SBCMS News/Media

Call to Action: Act now to ensure patients can get needed prescriptions

Flawed implementation of a new state law that requires all security prescription forms to have a uniquely serialized number law has left pharmacies unable to fill prescriptions and patients being refused necessary medications.

The California Medical Association (CMA) is currently working on a legislative fix to address this issue immediately to ensure no patient goes without the essential medicine and care they need. Last week, AB 149 (Assemblymembers Cooper, Arambula and Low) was introduced to correct the flawed implementation the new law, which was intended to improve the security of physician prescription pads as a solution to the opioid crisis.

AB 149 will be heard in the Assembly Business and Professions Committee tomorrow, January 29, then will head to the Assembly floor. Contact your legislators today and urge them to take swift action so patients can once again receive the medical treatment they require.

Click here to contact your legislator through CMA’s grassroots portal. A sample letter and talking points are provided.

Bill introduced to fix security prescription law

Flawed implementation of a new state law that requires all security prescription forms to have a uniquely serialized number law has left pharmacies unable to fill prescriptions and patients being refused necessary medications.

The California Medical Association (CMA) is currently working on a legislative fix to address this issue immediately to ensure no patient goes without the essential medicine and care they need. This week, AB 149 (Assemblymembers Cooper, Arambula and Low) was introduced to correct the flawed implementation the new law, which was intended to improve the security of physician prescription pads as a solution to the opioid crisis.

CMA understands that reordering security prescription forms presents a great expense for many physician practices and is working to ensure that physician are able to comply with this new requirement in a way that does not adversely affect patient care.

The California Board of Pharmacy recently said it would “not make enforcement a priority” if pharmacists choose to fill prescriptions written on security prescription forms that were compliant prior to January 1, but are not compliant with the new serialization requirement. The pharmacy board has urged pharmacists and pharmacies to exercise their best professional judgement when handling these situations, to determine if it is in the best interest of the patient or public health or safety to nonetheless fill such prescriptions. Similarly, the Medical Board of California has also recently issued a memorandum emphasizing the pharmacy board's decision not to aggressively enforce the new requirement. Prescribers should, however, expect to receive calls from pharmacies seeking to validate prescriptions written on non-compliant forms.

For more information, including answers to frequently asked questions about the implementation of this new law, see the joint statement from the medical board, pharmacy board and the Department of Justice.

CMA will provide additional information as it becomes available.

Contact: CMA legal information line, (800) 786-4262 or via email.

Prop. 56 webinar: Are you getting your share of the supplemental Medi-Cal funds?

The California Health Care, Research and Prevention Tobacco Tax Act of 2016 (Prop. 56) created new revenues dedicated to the Medi-Cal program. Physicians receive supplemental payments in both fee-for-service and Medi-Cal managed care when providing Medi-Cal services under certain CPT codes. A total of $325 million was allocated for physician payments in the budget for 2017-18, with $488 million proposed for 2018-19.

The California Medical Association (CMA) is hosting a webinar with the California Department of Health Care Services on Wednesday, November 7, to discuss the status of distribution of both 2017-2018 and 2018-2019 supplemental Medi-Cal funds and their distribution timelines. This webinar will cover eligible services, supplemental payment amounts by CPT code and tips on ensuring your practice receives the full amount of eligible funds.

It will also provide information on how to file grievances on Prop. 56 funds and how the CMA can help.  

To register for the free, one-hour webinar, “Prop 56 Implementation: What Physicians Need to Know about the Supplemental Payments,” visit cmadocs.org/events.

CMA Applauds the Enactment of Federal Opioid Legislation

The California Medical Association (CMA) applauded the enactment of H.R. 6 – a sweeping bipartisan bill that addresses nearly every component of the national opioid epidemic.

The legislation would improve access to preventive services, opioid use disorder treatment programs, medication-assisted treatment (MAT) and non-opioid therapies, including mental health services. It would lift restrictions on using telemedicine for treatment of substance use disorders. To address the escalation in overdose deaths, it would also strengthen law enforcement efforts to crack down on international shipments of illicit drugs such as fentanyl. H.R. 6 also includes an innovative Medicare alternative health care delivery model to allow a multidisciplinary approach to managing and coordinating care for patients with substance use disorders. 

“H.R. 6 provides crucial resources to expand access to treatment and prevention programs to combat opioid use disorder,” said CMA President David H. Aizuss, M.D. “On behalf of California physicians, we commend Congress for working with CMA and others to create a balanced approach that ensures patients have access to appropriate treatment, while reducing the risk of prescription misuse, addiction and overuse.”

