Medicare Program; Contract Year 2019 Policy and Technical Changes to the Medicare Advantage, Medicare Cost Plan, Medicare Fee-for-Service, the Medicare Prescription Drug Benefit Programs, and the PACE Program. Final rule.

This final rule will revise the Medicare Advantage (MA) program (Part C) regulations and Prescription Drug Benefit program (Part D) regulations to implement certain provisions of the Comprehensive Addiction and Recovery Act (CARA) to further reduce the number of beneficiaries who may potentially misuse or overdose on opioids while still having access to important treatment options; implement certain provisions of the 21st Century Cures Act; support innovative approaches to improve program quality, accessibility, and affordability; offer beneficiaries more choices and better care; improve the CMS customer experience and maintain high beneficiary satisfaction; address program integrity policies related to payments based on prescriber, provider and supplier status in MA, Medicare cost plan, Medicare Part D and the PACE programs; provide an update to the official Medicare Part D electronic prescribing standards; and clarify program requirements and certain technical changes regarding treatment of Medicare Part A and Part B appeal rights related to premiums adjustments.

Getting Paid for Clinical Services.

Increasingly, pharmacists are providing advanced, patient-centered clinical services. However, pharmacists are not currently included in key sections of the Social Security Act, which determines eligibility to bill and be reimbursed by Medicare. Many state and private health plans also cite the omission from Medicare as the rationale for excluding reimbursement of pharmacists for clinical services. This has prompted forward-thinking pharmacists to seek opportunities for reimbursement in other ways, allowing them to provide value to the health care system, while carving out unique niches for pharmacists to care for patients.

Pathway to pharmacist medical provider status in Washington State.

OBJECTIVES: To describe Washington State's successful legal and legislative efforts to gain pharmacist medical provider status and major medical compensation and to compare those efforts with similar efforts in other states to identify key lessons learned. SUMMARY: Washington State Engrossed Substitute Senate Bill 5557 was enacted in 2015, securing pharmacists as medical providers and requiring compensation under major medical insurance for pharmacists providing health services (Revised Code of Washington 48.43.715). Other states have passed, or attempted to pass, pharmacist provider status bills, but none have achieved both pharmacist medical provider status and mandatory major medical compensation. CONCLUSION: Pharmacist medical provider status ideally should include recognition as a medical provider and compensation through major medical health insurance as a clinical decision maker rather than an "incident-to" provider. Both elements should be sought as part of a complete legislative package to ensure sustainable patient access to needed health care services.

Medicare Program; Medicare Shared Savings Program: Extreme and Uncontrollable Circumstances Policies for Performance Year 2017. Interim final rule with comment period.

This interim final rule with comment period establishes policies for assessing the financial and quality performance of Medicare Shared Savings Program (Shared Savings Program) Accountable Care Organizations (ACOs) affected by extreme and uncontrollable circumstances during performance year 2017, including the applicable quality reporting period for the performance year. Under the Shared Savings Program, providers of services and suppliers that participate in ACOs continue to receive traditional Medicare fee-for-service (FFS) payments under Parts A and B, but the ACO may be eligible to receive a shared savings payment if it meets specified quality and savings requirements. ACOs in performance-based risk agreements may also share in losses. This interim final rule with comment period establishes extreme and uncontrollable circumstances policies for the Shared Savings Program that will apply to ACOs subject to extreme and uncontrollable events, such as Hurricanes Harvey, Irma, and Maria, and the California wildfires, effective for performance year 2017, including the applicable quality data reporting period for the performance year.

Association Between Hospital Penalty Status Under the Hospital Readmission Reduction Program and Readmission Rates for Target and Nontarget Conditions.

