The NYS PCMH model is an integrated care delivery and payment model that ties together a service delivery model and reimbursement to promote improved health and health care outcomes that are financially sustainable. The NYS PCMH model was designed to help primary care practices evolve to assure readiness to participate in the Value Based Payment (VBP) models being developed and implemented by both public and private payers.
NYACP, in collaboration with the NYSDOH and Health Research, Inc. (HRI), will be conducting two brief surveys in the next few weeks for (1) physicians that have achieved recognition through the NYS PCMH program; and (2) those that have chosen to not participate in NYS PCMH. The purpose of the surveys will be to assess the effectiveness of the program and identify successes, barriers and concerns on sustainability and capability for value based payment.
Price transparency is a hot topic in healthcare. Patients are asking more questions related to the cost of their care. Physicians are incorporating the topic into patient visits as part of whole-person care. NYACP and ACP have supporting resources for addressing this topic. The following are resources for the most common topics encountered in practice:
Getting the Conversation Started
Recent outbreaks of measles in Rockland County, Orange County, and New York City have contributed to the largest measles outbreak in New York State since the elimination of measles in the US in the year 2000. Over 390 cases of measles outbreaks have been reported in Brooklyn and Queens alone.
Multiple studies have shown how impactful a state’s nonmedical vaccination exemption policies can be to the risk of an outbreak of a contagious disease. One recent publication in the journal of Academic Pediatrics found that “a state with easy nonmedical vaccine exemption policies is 140% and 190% more likely to experience a measles outbreak compared with states with medium or difficult policies, respectively.” The same report found that the magnitude of outbreaks decrease in half when there are fewer exemptions.
NYACP is supporting legislative efforts to address the measles outbreak, including support for NYS Bill S.2994 (Hoylman)/A.2371 (Dinowitz), which would eliminate non-medical vaccination exemptions for children. In addition, The Chapter has made available resources with the help of our members to help communicate with patients and physicians the importance of vaccinations. Here are a few:
From the DOH:
To read more, please view the Measles Page here.
*A special thanks to Rabbi Aaron Glatt, MD, FACP, for developing and producing this information to share.
5.3.19:Geriatric Spotlight: Deprescription, The New Fashion in Prescribing!
TS Dharmarajan MD, MACP, AGSF, FRCPE
Vice Chairman, Department of Medicine; Clinical Director, Geriatrics; Program Director, Geriatric Medicine Fellowship Program
Montefiore Medical Center (Wakefield Campus)
Professor of Medicine, Albert Einstein College of Medicine
Deprescription or Deprescribing is a relatively new term referring to the “appropriate and safe reduction in number or dosage of medications prescribed to an individual”; the process is intended to withdraw unwanted, ineffective medications.1 Deprescribing is not enforced, rather, is voluntary and carried out following discussions between provider and patient and/or caregiver, including acceptance by the latter. Following deprescribing the patient is followed for unexpected consequences that may warrant re-introduction of the medication.
An aging population with associated co-morbidity has resulted in the prescribing of numerous medications to older individuals. The redundant, excessive and inappropriate use of medications is termed “polypharmacy.” Definition of polypharmacy varies, ranging from three to five or more medications prescribed on a continued basis.2,3 Polypharmacy, in conjunction with over-the-counter medications and supplement use leads to adverse drug events (ADEs) and poor outcomes, including hospitalization. Examples of ADEs include falls, fractures, delirium, syncope, organ dysfunction and more. Sometimes, as exception, patients are appropriately on six or more essential medications, as with chronic kidney disease or heart failure. Seniors also visit multiple providers, each adding medications to the list; additionally, many elders also consume over-the-counter supplements.
Polypharmacy and associated ADEs result from drug-drug, drug-nutrient or drug-disease interactions. An ADE is “harm resulting from use of a drug, including all adverse drug reactions.”4 Failure to recognize an ADE leads to evaluation, additional prescribing and more poor outcomes. A new geriatric syndrome must be viewed as potentially drug related, prior to needless, expensive testing.
Who owns responsibility for addressing the burden of polypharmacy? In large part, it is the primary provider or geriatrician, whose onus it is to coordinate care for patients who visit multiple providers of care. Medication reconciliation and opportunity for deprescribing exist at every patient encounter. Periodically, a patient feels overburdened by the number of medications and initiates a request for deprescribing. Unfortunately, there is no incentive for providers to engage patients into long-drawn discussions to assess and withdraw medications which may contribute to the reluctance for providers to attempt deprescribing!