Even prior to the passage of H.R. 6, California has been making significant strides in addressing the opioid epidemic. A recent American Medical Association (AMA) report found that California saw two consecutive years of decreases in prescription-related opioid deaths, as well as a 24 percent decrease in opioid prescriptions between 2014 and 2017, which surpassed the national average. CMA offers physicians who prescribe opioids and other controlled substances access to up-to-date information on a wide range of issues, including how to provide treatment that meets the community standard of care, and how to manage the risks that come with prescribing opioids.

“These additional federal resources, combined with our current state efforts, further enable California physicians to lead the nation in implementing effective policies that focus on treatment for those suffering from substance use disorders, while ensuring access to high-quality, evidence-based treatment for pain,” said Dr. Aizus.

CMA proposes site-neutral payments for some physician services

The Centers for Medicare and Medicaid Services (CMS) has proposed eliminating the Medicare site of service payment differential for physician services. Under the proposed policy, Medicare would pay the same amount for office visit services provided by physicians in “off-campus” hospital outpatient departments as it would for the same office visit service provided in a physician’s office.

Currently, Medicare pays a “facility fee” that results in a much higher rate for the same service when performed in outpatient clinics owned by hospitals, rather than in a physician’s office. For example, cardiac imaging payments are more than triple when patients receive care at a hospital outpatient department instead of a physician’s office – roughly $2,100 vs. $655.

This rule change would result in significant savings for Medicare and its beneficiaries and foster greater competition in the health care market.

Health care policy experts have demonstrated that this site of service payment differential has incentivized hospitals to acquire physician practices, with an 86 percent increase between 2012 -2015 in number of physician practices owned by hospitals nationwide. This unprecedented trend in hospital acquisition of physician practices has caused provider consolidation in the marketplace that has decreased competition, led to increased prices and premiums in the private sector, and increased Medicare costs. Medicare hospital spending has increased 60 percent since 2000.

UC Berkeley researchers recently reported that 40 percent of California physicians now work for foundations owned by hospitals, up from 25 percent in 2010. Nationwide, nearly 33 percent of physicians were employed by hospitals in 2014 (the most recent data available), up from 29 percent in 2012. 

Most health care economists, policymakers and clinicians are now supporting site neutral payments in Medicare to reverse the policies that have artificially driven hospital-physician consolidation and increased costs. 

The California Medical Association (CMA) believes that two factors led to this hospital-physician consolidation: The higher facility fees for hospital outpatient services and the low Medicare physician payment rates.

Medicare physician payments have remained flat since 2001, and now lag at least 25 percent behind the costs to operate a medical practice. While payments have remained flat, the administrative and reporting burdens of running a practice have dramatically increased. Without the resources to invest in practice infrastructure, such as EHRs and quality improvement activities now required for participation in value-based payment programs, independent practices have been driven to seek resources and assistance from hospitals.   

To reverse the trend in hospitals acquiring physician practices and the consolidation in the market that has increased costs, CMA is recommending the following:

• CMS should eliminate the site of service payment differential for ALL services (not just office visits) and ALL settings (off campus and on-campus outpatient departments, except emergency departments).
• CMS should reinvest the savings achieved by site neutrality in a budget neutral way by reinvesting in physician payment so that independent practices have the resources to remain viable, protect access to care and participate in value-based payment programs.
• CMS should provide a six-month transition period for providers to make adjustments, transition their practices, and maintain continuity of care for their patients.

CMA pushes back on CMS' proposed Medicare payment changes

The California Medical Association (CMA) recently submitted comprehensive comments to the Centers for Medicare and Medicaid Services (CMS) on the proposed 2019 Medicare Physician Fee Schedule and MACRA Quality Payment Program rule.

CMA is supporting CMS’s proposal to substantially reduce the Evaluation and Management (E/M) documentation requirements because it would reduce note bloat, improve workflow, and allow physicians to devote more time to their patients.

However, CMA is strongly opposed to the proposal to restructure payment and coding for (E/M) office visits by collapsing the codes from five to two for both new and established patients. Even with the new proposed add-on codes for prolonged visits, primary care and certain specialties treating sicker patients, the proposal would result in significant payment cuts that would harm physicians in specialties that treat the sickest patients, as well as those who provide comprehensive primary care. Collapsing E/M codes as proposed would jeopardize access to care for the chronically ill and patients with complex conditions.

CMA believes there are a number of unanswered questions and potential unintended consequences that would result from the coding policies in the proposed rule. CMA strongly recommends that CMS work with CMA and the proposed American Medical Association task force to develop alternative solutions.  

