The Return on Your Dues Investment

The American Hospital Association (AHA) is proud to be working for you. And as you transform health care delivery, we are transforming to better meet your needs. Below are just some of the advances we have made in the past year by working together and speaking with one voice to advocate for hospitals, health systems and the patients and communities they serve.

On the Hill…

Protecting Health Coverage. Working together throughout the debate over the future of the Affordable Care Act, we protected health coverage for millions and ensured hundreds of billions of dollars were not stripped from health care programs, such as Medicaid, that serve our most vulnerable. Through sustained grassroots advocacy, we shared our concerns in person with every member of Congress. This included sending more than half a million emails to congressional offices and urging thousands more to take action via television/radio ads and social media. Telling our story and sharing the potential real-life impact on patients helped drive the national conversation in the media and online.

In addition, as urged by the AHA, Congress in 2018 passed a 10-year extension of funding for the Children’s Health Insurance Program.

Delaying Medicaid DSH Cuts. The Bipartisan Budget Act (BiBA), passed in February 2018, delayed $5 billion in Medicaid disproportionate share hospital reductions scheduled for fiscal years 2018 and 2019. Last fall, at AHA’s urging, 221 members of the House of Representatives urged congressional leaders to delay for at least two more years cuts to hospitals that serve a disproportionate share of Medicaid and uninsured patients.

Bringing Stability to Rural Health Care. As urged by AHA, the BiBA extended a number of critical programs protecting health care in rural communities:

  • Low-volume Adjustment Program – The bill extended for five years, through FY 2022, the enhanced LVA program, which expired Sept. 30, 2017. However, the bill changes the program so that, for FYs 2019 through 2022, the add-on payment will be a sliding scale adjustment ranging from 25 percent for low-volume hospitals with total discharges of 500 or fewer, to no adjustment for hospitals with more than 3,800 total discharges.
  • Medicare-dependent Hospital Program – The bill extended for five years, through FY 2022, the MDH program, which expired Sept. 30, 2017, and requires a study to examine payments made under the program. AHA has long advocated for the extension of this vital program and will continue to advocate that it be made permanent.
  • Ambulance Add-on Payments – As advocated by AHA, the bill extended the 2 percent urban and 3 percent rural ambulance add-on payment for five years through calendar year 2022. It also extended the “super rural” add-on through CY 2022.

Introduction of the Rural Emergency Medical Center Act. Building on the work of the AHA Task Force on Ensuring Access in Vulnerable Communities, secured the introduction of The REMC Act of 2018 to create a new designation under the Medicare program allowing hospitals meeting certain criteria to transition to a 24/7 emergency medical center with enhanced reimbursement and transportation to higher acuity facilities, as needed.

Extending the Direct Supervision Moratorium. As urged by AHA, the BiBA extended the enforcement moratorium on “direct supervision” of outpatient therapeutic services for critical access hospitals and small, rural hospitals with 100 or fewer beds for CY 2017. The Centers for Medicare & Medicaid Services, in the CY 2018 outpatient prospective payment system (PPS) final rule, extended the moratorium for CYs 2018 and 2019 but did not include the remainder of 2017. The bill closed the gap so that hospitals are no longer at risk for enforcement actions. Further, the bill expanded the type of personnel permitted to supervise cardiac, intensive cardiac and pulmonary rehabilitation programs to include certain non-physician practitioners.

Reducing EHR Burden. The BiBA eliminated a clause in the Health Information Technology for Economic and Clinical Health (HITECH) Act that mandated more stringent measures over time in the EHR Incentive Program. AHA advocated for this relief for hospitals and CAHs from Stage 3 Meaningful Use provisions that are challenging to meet and require use of immature technology standards.

Expanding Access to Telehealth. Telehealth continues to be widely discussed on Capitol Hill, and the BiBA will expand Medicare coverage and payment of telehealth for stroke patients in Medicare accountable care organizations and by Medicare Advantage plans. Several stand-alone telehealth bills saw action in both the House Energy & Commerce and Ways & Means Committees.

Extending Access to Rural Broadband. The omnibus appropriations bill passed in March 2018 included $600 million for a new Department of Agriculture pilot program to expand broadband access in rural areas, as well as telehealth programs.

Fighting th Opioid Epidemic. Helped secure passage of the SUPPORT for Patients and Communities Act, which will provide hospitals with needed tools and resources to better care for patients with substance use disorders and to prevent further addiction; it partially repeals the longstanding Institutions for Mental Diseases exclusion by giving state Medicaid programs the option to cover up to 30 days per year of services for SUD in an IMD for patients 21-64 years old.

