Physicians News September 2010 : Page 1

PHYSICIANSNEWS F Philadelphia Metro Edition PhysiciansNews.com September 2010 Einstein-Montgomery Partnership Builds New Medical Center By Richard Montalbano or the first time in more than a decade, southeast-ern Pennsylvania will become the home of a new, state-of-the-art medical center. Through a partnership estab-lished by Albert Einstein Healthcare Network and Montgomery Hospital Med-ical Center, the new medical center will provide enhanced access to high-quality clinical services to the growing popu-lation in the northwest sub-urbs of Philadelphia. Currently, more than 60 percent of Central Mont-gomery County residents travel to obtain care at other hospitals in the Pennsylvania sub-urbs and the city of Philadelphia. The Einstein-Montgomery partner-ship and this new medical center is a direct response to the commu-cer care services. Following a thorough site search, construction began in July and the new hospital is slated to open its doors in September, 2012. nity’s need for a modern setting to provide advanced medical services including intensive care for infants, neurosurgery, and cardiac and can-The creation of the medical center, located on Germantown Pike in East Norriton Township, will have a significant economic impact on the region, most notably by pro-viding job growth at a time of ongoing high unemploy-ment. The medical center project is due to create ap-proximately 600 construc-tion jobs, preserve approximately 800 current jobs at MHMC and create a future need for nearly 300 new positions. When it opens, the 360,000 square foot, five-floor medical center will op-erate as a full-service acute care hospital. The facility will boast 146-beds, includ-ing 96 medical/surgical beds, a 22-bed intensive care unit, a 20-bed obstetrical unit, and an eight-bed See Einstein-Montgomery on page 2 Proposed Physician Fee Schedule Update Implements Key Reform Provisions (Part 1 of 2) By Esther Chang, Peter R. Leone, Arnold Pamplona, Daniel Melvin, Emily Cook, Jeanna Palmer Gunville, Amy Kearbey,Webb Millsaps and Sarah Nelson, McDermott Will & Emery, LLP The Centers for Medicare & Medi-caid Services (CMS) published its an-nual regulatory update to the Medicare Physician Fee Schedule (the proposed 2011 update), including rules imple-menting key provisions of the Patient Protection and Affordable Care Act of 2010, as amended by the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the Af-fordable Care Act). Published in the July 13, 2010, Federal Register, CMS is accepting comments on the proposed 2011 update until August 24, 2010. A final rule will be issued on or about November 1, 2010, to be effective Jan-uary 1, 2011. The proposed 2011 update ad-dresses a range of payment policies and rates affecting physicians and an array of Medicare Part B suppliers, in-cluding outpatient rehabilitation, di-agnostic imaging and telehealth. This White Paper discusses some notable provisions of the proposed 2011 up-date, including the new patient-notice provision of the Stark in-office excep-tion and other provisions mandated by the Affordable Care Act. PhySiCiaN PaymeNt UPdate The update projects a 6.1 percent reduction to physician payment rates in 2011 under the sustainable growth rate (SGR) formula. Enacted by Con-gress in 1997, this formula has called for an across-the-board reduction in physician payment rates every year PRST STD US Postage Paid Permit No. 397 Bellmawr, NJ beginning with 2002. Beginning in 2003, these cuts have been averted by Congressional action, most recently by the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010, which replaces the 21.3 percent reduction in physician payment rates that was required by the SGR formula for 2010 with a 2.2 percent payment increase for services furnished on or after June 1, 2010 through November 30 2010. Congress has been pre sured t devise a permanent fix to the SGR problem, but such a fix is complicated by the fact that any fix will be contro-versial. WeLLNeSS aNd PreveNtative ServiCeS: Removal of Barriers to Preventive Services The Affordable Care Act revises the definition of “preventive services” under the Social Security Act to in-clude the following: a list of specific preventive services, an initial preven-tive physical examination (IPPE), and an annual wellness visit (discussed fur-ther below). The proposed 2011 update would also add preventive services to benefits covered under Medicare Part See Physician Fee on page 2 control 10 Understan Planning needs lOcal newS 13 Digest INSIDE THI S ISSUE Medicine & law 4 Understanding the are appeals Process Medicine & finance abington neurosciences Team discerns Hard-To-detect Progressive disease DEPARTMENTS Business . . . . . . . . . . . . . . . . . . . . . . . . 8 & 12 Classifieds. . . . . . . . . . . . . . . . . . . . . . . . . . 15 Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Local News . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 News. . . . . . . . . . . . . . . . . . . . . . . . . . 6, 7, & 12 Opinion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Patient Safety. . . . . . . . . . . . . . . . . . . . . . . 14 PA

