Saturday, December 16, 2017

OCMA Blog

AMA Statement on Meaningful Use Hardship Exemption Announcement

Due to significant pressure from the AMA, the Centers for Medicare & Medicaid Services (CMS) announced the reopening of its Meaningful Use (MU) hardship exception application for physicians and hospitals to avoid the 2015 penalty. 
 
CMS' action gives physicians the opportunity to seek exemption from meeting Meaningful Use requirements in 2014 and avoid Medicare payment penalties in 2015.
 
The new deadline will be November 30, 2014.  Previously, the hardship exception application deadline was April 1, 2014 for hospitals and July 1, 2014 for physicians.
 
While all Medicare physicians have until February 28, 2015 to attest to any 90-day reporting period in 2014 to obtain an MU incentive, Medicare physicians who started the program this year were required to attest by October 1, 2014 to avoid a penalty of up to 2 percent in 2015.  Those new to the MU program can now apply for a hardship exception to avoid this penalty if they missed the October 1 deadline.  In addition, even if you are prepared to attest by February 28, 2015, you can still apply for a hardship exception as a fallback precaution to avoid the penalty.  We believe this hardship exemption will be interpreted broadly by CMS and we therefore encourage all physicians who meet the following criteria to apply by the November deadline.
 
The hardship exception, however, only provides relief from the MU penalty and will not earn you an incentive.  Meaningful Use incentives are still available for those who are able to meet and attest to the Stage 1 or Stage 2 measures by the February deadline. 
 
This reopened hardship exception period is for Medicare physicians and hospitals that:

  • Have been unable to fully implement 2014 Edition CEHRT due to delays in 2014 Edition CEHRT availability; and
  • Physicians who were unable to attest by October 1, 2014 and hospitals that were unable to attest by July 1, 2014 using the flexibility options provided in the CMS 2014 CEHRT Flexibility Rule.

The CMS 2014 CEHRT Flexibility Rule allows physicians to use older certified EHR technology (Version 2011), a combination of old and new technology (Version 2011 and Version 2014), or just new technology (Version 2014) to attest for their 2014 reporting period. A more in-depth review of the rule can be found on the AMA website under "Avoiding meaningful use penalties / Hardship Exceptions." Unfortunately, the CMS system was not ready to accept attestations by the October 1, the last date Medicare physicians new to MU could attest to avoid a penalty.  This is part of the reason why CMS elected to re-open the hardship filing period, ensuring more doctors avoid a 2015 penalty.
 
For more information, and for a link to the hardship exemption application, visit the CMS website.

Below is the AMA press statement.


FOR IMMEDIATE RELEASE

October 7, 2014
 
AMA Statement on Meaningful Use Hardship Exemption Announcement
Statement attributed to:
Robert M. Wah, MD
President, American Medical Association
 
"The American Medical Association (AMA) is pleased that the Centers for Medicare and Medicaid Services (CMS) has taken a step towards addressing AMA concerns and has decided to reopen the Meaningful Use hardship submission period.  Medicare physicians who were unable to fully implement their new certified electronic health record software due to delays in receiving it and who were unable to successfully attest by the October 1 deadline can apply for the exception through November 30th. This change will allow more physicians to avoid an unfair Meaningful Use financial penalty in 2015.
 
"Giving physicians more time to file for a hardship exemption provides necessary relief as many physicians are struggling to meet a number of reporting mandates to avoid multiple penalties.
 
"The AMA remains committed, however, to ensuring that the Meaningful Use program requirements are in fact meaningful and deliver the intended improvements in patient care and practice efficiencies. We look forward to continuing to work with the Administration to make the program requirements more flexible and ensure physicians have certified products that better support their practices and patients' needs."


Ebola Resources from the OC Health Care Agency

The first case of Ebola Virus Disease (EVD) diagnosed in the United States was confirmed on September 30, 2014 in Dallas, Texas. However, the risk of an Ebola outbreak in the United States remains low. Health care providers should remember to obtain a travel history for any patients with febrile illness, and be familiar with Ebola's clinical presentation and infection control requirements.  Any suspect cases meeting the clinical and epidemiologic criteria for EVD should be reported immediately to Orange County Public Health Epidemiology at 714-834-8180. 


