Americans in favor of end-of-life discussions, split on ACA

Americans overwhelmingly believe that Medicare should cover end-of-life advance planning discussions with physicians, although few have actually engaged in such discussions, according to a September 2015 Kaiser Family Foundation (KFF) poll. However, they remain split in their overall views of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), with 41 percent expressing favorable views and 45 percent expressing unfavorable views. Americans also differ as to their support of various, specific provisions. For example, although they tend to oppose certain ACA-imposed taxes, their views on these taxes are less firm than their views on other aspects of the law. The poll is the latest of KFF’s monthly health tracking polls, which survey Americans on their views of the U.S. health care system overall, and the ACA, in particular.

End-of-life care

In its July 15, 2015, physician fee schedule (PFS) proposed rule, CMS included provisions for Medicare coverage of advance care planning (ACP) discussions with physicians through the use of two new Current Procedural Terminology (CPT) codes (see Proposed rule, 80 FR 41686). The ACA originally encouraged such discussions, and CMS intended to include coverage for APT discussions as part of annual wellness visits, but the regulation was never implemented, as opponents raised discussions of “death panels” (see Medicare wellness coverage no longer includes advance care planning, Health Law Daily, January 11, 2011). According to the KFF poll, conducted from September 17 to September 23, 2015, 89 percent of respondents believed that doctors should engage in APT discussions and 81 percent believed that Medicare should cover such discussions. However, only 17 percent said they had actually engaged in APT discussions, including only 27 percent of seniors and 31 percent of people with debilitating disabilities or chronic conditions. Respondents were significantly more comfortable having APT discussion with spouses, with 83 percent claiming they would be “very comfortable” discussing APT with spouses, as opposed to 57 percent with physicians or other health care providers.


The public overall supported various ACA transparency provisions requiring insurance companies to make certain information publicly available. Eighty-four percent are in favor of the release of data on the availability of in-network doctors and hospitals, 83 percent would like to see data on how often claims are denied or appealed, 82 percent believe the public should know how quickly the company pays claims, and 73 percent think insurance companies should release data on what a typical person pays to see a doctor not in the plan network. Roughly 70 percent say they would be at least somewhat likely to use these types of information when seeking insurance.


Overall, respondents opposed the Cadillac and medical device taxes authorized by the ACA. Section 9001 of the ACA created the Cadillac tax, which imposes a tax beginning in 2018 on higher-cost employer-sponsored health plans. Only 37 percent of respondents had followed Cadillac tax news in the past month, but 60 percent opposed the tax. However, many were easily swayed by arguments for or against the tax. Twenty-seven percent of those who opposed the tax changed their minds to favor the tax after being told that it could lower health care costs, bringing overall support to 55 percent. Fifteen percent of those in favor of the tax switched to oppose the tax after being told that it would likely cause employees to pay more in out-of-pocket expenses.

Fifty-seven percent of respondents opposed the medical device tax imposed by ACA section 9009, which imposes a 2.3 percent excise tax on medical device manufacturers.

SGR out, MIPS in—but how? CMS requesting input on implementation

As CMS figures out how to implement the new merit-based incentive payment system (MIPS) that replaces the sustainable growth rate (SGR) methodology, it is requesting information from the industry about alternative payment methods and incentive payments. CMS particularly seeks information on such topics as identifiers for MIPS eligible professionals (EPs), the quality performance category, data quality assurances, and the use of electronic health records (EHRs). The request will be published in the Federal Register on October 1, 2015, and comments must be received within 30 days to be assured consideration.


For the first two years of the program, the MIPS will apply to the following as EPs: physicians, physician assistants (PAs), nurse practitioners (NPs), clinical nurse specialists (CNSs), certified registered nurse anesthetists (CRNAs), and professional groups. Starting in the third year, the HHS secretary has the discretion to specify additional EPs. CMS currently uses Tax Identification Numbers (TINs) and National Provider Identifiers (NPIs) or a combination of the two to identify EPs in other programs. The agency requests input on which identifiers to use for MIPS, including potentially creating a distinct MIPS identifier. It also requests comments on parameters for virtual MIPS EP groups.

Quality measures

MIPS EPs may choose from a list of quality measures for assessments. CMS plans to use other quality programs to shape the performance category, but requests input about using physician quality reporting system (PQRS) reporting mechanisms for MIPS. The questions also address the application of the quality performance category to MIPS EPs in specialties. In a similar vein, CMS also wants to address how it should test for data accuracy and integrity, as data quality is vital to properly calculating the MIPS composite score.


A quarter of the MIPS composite performance score will be based on meaningful use of certified EHR technology. CMS is currently considering the methodology for assessing meaningful use, weighing methods such as basing the performance score solely on full achievement of meaningful use versus using a tiered methodology. The request for information notes that comments are only sought on meaningful use under MIPS, not the Medicare and Medicaid EHR Incentive Program.

