CMS proposes changes in payment rules for outpatient care

On July 6, 2016, the Centers for Medicare and Medicaid Services (CMS) proposed changes in Medicare payment methods under the hospital outpatient prospective payment system (hospital outpatient PPS) and the ambulatory surgical center (ASC) payment system.  The proposed Medicare rules would have a substantial impact in 2017 on “off campus” ambulatory facilities, incentive payments for adoption and “meaningful use” of electronic health records (EHRs), and the hospital value-based purchasing (VBP) program. 

The proposed rules would:


  • Require some “off campus” facilities not billing Medicare under the hospital outpatient PPS before November 2, 2015 to bill Medicare under the Medicare physician fee schedule or the ASC payment system, rather than the hospital outpatient PPS.  Ambulatory facilities located more than 250 yards from a main hospital campus could be considered “off campus” facilities.
  • Allow EHR “meaningful use” for a year to be shown over a 90 day period, rather than an entire year.      
  • Adopt new quality of care metrics under the VBP program, such as metrics on reducing the need for emergency department visits for patients undergoing chemotherapy.
  • Remove certain pain management survey questions from the VBP program based on concerns that they might become a factor in over-prescribing of opioids and other pain medications.

Overall, the proposed rules would increase Medicare hospital outpatient PPS payments by about 1.6 percent and would increase Medicare ASC payments by about 1.2 percent in 2017.  The proposed rules were published officially in the Federal Register on July 14, 2016.  Public comments will be due September 6, 2016.  Additional information is available here and here.

Legislation to address opioid use receives bipartisan support

Child welfare agencies have identified substance misuse and abuse as the leading reason for the significant increase in abuse and neglect reports, and the subsequent removal of children from their homes. Overdoses from heroin, prescription drugs, and opioid pain relievers in 2014 surpassed car accidents as the leading cause of injury-related death in America, according to the Centers for Disease Control. Injury-related deaths reached their highest levels of the 21st century in 2014, the most recent year for which data is available, according to the National Institute on Drug Abuse. Heroin overdoses have more than tripled in the last five years, an issue receiving outsize attention nationally but especially during the presidential campaign season as New Hampshire has been one of the hardest-hit states. 


New legislation aims to tackle this epidemic. The Comprehensive Addiction and Recovery Act, S. 524 and H.R. 953, was introduced by Sen. Sheldon Whitehouse (D-RI) and Rep. Jim Sensenbrenner (R-WI5) and will receive a hearing on Thursday, July 14, from the Senate Judiciary Committee.


This topic appears to be one of the few political issues with potential bipartisan agreement. The Senate version has 17 Democrat and eight Republican co-sponsors while the House version has 53 Democrats and 21 Republicans.  The bill provides for significant restrictions, guidance and monitoring of distribution and use of pain medications and treatments.  


The legislation addresses many issues while providing for amendments to the Child Abuse Prevention and Treatment Act (CAPTA). Title VII – Infant Plan of Safe Care Improvement Act amends the CAPTA to require states to identify evidence-based and nationally recognized best practices that will support a state’s efforts.  This CAPTA amendment is important as it acknowledges that a majority of the children who become known to the state agency are infants, and these children are the ones not leaving foster care rapidly.   



  • (Sec. 702) This bill amends the CAPTA to require the national clearinghouse for information relating to child abuse to maintain and disseminate information about requirements and best practices relating to the development of plans of safe care for infants born affected by illegal substance abuse symptoms, withdrawal symptoms, or a Fetal Alcohol Spectrum Disorder.
  • (Sec. 703) The plan of safe care for such infants that is required for a state to receive a grant to improve its child protective services system must: (1) address the health and substance use disorder treatment needs of the infant and affected family or caregiver, and (2) specify a system for monitoring whether and in what manner local entities are providing services in accordance with state requirements.
  • (Sec. 704) Annual state data reports must include the number of such infants, the number for whom a plan of safe care was developed, and the number for whom referrals are made for services, including services for the affected family or caregiver.
  • (Sec. 705) U.S. Department of Health and Human Services (HHS) must monitor state compliance with child protective services system grant requirements.


The text of the entire legislation can be found here.