Long-term Care Hospital Payments. The BiBA extended the current blended payment rate applied to LTCH site-neutral cases for an additional two years, which will now include cost-reporting periods beginning during FYs 2018 and 2019. To offset this provision, for FYs 2018 through 2026, the bill will reduce the market basket otherwise applied to LTCH site-neutral cases by 4.6 percent.

Preserving Hospitals’ and Health Systems’ Access to Tax-exempt Bond Financing. At AHA’s urging, House and Senate conferees working on the final tax reform bill protected hospitals’ access to tax-exempt private-activity bonds, ensuring access to modernized facilities that are better able to provide high-quality care in thousands of communities across America. A vital source of low-cost capital financing, which helps keep health care more affordable, private-activity bonds are a proven benefit to the public at large and will be preserved under this legislation. The final bill also preserved in the near term the definition of taxable income for purposes of calculating interest expense deductions as Earnings Before Interest, Taxes, Depreciation, and Amortization. Moreover, it lowered the threshold from 10 percent to 7.5 percent for taxpayers with high medical expenses to make medical expense deductions for two years.

Fighting for 340B. At AHA’s urging, Reps. David McKinley (R-WV) and Mike Thompson (D-CA) introduced H.R. 4392, a bill that would prevent a dramatic reduction in Medicare Part B payments for certain hospitals that participate in the 340B program. CMS in November finalized a rule that reduces by nearly 30 percent, or $1.6 billion annually, Medicare payments to certain public and non-profit hospitals for outpatient drugs purchased under the 340B program.

Bipartisan majorities of both the Senate and the House – 57 senators and 228 members of the House – earlier signed letters urging CMS to carefully consider stakeholder feedback before finalizing changes to 340B reimbursement.

Eliminating the Therapy Cap. As urged by AHA and others, the BiBA permanently repealed the Medicare payment caps for outpatient physical, speech language and occupational therapy services beginning Jan. 1, 2018 and lowered the threshold for targeted manual medical review to $3,000 from $3,700.

Opioid Funding. The omnibus appropriations bill passed in March contained $3.6 billion to fight opioid abuse, including $415 million to expand prevention and treatment services and develop an appropriately trained workforce, and $1 billion in state opioid response grants. The AHA continues to advocate for policies to help fight the opioid epidemic as Congress works to pass comprehensive legislation this summer.

Improving Emergency Access to Controlled Medications. Congress passed the Protecting Patient Access to Emergency Medicines Act (Public Law No: 115-83). The AHA-supported legislation clarifies that emergency medical services practitioners, under a standing order issued by the EMS agency’s physician medical director, may administer medications governed by the Controlled Substances Act.

Medicaid Funding for Puerto Rico and the Virgin Islands. As urged by AHA, Congress included $4.9 billion in additional Medicaid funding for Puerto Rico and the U.S. Virgin Islands in the BiBA.

Medical Liability Reform. The House of Representatives approved AHA-supported medical liability reform legislation (H.R. 1215) that would limit non-economic damages to $250,000 in lawsuits where health coverage was provided or subsidized by the federal government. The Protecting Access to Care Act is based on the proven model of reform, which was enacted decades ago in California.

Supporting the Next Generation of Physicians. As urged by AHA and others, the omnibus appropriations bill passed in March included $315 million for Children’s Hospitals Graduate Medical Education, $15 million more than in FY 2017.

Enhancing the Nursing Workforce. AHA’s American Organization of Nurse Executives (AONE), in collaboration with the greater nursing community, was successful in urging the introduction of the Title VIII Nursing Workforce Reauthorization Act in both the House and Senate. This will reauthorize the Health Resources and Services Administration’s Nursing Workforce Development programs (authorized under Title VIII of the Public Health Service Act (42 U.S.C. 296 et. Seq) through fiscal year 2022. For over 50 years, Title VIII has helped to build the supply and distribution of qualified nurses to meet our nation’s health care needs.

AONE, in collaboration with the Health Professions and Nursing Education Coalition, also was successful in urging the introduction of the Educating Medical Professionals and Optimizing Workforce Efficiency and Readiness (EMPOWER) Act of 2017 (H.R. 3728). The act reauthorizes until 2022 programs that help shape the workforce in targeted ways by promoting service in underserved areas and filling workforce gaps that preserve the federal investment in the health care workforce.

Promoting Research on Gun Violence. As urged by AHA and others, the omnibus appropriations bill passed in March clarifies that the Dickey Amendment does not prohibit the Centers for Disease Control and Prevention from awarding grants to study gun violence.

