Category Archives: Uncategorized

THE RACES AND ISSUES HEALTHCARE LEADERS NEED TO WATCH ON ELECTION NIGHT

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , , , • Leave a comment

https://www.healthleadersmedia.com/strategy/races-and-issues-healthcare-leaders-need-watch-election-night

The 2018 midterm elections will decide the fate of numerous healthcare-related ballot measures as well as which leaders will shape health policy in the coming years.

KEY TAKEAWAYS

Issues to watch: Medicaid expansion in 4 states, a healthcare bond initiative in California, and the debate over preexisting condition protections.

Candidates to watch: Wisconsin Gov. Scott Walker, former Gov. Phil Bredesen, former HHS Secretary Donna Shalala, and others.

Healthcare has been an overarching issue for voters in the 2018 midterm election cycle, with many focusing on the future of the Affordable Care Act when it comes to national health policy but also taking stock of state and local ballot initiatives as well.

Several traditionally Republican states will decide whether to expand Medicaid under the ACA; staffing requirements for nurses are a hot-button topic in Massachusetts; and a major children’s hospital bond is on the table in California. 

Beyond the issues are the candidates, including many Republican leaders on Capitol Hill in tight races to defend their seats after voting to repeal and replace the ACA. At the state level, Republican governors and their attorneys general are having their healthcare records put to the test as Democrats make protecting preexisting conditions and rejecting Medicaid work requirements key parts of the campaign.

Here are the key issues and candidates healthcare leaders will be watching as results begin rolling in Tuesday evening, with voters determining the direction of healthcare policymaking for years to come.

MEDICAID EXPANSION IN 4 RED STATES

One year after voters approved Medicaid expansion in Maine, the first state to do so through a ballot initiative, four other states have the opportunity to join the Pine Tree State.

Montana: The push to extend Medicaid expansion in Montana before the legislative sunset at the end of the year is tied to another issue: a tobacco tax hike. The ballot measure, already the most expensive in Montana’s history, would levy an additional $2-per-pack tax on cigarettes to fund the Medicaid expansion which covers 100,000 persons.

Nebraska: Initiative 427 in traditionally conservative Nebraska, could extend Medicaid coverage to another 90,000 people. The legislation has been oft-discussed around the Cornhusker State, earning the endorsement of the Omaha World-Herald editorial board.

Idaho: Medicaid expansion has been one of the most talked about political items in Idaho throughout 2018. Nearly 62,000 Idahoans would be added to the program by Medicaid expansion, some rural hospitals have heralded the move as a financial lifeline, and outgoing Gov. Bruce Otter, a Republican, blessed the proposal last week.

Utah: Similar to Montana’s proposal, Utah’s opportunity to expand Medicaid in 2018 would be funded by a 0.15% increase to the state’s sales tax, excluding groceries. The measure could add about 150,000 people to Medicaid if approved by voters, who back the measure by nearly 60%, according to a recent Salt Lake Tribune/Hinckley Institute poll.

4 MORE BALLOT INITIATIVES

In addition to the four states considering whether to expand Medicaid, there are four others considering ballot initiatives that could significantly affect the business of healthcare.

Massachusetts mulls nurse staffing ratios. Question 1 would implement nurse-to-patient staffing ratios in hospitals and other healthcare settings, as Jennifer Thew, RN, wrote for HealthLeaders. The initiative has backing from the Massachusetts Nurses Association.

Nurses have been divided, however, on the question, and public polling prior to Election Day suggested a majority of voters would reject the measure, which hospital executives have actively opposed. The hospital industry reportedly had help from a major Democratic consulting firm.

California could float bonds for children’s hospitals. Proposition 4 would authorize $1.5 billion in bonds to fund capital improvement projects at California’s 13 children’s hospitals, as Ana B. Ibarra reported for Kaiser Health News. With interest, the measure would cost taxpayers $80 million per year for 35 years, a total of $2.9 billion, according to the state’s Legislative Analyst’s Office.

Proponents say children’s hospitals would be unable to afford needed upgrades without public assistance; opponents say the measure represents a fiscally unsound pattern. (California voters approved a $750 million bond in 2004 and a $980 million bond in 2008.)