USDA examines dual participants in SNAP

A July 12th Governing article shares findings of the U.S. Department of Agriculture’s (USDA) recent report examining a new data-sharing system’s ability to identify Supplemental Nutrition Assistance Program (SNAP) participants receiving benefits in more than one state. “Dual participants” cost the government millions in unintended costs and the data-sharing system, called the National Accuracy Clearinghouse, was successful in saving states money by identifying people who already get food stamps in another jurisdiction. According to the USDA’s report: “after joining the system, states saw dramatic declines in the numbers of dual participants -- ranging from 81 percent in Mississippi to 27 percent in Florida.” Public Consulting Group (PCG) conducted the report for the USDA. PCG’s Paul Lefkowitz speaks to the findings in the Governing article titled, “Food Stamps' Extremely Rare but Expensive Problem.” Read the full article here.

CMS proposes revisions in Medicare fee schedules

On July 7, 2016, the Centers for Medicare and Medicaid Services (CMS) proposed revisions in Medicare fee schedules for physicians and other medical practitioners (e.g., physician assistants, nurse practitioners, and therapists).  The proposed revisions include changes that would be effective January 1, 2017 in order to improve care for patients with multiple chronic conditions, mental/behavioral health disorders, and cognitive or mobility-related disabilities.  


Under the proposed changes, payments in 2017 would be separated using new codes for: comprehensive assessments and care planning related to patients with cognitive impairments (e.g., dementia resulting from Alzheimer’s disease), collaborative care models involving primary care and behavioral health specialists for patients with dual diagnoses, and increased resource intensity of care for patients with mobility-related disabilities.  The proposed changes would also include separate payments in 2017 under current codes for enhanced/prolonged evaluation and management (E&M) services and additional codes for services such as critical care consultations that can be provided to patients in remote locations via telehealth.  Overall, the proposed changes would increase Medicare funding for primary care in 2017 by about $900 million.


Starting in 2018, the proposed revisions would also implement a diabetes prevention model tested under the auspices of the Center for Medicare and Medicaid Innovation (CMMI) established by the Affordable Care Act (ACA).  The diabetes prevention model is the first CMMI tested disease prevention model certified for expansion to all Medicare beneficiaries who may be at risk. 


The proposed rule is scheduled for official publication in the Federal Register on July 15, 2016.  Public comments will be due September 6, 2016. Additional information is available here.

PCG Subject Matter Expert offers insights into ESSA in Language Magazine

A July 6 article published by Language Magazine examines funding, accountability and professional development under the recently passed Every Student Succeeds Act (ESSA).  The author, Dr. Paula Love, a funding expert in the education industry shares insights – her own and those of K-12 industry leaders – into the impact ESSA will have on schools and districts, with attention given to opportunities for English Language Arts (ELA) and English Language Learner (ELL) educators. Among the K-12 industry leaders cited in Love’s article is Public Consulting Group’s (PCG) Amy Howie, director of Project SUCCESS, the statewide special education Resource Center that PCG developed and manages for the Indiana Department of Education. Amy comments on the changes to come from ESSA, highlighting the importance of using data effectively to inform instruction as well as professional development focused on evidence-based practices. She states both are key to meeting individual student needs and impacting student performance.  Read the full article, “How will ESSA affect your bottom line,” here

Ensuring educational stability for children in foster care

On June 23, 2016, the U.S. Department of Education and U.S. Department of Health and Human Services released a joint document addressing the Early and Secondary Education Act (ESEA) of 1965, which was reauthorized when Congress passed the Every Student Succeeds Act (ESSA) in December 2015.  The joint publication outlines ways that foster children will be better supported through collaboration with Local Education Agencies (LEAs) and State Education Agencies (SEAs). Such collaboration is important, as seen under the guidance of the Fostering Connections Act of 2008: there is evidence that when State and local level child welfare and education agencies work together, their collaborative efforts can impact the education of children in foster care.