For more information, see www.ochealthinfo.com/ebola

For specific health care-related guidance including infection prevention and environmental infection control precautions, see www.cdc.gov/vhf/ebola/hcp/index.html

To receive alerts, updates and newsletters on communicable disease issues affecting Orange County, email epi@ochca.com.


Understanding Advancements in Genetic Testing for Breast Cancer

Written by Nimmi Kapoor, MD, Surgical Oncologist, Breastlink

Our understanding of breast cancer is rapidly advancing.  Breast cancer is not a single disease entity, but a heterogeneous disease spectrum with numerous genetic alterations involved in its pathogenesis. Some breast cancers are indolent and not life-threatening, while others are very aggressive. Similarly, we find different genetic alterations in different breast cancers. Some of these genetic changes are familial, or the result of genetic mutations passed from parent to child. The BRCA genes were the first to shed light on familial breast cancer genetics. Now we are capable of screening over a dozen different genes for mutations implicated in breast cancer risk. Navigating these new complexities in genetic testing can be challenging. It will be important for all physicians to become more familiar with this expanding area of medicine.

Background to Genetic Testing for Breast CancerIt is the 20-year anniversary since the first BRCA gene mutation was identified. By the mid-2000s, enough data had been collected for the National Comprehensive Cancer Network (NCCN) to issue guidelines on genetic testing. Most insurance plans began to offer some sort of coverage for genetic testing by 2010. In the short time since, genetic testing has become much more widespread and tests have advanced to identify numerous genetic mutations linked to breast cancer.

Two of the most well-known genes associated with increased risk for developing breast cancer are BRCA1 and BRCA2. Between 15 and 20 percent of all breast cancers are familial, with BRCA1 and BRCA2 responsible for approximately half of these familial cancers. These genes have been well described and there are established guidelines for their management. However, there are numerous other genes also known to increase risk for breast cancer. The most updated NCCN guidelines now recommend considering multi-gene testing over single gene testing. Some of these genes, in addition to the BRCA genes, include:
 

• PALB2
• PTEN
• TP53
• CDH1
• ATM
• CHEK2

Of these genes, PALB2, PTEN, TP53 and CDH1 are also well described and guidelines exist for their management. ATM and CHEK2, along with a handful of other genes, explain a significant portion of hereditary breast cancers, but are less understood and guidelines do not exist for their management.

Choice in Genetic Testing
Initially, there was not much choice when it came to testing for genes associated with increased risk for developing breast cancer. However, there are several factors at play today when physicians identify patients who may benefit from genetic testing.

Steps involved in completing genetic testing include assessing patient personal health and familial history, determining an appropriate test, educating the patient and obtaining informed consent, facilitating testing, interpreting results and developing a management plan. Several resources are available, such as the IBIS Breast Cancer Risk Evaluation Tool, to help physicians determine patient risk.

Numerous sequencing panels exist for testing of breast cancer genes, including single gene tests and multi-gene panels. Single gene tests may not reveal the presence of certain genes associated with increased risk for breast cancer, but are straightforward with clear guidelines for management. Multi-gene panels cast a wider net, concurrently testing for multiple genes, but results can include variants of unknown significance and be more difficult to manage.

There are also variables when it comes to choosing a laboratory for the analysis of genes. These include a patient’s insurance status and cost-effectiveness, turn-around time, ease-of-use services and patient tolerance for uncertain answers. For instance, a quick turn-around time may be necessary to inform decisions about surgery.

Breastlink’s Experience with Multi-Gene Panels
Breastlink began to offer multi-gene testing in 2013. Through a high-risk program, physicians working with Breastlink identify patients at high risk for developing breast cancer, a member of the Breastlink medical staff provides a consultation and coordinates genetic testing if necessary, and the physician uses results to inform a management plan.