Einstein-Montgomery Partnership Builds New Medical Center

For the first time in more than a decade, southeastern Pennsylvania will become the home of a new, state-ofthe- art medical center.

Through a partnership established by Albert Einstein Healthcare Network and Montgomery Hospital Medical Center, the new medical center will provide enhanced access to high-quality clinical services to the growing population in the northwest suburbs of Philadelphia.

Currently, more than 60 percent of Central Montgomery County residents travel to obtain care at other hospitals in the Pennsylvania suburbs and the city of Philadelphia.The Einstein-Montgomery partnership and this new medical center is a direct response to the community’s need for a modern setting to provide advanced medical services including intensive care for infants, neurosurgery, and cardiac and cancer care services.

Following a thorough site search, construction began in July and the new hospital is slated to open its doors in September, 2012.

The creation of the medical center, located on Germantown Pike in East Norriton Township, will have a significant economic impact on the region, most notably by providing job growth at a time of ongoing high unemployment.The medical center project is due to create approximately 600 construction jobs, preserve approximately 800 current jobs at MHMC and create a future need for nearly 300 new positions.

When it opens, the 360,000 square foot, fivefloor medical center will operate as a full-service acute care hospital. The facility will boast 146-beds, including 96 medical/surgical beds, a 22- bed intensive care unit, a 20-bed obstetrical unit, and an eight-bed Neonatal intensive care unit.

With the primary goal of enhancing access to leading-edge medical care, the new medical center will offer clinical services and programs including: 24-hour emergency care and trauma response, delivered by board-certified emergency room physicians; advanced cancer care; state-of-the-art cardiac services; medical offices for convenient access to primary care physicians and specialists; and health education and wellness programs.

In addition to providing enhanced access to services for patients, attending physicians and residents alike will have the benefit a brand-new, world class clinical environment.

The new medical center provides a unique opportunity for physicians from a wide range of practice areas to provide a premium level of care and excel in the community’s most modern facility. The range of both inpatient and outpatient services at the new hospital will include Emergency Medicine, Cardiology, General Medicine, Obstetrics/ Gynecology, General Surgery, Interventional Radiology /Vascular/Interventional Cardiology, Oncology, and Orthopedics.

The new medical campus will also feature a 75,000 square foot medical office building with convenient, on-site access to primary care practices and specialists. The twostory building, which will open in 2012 at the same time as the new hospital, will be connected to the main medical center.

Einstein is the largest independent academic medical center in the Delaware Valley and plans to provide resident training at the new hospital.In addition, clinical staff will continue to be informed about and trained in the latest clinical treatments and technology for patients.Through the new medical center, the AEHN-MHMC partnership will be able to provide Montgomery County residents with a broader and deeper array of medical care and health and wellness services.

Proposed Physician Fee Schedule Update Implements Key Reform Provisions

The Centers for Medicare & Medicaid Services (CMS) published its annual regulatory update to the Medicare Physician Fee Schedule (the proposed 2011 update), including rules implementing key provisions of the Patient Protection and Affordable Care Act of 2010, as amended by the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the Affordable Care Act). Published in the July 13, 2010, Federal Register, CMS is accepting comments on the proposed 2011 update until August 24, 2010. A final rule will be issued on or about November 1, 2010, to be effective January 1, 2011.

The proposed 2011 update addresses a range of payment policies and rates affecting physicians and an array of Medicare Part B suppliers, including outpatient rehabilitation, diagnostic imaging and telehealth. This White Paper discusses some notable provisions of the proposed 2011 update, including the new patient-notice provision of the Stark in-office exception and other provisions mandated by the Affordable Care Act.