CMS announces Enhanced MTM model, hopes to bring efficiency to Part D

The CMS Center for Medicare and Medicaid Innovation (CMMI) announced a model designed to test strategies to improve the use of medication among Medicare Part D beneficiaries. The new CMMI program—The Part D Enhanced Medication Therapy Management (Enhanced MTM) model—will attempt to more effectively use MTM, to improve health care outcomes and quality. According to the CMS announcement, enhanced MTM also has the potential to lower overall health care costs.


Section 3021 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) established the CMMI to test innovative health care payment and service delivery models. A primary goal of the CMMI was to improve the quality of care and reduce Medicare, Medicaid, and CHIP expenditures. The ACA appropriated $10 billion to support Innovation Center activities initiated from FY 2011 to FY 2019.

Enhanced MTM model

The new model will evaluate whether Medicare Prescription Drug Plans (PDPs) that are given additional incentives and flexibilities to innovate will be better able to meet the goals of the MTM programs. CMS wants to test whether changes to PDPs will help meet the MTM goals of: “(1)improving compliance with medication protocols, including high-cost drugs, ensuring that beneficiaries get the medications they need, and they are used properly; (2) reducing medication-related problems, such as duplicative or harmful prescription drugs, or suboptimal treatments; (3) increasing patients’ knowledge of their medications to better achieve their or their prescribers’ goals of therapy; and (4) improving communication among prescribers, pharmacists, caregivers and patients.”


The Enhanced MTM model will consist of a five-year performance period beginning on January 1, 2017. CMS plans to test the model in five regions: Region 7 (Virginia), Region 11 (Florida), Region 21 (Louisiana), Region 25 (Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota, Wyoming), and Region 28 (Arizona). Eligible PDPs in each of those regions can apply to vary the intensity and types of MTM interventions they offer. CMS will waive certain MTM program requirements for participating plans during the model’s performance period. Participating plans will be expected to work closely with their network pharmacy providers and local prescribers to identify enrollees with “medication usage that has caused, or is likely to cause, adverse outcomes and/or significant non-drug program costs.” Plans will be expected to offer targeted assistance to those beneficiaries in order to optimize medication use.

Kusserow on Compliance: ICD-10 final countdown: even CMS not sure how its systems will work

Halloween may not be the only scary day in the month as it is now a matter of a few days until the health care sector changes over from ICD-9 to ICD-10. The entire health care section is on edge as to whether, after the transition, their systems will work properly. Failure to properly prepare for the transition will definitely result in negative impact on revenue streams. It is no wonder, therefore, that great concern exists on how this transition will work. In a recently released report, the Government Accountability Office (GAO) has warned that even CMS should be among those concerned, as unanticipated CMS system errors could disrupt claims processing. The transition will have a major impact on clinical management systems and functions, including: coverage and payment determinations, medical review policies, plan structures, statistical reporting, actuarial projections, fraud and abuse monitoring, and quality measurement.

GAO report

The GAO report on CMS preparedness for the transition found despite the fact CMS has engaged in extensive testing that supports transitions to ICD-10, concerns about how well the agency will function once the transition takes place on October 1, 2015, remain. The report concluded that although CMS has continually worked to update, test, and validate their systems and it has made detailed plans for contingencies, there is no guarantee against systems errors. How those errors may affect the ability to properly process claims cannot be determined until actual ICD-10 code processing begins.

The differences between ICD-9 and 10 are significant. While there are approximately 15,000 ICD-9 diagnosis codes, there are approximately 70,000 ICD-10 diagnosis codes. Likewise, there are approximately 4,000 ICD-9 procedure codes versus 72,000 ICD-10 procedural codes. The difference between the ninth and tenth versions of the codes is the terminology and disease classifications, which are to be updated so that they are consistent with new technology and current clinical practice. Other differences include the addition of new concept, such as expansion of postoperative codes to distinguish between intraoperative and post-procedure complications, and the designation of trimester for pregnancy codes.

GAO detailed CMS work to date, including processing systems updates as well as testing and validation of system changes and described the technical support that CMS will be offering. It noted that CMS began updating its systems in early 2010, as part of an established change management process for releasing system updates on a quarterly basis, and, by October 2013, had completed actions to modify its systems to process the new data. The costs are estimated to be approximately $116 million for developing, testing, and implementing the system changes. Beyond the estimated costs reported by CMS, little is known about the costs that providers, clearinghouses, and insurers incurred for updating their Medicare claims submission system. On October 1, 2015, CMS’s Office of Technology Solutions’ claims processing systems are expected to begin referencing the internal tables that store ICD-10 codes to validate, edit, and authorize payments to Medicare fee-for-service providers when claims data indicate a service date of October 1, 2015, or later.

Although the report cautions that unanticipated system errors could disrupt Medicare claims processing when systems are required to begin processing ICD-10 codes, the GAO notes that CMS has taken actions to determine and implement the necessary changes minimize potential disruptions.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2015 Strategic Management Services, LLC. Published with permission.