21St Century Cures Act Winners

The Source that Connects the Arizona Healthcare Community

CONGRESS PASSES 21ST CENTURY CURES ACT SPOTLIGHT: 2017 MEDICARE In a welcome sign of bipartisanship, Congress PHYSICIANS’ FEE SCHEDULE passed and President Obama signed the 21st 21st Century CMS released its final rule updating payment Century Cures Act, a $6.8 billion spending bill for Lobbyist policies and rates under the Medicare Physi- healthcare research. Spend Cures Act cian Fee Schedule (MPFS). Winners The most controversial provision of the 21 “In addition to policies affecting the Century Cures Act is it decreases the obstacles calculation payment rates, this final rule pharmaceutical companies face in drug FDA CHANGES TO DRUG & identifies potentially misvalued codes, research and approval. The Cures Act allows $192 M DEVICE APPROVAL adds procedures to the telehealth list, pharmaceutical companies to request expedited Pharmaceutical Companies and finalizes a number of new policies, approval for new drugs from the Food and Drug Medical Device Makers including several that are a result of Administration (FDA), while reducing the agency’s BioTech Industry recently enacted legislation.” scrutiny of drugs before approval. The new law Centers for Medicare & Medicaid Services National Institutes of Health also extends the exclusivity period on new drugs Biotech Industry combating rare diseases by six months and $120 M Hospitals The new policies are designed to improve pay- mandates that the FDA establish a priority review Research Universities ments to primary care physicians for patients program for breakthrough medical devices. Medical Centers with multiple chronic conditions, mental and behavioral health issues, and cognitive impair- Critics cite this deregulation as a huge handout to Mental Health & Substance ment conditions. But physicians won’t be the pharmaceutical companies. Senators Elizabeth Abuse Services only practitioners who will feel the impact of $1.8 M Individual States Warren and Bernie Sanders voted against the the changes beginning January 1, 2017. Oth- Treatment Facilities Cures Act because of the provisions allowing er Medicare service providers including nurse Research Projects “big pharma” an easier path into the marketplace, practitioners, physician assistants, physical without addressing the pharmaceutical industries Health Information therapists, radiation therapy centers and in- growing controversy over price hikes on drugs Technologies dependent diagnostic testing facilities are essential to some Americans’ healthcare. $35 M Computer Makers also paid under the MPFS. Physician payment Software Industry rates are up by just 0.24 percent in 2017. The Cures Act will provide states a total of $1 Telecommunications billion in grants to fight the growing opioid epidemic The new rules provide a variety of benefits to across the nation. The Centers for Disease Control Medicare providers, ends the Medicare outpa- (CDC) reports 50,000 Americans died from opioid tient reimbursement rate for off-campus, hospital outpatient departments and adds new overdoses in 2016. The National Institutes of Health (NIH) will reporting and credentialing requirements to receive nearly $5 billion for research into rare and Medicare Advantage insurers. New Arizona Medicaid Guidelines deadly diseases including various cancers and Fight Opioid Addiction Alzheimer’s disease. The NIH is also expected to Designed to improve payment accuracy and recognize the value of primary care, care man- Governor Doug Ducey recently limited create a research incentive program for rigorous agement and cognitive services; new codes adults on Medicaid to a seven-day opioid drug research. prescription the first time they fill their order. from CMS will identify chronic care and tran- CDC guidelines from March recommend a sitional care management services separately, The NIH will also receive $1.8 billion designated three-day supply limit for opioid painkillers rather than bundling the services into evalua- and that a seven-day supply is adequate for Vice President Biden’s Cancer Moonshot tion and management codes used by all mem- to address most patients’ needs. Before program. The law includes $1.6 million for mental bers of the care team. Arizona’s tact to curb the epidemic can begin, illness research and appropriates funds for AHCCCS will solicit public comment and draft President Obama’s “Precision Medicine Initiative,” The new rules also create new codes to ex- new rules. Pharmacy benefit managers will a government effort to collect genetic data on one pand eligible telehealth services such as criti- have 90 days to enact the new policy. Expect million Americans for treatment research. cal care consultations for those with end stage the change to take affect April 1, 2017.