From July 2013 to September 2014, Breastlink collected data on the multi-gene panel testing results of 398 patients referred to Breastlink through the high-risk program. Of these, 83% had negative results while 6% tested positive for a gene associated with increased risk for developing breast cancer. In the 23 patients with mutations, a mutation in a non-BRCA1/BRCA2 gene was identified in 10 patients, or 43%. In other words, multi-gene testing increased diagnostic yield by 77%.

As knowledge of the relationship between genetics and breast cancer grows, multi-gene testing will likely prove beneficial. It offers efficient sequencing of multiple genes and helps clinicians to better understand the true nature of individual cancers.

Physicians must learn how to talk with patients about genetic testing without limiting discussions to BRCA genes. A better understanding of the relationship between genetics and breast cancer risk will help women to make informed decisions about testing. Also, by identifying patients who are mutation carriers, we can counsel patients on individual risk management options, identify family members who can also be screened and contribute to our understanding of cancer biology.

Management options for gene mutation carriers
Once a patient is diagnosed with a mutation related to an increased cancer risk, they should be given adequate counseling on management options. Ideally, early involvement of a genetic counselor is a good idea. At the same time, all physicians should be aware of options and how to generally guide patients. Some gene mutations, such as those in the BRCA1 gene for example, will lend to an increased risk of multiple types of cancer including breast, ovarian, melanoma, and even pancreas cancer.

Not all gene carriers will necessarily develop cancer and each patient will have an individualized risk based on their personal and family history. There are on-line tools and algorithms such as brcatool.stanford.edu that can help guide individuals with gene mutations on their risk of developing breast or ovarian cancer and dying from cancer depending on how and when they choose particular interventions.  For example, a 35 year-old woman with a BRCA-1 mutation who chooses to have a prophylactic oophorectomy by age 35 and will have a 30% risk of developing breast cancer by age 70 compared to a similar woman who does not remove her ovaries with a 50% risk of breast cancer. This decrease of breast cancer risk by 20% with a prophylactic oophorectomy can be helpful to young women deciding on how to best manage their high risk state.

While preventive surgery is an option for women at high risk, alternatives include high risk screening with MRI or medical prophylaxis. Fortunately, because of advances in surgical technique, many women who choose to have prophylactic mastectomy will be able to undergo nipple-sparing mastectomy with some form of immediate reconstruction. This type of surgery offers superior cosmetic outcome and is ideal for the appropriate candidate.

Upcoming Event
Physicians, nurse practitioners and physician assistants are invited to join Dr. Lisa Curcio and Dr. Nimmi Kapoor, two Breastlink surgical oncologists, to learn more about the genetic testing landscape at a CME course to be held at MASTRO’s Steak House in Costa Mesa on October 23. For more information or to RSVP, please call 714-804-0940 or email events@breastlink.com.  

Click here for the event flyer.


Blue Shield makes positive changes to reimbursement policy for physicians treating out-of-network exchange PPO patients

Blue Shield of California recently announced a two-part reimbursement policy change for contracted providers that do not currently participate in the plan's Individual and Family Plan (IFP) PPO product, otherwise known as its exchange/mirror PPO product.
 
Effective with September 14, 2014 dates of services, Blue Shield will implement changes to the out-of-network claims payment process and will now reimburse providers directly when PPO exchange/mirror product patients are seen out of network. Previously, Blue Shield issued payment directly to the patient. The notice also states that out-of-network physicians may continue bill patients for the balance of billed charges.
 
Additionally, for Blue Shield contracted providers who see Blue Shield PPO exchange/mirror patients out of network, the plan will process payment based on the provider's PPO contracted amount. Please note out-of-network benefit rules will still be applied, meaning the patient will still have the same out-of-network cost sharing. Previously, Blue Shield processed out-of-network PPO claims based on the reimbursement rate for its IFP product, which is typically discounted from the PPO rate.
 
The policy change does not affect services provided to patients with a Blue Shield IFP EPO plan, as there are no out-of-network benefits with an EPO product.
 