Importance: Readmission rates declined after announcement of the Hospital Readmission Reduction Program (HRRP), which penalizes hospitals for excess readmissions for acute myocardial infarction (AMI), heart failure (HF), and pneumonia. Objective: To compare trends in readmission rates for target and nontarget conditions, stratified by hospital penalty status. Design, Setting, and Participants: Retrospective cohort study of Medicare fee-for-service beneficiaries older than 64 years discharged between January 1, 2008, and June 30, 2015, from 2214 penalty hospitals and 1283 nonpenalty hospitals. Difference-interrupted time-series models were used to compare trends in readmission rates by condition and penalty status. Exposure: Hospital penalty status or target condition under the HRRP. Main Outcomes and Measures: Thirty-day risk adjusted, all-cause unplanned readmission rates for target and nontarget conditions. Results: The study included 48 137 102 hospitalizations of 20 351 161 Medicare beneficiaries. In January 2008, the mean readmission rates for AMI, HF, pneumonia, and nontarget conditions were 21.9%, 27.5%, 20.1%, and 18.4%, respectively, at hospitals later subject to financial penalties and 18.7%, 24.2%, 17.4%, and 15.7% at hospitals not subject to penalties. Between January 2008 and March 2010, prior to HRRP announcement, readmission rates were stable across hospitals (except AMI at nonpenalty hospitals). Following announcement of HRRP (March 2010), readmission rates for both target and nontarget conditions declined significantly faster for patients at hospitals later subject to financial penalties compared with those at nonpenalized hospitals (for AMI, additional decrease of -1.24 [95% CI, -1.84 to -0.65] percentage points per year relative to nonpenalty discharges; for HF, -1.25 [95% CI, -1.64 to -0.86]; for pneumonia, -1.37 [95% CI, -1.80 to -0.95]; and for nontarget conditions, -0.27 [95% CI, -0.38 to -0.17]; P < .001 for all). For penalty hospitals, readmission rates for target conditions declined significantly faster compared with nontarget conditions (for AMI, additional decline of -0.49 [95% CI, -0.81 to -0.16] percentage points per year relative to nontarget conditions [P = .004]; for HF, -0.90 [95% CI, -1.18 to -0.62; P < .001]; and for pneumonia, -0.57 [95% CI, -0.92 to -0.23; P < .001]). In contrast, among nonpenalty hospitals, readmissions for target conditions declined similarly or more slowly compared with nontarget conditions (for AMI, additional increase of 0.48 [95% CI, 0.01-0.95] percentage points per year [P = .05]; for HF, 0.08 [95% CI, -0.30 to 0.46; P = .67]; for pneumonia, 0.53 [95% CI, 0.13-0.93; P = .01]). After HRRP implementation in October 2012, the rate of change for readmission rates plateaued (P < .05 for all except pneumonia at nonpenalty hospitals), with the greatest relative change observed among hospitals subject to financial penalty. Conclusions and Relevance: Medicare fee-for-service patients at hospitals subject to penalties under the HRRP had greater reductions in readmission rates compared with those at nonpenalized hospitals. Changes were greater for target vs nontarget conditions for patients at the penalized hospitals but not at the other hospitals.

Medicare Program; Medicare Shared Savings Program; Accountable Care Organizations--Revised Benchmark Rebasing Methodology, Facilitating Transition to Performance-Based Risk, and Administrative Finality of Financial Calculations. Final rule.

Under the Medicare Shared Savings Program (Shared Savings Program), providers of services and suppliers that participate in an Accountable Care Organization (ACO) continue to receive traditional Medicare fee-for-service (FFS) payments under Parts A and B, but the ACO may be eligible to receive a shared savings payment if it meets specified quality and savings requirements. This final rule addresses changes to the Shared Savings Program, including: Modifications to the program's benchmarking methodology, when resetting (rebasing) the ACO's benchmark for a second or subsequent agreement period, to encourage ACOs' continued investment in care coordination and quality improvement; an alternative participation option to encourage ACOs to enter performance-based risk arrangements earlier in their participation under the program; and policies for reopening of payment determinations to make corrections after financial calculations have been performed and ACO shared savings and shared losses for a performance year have been determined.

[Topical chemotherapy for conjunctival tumours - the medical and legal bearings of the case]. / Lokale Chemotherapie von Tumoren der Bindehaut - interdisziplinär medizinische und administrative Aspekte.

