final rule fact sheet and the QPP final rule overview.


CMS Releases Medicare ESRD, DME-POS Final Rule
On Thursday, the Centers for Medicare & Medicaid Services (CMS) published a display version of its annual calendar year (CY) final rule addressing changes in payments for the End-Stage Renal Disease Prospective Payment System (ESRD-PPS) and the Durable Medical Equipment-Prosthetics, Orthotics and Supplies (DME-POS) competitive bidding programs. CMS projects that payments to all renal dialysis facilities in 2019 will increase by approximately 1.6 percent, when compared to payments made in 2018. Estimated payment increases for hospital-based and free-standing facilities are 1.7 percent and 1.6 percent, respectively.

ESRD-PPS highlights include:

  • The final ESRD-PPS base rate is $235.27, an increase of 1.25 percent;
  • This increase is comprised of an Affordable Care Act (ACA)-mandated market basket increase of 1.3 percent and an adjustment for budget neutrality;
  • Updated wage index values; and
  • Changes to the ESRD Quality Incentive Program.

DME-POS highlights include:

  • Adjustments to the DME-POS Competitive Bidding Fee Schedule (CFS) based on more current data;
  • Implementing “lead item” pricing; and
  • Establishing three fee-schedule methodologies based on the area in which the items or services are provided.

A CMS fact sheet is available.


IL Hospitals Recognized for Surgical Patient Care Efforts
Last week, the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) recognized 83 hospitals in its adult program, 12 in Illinois, for achieving meritorious outcomes for surgical patient care in 2017.

The ACS NSQIP recognition program commends a select group of hospitals for achieving a meritorious composite score in either an "All Cases" category or a category which includes only "High Risk" cases. Seventy-one hospitals were recognized on the "All Cases" list and 71 hospitals were recognized on the "High Risk" list. Fifty-eight hospitals were recognized on both the "All Cases" and "High Risk" lists, 12 other hospitals were on just the "All Cases" list, and 13 other hospitals were on the "High Risk" list only—yielding 83 hospitals in total.

The outcome performances related to patient management were in the following eight clinical areas:

  • Mortality;
  • Cardiac: cardiac arrest and myocardial infarction;
  • Pneumonia;
  • Unplanned intubation;
  • Ventilator care exceeding 48 hours;
  • Kidney failure;
  • Surgical site infection (SSI): superficial incisional SSI, deep incisional SSI, and organ/space SSI; and
  • Urinary tract infection.

To be eligible for either list, the hospital must have submitted at least one case in each of the calendar years of 2015, 2016, and 2017, though only performance in calendar year 2017 was evaluated for the 2018 meritorious lists. Risk-adjusted data from the July 2018 ACS NSQIP Semiannual Report, which presents data from the 2017 calendar year, were used to determine which hospitals demonstrated meritorious outcomes. This program measures the actual surgical results 30 days postoperatively as well as risk adjusts patient characteristics to compensate for differences among patient populations and their severity of illness.

The Great Lakes Partners for Patients (GLPP) Hospital Improvement Innovation Network (HIIN), a collaborative between IHA, the Michigan Health and Hospital Association and the Wisconsin Hospital Association, is working to reduce hospital-acquired conditions by 20 percent and readmissions by 12 percent from a 2014 baseline. Of the 318 total GLPP HIIN members, 130 are IHA members.