Blue Shield reports the policy change is in response to provider feedback of difficulties collecting from exchange/mirror patients they have seen out-of-network. The policy change also brings its physician payment rules in line with Blue Shield's facility payment policy for PPO exchange/mirror patients who are seen out of network.
 
CMA believes the policy change will be positive for physicians and commends Blue Shield for their responsiveness to provider concerns.
 
To view the Blue Shield notice, click here.
 
Physicians with questions about the policy can contact Blue Shield Provider Information & Enrollment at (800) 258-3091. OCMA members can contact Mitzi Young, OCMA Physician Advocate at (888) 236-0267 or myoung@cmanet.org

Prop 46 Update for Physicians: Proposition 46 isn’t the CURE(S)

Today in California, trial lawyers are waging an aggressive campaign to overturn California's landmark Medical Injury Compensation Reform Act (MICRA).
 
On November 4, voters will be asked to weigh in on Proposition 46, a costly and deceptive measure funded and sponsored almost exclusively by trial lawyers. In addition to raising health care costs and reducing access to quality medical care, Prop. 46 could put patient prescription drug history at risk of being hacked and would force physicians and pharmacists to use an unworkable database.
 
The Controlled Utilization Review and Evaluation System, or CURES, is a statewide, government-run database that allows physicians to know which medications patients are taking. In concept, it could be a helpful tool in ensuring that patients don't "doctor shop" - or visit several doctors to get multiple prescriptions for controlled substances.
 
Though the database already exists, it is underfunded, understaffed and technologically incapable of handling the massively increased demands this ballot measure will place on it. In its current form, the CURES database is plagued with system errors and major deficiencies. The state staffer in charge of CURES recently testified that the database is "not sufficient enough to carry out the mission that we need." To see excerpts of his testimony, click here
 
In fact, in evaluating Prop. 46 the independent, non partisan Legislative Analyst noted, "Currently CURES does not have sufficient capacity to handle the higher level of use that is expected to occur when providers are required to register beginning in 2016."
 
Despite all of this, Prop. 46 includes a provision that would mandate physicians and pharmacists check the CURES database before prescribing Schedule II or III drugs - a list of medications that is far too long for this newsletter. This "CURES mandate flaw" puts physicians in the untenable position of either breaking their professional oath to give patients the best possible care or breaking the law.
 
What's more, the CURES mandate comes without any increased security to ensure that the database is up and running efficiently, effectively and safely before legally making health care professionals check it.

That's a risky gamble in these days of massive data breaches.   

In the few weeks left between now and Election Day, I cannot stress enough how important it is to spread the word about the dangers of Prop. 46.    As you've read in previous issues of this publication, Prop. 46 is really three measures carelessly thrown together by trial attorneys with the hopes that adding "sweetener" provisions - including the CURES piece discussed above  - will trick voters. The real intention is to increase the cap on medical malpractice payouts, which will increase health care costs for everyone and decrease access for those who need it most. Prop. 46 will result in money being pulled directly out of the health care delivery system and put into the pockets of trial attorneys at the expense of voters everywhere.  


How can you get engaged in the final stages of the No on Prop. 46 campaign?


- "Like" the No on 46 Facebook page

- Follow the No on 46 Twitter page

- Visit the offical campaign website at www.noon46.com


FREE Campaign Materials

OCMA has campaign materials at our offices available for physicians to pick up, including yard signs, campaign buttons, patient brochures, office posters and bumper stickers.

You can also order these materials to be sent straight to your office (yard signs only available for pick-up at OCMA). Just fill out the No on 46 order form.


No on 46 "Take Action" Contest

Take action in the No On 46 fight now through October 19, 2014 and your practice could win $500! 

Click here for information on the contest.


More information

Visit these websites in order to learn more about MICRA and Prop 46 so that you can educate your colleagues, friends, peers and family:

- The CMA website

- No on 46 campaign website

- Californians Allied for Patient Protection (CAPP) Website

 


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