Congress has built new protections for children in foster care into the ESSA (and reauthorized ESEA) legislation.  These provisions go into effect on December 10, 2016. The intent of this legislation is to ensure that foster children are provided, to the highest degree possible, a stable educational experience.  The recently released joint document provides answers to Frequently Asked Questions (FAQs) related the provisions of this new legislation. These provisions are:


  • Educational Stability – This section highlights the need to provide educational stability for children in foster care, with particular emphasis on collaboration between SEAs, LEAs, and child welfare agencies to ensure that students in foster care have the opportunity to achieve at the same high levels as their peers.
  • School of Origin – The school of origin is the school in which a child is enrolled at the time of placement in foster care. An SEA and its LEAs must ensure that a child in foster care enrolls or remains in his or her school of origin unless a determination is made that it is not in the child’s best interest.
  • Best Interest Determination – An SEA, in collaboration with the child welfare agency, must ensure that an LEA takes into consideration all factors relating to a child’s best interest when determining whether it is in a child’s best interest to remain in his or her school of origin. These factors include the appropriateness of the current educational setting and proximity of placement.
  • Dispute Resolution – Child welfare agencies, SEAs, and LEAs each bring valuable, but often different perspectives related to the best interest determination. Recognizing this, both the Fostering Connections Act and Title I require coordination among agencies at the State and local level to ensure the educational stability of children in foster care.  However, if there is disagreement regarding school placement for a child in foster care, the child welfare agency should be considered the final decision maker when determining the best interest determination (unless State law or policy dictates otherwise). The child welfare agency is uniquely positioned to assess vital non-educational factors such as safety, sibling placements, the child’s permanency goal, and the other components of the case plan. Further, the child welfare agency also has the authority, capacity, and responsibility to collaborate with, and gain information from, multiple parties (e.g., parents, children, schools, the court) when making decisions to resolve disputes. 
  • Transportation – Some children in foster care will need transportation to remain in their school of origin when it is in their best interest. To facilitate transportation for these children, an LEA receiving Title I funds must collaborate with the child welfare agency to ensure that transportation for children in foster care is provided, arranged, and funded. (ESEA section 1112(c)(5)(B)). SEAs and child welfare agencies also play a key role in ensuring the adequate provision of transportation for children in foster care, as part of their overall responsibilities under Title I and the Fostering Connections Act to provide educational stability for these children.
  • Immediate Enrollment and Records Transfer – Having records follow a child to the school of enrollment is critical as foster children change schools frequently.  These delays can negatively impact attendance and lead to other adverse consequences, such as being incorrectly enrolled in classes and not receiving the necessary academic services.  SEAs and LEAs must ensure that a child in foster care is immediately enrolled in his or her new school, even if the student does not have the required documentation. The enrolling school must then contact the student’s prior school for relevant records.
  • State and Local Points of Contact – An SEA must designate a point of contact (POC) for child welfare agencies to oversee the State responsibilities under the Title I educational stability provisions for children in foster care. This POC must not be the same person as the State Coordinator for the Education of Homeless Children and Youths under section 722(d)(3) of the McKinney-Vento Homeless Assistance Act.  LEAs must also designate a local POC for child welfare agencies if the corresponding child welfare agency notifies the LEA, in writing, that the agency has designated a POC.
  • Student Data and Privacy – Continuous sharing of information between an SEA or LEA with the child’s case worker is critical to ensure that the educational needs of each foster child are served.  Monitoring a foster child’s education and reporting to the court is an essential part of each case worker’s review; likewise, for school officials, understanding the living situation of a foster child can be essential to addressing his or her unique needs within the school setting.
  • Collaboration – Though child welfare and educational agencies both serve the children and have a shared desire for improved educational outcomes, a collaborative process may not be in place.  Without working together, the implementation of the Title I provisions of ESEA will be difficult to implement. 


“Non-Regulatory Guidance: Ensuring Educational Stability for Children in Foster Care,” which includes FAQs related to the provisions listed above, is available here.

CMS expands authorized use of Medicare data

On July 1, 2016, the Centers for Medicare and Medicaid Services (CMS) issued final rules which expand authorized uses of Medicare claims data in order to improve health care quality and to control costs.  The new rules allow CMS-approved “qualified entities” (QEs) to purchase Medicare claims data from CMS, to combine Medicare data with data from other payers, and to use such combined data to prepare multi-payer data analyses that QEs can provide or sell to authorized users.   


Authorized users of QE data analyses include: state agencies, federal agencies, providers, suppliers, provider/supplier associations, medical societies, health insurance issuers, and employers, as defined under the rules.