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www.thehertelreport.com DUPLICATION WITHOUT WRITTEN AUTHORIZATION VIOLATES FEDERAL LAW MEDICARE BENEFICIARIES 2016 GIANT OF CANCER CARE FACE RISING COSTS OneLive recognized Translational Genomics In 2017, the majority of the 53.5 million Medicare Research Institute (TGen) Physician in Chief, Part B beneficiaries (70 percent) will hardly notice Dr. Daniel Von Hoff above nearly 200 nomi- a rise in their monthly premium to $109 per month, MIHS GIVES GREEN LIGHT nees for his work in the field of gastrointestinal a modest 3.9 percent from 2016’s monthly rate After approving in September a plan to move cancer. of $104. Because the increase is tied to Social ahead with its $1 billion improvement and “Every single person on this team has lost Security’s cost-of-living adjustment (COLA) of 0.3 expansion project, the Maricopa County somebody to pancreatic cancer… many of percent, most Part B beneficiaries qualify for the Special Health Care District, which governs Social Security Act’s “hold harmless” provision,” Maricopa Integrated Health Systems (MIHS), us see patients with it every single day… which stipulates premium increases can’t rise faster has now entered into a three-month contract We can do things, we can help with their greater than their Social Security checks. with Vanir Construction Management to start pain, we can improve their survival some. the process. But we want to do something dramatic.” The hold harmless provision, however, doesn’t Dr. Daniel D. Von Hoff protect 24 percent of Medicare recipients who will Vanir will work with MIHS staff and doctors see their premiums rise from $121.80 to $134, an to develop and align objectives for the new As a “Giant of Cancer Care” Von Hoff joins increase of nearly 10 percent. Those impacted facilities, including budgetary and time other honorees recognized for devoting their are Medicare Part B beneficiaries who deferred criteria, performance expectations, roles, time, talent and resources to improve care for Social Security Benefits, enrolled in Part B for the relationships and responsibilities and stakeholder those affected by cancer. Beyond his work as first time in 2017 or were billed directly for their engagement needs. a distinguished professor at TGen, a professor Part B premiums. of medicine at Mayo Clinic and the chief scien- The improvement project was approved in tific officer at HonorHealth Research Institute, Also experiencing a 10 percent premium hike are 2014 when voters overwhelmingly passed Von Hoff also co-leads an international Stand higher income beneficiaries (6 percent) with annual Proposition 480, authorizing a $935 million Up to Cancer (SU2C) scientific research team, incomes of $85,000 or more and married couples bond on property taxes for the next 27 years. filing joint tax returns with incomes greater than “Cutting off the Fuel Supply: A New Approach $170,000. In addition to rising Part B monthly “The size and scope of Maricopa to the Treatment of Pancreatic Cancer.” premiums, affluent seniors will face rising Medicare Integrated Health System’s plans makes it Part D premiums in 2017. In October, CMS one of the most ambitious and significant To learn more about the dream team led by announced that Part D monthly premiums would projects ever in Arizona.” Von Hoff and Dr. Craig B. Thompson, presi- rise nearly 12 percent or an additional $13.30 to Guy Mehula dent and CEO of Memorial Sloan- $76.20 per month. Construction Manager/President Kettering Cancer Center, Vanir Construction click here.

All Medicare beneficiaries will see a 10 percent rise The funding included $571 million to replace Kaiser Family Foundation Poll in their Part B deductible from $166 to $183 and Maricopa Medical Center, which houses a Level In November, the majority a 2 percent rise in their Part A (hospital insurance) 1 trauma center and the Arizona Burn Center and of Americans expressed a annual deductible from $1,288 to $1,316 for $138 million to improve outpatient facilities. favorable opinion of many hospital stays up to 60 days. of the ACA’s core princi- The proposition also provided $226 million to ples - except penalties 2017 Part B Premium Changes construct a new behavioral health facility. for those who go without 70% health insurance. Medicare Beneficiaries According to MIHS, its interim behavioral Young adults should be allowed to stay “Held Harmless” health plan includes adding 22 adult inpatient 85% on parents’ insurance until age 26. 30% Medicare Beneficiaries behavioral health beds for patients with Eliminate out-of-pocket costs for 10% Increase medical conditions who have a psychiatric many preventive services. condition as the primary diagnosis. 83% Closing of the Medicare prescription All Medicare Beneficiaries drug “doughnut hole” so people on MIHS JOINS ACN 81% Medicare will no longer be required to 54 Million Maricopa Integrated Health Systems joined pay the full cost of their medications. Arizona Care Network’s MSSP ACO. The local Part B Deductibles Financial help to low- and moder- ACO also has contracts with Cigna Medical 10% Increase ate-income Americans who don’t get Group and District Medical Group. insurance through their jobs to help Part D Premiums them purchase coverage. 12% Increase ACN has its eye on expanding its reach across 80% Give states the option of expand- Part A Deductibles the state and is now establishing a Next Gen- ing their existing Medicaid pro- 2% Increase eration ACO and developing commercial and gram to cover more low-income, MA agreements. uninsured adults.