At times, reduction in the dose or drug withdrawal results in negative consequences, as with beta blockers, benzodiazepines and antidepressants. In such cases the drug must be promptly re-introduced. Options always exist. Is a non-drug (life style) approach available? Is the patient on another medication that suffices? Is there any benefit at all from the drug, considering co-morbidity and life expectancy? Has harm resulted from the drug, e.g. renal dysfunction, a fall or hyperkalemia? Several drug classes are always considerations for deprescribing: analgesics, anti-histamines, anti-psychotics, H2 blockers, proton pump inhibitors, vitamins, supplements and sedative hypnotics. In addition to improving outcomes, deprescribing reduces medication costs to patients and participating facilities.5
Ethical aspects may warrant consideration. One must factor comorbidity, life expectancy, quality of life and importantly, opinion of the patient with capacity (or that of caregiver should capacity be lacking). Properly utilized, safe deprescribing is a boon to older adults and results in better healthcare!
- Sivagnanam G. Deprescription: the prescription metabolism. J Pharmacol Pharmacother. 2016;7(3):133-37
- Rambhade S, Chakraborty A, Shrivastava A et al. A survey on polypharmacy and use of inappropriate medications. Toxicol Int. 2012;19(1): 68-73.
- Heuberger R. Polypharmacy and food-drug interactions among older persons: a review. J Nutr Gerontol Geriatr. 2012;31(4): 325-403.
- Nebeker JR, Barach P,Samore MH. Clarifying adverse drug events: a clinician's guide to terminology, documentation, and reporting. Ann Intern Med. 2004;140:795-801.
- Page AT, Clifford RM, Potter K et al. The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis. Br J Clin Pharmacol. 2016;82(3): 583-623
5.3..19: Funding Still Available: Health Information Exchange Adoption
is Now Easier with the DEIP
The New York State Department of Health (DOH), with support from Centers for Medicare & Medicaid Services (CMS), has established the Data Exchange Incentive Program (DEIP) to increase Health Information Exchange (HIE) adoption across the state for Medicaid providers.
Participating organizations are incentivized to contribute a pre-defined set of data elements to the SHIN-NY through a QE. This program is designed to help defray the cost for an organization when connecting to their local QE.
Still not connected? New York eHealth Collaborative is coordinating the rollout of the program and the incentive payments on behalf of the State Department of Health. Limited funding is still available.
Eligible practices may receive up to $13,000 in incentives to offset the cost and efforts of health information exchange adoption. In order to receive funding, all milestones must be completed by September 30, 2020 as long as funding is not exhausted before this time.
To be eligible for enrollment in DEIP, an organization must:
- Have at least one provider that accepts Medicaid (Fee-For-Service, Medicaid Managed Care, or HARP); AND
- Have at least one provider that has attested to and been paid under Medicare or Medicaid MU (any year, any stage)
You can learn more about DEIP here or you can contact your local Qualified Entity (QE) to get started.
3.26.19 MIPS Year 2 (2018) Data for the Quality Payment Program Must Be Submitted
by April 2
The data submission deadline for Merit-based Incentive Payment System (MIPS) is two weeks away for eligible clinicians who participated in Year 2 (2018) of the Quality Payment Program. Data can be submitted and updated any time until 8:00 p.m. ET on Tuesday, April 2, 2019.
CMS Web Interface users need to report their Quality performance category data by 8:00 p.m. EST on March 22, 2019. Physicians who reported Quality measures via Medicare Part B claims can sign in to qpp.cms.gov to view current performance based on claims that have been processed by your Medicare Administrative Contractor.
If you are working with a third-party intermediary to submit data on your behalf, we encourage you to sign in to the Quality Payment Program website during the submission period and review the submission for accuracy. Data cannot be resubmitted after the submission period closes.
For More Information
To learn more about how to submit data, please review the 2018 MIPS data submission FAQs, User Guide and video series available in the QPP Resource Library.
If you have questions about how to submit your 2018 MIPS data, contact:
- The Quality Payment Program by phone: 1-866-288-8292/TTY: 1-877-715-6222; or email: QPP@cms.hhs.gov
Your local technical assistance organization
3.26.19 NY Department of Health Influenza Surveillance
The New York State Department of Health (NYSDOH) collects, compiles, and analyzes information on influenza and produces a weekly report during the influenza season (October through the following May).