Improving Access to Care for Veterans. As supported by the AHA, Congress in May approved bipartisan legislation (S. 2372) to streamline and consolidate the Department of Veterans Affairs' community care programs into a permanent Veterans Community Care Program. Among other provisions, the VA MISSION Act of 2018 would require access to community care based on certain access criteria, doing away with the 40-mile limit or 30-day wait period required through the Choice Program; establish Medicare payment rates for community care, with certain exceptions for rural areas and value-based payment models; and require VA to establish prompt payment deadlines.

 

In the Agencies…

ICD-10 Codes for Human Trafficking. The AHA’s Hospitals Against Violence initiative, in partnership with Catholic Health Initiatives and Massachusetts General Hospital’s Human Trafficking Initiative and Freedom Clinic, secured 29 ICD-10 diagnostic codes to identify and document victims of human trafficking from the National Center for Health Statistics, which will allow hospitals and health systems to better track victim needs and identify solutions to improve the health of their communities. The codes took effect Oct. 1. For additional hospital and health system resources to combat human trafficking, visit www.aha.org/combating-human-trafficking.  

Reducing Burden for Post-acute Care Providers.

  • Long-term Care Hospitals: As urged by the AHA, the FY 2019 LTCH PPS final rule permanently withdrew the 25% Rule following CMS’s FY 2018 regulatory moratorium on the policy.
  • Quality Measurement: CMS removed three faulty quality measures from the LTCH Quality Reporting Program and two from the Inpatient Rehabilitation Facility QRP in the FY 2019 rules.

Preserved Coding Differentiation for Evaluation and Management Services. CMS, in its final Physician Fee Schedule rule for 2019, responded to our concerns and mitigated its proposal to consolidate evaluation and management codes for providers. CMS will now retain three levels of codes and delay implementation until 2021, which will allow us to work with the agency to ensure that physicians who treat a disproportionate number of higher-acuity patients are not financially penalized. 

 

Protected Grandfathered Hospital Provider-based Clinics’ Ability to Modernize Services. At AHA’s urging, CMS in its final outpatient PPS rule for 2019 did not finalize a proposal to reduce payments for new families of services furnished in grandfathered off-campus PBDs to 40 percent of the outpatient PPS rate. This proposal would have penalized hospital outpatient departments that expand the types of critical services they offer to their communities – preventing them from caring for the changing needs of their patients.

 

Enhancing Electronic Health Record Program Flexibility. In the inpatient PPS final rule for FY 2019, CMS renamed the EHR Incentive Program as the Promoting Interoperability Program. The agency also removed a number of burdensome requirements and adopted a performance-based approached. This included extending a 90-day reporting period to 2019 and 2020. The agency also reduced burden related to electronic clinical quality measures, shortening the reporting period to one quarter and requiring only four measures in 2019, and removed seven eCQMs for 2020. CMS also in its final Physician Fee Schedule rule for 2019 finalized changes to increase flexibility and better align the promoting interoperability requirements for MIPS-eligible clinicians with those for hospitals.

 

Making headway on security of medical devices. In the wake of the WannaCry cyber attack, the Food and Drug Administration released a Medical Device Safety Plan that outlines how it will improve accountability of medical device manufacturers for the security of their devices. In October, the agency released draft pre-market guidance for manufacturers that sets expectations for device manufacturers to secure medical devices over their lifetime and provide customers with a software bill of materials outlining the third-party applications embedded in devices. AHA will continue to advocate for additional steps to improve security.

Auditing Improvements. As urged by AHA, CMS is broadly transitioning its Medicare Audit Contractor audits to a “probe and educate” model, which means that the number of claims reviewed will be narrowly targeted and relatively small in comparison to previous reviews.

Merit-based Incentive Payment System Facility-based Measurement. The AHA has long advocated for this approach, which allows those clinicians who provide 75 percent or more of their services in the inpatient and ED settings to use their hospital’s value-based purchasing program results in the MIPS rather than reporting separate MIPS cost and quality data. As urged by the AHA, CMS proposed to expand the definition of “facility-based” services to include services in on-campus outpatient departments. Facility-based measurement allows hospitals and clinicians to align on measures, and to spend less time reporting data and more time improving care.

