Tag Archives: physicians: reform updates

United States Supreme Court to Hear Affordable Care Act Cases

vIn a highly anticipated decision, on November 14, 2011 the United States Supreme Court granted certiorari in three cases on the constitutionality of the Affordable Care Act (“ACA”): National Federation of Independent Business v. Kathleen Sebelius, Secretary of HHS, et al.; Florida, et al. v. Department of Health and Human Services; and Department of Health & Human Services et al. v. Florida, et al. The Court’s review will address four fundamental questions: (1) whether the ACA’s individual mandate is constitutional, (2) whether the individual mandate may be severed from the ACA if it is unconstitutional, (3) whether the claim brought by the opponents to the mandate is barred by another federal statute, and (4) whether the ACA’s expansion to Medicaid coverage was valid. The Court has granted a total of four and a half hours of oral argument for the three issues, which is highly unusual. This decision will be monumental for the future of the ACA, and will be closely followed by Duane Morris attorneys.

View the United States Supreme Court’s order here.

CMS Announces Coverage of Preventive Services to Reduce Cardiovascular Disease

Recently the Centers for Medicare and Medicaid Services (“CMS”) announced new coverage under the Medicare program for preventive services for the reduction of cardiovascular disease. CMS’ decision details that Medicare will now cover one-to-one cardiovascular disease risk reduction visits that may include three components: (1) encouraging aspirin use; (2) high blood pressure screening for adults 18 years or older, and (3) intensive behavioral counseling to encourage healthy diets.

The new coverage is part of a joint initiative between CMS and the Centers for Disease Control, the Million Hearts Initiative. Read more about the initiative here, and access CMS’ entire coverage decision here.

DC Circuit Court of Appeals Upholds Individual Mandate

On November 8, 2011, in the latest scrimmage regarding the Affordable Care Act’s (ACA’s) individual mandate, the D.C. Circuit Court of Appeals upheld the mandate’s constitutionality. The Court found that Congress could create “national solutions to national problems, no matter how local–or seemingly passive–their individual origins,” and that the individual mandate was therefore constitutional because it was within Congress’ authority.

On November 10, 2011, the United States Supreme Court will hold a private conference to decide whether to hear the challenges to the ACA.

Read the entire decision here.

2012 Hospital Outpatient Prospective Payment System Final Rule Released by CMS

On November 1, 2011, the Centers for Medicare and Medicaid Services (“CMS”) released the 2012 Hospital Outpatient Prospective Payment System Final Rule with comment period (“Final Rule”). The Final Rule, effective January 1, 2012, addresses the 2012 hospital outpatient prospective payment system including payment policies, the process for physician-owned hospitals seeking an exemption on the prohibition on expansion, and changes to patient notification requirements.

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2012 Physician Fee Schedule Final Rule Released by CMS

On November 1, 2011, the Centers for Medicare and Medicaid Services (“CMS”) released the 2012 Physician Fee Schedule Final Rule with comment period (“Final Rule”). Effective January 1, 2012, the Final Rule addresses several key components of physician reimbursement through Medicare including, to name a few, the new practice expense relative value units, changes to the adjustment of geographic practice cost indices, updates to the electronic health records incentive program, expanding the list of eligible services for telehealth services coverage, and reducing physician payments at physician wholly owned or hospital operated practices for hospital admissions occurring within 3 days of a physician service.

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CMS Releases Final ACO Regulations

Yesterday afternoon the Centers for Medicare & Medicaid Services (CMS) released the long anticipated final Accountable Care Organization (ACO) regulations, after considering the nearly 1200 comments submitted in response to the earlier proposed regulations. ACOs, created under the Affordable Care Act, are a model of health care that focuses on collaboration between providers across a continuum of care including different health care settings. The new regulations set forth the specifics for the program including payment mechanisms through which providers will be compensated for care provided through the integrated ACO model, as well as performance requirements for participating providers. The first ACOs will start operating in 2012.

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HHS Announces Launch of Primary Care Bonus Initiative

The U.S. Department of Health & Human Services (HHS) recently announced the launch of its new Primary Care initiative to provide bonuses to primary care doctors for improvement of care coordination and cost efficiency. The goal of the initiative, created under the Affordable Care Act, is to facilitate care that is focused on the patient, coordination, and higher quality. The bonuses will be offered through commercial and state health insurance plans, and will come in the form of monthly fees above and beyond Medicare fees received for patient care. HHS has identified five primary areas that the fees will support including personalized care plans for chronically ill patients, 24-hour access to care and health information, preventive care, patient and family participation in care, and coordination among providers.

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Medicare Advantage Premiums Falling and Enrollment Up for 2012

HHS recently announced its expectation that Medicare Advantage premiums will fall approximately four percent in 2012, with enrollment expected to increase by 10 percent. This drop in premiums has been supported by the Affordable Care Act, which allowed CMS to prevent substantial cost increases or program cuts through elimination of co-pays and deductibles for Medicare-covered preventive services and additional discounts for Medicare beneficiaries that reach the prescription coverage “donut hole.” CMS is also offering high-quality performance incentives, including financial rewards and continuous marketing and enrollment to Five-Star Medicare Advantage and Part D plans.

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CMS Asking Providers to Submit Letter of Intent to Participate in Bundled Payments for Care Improvement Initiative

Providers, including hospitals, physicians and non-physician practitioners still have time to contribute to the growing accountable care model by submitting to CMS a Letter of Intent to participate in the Bundled Payments for Care Improvement initiative to CMS. CMS is seeking applicants who are willing to participate in one of the four models for episode-based payment for acute and post-acute care created under the Bundled Payments for Care Improvement initiative. The initiative will start in 2012 and is geared toward aligning incentives between providers to improve coordination throughout episodes of care. The four models are described in detail here: http://innovations.cms.gov/documents/pdf/Fact-Sheet-Bundled-Payment-FINAL82311.pdf.

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Pennsylvania District Court Finds Individual Mandate Unconstitutional

On September 13, 2011, the United States District Court of the Middle District of Pennsylvania held that the Affordable Care Act’s individual mandate was unconstitutional as a violation of the Commerce Clause. In Goudy-Bachman v. U.S. Department of Health and Human Services, No. 1:10-CV-763 (M.D. Pa. Sept. 13, 2011), the court found, similar to its predecessors in other courts, that the federal government was one of limited enumerated powers and that “Congress [could not] invoke its Commerce Clause power to compel individuals to buy insurance as a condition of lawful citizenship or residency.” Thus, although the court recognized that “[t]he nation undoubtedly faces a health care crisis,” it severed the individual mandate, the guaranteed issue, and preexisting conditions reforms from the Affordable Care Act as unconstitutional. However, because the provisions found unconstitutional were severed from the Affordable Care Act, this decision allows the rest of the Act to stay intact and operative. The full decision is available at http://www.pamd.uscourts.gov/opinions/conner/10v763a.pdf.