Authorized uses include: health care operations as defined under HIPAA rules, treatment, training, quality improvement activities, evaluating practitioner and provider performance, care coordination, patient safety activities, reduction of health care disparities, improvement of coverage and payment policies, and detection of fraud and abuse.   


Data must be protected under HIPAA privacy and security standards, beneficiaries’ protected health information (PHI) usually must be de-identified in QE data analyses, and certain uses such as marketing are explicitly prohibited in the CMS rules.  Medicare claims data to be released to QEs include Medicare Part A, Part B, and Part D data. Prior to obtaining Medicare data, QEs must execute data use agreements with CMS.  QEs must also execute data use agreements with authorized users of QE data analyses.


The new rules on expanded QE data use are authorized under section 105 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The QE program was created under section 10332 of the Affordable Care Act (ACA).   


The new rules are scheduled for publication in the Federal Register on July 7, 2016.  The rules will be effective 60 days later.  Additional information is available here

Federal Court of Appeals Panel strikes down 2014 CMS rule outlawing stand-alone fixed indemnity insurance policies for ACA purposes

On July 1, 2016, a Three-Judge Panel of the U.S. Court of Appeals for the District of Columbia Circuit overturned a 2014 final rule of the Centers for Medicare and Medicaid Services (CMS) that prevented individuals from having fixed indemnity insurance policies, which did not meet the “minimum essential insurance coverage” requirement of the Affordable Care Act (ACA).  


CMS had issued the rule because of its concern that such free standing fixed policies generally failed to provide the type of comprehensive insurance coverage required by the ACA.  It was noted by some plaintiff groups in the case that a number of individuals could afford to buy such policies and pay the ACA penalty rather than buy the comprehensive coverage called for under the ACA. 


The Panel decision concluded that the CMS rule constituted “administrative overreach.”

EPIC Summer Camp featured in The Post and Courier

On July 4, 2016, an article in The Post and Courier highlighted a summer learning initiative at North Charleston Creative Arts Elementary school in South Carolina where, for the third year, students are participating in PCG’s EPIC™ Summer Camp program. This year, EPIC Summer Camp is serving more than 1,000 students at nine schools in Charleston County and during the seven-week program, students are encouraged to be creative while exercising their problem-solving skills. EPIC content emphasizes “21st-century learning skills,” focused on creativity, collaboration, critical thinking and communication. Read the full article, “At summer day camp, teachers preach: ‘You are all scientists,’” to hear what students and staff at North Charleston Creative Arts Elementary are saying about EPIC Summer Camp.

CMS proposes changes in Medicare home health programs

On June 27, 2016, the Centers for Medicare and Medicaid Services (CMS) proposed changes to the Medicare home health prospective payment system (HH-PPS), the home health quality reporting program (HH-QRP), and the home health value-based purchasing program (HH-VBP).   The net effect of the proposed changes on home health agencies in 2017 would be to reduce aggregate Medicare payments on behalf of 3.4 million Medicare beneficiaries to 11,400 HHAs by about $180 million, about one percent of Medicare HHA expenditures.


The proposed changes to the HH-PPS would include re-basing adjustments and case-mix adjustments to the 60 day episode rate as well as changes in the methodology for calculating outlier payments.


The proposed changes to the HH-QRP would include new performance measures related to preventable hospital re-admissions, discharges to the community, controlling total Medicare spending per beneficiary, and medication reconciliation.


The proposed changes to the HH-VBP would include new payments adjustments (up or down) that will be made beginning in 2018 based on each home health agency’s VBP performance scores.  The new adjustments will be up to +/- 3 percent in 2018, gradually increasing to +/- 8 percent in 2022.  A nine state HH-VBP pilot is now underway in Massachusetts, North Carolina, Florida, Arizona, Maryland, Iowa, Nebraska, Tennessee, and Washington State.  The overall economic impact of the HH-VBP for 2018-2022 is an estimated $378 million in savings from reductions in unnecessary hospitalizations and nursing facility admissions as a result of home health quality and performance improvements. 


The proposed rules are scheduled to be published for public comment in the Federal Register on July 5, 2016.  Additional information on the proposed rules is available here