Streamlining CMS Quality Measures. Through much advocacy by the AHA, CMS this year developed a “Meaningful Measures” framework, whose priority areas align closely with the quality measure priority topics the AHA developed in 2016. CMS used the framework to adopt and propose substantial reductions in the number of measures across its quality measurement programs, including:

    • 29 percent reduction in inpatient hospital measures
    • 28 percent reduction in inpatient psychiatric measures
    • 55 percent reduction in outpatient hospital measures (proposed)
    • 34 measures removed from MIPS (proposed)
    • 10 measures removed from various post-acute care programs 

Working to Ensure Hospital Star Ratings and Soliciting Input from the Field. As strongly urged by AHA, CMS chose not to update its Hospital Star Ratings in July 2018 after AHA shared significant underlying problems with the methodology. Also at AHA’s urging, CMS has continued to solicit input from the field on how to improve the ratings moving forward.

Reducing Burden on Conditions of Participation.  In late 2017, AHA released its report documenting the administrative costs of regulation. The report noted that the administrative burden was greatest for COP compliance. In mid-September of this year, CMS took the first steps toward reducing the regulatory burden of the COPs by proposing a number of changes, many urged by the AHA, that would eliminate some duplicative requirements and enable a system-wide approach to quality and infection control. AHA is pleased to see this first step and is putting forward additional changes CMS should consider. 

Access to Rural Broadband. At the AHA’s urging, the Federal Communications Commission voted unanimously to increase funding for the Rural Health Care Program by $171 million, increasing the program's annual cap to $571 million. The increase represents what the funding level would be today had the cap, which was established in 1997, included an inflation adjustment. The cap also will be adjusted annually for inflation, and FCC will allow unused funds from prior years to be carried forward to future years. In addition, FCC fully funded all 2017 and 2018 applications. The agency also is exploring a new Connected Care Piulot Program to support Connectivity for remote monitoring of low-income individuals.

Expanding Access to Telehealth. At AHA’s urging, CMS finalized its proposal to add to the list of Medicare-payable telehealth services codes for psychotherapy for crisis, health risk assessments, care planning for chronic care management and counseling visits to determine low-dose computed tomography eligibility.

Revisiting Bundled Payment Programs. CMS canceled the cardiac and surgical hip and femur fracture treatment bundled payment models, which had been scheduled to begin Jan. 1, 2018. In addition, the agency finalized its proposal to scale back the Comprehensive Care for Joint Replacement model by giving certain participant hospitals a one-time option to choose whether to continue their participation.

Revisiting Compounding Rules. As urged by AHA, the United States Pharmacopeia announced they are postponing the official date of General Chapter <800> Hazardous Drugs – Handling in Healthcare Settings to Dec. 1, 2019 (previously USP chapter 800 was to become official on July 1, 2018). The announcement also describes the intent to republish USP <797> Pharmaceutical Compounding – Sterile Preparations for another round of public comment in Sept./Oct. of 2018 and that this chapter will also become official on Dec. 1, 2019. Some hospitals, particularly small hospitals, have expressed concerns about the challenges they will face in meeting these standards given remodeling costs.

In the Courts…

Eliminating the Medicare Claims Backlog. In response to litigation by the AHA challenging unacceptable delays in processing disputed Medicare payment claims, the U.S. District Court in November 2018 reinstated a mandamus order establishing annual deadline-based targets for reducing the backlog of Medicare appeals at the Administrative Law Judge level. The order by U.S. District Judge James Boasberg requires that the Department of Health and Human Services achieve the following reductions from its own currently projected fiscal year 2018 backlog of 426,594 appeals: a 19 percent reduction by the end of FY 2019; a 49 percent reduction by the end of FY 2020; a 75 percent reduction by the end of FY 2021; and elimination of the backlog by the end of FY 2022. The order also requires HHS to file quarterly status reports beginning Dec. 31. At an October hearing, government counsel had argued that court-ordered reduction targets are now unnecessary because of additional agency funding to expand adjudicatory capacity and the reduced volume of Recovery Audit Contractor-related appeals currently entering the system.

 

Requiring Transparency for 340B Manufacturers. Facing deadlines for responding to the lawsuit brought by the AHA, Association of American Medical Colleges, America’s Essential Hospitals, 340B Health and three hospital systems, the Department of Health and Human Services Oct. 31 proposed implementing on Jan. 1 its final rule on 340B drug ceiling prices and civil monetary penalties for manufacturers. The rule describes how ceiling prices must be calculated and allows the federal government to levy CMPs against drug companies that intentionally overcharge 340B providers. HHS most recently proposed delaying the rule’s effective date to July 1. The rule also requires that HHS make pricing information available online to 340B hospitals and other providers.

 

 

November 2018