During the week ending March 9, 2019:
- There were 6,493 laboratory-confirmed influenza reports, a 6% decrease over the previous week.
- Of the 2,933 specimens submitted to NYS WHO/NREVSS laboratories, 651 (22.20%) were positive for influenza. 645 were for influenza A, and 6 were influenza B.
- Of the 101 specimens submitted to the Wadsworth Center, 94 were positve for influenza. 34 were influenza A (H1), 51 were influenza A (H3), 8 were influenza A (Not Subtyped), and 1 was influenza B (Victoria).
- Reports of percent of patient visits or influenza-like illness (ILI3) from ILINet providers was 2.93%, which is above the regional baseline of 3.10%.
- The number of patients hospitalized with laboratory-confirmed influenza was 1,037, a 17% decrease over last week.
- There were no influenza-associated pediatric death reported this week, and four influenza-related pediatric deaths so far this season.
Read the entire report here.
1.17.19: Drug Take Back Program Begins in New York State
From NY Assemblymember John T. McDonald III
The New York State Drug Take Back Act went into effect January 6, creating a statewide drug takeback program – paid for by drug manufacturers, not taxpayers (Ch. 120 of 2018). The program requires participation by all chain and mail-order pharmacies doing business in the state and is part of the Assembly Majority’s continued efforts to fight the opioid epidemic and save lives. The Assembly previously led the push for “I-STOP,” creating the first real-time prescription-drug database in the country.
Opioid overdoses took the lives of more than 42,000 Americans in 2016. In New York, the rate of opioid overdose deaths doubled between 2010 and 2015. The nationwide crisis has reached such epidemic proportions that life expectancy in the U.S. has decreased for the second time in three years.
The new law requires all drug manufacturers to implement a takeback program in which both chain and mail-order pharmacies offer on-site collection or prepaid envelopes for New Yorkers to dispose of unused medication. Opioid addiction often begins with the use of prescription painkillers, whether obtained legitimately through a doctor or illegally from someone else’s medicine cabinet, and that the program will help cut off supply. The program will also help ensure that these drugs are not improperly disposed of by flushing down the toilet or throwing them in the trash, which can cause them to seep into the water supply.
To learn more please read Assembymember McDonald's full blog piece here
11.9.18: Extortion Scam Targeting DEA Registrants, Including Physicians
DEA is aware that registrants are receiving telephone calls and emails by criminals identifying themselves as DEA employees or other law enforcement personnel. The criminals have masked their telephone number on caller id by showing the DEA Registration Support 800 number. Please be aware that a DEA employee would not contact a registrant and demand money or threaten to suspend a registrant’s DEA registration.
If you are contacted by a person purporting to work for DEA and seeking money or threatening to suspend your DEA registration, submit the information through “Extortion Scam Online Reporting” posted on the DEA Diversion Control Division’s website, www.DEADiversion.usdoj.gov.
Extortion Scam Online Reporting
For more information contact:
Locate DEA Field Office for your area - https://apps.deadiversion.usdoj.gov/contactDea/spring/fullSearch
Registration Service Center - 1-800-882-9539
Email - DEA.Registration.Help@usdoj.gov
11.9.18: New: ACP Practice Advisor® Opioid Risk Management Module*
This online tool can help your practice enhance patient care and office efficiency. The Opioid Risk Management module (ACP Practice Advisor log-in required) has resources to help mitigate risk and improve outcomes for patients and medical practices. It includes tools to address the major components of the Blueprint for Prescriber Education for Extended Release and Long-Acting Opioid (ER/LA) Analgesics.
On-Demand Webinars: Chronic Pain/Opioid Prescribing
Safer Opioid Prescribing (recorded August 2018)
Learn more about safer opioid prescribing–including agreements and monitoring for benefits and harms.
Managing Patients Not Benefiting From (or Being Harmed by) Opioids (recorded September 2018)
Experts in opioid management and weaning discuss how to assess patients on opioids for lack of benefit and implement a patient-centered opioid taper and treatment plan with alternative therapies, as well as how to assess for and treat opioid use disorder
These webinars are supported by Funding Opportunity 1L1CMS331476-03-00 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the presenters and do not necessarily represent the official views of HHS or any of its agencies
*Free access is available through 12/31/18.