PhySiCiaN PaymeNt Update

The update projects a 6.1 percent reduction to physician payment rates in 2011 under the sustainable growth rate (SGR) formula. Enacted by Congress in 1997, this formula has called for an across-the-board reduction in physician payment rates every year beginning with 2002. Beginning in 2003, these cuts have been averted by Congressional action, most recently by the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010, which replaces the 21. 3 percent reduction in physician payment rates that was required by the SGR formula for 2010 with a 2.2 percent payment increase for services furnished on or after June 1, 2010 through November 30,2010. Congress has been pre sured to devise a permanent fix to the SGR problem, but such a fix is complicated by the fact that any fix will be controversial.

WeLLNeSS aNd PreveNtative ServiCeS

Removal of Barriers to Preventive Services The Affordable Care Act revises the definition of “preventive services” under the Social Security Act to include the following: a list of specific preventive services, an initial preventive physical examination (IPPE), and an annual wellness visit (discussed further below). The proposed 2011 update would also add preventive services to benefits covered under Medicare Part

B. The A fordable Care Act requires 100 percent Medicare payment for the IPPE and certain preventive services to which the U.S. Preventive Services Task Force has given a grade of A or B, and the provision waives any coinsurance or Part B deductible that would otherwise be applicable to such preventive services or for the annual wellness visit. This provision is specifically designed to remove barriers to affording and obtaining preventive services under Medicare.

Such provisions are effective for services provided on and after January 1, 2011. The deductible for the IPPE was the subject of a statutory waiver, effective January 1, 2009. CMS notes that all existing Medicare coverage policies for such services, including any limitations based on indication or population, continue to apply.

The update also proposes the inclusion of influenza and hepatitis B vaccines and their administration as services not subject to the Part B annual deductible, as well as new exceptions from the Part B annual deductible for bone mass measurement, medical nutrition therapy services and the annual wellness visit. With regard to Federally Qualified Health Centers (FQHCs), the update proposes application of the new definition of preventive services as described above to the new Medicare FQHC preventive services definition, waiver of coinsurance for the preventive services that are recommended with a grade of A or B by the U.S. Preventive Services Task Force for any indication or population and the addition of a 20 percent co-pay on all FQHC services after implementation of the FQHC prospective payment system.

The update also proposes the extension of the Affordable Care Act’s waiver of deductible to services furnished in connection with or in relation to a colorectal cancer screening test that becomes diagnostic or therapeutic.

Coverage Of aNNUaL WeLLNeSS viSit

Extending the preventive focus of Medicare coverage, which currently pays for a one-time-only initial preventive physical examination, the Affordable Care Act expanded Medicare coverage under Part B to include an annual wellness visit that provides personalized prevention plan services, effective January 1, 2011. CMS proposes definitions for key terms and stipulates the required elements for the first annual wellness visit and subsequent annual wellness visits. The annual wellness visit will be paid under the Physician Fee Schedule. For this purpose, CMS proposed two new HCPCS G codes for reporting the first and subsequent visits.

NotiCe Of aLterNative imagiNg SUPPLierS

The Affordable Care Act amended the statutory Stark in-office ancillary services exception to require that CMS impose a requirement (under the exception) that a Medicare beneficiary referred for an MRI, CT or PET scan be given, at the time of the referral, a written notice that the patient may receive the services from a supplier other Than the referring practice and that informs the patient of alternative suppliers located in the area in which the patient resides. This statutory amendment was effective January 1, 2010.

The proposed 2011 update includes an amendment to the Stark regulatory exception for in-office services consistent with this provision of the Affordable Care Act. This regulatory amendment is effective January 1, 2011, and thus addresses concerns that the Affordable Care Act’s amendment to the exception was self-implementing, effective January 1, 2010. The regulatory amendment requires that a Medicare beneficiary referred for MRI, CT or PET scans be given a written notice at the time of referral that the patient may receive the scan from a supplier other than the referring practice and that lists at least 10 alternative imaging suppliers located within a 25-mile radius of the practice site. If there are not 10 alternative imaging suppliers within a 25-mile radius of the practice site, then the list must include all of the alternative imaging suppliers within this area. If there are no alternative imaging suppliers within this 25-mile area, the practice is only required to give the patient a written notice that the patient may receive the referred services from a supplier other than the referring practice.

