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 (ACA), 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 recently 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 (DSH) reductions scheduled for fiscal years (FY) 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 (LVA) 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 (MDH) 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 (CY) 2022. It also extended the “super rural” add-on through CY 2022.

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 (CAHs) and small, rural hospitals with 100 or fewer beds for CY 2017. The Centers for Medicare & Medicaid Services (CMS), 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.

Long-term Care Hospital (LTCH) 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 recently 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…

Reducing Burden for Post-acute Care Providers.

  • LTCHs: The FY 2018 LTCH PPS final rule implemented a 12-month delay of full implementation of the “25% Rule” during FY 2018, which is a seamless extension of the congressionally-authorized hold on this policy, which expired September 30. The AHA called for a hold on the full 25% Rule given the major transformation already underway due to LTCH site-neutral payment, which began its implementation in 2015.
  • Inpatient Rehabilitation Facilities (IRF): As advocated by AHA, the FY 2018 final rule for the IRF PPS made positive revisions to the coding guidelines used to determine a facility's compliance with the "60% Rule" presumptive test, a standard that must be met for a facility to remain in the IRF payment classification. These changes by CMS allow more IRF cases to be counted toward 60% Rule compliance.
  • Home Health (HH) Agencies: Last July, CMS announced a delay of the new Home Health conditions of participation (COP) for six months until January 13, 2018. AHA argued that the extensive scope of these COP changes required more time for preparation by the field. In addition, CMS paused the onerous home health pre-claim review demonstration.
  • LTCH/IRF/Skilled Nursing Facilities (SNFs): As urged by AHA, the FY 2018 final rules for the LTCH, IRF and SNF PPS’s scaled back the overall reporting load for these settings as part of CMS’s implementation of the quality reporting mandate under the IMPACT Act of 2014. Specifically, these final rules reduced the reporting burden by eliminating 25 measures, including existing measures that were phased out and proposed new measures that were not finalized.

Reducing Burden for Small and Rural Hospitals. At AHA’s urging, in the inpatient PPS final rule for FY 2018, CMS indicated its contractors will make reviews of the 96-hour rule a "low priority," thereby acknowledging that this condition of payment could stand in the way of promoting essential, and often lifesaving, health care services to rural America. AHA was successful in ensuring that CMS will implement the congressionally mandated five-year extension of the Rural Community Hospital (RCH) Demonstration seamlessly so that hospitals previously participating in the program will receive reasonable cost payments immediately after the date their previous period of performance ended.

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.

EHR Incentive Program and Electronic Clinical Quality Measurement (eCQM) Relief. At AHA’s urging, CMS offered significant relief to hospitals by shorting the meaningful use reporting period for 2018 from a full year to 90 days. The agency also will allow hospitals the option to report modified Stage 2 or Stage 3. Depending on what is reported, hospitals will be able to use their existing 2014 EHRs in 2018, upgrade to the 2015 Edition or use a combination of the two editions. With respect to eCQMs, CMS has decreased both the number of measures required and shortened the reporting period.

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.

Supporting the Transition to MACRA. The AHA successfully advocated for greater flexibility and less burden in MACRA’s Quality Payment Program. Most notably, starting in 2019, CMS will allow hospital-based clinicians (i.e., those that bill 75 percent of their part B charges in inpatient hospitals and/or emergency departments) to use their hospital’s CMS value-based purchasing program results in the Merit-based Incentive Payment System (MIPS). This means less time reporting data and more time collaborating to improve care. CMS also has adopted a gradual increase in reporting requirements, allowing hospitals and clinicians alike more time to prepare. Lastly, as an interim step to better account for the clinical and socioeconomic factors that can drive performance, CMS will implement a “complex patient bonus” starting in 2019.

Modifying Pain Relief Questions. At AHA’s urging, CMS finalized its proposal to update the pain management questions in the HCAHPS survey in an effort to reduce the emphasis on using pharmacotherapy, such as opioids, to manage pain. The new questions were implemented with surveys starting Jan. 1, 2018. CMS will delay publicly reporting the results by one year (i.e., until Oct. 2020).

Streamlining Quality Measures. The AHA has long urged CMS to take a more strategic approach to quality measurement and only require the use of measures in their public reporting and pay-for-performance programs that assess critical aspects of care, are valid and reliable, and that are appropriately adjusted to reflect differences in patients’ clinical conditions and socio-demographic factors that influence outcomes. In late 2017, CMS Administrator Seema Verma announced that the agency would launch an initiative to ensure that they were requiring only meaningful measures in their various public reporting and pay-for-performance programs.