More Opioid Treatment Resources can be found here
11.9.18: Influenza Resource Sheet
The National Governmental Resources Contractor Advisory Committee (NGS CAC) recently released a helpful information sheet for this year's influenza season. It covers Medicare reimbursement rates and coding guidelines, as well as educational products for all health care providers. It also contains helpful links immunization-related websites, like the Food and Drug Administration, National Vaccine Program, Immunization Action Coalition, and more!
These resources were recently reviewed with the NGS Contractor Advisory Committee (CAC). The Chapter is well represented on the CAC with two NYACP Masters, John Maese, MD, MACP, and Ed Stehlik, MD, MACP serving.
You can view the fact sheet here.
11.9.18: CMS Releases Letter on Reducing Administrative Burdens
On Thursday, November 8, CMS released a letter to physicians outlining how the agency is reducing burden through reform of documentation and coding requirements. An excerpt:
"CMS has been hard at work to address the burden placed on clinicians by federal health care regulations. Through [CMS'] “Patients over Paperwork” initiative [they] are collecting feedback and updating policies in Medicare and Medicaid that are outdated, duplicative, or overly burdensome.
One key initiative that [CMS has] launched involves streamlining the measures that clinicians report; a recent Health Affairs study found that U.S. medical practices in four common specialties on average spend, per physician, a striking 15.1 hours per week and over $40,000 per year reporting quality metrics. The litany of regulations in healthcare contributes to the consolidation we’re seeing in the system. According to a survey by the American Medical Association, the percent of clinicians with ownership status in their practice declined from 53 percent in 2012 to 47 percent in 2016, with younger physicians more than three times as likely as older physicians to be employed by hospitals."
You can read the full letter here.
11.9.18: Promoting Interoperability: Attestation and Financial Support with NyeC
The New York eHealth Collaborative's Medicaid Eligible Professional Program (EP2) provides free assistance and a hands-on approach to help your practice successfully achieve Promoting Interoperability (formerly Meaningful Use) objectives.
FREE Services include:
- Readiness assessment
- Promoting Interoperability (formerly Meaningful Use) Support
- Education and Training
- Audit Readiness and Preparation
- HIE Connectivity
Eligible practices can receive up to $34,000 in incentive payments through New York Medicaid EHR Incentive Program. The EP2 Program is only open to providers who started participating in the New York Medicaid EHR Incentive Program in 2016.
You can find out more here.
9.18.18: ACP Comments on Medicare Payment Proposal, Offers Alternate Way Forward
The Centers for Medicare & Medicaid Services (CMS) released the proposed rule for the 2019 Medicare physician fee schedule and Quality Payment Program on July 12, 2018, which would change documentation requirements and how physicians are paid for office visits. Since that time, ACP has been reviewing the proposed rule in detail and evaluating potential short- and long-term effects on Internal Medicine specialists, subspecialists, and their patients.
ACP strongly supports CMS easing documentation of E/M services. As ACP has long advocated and asserted, the proposed changes can and should be implemented starting next year, without resulting in reductions in pay for the most complex visits.
The College strongly opposes the proposed change to pay the same for complex cognitive care as more basic care, which would adversely affect internal medicine specialists, subspecialists, and their patients and urges CMS to test alternatives to their proposed flat fee structure.
ACP observed in a 2015 position paper on clinical documentation, “In place of a thoughtfully written review of systems that listed pertinent positive or negative findings, clinically meaningless terms such as ‘ten point review of systems was negative’ were introduced into the record to satisfy E&M guidelines ... [an] imbalance of values has been created, with compliance, coding, and security trumping patient care, clinical well-being, and efficiency.”
ACP's comments offer an alternative way forward for CMS to immediately implement changes that will address the adverse impacts of documentation on patient care while preserving the principle that more complex cognitive care must be valued more than less complex care. If CMS eases documentation of E/M services without devaluing complex cognitive care, it would be a big step forward for ACP members and ACP's Patients Before Paperwork initiative.
In its official comment letter to CMS last week addressing the proposed rules, ACP detailed concerns and made recommendations for change. You can read the letter here.