The written notice must include for each supplier on the list the supplier’s name, address, telephone number and distance from the referring practice’s site. CMS has requested comments on whether it should expand the notice requirement to additional imaging modalities and whether it should require the notice include alternative “providers of services,” in addition to suppliers. Notably, the statutory amendment and the proposed rule only require that the list include alternative “suppliers,” a defined term that excludes hospitals and other institutional providers of imaging services.

eLeCtrONiC PreSCriBiNg iNCeNtive PrOgram

2011 eRx Incentive Payment For 2011, the update proposes that the incentive payment for successful electronic prescribers equal 1 percent of the total estimated Medicare Part B Physician Fee Schedule allowed charges for all covered professional services furnished during the 2011 reporting period. The incentive payment for successful electronic prescribers for 2012 is anticipated to be at 1 percent and will decrease to 0.5 percent in 2013.

To determine whether an individual eligible professional (EP) or group practice is a successful electronic prescriber, Eps and group practices must submit reports to CMS using an eRx measure. Under the proposed measure, individual Eps must report a minimum of 25 Medicare Part B professional service patient encounters during the 2011 reporting period, where certain current procedural terminology (CPT®) codes (pre-identified by the U.S. Department of Health and Human Services [HHS]) are implicated and where at least one prescription is generated and transmitted electronically through a qualified e-prescribing system. Group practices, on the other hand, must meet the applicable minimum patient encounter benchmark, which is based on a sliding scale, based on the number of national provider identifier (NPI) numbers linked to the group practice (e.g., 75 reporting patient encounters for a group of 2-10 NPIs). HHS plans to post the final eRx measure by December 31, 2010, on the CMS website at www.cms.gov/ERXIncentive.

In addition, the EP or group practice’s total 2011 Physician Fee Schedule allowed charges for all covered professional services submitted under the eRx measure, divided by the EP’s total Physician Fee Schedule allowed charges for all covered professional services, must be 10 percent or more. If the result of this calculation is less than 10 percent, then the EP or group practice will not earn an eRx incentive payment.

2012 erx PeNaLty

The Physician Quality Reporting Initiative (PQRI) is a voluntary program for Eps (physicians and other specified non-physician practitioners) to receive incentive payments for reporting data to CMS on selected quality measures. The update proposes continued reporting of PQRI measures via

Claims-based, registry-based or electronic health record (EHR)-based reporting for a 12-month period (for all reporting methods) or a six-month period (for claims-based and registrybased reporting methods). The proposed 2011 update seeks comment on limiting the option for claims-based reporting, as well as other options for additional reporting methods.

The update proposes to use the same method for selection of new PQRI measures that it used for 2009 and 2010. New measures would be required to have a high impact on health care, facilitate alignment with other federal health care programs, be endorsed by the National Quality Forum, address gaps in the existing PQRI measure set, measure various aspects of clinical quality and be functional.Based on the proposed criteria, CMS proposes to include a total of 198 measures for 2011, comprising 190 individual measures and 14 measures groups (some individual measures are also included within measures groups).

Finally, the update proposes to make several changes to the PQRI in response to Affordable Care Act provisions.As required by the act, CMS would reduce the incentive payment amount from 2 percent to 1 percent of estimated Part B Physician Fee Schedule allowed charges. CMS would also convert the existing Physician and Other Health Care Directory into the Physician Compare website. The update also proposes to implement the Affordable Care Act provision providing for additional incentive payments to Eps that submit PQRI data through a Maintenance of Certification Program operated by the American Board of Medical Specialties.

In order to implement the provision requiring alignment of PQRI measures with meaningful use of EHRs, CMS proposes to include many of the core clinical quality measures from the American Recovery and Reinvestment Act that demonstrate meaningful use of EHR as PQRI measures.CMS also

Proposes to expand their existing feedback process to include an interim feedback report available in June 2011 in order to comply with the Affordable Care Act’s requirement that CMS implement a “timely” feedback program and to make modifications to their existing inquiry process to comply with the act’s requirement that CMS implement an informal review process permitting Eps to seek review of a determination that the EP did not meet PQRI submission requirements.

Publication List