www.thehertelreport.com DUPLICATION WITHOUT WRITTEN AUTHORIZATION VIOLATES FEDERAL LAW STICKER SHOCK: NO HOLIDAY SALES ON HEALTHCARE.GOV Navajo County Arizonans enrolling on the Health Insurance In Maricopa County, silver plan rates are in- Adults Age 40 $380 $638 Marketplace are facing an average rate in- creasing by 91 percent. In other counties, sil- Couple Age 40 $760 $1275 crease of 116 percent, placing Arizona at the ver plan rates more than doubled and La Paz Couple Age 40 + 2 $916 $1909 81% top of the list of states most affected by pre- County residents shopping on HealthCare.gov mium rate hikes on ACA plans offered on the will see a premium increase of as much as Single Age 25 $275 $501 exchange. 147 percent. Pinal County

Adults Age 40 $346 $570 Nearly 180,000 Arizonans Federal subsidies lower the burden of rate purchased health insurance hikes on most enrollees, but premium increas- Couple Age 40 $539 $1,154 on HealthCare.gov in 2016. es hit higher income individuals and families Couple Age 40 + 2 $886 $1,728 93%

who are ineligible for federal support. Single Age 25 $219 $453 The majority (74 percent) received an average This year, 78 percent of Arizona enrollees Santa Cruz County monthly tax credit of $204. are expected to qualify for a subsidy on Adults Age 40 $242 $502 HealthCare.gov Couple Age 40 $484 $1004 107% ARIZONA 2017 SILVER PLAN RATES Couple Age 40 + 2 $724 $1503 Non-Smoker Single Age 25 $190 $395 Maricopa 2016 2017 Average Pima 2016 2017 Average County Increase County Increase Yavapai County

Adults Age 40 $257 $491 Adults Age 40 $244 $349 Adults Age 40 $395 $746

Couple Age 40 $514 $982 Couple Age 40 $485 $698 Couple Age 40 $783 $1492

Couple Age 40 + 2 $768 $1470 94% Couple Age 40 + 2 $726 $1046 44% Couple Age 40 + 2 $1171 $2233 82%

Single Age 25 $206 $386 Single Age 25 $190 $275 Single Age 25 $294 $586

RURAL COUNTIES IN ARIZONA Yuma County Apache County Graham County Adults Age 40 $391 $755

Adults Age 40 $346 $638 Adults Age 40 $306 $618 Couple Age 40 $617 $1509

Couple Age 40 $760 $1275 Couple Age 40 $612 $1236 Couple Age 40 + 2 $924 $2260 127%

Couple Age 40 + 2 $1137 $1909 82% Couple Age 40 + 2 $916 $1850 102% Single Age 25 $261 $593

Single Age 25 $275 $501 Single Age 25 $238 $486 NOBILIS HEALTH ARIZ. DEAL Cochise County Green Lee County Nobilis Health closed its $22 million deal to acquire Adults Age 40 $346 $618 Adults Age 40 $306 $618 Arizona Vascular Clinics (AVC) and its four affiliated Couple Age 40 $612 $1236 Couple Age 40 $612 $1236 surgery centers operating as The Arizona Center for

Couple Age 40 + 2 $916 $1850 97% Couple Age 40 + 2 $916 $1850 102% Minimally Invasive Surgery. Single Age 25 $238 $486 Single Age 25 $238 $486 The acquisition provides Nobilis with a new vascular surgical division and new leadership. Dr. L. Philipp Coconino County La Paz County Wall, the founder of AVC and its surgical centers, will Adults Age 40 $380 $638 Adults Age 40 $309 $755 head the new division for Nobilis Health. Couple Age 40 $760 $1275 Couple Age 40 $617 $1509 75% 141% Couple Age 40 + 2 $1137 $1909 Couple Age 40 + 2 $916 $2260 WINTER 2017 Single Age 25 $275 $501 Single Age 25 $261 $593 STATE OF THE STATE Gila County Mohave County

Adults Age 40 $290 $570 Adults Age 40 $411 $638 Tucson: Wednesday, February 8

Couple Age 40 $769 $1154 Couple Age 40 $823 $1275 Phoenix: Friday, February 10

Couple Age 40 + 2 $1037 $1728 80% Couple Age 40 + 2 $1232 $1909 62% Single Age 25 $219 $453 Single Age 25 $275 $501 REGISTER TODAY!