The treatment management of malignant tumours is characterised and limited by specific features of the topographical structure of the eye. The anatomic characteristics of the conjunctival sac, the movable tissue structures and the need to take care of corneal transparency and conjunctival stability are the main concerns of the experts. Clinical studies have revealed adjuvant chemotherapy to have a positive effect as a therapeutic treatment for neoplasia of the conjunctiva and cornea. Although mitomycin and interferon are widely used, there are no phase III studies on local adjuvant chemotherapy (interferon, mitomycin, 5-fluorouracil) that evaluate the proof of effectiveness, potential adverse effects or interactions with other drugs. For this reason, the currently available studies fail to comply with the jurisdiction of the German Federal Social Court. Hence, the Medical Service of the Health Insurance Funds (MDK) regionally does not accept the medical preconditions for reimbursement of the costs in adjuvant local chemotherapy. A doctor's unquestioned acceptance of such an MDK decision could have legal consequences. An off-label use is acceptable by law if there is no alternative treatment available with a higher evidence level that conforms to the medical standard. It is therefore recommendable for the Joint Federal Committee commissions the experts in ophthalmology and oncology on off-label use, to review the scientific evidence regarding adjuvant therapy of malignant tumours of the ocular surface. Only in this way can regional disparities in patient care, and intrusions on the doctor-patient relationship, be avoided.

A newly introduced comprehensive consultation fee in the national health insurance system in Japan: a promotive effect of multidisciplinary medical care in the field of radiation oncology--results from a questionnaire survey.

OBJECTIVE: The consultation fee for outpatient radiotherapy was newly introduced in the national health insurance system in Japan in April 2012. We conducted a survey on the use of this consultation fee and its effect on clinical practices. METHODS: The health insurance committee of the Japanese Society of Therapeutic Radiology and Oncology conducted a questionnaire survey. The questionnaire form was mailed to 160 councilors of the Society, the target questionees. A total of 94 answers (58% of the target questionees) sent back were used for analyses. RESULTS: The analyses revealed that 75% of the hospitals charged most of the patients who receive radiotherapy in an outpatient setting a consultation fee. The introduction of the consultation fee led to some changes in radiation oncology clinics, as evidenced by the response of 'more careful observations by medical staff' in 37% of questionees and a 12% increase in the number of full-time radiation oncology nurses. It was also shown that the vast majority (92%) of radiation oncologists expected a positive influence of the consultation fee on radiation oncology clinics in Japan. CONCLUSIONS: Our questionnaire survey revealed the present status of the use of a newly introduced consultation fee for outpatient radiotherapy, and the results suggested its possible effect on promoting a multidisciplinary medical care system in radiation oncology departments in Japan.

Medicare program; inpatient rehabilitation facility prospective payment system for federal fiscal year 2014. Final rule.

This final rule updates the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2014 (for discharges occurring on or after October 1, 2013 and on or before September 30, 2014) as required by the statute. This final rule also revised the list of diagnosis codes that may be counted toward an IRF's "60 percent rule'' compliance calculation to determine "presumptive compliance,'' update the IRF facility-level adjustment factors using an enhanced estimation methodology, revise sections of the Inpatient Rehabilitation Facility-Patient Assessment Instrument, revise requirements for acute care hospitals that have IRF units, clarify the IRF regulation text regarding limitation of review, update references to previously changed sections in the regulations text, and revise and update quality measures and reporting requirements under the IRF quality reporting program.

Understanding how the Physician Quality Reporting System affects primary care physicians.

The Physician Quality Reporting System (PQRS) uses a combination of payment incentives and adjustments to promote reporting of quality information by eligible professionals who satisfactorily report data on quality measures for covered Physician Fee Schedule services furnished to Medicare Part B Fee-for-Service beneficiaries. Physicians should become familiar with the PQRS core measures to maintain compliance with the Centers for Medicare & Medicaid Services. Adherence to these basic guidelines will allow physicians to not only maximize their income, but also increase quality of care, decrease complications, and decrease healthcare expenditures.

Episodes of care: is emergency medicine ready?

Optimizing resource use, eliminating waste, aligning provider incentives, reducing overall costs, and coordinating the delivery of quality care while improving outcomes have been major themes of health care reform initiatives. Recent legislation contains several provisions designed to move away from the current fee-for-service payment mechanism toward a model that reimburses providers for caring for a population of patients over time while shifting more financial risk to providers. In this article, we review current approaches to episode of care development and reimbursement. We describe the challenges of incorporating emergency medicine into the episode of care approach and the uncertain influence this delivery model will have on emergency medicine care, including quality outcomes. We discuss the limitations of the episode of care payment model for emergency services and advocate retention of the current fee-for-service payment model, as well as identify research gaps that, if addressed, could be used to inform future policy decisions of emergency medicine health policy leaders. We then describe a meaningful role for emergency medicine in an episode of care setting.