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.

For our latest accomplishments, see our Legislative Advisory on the Bipartisan Budget Act of 2018.

On the Hill…

Protecting Health Coverage. Working together in 2017 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.

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 and lowered the threshold for taxpayers with high medical expenses to make medical expense deductions from 10 percent to 7.5 percent 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. The Centers for Medicare & Medicaid Services (CMS) in November finalized a rule that reduces by nearly 30percent, 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.

Delaying Medicaid DSH Cuts. In September, 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.

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.

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.

Reducing EHR Burden. The House approved AHA-supported legislation (H.R. 3120) that would remove from the HITECH Act of 2009 a requirement that the Health and Human Services Secretary make meaningful use standards for electronic health records (EHRs) more stringent over time.

Expanding Access to Telehealth. Telehealth continues to be widely discussed on Capitol Hill, and the Senate passed the CHRONIC Care Act, which would 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.

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.


In the Agencies…

Reducing Burden for Post-acute Care Providers.

  • Long-term Care Hospitals (LTCH): The fiscal year (FY) 2018 LTCH prospective payment system (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: In 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.
  • IRF/Skilled Nursing Facilities (SNF)/LTCH. 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.


Extending Direct Supervision Moratorium. In the CYs 2009 and 2010 Outpatient PPS/ASC rules, CMS revised its regulations to require direct supervision for outpatient therapeutic services furnished in hospitals and critical access hospitals (CAHs). Because of advocacy from the AHA and others, for several years there has been a moratorium on the enforcement of the direct supervision requirement for CAHs and small rural hospitals, with the latest moratorium having expired on Dec. 31, 2016. As urged by the AHA, in the CY 2018 final rule, CMS reinstated the enforcement moratorium for CAHs and small rural hospitals having 100 or fewer beds for CYs 2018 and 2019. As a result, these hospitals have more time to comply with the supervision requirements and providers have more time to submit specific services to be evaluated by the Advisory Panel on Hospital Outpatient Payment for a recommended change in supervision level.

Auditing Improvements. As urged by AHA, CMS is broadly transitioning its MAC 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 a combination of the two editions. With respect to eCQMs, CMS has decreased both the number of measures required and shortened the reporting.


Expanding Access to Rural Broadband. At AHA’s urging, the Federal Communications Commission has proposed raising the cap on its Rural Healthcare Program, which subsidizes broadband deployment and services in rural and frontier areas. The current $400 million cap, exceeded in FYs 2016 and 2017, lead to reduced support for program participants. The FCC has also announced that it will tap unused funds to offset the FY2017 reductions.

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 will be implemented with surveys starting Jan. 1, 2018. CMS will delay publicly reporting the results by one year (i.e., until Oct. 2020).

Improving the Star Rating Methodology. The AHA has called on CMS to suspend and re-think star ratings. Additionally, AHA identified substantial errors made by CMS in executing its chosen methodology. CMS acknowledged these flaws and suspended the star ratings for nearly all of 2017, finally republishing them in late December after correcting errors in the calculations. 

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. The agency does not expect general medical/surgical beds and other parts of hospitals that care for a wide variety of patients to be free of ligature risks. Instead, when patients needed medical or surgical care and had indications that they might harm themselves or others, CMS expected 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. In addition, as urged by AHA, CMS signaled that it will soon announce new voluntary payment bundles that will qualify as advanced alternative payment models. Doing so will allow hospitals to not only capitalize on the work many of them already have done to prepare for such models, but to also partner with clinicians to provide better, more efficient care.

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 0utpatient 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. In April, 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.

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.