CMA also strongly opposes the new multiple service payment reduction policy in the proposed rule, as the issue of multiple services on the same day of service was factored into prior valuations of the affected codes and is an important payment for physicians, as well as patient convenience.

Provisions CMA supports:

• Year 3 of the CMA-sponsored California geographic payment updates and the transition to metropolitan statistical areas
• New payments for technology-based and telehealth services
• E/M documentation reduction
• Eliminating extra documentation requirements for home visits
• Eliminating the prohibition on billing for same-day visits by physicians in the same group or medical specialty

Provisions CMA opposes:

• New E/M payment structure
• Multiple procedure payment reduction
• Reimbursement reduction for new drugs administered in physician offices
• Reporting expansion for physician office labs

For more information:

• CMA’s Comments on the Proposed Medicare Physician Payment Rule
• AMA Summary of the Proposed Rule
• California Geographic Payment Impact Analysis
• Specialty Specific Impacts Including Payment Accuracy Adjustments
• Estimated Impact of CY2019 Evaluation and Management Proposed Policy by Medicare Specialty
• Estimated Impact on Total Allowed Charges by Specialty

CMA urges CMS to simplify the Quality Payment Program

The California Medical Association (CMA) has submitted comments to the Centers for Medicare and Medicaid Services (CMS) on the proposed changes to the Medicare Quality Payment Program for 2019.

CMA is disappointed that CMS did not reduce the reporting burdens in the Merit-based Incentive Payment System (MIPS) program in a more meaningful way. We also oppose the confusing new scoring tiers (gold, silver and bronze) and have urged CMS to simplify and overhaul the complex MIPS scoring system.

CMA strongly urges CMS to maintain the 10 percent weight of the cost category, rather than increasing it to 15 percent as proposed. Vast methodology improvements should be made to the cost category before its weighting is increased. Otherwise, physicians will be disincentivized from treating the sickest and most vulnerable patients, thereby jeopardizing access to care. CMA has also requested a delay in the new attribution methods for the inpatient condition measures.

CMA continues to urge CMS to expand the number and types of innovative physician-led alternative payment models (APM) and to remove the current administrative and financial barriers to participation. California physicians have been innovators in health care delivery and we cannot emphasize more strongly the need to move forward with more innovative physician-led models. APMs can address the shortcomings of a fee-for-service system that fails to incentivize high-value services, such as chronic care case management or palliative care – services that reduce spending and improve care.

CMA has also urged CMS to:

• Significantly reduce the number of quality measures; restore the topped-out quality measures to give physicians a sufficient number of measures to report; reduce the threshold on patients from 60-50 percent; and only require 90 days of reporting.
• Eliminate the requirement for physicians to report all-payor data.
• Only require yes/no attestations in the electronic health record (EHR) Promoting Interoperability category and allow physicians to choose from a larger menu of measures applicable to their practice.
• Enforce EHR vendor interoperability and accountability
• Require vendors, not physicians, to report on certified EHR technology functionality and to bear the costs for interoperability updates.
• Reward high-performing physicians within 1-2 standard deviations of the national average.
• Restore the Small Practice Bonus to the overall MIPS score, rather than restricting it to the Quality category.
• Reduce the barriers to participation in virtual groups.

CMA has heard from numerous physicians across the state, in all specialties, from solo practice to large, sophisticated medical groups, who made substantial investments in order to participate in the MIPS program. Most of these physicians received high to perfect performance scores for 2017, but have now been told by CMS that they will only receive a 0.2-0.3 percent bonus in 2019 – if they receive a bonus at all. Additionally, APMs are so limited that these physicians cannot participate in the APM track either. Physicians are left without sustainable payment options and few resources to improve the quality of care.

While CMA understands that CMS is not responsible for the budget neutrality requirements of the Medicare Access and CHIP Reauthorization Act, the limited return on investment has discouraged many physicians to the point of withdrawing from MIPS and Medicare altogether. CMA and the American Medical Association have urged CMS to seriously consider these issues and work with physicians on improvements that will allow physicians to continue to participate in the program.

DHCS receives approval on Medi-Cal supplemental tobacco tax payments for FY 2018-2019

Have you received your supplemental Medi-Cal managed care payments?

Vote on Senate opioid package expected this week

• CMA’s white papers on prescribing opioids
• Links to relevant documents in CMA’s health law library
• Continuing medical education courses and webinars
• Current information on the state's prescription drug monitoring database
• Resources on prescribing controlled substances safely and effectively to relieve pain, while simultaneously reducing the risk of prescription medication misuse, addiction and overdose