9.18.18: Make Your Voice Heard: Take this Survey on Reducing Administrative from ACP
ACP is continuously working on your behalf to reduce administrative burdens and improve the Medicare payment system, as well as press legislators and regulators for changes that can successfully improve your daily work experience and patient care.
As part of that work, ACP is looking for members to complete this survey on Administrative Tasks and Best Practices. This survey will better assist the College in advocating for reform.
8.15.18: 2017 MIPS Performance Feedback and Payment Adjustment Update
If you submitted 2017 Merit-based Incentive Payment System (MIPS) data through the Quality Payment Program website, you can now view your performance feedback and MIPS final score.
CMS originally displayed a single payment adjustment amount, which included an additional adjustment for exceptional performance available to MIPS eligible clinicians and groups with a final score of 70 or greater. However, based on feedback from various clinicians and groups, CMS has updated the system so that the MIPS payment adjustment, and additional adjustment for exceptional performance (if applicable) are now displayed separately. The system will continue to display the total MIPS payment adjustment, which is a sum of MIPS performance and exceptional performance.
How to Access Your Final Score and Feedback
You can access 2017 MIPS performance feedback and final score by:
Upcoming Office Hours
CMS will be hosting an office hours session on August 14 to provide a brief overview of MIPS 2017 performance feedback and targeted review and to answer frequently asked questions.
8.3.18: FDA Approves Cannabis-Derived Drug
Excerpt Courtesy of Nixon-Peabody
On June 25, the Food and Drug Administration (FDA) approved Epidiolex, the first drug derived from cannabis in the United States. Epidiolex, produced by GW Pharmaceuticals (in the United Kingdom), is derived from cannabidiol (CBD), a non-psychoactive part of cannabis, which is intended to treat patients with Dravet and Lennox-Gastaut syndromes, two rare forms of epilepsy. Clinical trials have demonstrated that patients taking Epidiolex experience 40% less seizures.
Having been approved by the FDA, Epidiolex will now have to be approved by the Drug Enforcement Administration (DEA) before becoming available in jurisdictions that have legalized medical cannabis use. While legislation has been and is being introduced to change cannabis’s current classification as a Schedule I drug with no medical value, CBD, like cannabis, requires DEA reclassification, which is expected to occur within the next 90 days.
While other drugs have been approved to treat Lennox-Gastaut syndrome, Epidiolex is the first also specifically approved for Dravet syndrome. Analysts anticipate that Epidiolex will also be prescribed off-label (for purposes it has not been officially approved for) to treat many epileptic diseases besides Dravet and Lennox-Gastaut syndromes. Additionally, experts believe that Epidiolex’s approval will increase patient safety because it provides a regulated medication with standard dosing and supply to patients who were previously being treated with CBD at home, some without dosage guidance.
In case you missed it last week, see below for a link to the webcast of the panel discussion on Evaluation & Management Coding:
CMS Administrator Seema Verma, Dr. Rucker, National Coordinator for Health Information Technology, Dr. Kate Goodrich, CMS Chief Medical Officer and Director of CCSQ, Dr. Anand Shah, CMMI Chief Medical Officer, and Dr. Thomas Mason, ONC Chief Medical Officer host an informative live telecast on E/M Coding Reform. Many stakeholders maintain that current CMS evaluation and management documentation guidelines are outdated, complex, ambiguous, and that they fail to distinguish meaningful differences among code levels. CMS has acknowledged that the current guidelines create an administrative burden and increased audit risk for some providers. In response, CMS announced its intention to undertake a multi-year effort—with the input of providers and other stakeholders—to revise the current E/M documentation guidelines.
ACP has published a paper in the Annals of Internal Medicine that examines ways to reduce health care disparities. Addressing Social Determinants to Improve Patient Care and Promote Health Equity provides a set of recommendations aimed at improving patient care and health outcomes, and overcoming the special challenges associated with adverse conditions in which people are born, grow, work, and live. The Chapter's Council reviewed this paper in a lively discussion led by Maria Carney, MD, FACP, NYACP Long Island Governor.
Social determinants of health are non-medical factors that can impact an individual’s overall health and health outcomes. These include conditions that shape a patient’s daily life, such as income, social status and education, their physical environment including access to safe water and clean air; the safety and conditions of their workplace and home; employment opportunities and social support networks; and access to health services. The Council has made several suggestions to ACP to create meaningful resources for our physician members.