www.thehertelreport.com DUPLICATION WITHOUT WRITTEN AUTHORIZATION VIOLATES FEDERAL LAW Cont’d from Page 1 “site neutral” provision dictates that items and COMINGS & GOINGS Spotlight: Medicare Physician Fee Schedule services furnished by certain off-campus, pro- Apoorve (AP) Jain has left his position as di- renal disease and those who need to create vider-based departments will no longer be rector of revenue cycle at Integrated Medical an advanced care plan. CMS is also soliciting considered covered outpatient services start- Services (IMS) to become director of finance requests to add services to the list of Medi- ing January 1, 2017. The move is expected for Dignity Health in Santa Maria California. care telehealth services for MPFS 2018 new to reduce Medicare spending by $50 million rules. Submit your comments by December next year. Read more in the CMS fact sheet by is solutions engineer manager Marisa Balbo 31, 2016 by clicking here. clicking here. at Direct Care Innovations. She was previously with University of Arizona Health Network. “Become familiar with the new codes As a result of the new rule, Medicare Advantage for CCM, cognitive evaluation, be- (MA) insurers in 2019 will require providers and Rick Beavin was promoted to des- havioral health, and so on. suppliers be screened and enrolled in Medicare ert states Medicare president for Huma- CMS is now paying for things that in before providing items and services to the insur- na overseeing Nevada and California. the past [physicians] did for free.” er’s MA members. And each year, CMS will also Gary Goldstein returns from retirement to now require MA insurers and Part D sponsors to serve as Humana’s interim Arizona Medicare John Meigs, Jr., MD, release medical loss ratio (MLR) data. MA insur- market VP. President, American Academy of Family Physicians ers also must release data used to create their annual bids to participate in the MA program. Davey Ellison was promoted from associate The rule did scale back the agency’s ap- administrator at Banner University Medical proach to data tracking of postoperative vis- The Medicare Diabetes Prevention Program Center - Phoenix to Hospital Administrator at its for high-volume, high-cost procedures. In also got a boost in the final rule. The expanded Banner Thunderbird. its proposed rule, CMS recommended codes model, designed to prevent the onset of type 2 for post-operative care that distinguished diabetes among Medicare beneficiaries diag- Tida Garcia is now director of delegate claims services between settings of care and type nosed with pre-diabetes, is a brainchild of the oversight at UnitedHealth Group. She was of provider in 10-minute increments. Luckily Center for Medicare and Medicaid Innovation senior director of claims at Iasis Healthcare. providers won’t face another administrative Center (CMMI) and are now covered as an addi- challenge because the final rule applies only to tional preventive service under Medicare. Joan Goda is now executive director of practitioners who practice in groups with 10 or hospital/payer strategy and relations at more in select states – not Arizona. Reporting Arizona Oncology. is required by July 1, 2017 and applies only WINTER 2017 to services related to codes reported annually STATE OF THE STATE Rob Keefe is the new vice president, client by more than 100 practitioners, reported more relationship executive for eviCore Health- than 10,000 times or have allowed charges care. Keefe has 25 years of experience in the Tucson: Wednesday, February 8 of more than $10 million annually. CPT code Phoenix: Friday, February 10 healthcare market, addressing critical sales, 99024 will be used for reporting post-opera- membership, care management, provider re- tive services rather than the proposed set of lations and member service functions across G-codes. all lines of business. REGISTER

Jennifer Ruble was promoted from public Medicare Providers Benefit Snapshot TODAY! relations director to senior director, reputation Reimbursement for more management for Banner Health. care management visits The Hertel Report 29455 N. Cave Creek Road Suite 118 Box 453 Dr. Richard Sanchez has joined Health Prolonged E&M codes Choice as its new division chief medical of- now reimbursable Cave Creek, AZ 85331 ficer. Dr. Sanchez previously held senior ex- 602-679-4322 ecutive physician leadership positions with Reimbursement for remote advance Molina Healthcare, UnitedHealthcare and care planning and mental health visits Publisher: Jim Hammond Mercy Care Plan. Managing Editor: Paula Blankenship Increased focus on Diabetes Contributors: Rebecca Uhl and prevention and management Andrew Eversden George Sterling is senior director of healthcare for Philips Lighting. NEWSLETTER SPONSOR Jacque Thames is retiring from Health Net In an effort to reduce Medicare spending effective December 30, 2016 at off-campus hospital outpatient departments for services available in a physician’s Dave Weissman, THR Advisor, is now labor office at a lower rate, CMS developed new and employment attorney at Clark Hill PLC. Medicare reimbursement rates, reportedly He was formerly with Rose Law Group. priced about half the outpatient rates. The

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