Webinar gives tips on improving next eCQM submissions

Health care compliance professionals who are involved in electronic clinical quality measures (eCQM) submissions should prepare now for their 2017 submissions, according to Catherine Gorman Klug RN, MSN, Director, Quality Service Line, for Nuance Communications. In a Health Care Compliance Association (HCCA) webinar titled, “eCQM Lessons Learned and How to Prepare for 2017 Submissions,” Klug warned attendees about hidden dangers, including the lack of experience for eCQM vendors, inaccurate data submissions, and the challenges posed by multiple types of electronic health record (EHR) data files generated from more than one system. She also gave recommendations for reducing risk and listed sample questions for the information technology (IT) department.

CMS requires hospitals to report eight of 15 eCQMs, with data reported for the entire year. According to Klug, the agency expects “one file, per patient, per quarter,” that includes all episodes for care and measures associated with the patient. Many hospitals use vendors to assist with the eCQM submissions, but Klug noted that vendors must have an adequate amount of time to respond to required changes before submission, and that although many vendors support a broad number of eCQMs, they may lack adequate depth of coverage. Hospitals should choose vendors who are experienced in the eCQMs they are reporting. Further, there is no way to validate the files submitted. Possible consequences include an annual payment update reduction, failure to receive the EHR incentive payment, or poor quality scores on CMS’ Hospital Compare site.

To reduce risks, hospitals should ask the core measures vendor to validate files before submission to CMS. They should also review file error reports from the vendor and make corrections before the data is submitted. Aggregated file error reports should also be reviewed to ensure that formatting or data elements don’t result in an inaccurate submission. Klug said that accurate coding is absolutely essential. Therefore, hospital IT departments should be prepared to explain how files are validated prior to submission to ensure accuracy, and if not, what the remediation strategy is. Further, compliance professionals should request a file error report, and any other reports to help understand the data being submitted.

Senate committee works to understand balance between drug innovation, affordability

Drug pricing is a complex system in the United States, and costs vary significantly between different payers and consumers for a number of reasons, including rebates and discounts offered by manufacturers, drug patents, agreements with insurers, and changes from volume- to value-based payment systems. In a hearing before the U.S. Senate Committee on Health, Education, Labor & Pensions titled “The Cost of Prescription Drugs: How the Drug Delivery System Affects What Patients Pay,” experts testified about who pays for prescription drugs, and what that money pays for. In his opening statement, Committee Chair Sen. Lamar Alexander (R-Tenn) explained that this is the first of three planned hearings; the second hearing will consider the full drug delivery process and its associated costs, and the third hearing will focus on ensuring patient access to affordable drugs.

Dan Mendelson, President, Avalere Health, said in his testimony that consumer drug prices are “determined jointly by health system design, pharmaceutical company pricing, and decisions by health plans, pharmacy benefit management (PBM) practices, and other transactions involving distributors and pharmacies along the supply chain.” He explained that total costs often include payments for (1) the product; (2) services provided; (3) shipping; (4) rebates; (5) pharmacy reimbursement; and (6) costs associated with PBMs and third-party payers including reimbursement, share of rebates, and contractual obligations. Mendelson noted that most patients pay cost-sharing for prescription drugs based on list price, not net price, because many rebates are not shared directly with consumers. He added that the patient protections included in the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) led to payers increasing deductibles for consumers in order to offer lower monthly premiums. However, he said, the ACA’s cost-sharing reductions have allowed individuals using the health insurance exchange to pay less for drugs; Mendelson reminded committee members that the American Health Care Act (AHCA) (H.R. 1628) in its current form would repeal cost-sharing reductions.

Allan Coukell, Senior Director of Health Programs, Pew Charitable Trusts, testified that net pharmaceutical spending has increased 42 percent since 2006, but two-thirds of that growth has occurred in the past four years. He listed the following limitations on effective drug pricing competition:

  • monopoly pricing for new drugs;
  • lack of competition for some older drugs;
  • misaligned incentives and incomplete information for stakeholders, including payers, providers and patients at many points in the system, and
  • a historical willingness to cover new therapies without ensuring that their clinical benefits justify the price.

Coukell said that the cost of new medicines is rising, and that is largely responsible for increased drug spending—for example, high-cost specialty products, particularly biologics that are not used by many individuals, account for more than 40 percent of drug spending. He suggested that the 12 years of exclusivity granted to biologic manufacturers, particularly when compared with the five years that drug manufacturers get, is excessive.

Paul Howard, Ph. D., Senior Fellow and Director of Health Policy, Manhattan Institute, also spoke about the challenges involved with specialty medicines, such as those that treat hepatitis C, cystic fibrosis, and rheumatoid arthritis. He said noted that the vast majority of prescription drugs are “highly affordable,” and that the “outlook for innovation has never been brighter,” but mentioned the need for increased competition to reduce waste and ineffective care. Howard recommended that Congress “create incentives that reward providers who use medicines (both generic and branded) and technology to deliver care as efficiently as possible, while also empowering patients with the information they need to identify high quality providers.” He suggested changes to the 340B drug discount program, HHS and FDA coordination on safe harbors for innovative contractual arrangements, and broader Medicare, Medicaid, and patient-empowerment reforms.

Gerard Anderson, Ph.D., Professor of Medicine, Johns Hopkins University School of Medicine, also blamed high costs on specialty drugs and chronic conditions, but added that state and federal health care programs cannot afford to continue paying high prices for these expensive drugs for Medicare and Medicaid recipients, and are being forced to make “life or death decisions.” His recommendations are increasing competition and changing policies to increase access to pharmaceuticals, such as including drugs in bundled payments and accountable care organizations (ACOs) while eliminating rebates from PBMs and prescription drug plans. Anderson also recommended cracking down on abuse of orphan drug designations and allowing branded drugs to move to the generic market sooner. He suggested that negotiating drug prices, specifically by a single designated federal agency using existing authority under 28 U.S.C. §1498, and enacting price-gauging legislation.

Wolters Kluwer Holiday

We will not be posting today or Monday in commemoration of Memorial Day. We will resume our regular posting schedule on Tuesday, May 30.

CPC+ Round 2 taking applications from Louisiana, Nebraska, North Dakota, and Buffalo NY practices

The second round of regions for participation in the Comprehensive Primary Care Plus (CPC+) model, an Advanced Alternative Payment Model (Advanced APM) has been announced by CMS, which is seeking eligible practices in three statewide regions—Louisiana, Nebraska, and North Dakota—and in the Greater Buffalo Region (Erie and Niagara Counties), New York. CPC+ Round 2 will accept applications beginning May 18 through July 13, 2017; accepted practices will be part of an innovative payment structure that rewards value and quality for primary care practices that improve quality, access, and efficiency. The four regions were chosen based on payer alignment and market density.

CPC+ Round 2 is smaller than Round 1, which included 14 regions (see More clinicians able to join Next Generation ACOs, CPC+ for 2018, December 16, 2016), and chosen practices will participate from 2018 through 2022. Practices located in Round 1 regions are not eligible to participate in Round 2, even if they applied for Round 1 and were not accepted or did not apply for Round 1. As part of the announcement for Round 2, CMS also provisionally selected five payer partners to provide additional support in certain Round 1 regions.

CPC+ was developed by the CMS Innovation Center, which was established by section 3021 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). As an Advanced APM, the program is part of the Quality Payment Program (QPP), which is designed to reform Medicare payments to physicians as part of CMS’ implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (P.L. 114-10).