Clarity Around Ligature Risk Citations. In late 2016, CMS told The Joint Commission (TJC) and state agencies that more diligence was needed in identifying ligature risks during surveys of hospitals that provide mental health/behavioral health services due to concerns that patients with suicidal ideation could harm themselves during the course of treatment. However, the agency did not provide clear survey guidance. Working with TJC and others, the AHA was able to help CMS understand the confusion created and, in December, CMS issued clarifying guidance. When patients need medical or surgical care and have indications that they might harm themselves or others, CMS expects hospitals to mitigate the risk of harm, such as using sitters.

Hospital Accreditation Survey Reports. In the FY 2018 inpatient PPS proposed rule, CMS proposed to require accrediting bodies, such as TJC and DNV, to publish individual hospital survey reports on the accrediting body’s website. The AHA worked collaboratively with other key organizations to ensure that CMS understood this was an idea that would diminish the ability of the survey entities to identify opportunities for organizations to improve safety and was an obvious attempt to circumvent the intent of the provision in the Social Security Act that prohibits CMS from publishing these reports themselves. CMS withdrew this proposal.

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 (SHFFT) 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 (CJR) model by giving certain participant hospitals a one-time option to choose whether to continue their participation.

Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging. The Protecting Access to Medicare Act of 2014 requires professionals furnishing advanced diagnostic imaging services to report on the Medicare claim information about AUC reviewed by the ordering professional. Although statute required the program to begin Jan. 1, 2017, CMS took a measured approach by establishing different components of the AUC program framework through rulemaking over the past couple of years. The agency proposed to begin the AUC program reporting requirements Jan. 1, 2019, but, at AHA’s urging, further delayed this start date until Jan. 1, 2020. In addition, 2020 will be considered an “education and operational testing year," and CMS will pay claims regardless of whether they contain information on the required AUC consultation. The agency also plans to implement an 18-month voluntary reporting period beginning mid-2018.

Delay of Outpatient and Ambulatory Surgical Center Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) Survey-based Measures. In the CY 2017 final rule, CMS adopted five measures that would be derived from the OAS CAHPS survey. According to that rule, data would be collected and submitted quarterly starting with visits on Jan. 1, 2018. However, CMS determined that they "lack important operational and implementation data" regarding the collection and reliability of the OAS CAHPS survey data.

Revisiting Compounding Rules. As urged by AHA, the United States Pharmacopeia (USP) 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…

Preventing Harmful Insurance Mergers. Last spring, the federal courts turned back the efforts of both Anthem to acquire Cigna and Aetna to acquire Humana. The AHA was instrumental in assuring both the federal agencies involved in reviewing the deal – Department of Justice (DOJ) and Health and Human Services (HHS) – were fully apprised of the anticompetitive potential of both deals and fully incented to block them. When DOJ did so, both Anthem and Aetna tried unsuccessfully to win court approval for their deals and once again AHA acted to ensure the courts understood the devastating impact the deals would have on the field, and most importantly, their patients.

Eliminating the Medicare Claims Backlog. In response to litigation by the AHA challenging unacceptable delays in processing disputed Medicare payment claims, the new administration has made eliminating the backlog a “top priority.” HHS launched additional efforts in 2017 to meet this goal, including two new settlement programs and expanded the Targeted Probe and Educate Program, which allows providers to discuss claims with Medicare contractors and correct errors and improve their claims submissions. However, progress remains slow. This spring a federal judge asked the AHA to provide detailed recommendations on behalf of hospitals and health systems for how HHS can reduce the backlog of appeals awaiting adjudication at the Administrative Law Judge level and prevent another huge influx of appeals as a result of inappropriate payment denials. The judge expressed considerable frustration with HHS over its lack of progress and requested that AHA expand upon the recommendations for clearing the backlog we’ve made over the course of our litigation by June 22. HHS will then have until July 6 to respond. Our recommendations will continue to include additional actions to alter incentives for the Recovery Audit Contractor program that result in excessive and inaccurate denials, steps HHS can take to more aggressively pursue settlement with providers including for rehabilitation claims, and steps to develop a program that tolls interest recoupment and repayment obligations, among other suggestions.

Protecting the Confidentiality of the Hospital Peer Review Process. The U.S. Court of Appeals for the District of Columbia Circuit in August unanimously reversed a National Labor Relations Board decision that directly threatened the confidentiality of the hospital peer review process. In the case brought by Menorah Medical Center in Overland Park, KS, the court held that employees’ rights to have union representation as required under the Weingarten rule, at the hospital’s Nursing Peer Review Committee proceeding are infringed only when an employer compels an employee’s attendance at an interview that might reasonably be expected to lead to discipline and denies his or her request for union representation. As required by and operated in accordance with Kansas state law, the committee investigates alleged violations of the prevailing standard of care that, if substantiated, are required to be reported to the state licensing agency which then may suspend or revoke a nurse’s license. The Committee itself does not impose discipline. The court also found that the hospital had clearly conveyed that attendance at the hearing was voluntary for the nurses involved and even allowed them to submit a written statement as an alternative to attending. Under these circumstances, the right to union representation was not triggered.

April 2018