Nevada nixing sales tax for medical equipment? Question 4 would amend the Nevada Constitution to require the state legislature to exempt certain durable medical goods, including oxygen delivery equipment and prescription mobility-enhancing equipment, from sales tax. The proposal, which passed a first time in 2016, would become law if it passes again.

Bennett Medical Services President Doug Bennett has been a key proponent of the measure, arguing that it would bring Nevada in line with other states, but opponents contend the measure is vaguely worded, as the Reno Gazette Journal reported.

Oklahoma weighs Walmart-backed optometry pitch. Question 793 would add a section to the Oklahoma Constitution giving optometrists and opticians the right to practice in retail mercantile establishments.

Walmart gave nearly $1 million in the third quarter alone to back a committee pushing for the measure. Those opposing the measure consist primarily of individual optometrists, as NewsOK.com reported.

INCUMBENTS, PLAINTIFFS, PREEXISTING CONDITIONS

It’s been more than two months since Republican attorneys general for 20 states asked a federal judge to impose a preliminary injunction blocking further enforcement of the Affordable Care Act, including its coverage protections for people with preexisting conditions. Some see the judge as likely to rule in favor of these plaintiffs, though an appeal of that decision is certain.

Amid the waiting game for the judge’s ruling, healthcare policymaking—especially as it pertains to preexisting conditions—rose to the top of voter consciousness in the midterms. That explains why some plaintiffs in the ACA challenge have claimed to support preexisting condition protections, despite pushing to overturn them.

The lawsuit and its implications mean healthcare leaders should be watching races in the 20 plaintiff states in the Texas v. Azar lawsuit: Alabama, Arizona, Arkansas, Florida, Georgia, Indiana, Kansas, Louisiana, Maine Gov. Paul LePage, Mississippi Gov. Phil Bryant, Missouri, Nebraska, North Dakota, South Dakota, South Carolina, Tennessee, Texas, Utah, West Virginia, and Wisconsin. Thirteen of those plaintiff states have active elections involving their state attorneys general, and several have races for governor in which the ACA challenge has been an issue, including these noteworthy states:

  • Texas: Attorney General Ken Paxton, a Republican representing the lead plaintiff in the lawsuit, is facing a challenge from Justin Nelson, a Democrat, and the race seemed to be competitive, as The Texas Tribune reported. Gov. Greg Abbott was expected to win against Democratic challenger Lupe Valdez.
  • Florida: Attorney General Pam Bondi, a Republican, is term-limited, so she’s not running for reelection. Ashley Moody, a Republican, and Sean Shaw, a Democrat, are facing off for Bondi’s position. Moody expressed support for Florida’s participation in the ACA challenge, while Shaw said he would pull the state out, calling the case a “partisan stunt,” as the Tampa Bay Times reported. Bondi has campaigned, meanwhile, for Republican gubernatorial candidate Ron DeSantis, who’s facing off with Democrat Andrew Gillum. Gillum said he would back a state law to protect people with preexisting conditions, while DeSantis said he would step in if federal action removed the ACA’s preexisting condition protections, as the Miami Herald reported. Gillum and DeSantis are vying to succeed term-limited Gov. Rick Scott, a Republican who’s running for U.S. Senate.
  • Wisconson: Attorney General Brad Schimel, a Republican, is facing a challenge from Josh Kaul, a Democrat who has slammed Schimel’s participation in the ACA challenge, as The Capital Times reported. Gov. Scott Walker, a Republican, said he supports preexisting condition protections, despite authorizing his state’s participation in the lawsuit. Democratic challenger Tony Evers accused Walker of “talking out of both sides of his mouth,” as the Milwaukee Journal Sentinel reported.

PROPONENTS OF MEDICAID WORK REQUIREMENTS

Five states have received approvals from the Centers for Medicare and Medicaid Services to institute Medicaid work requirements: Kentucky, Indiana, Wisconsin, New Hampshire, and Arkansas. (Only four have active approvals, however, since a federal judge blocked Kentucky’s last summer.)

Three incumbent governors who pushed for work requirements are running for reelection:

New Hampshire: After receiving approval for New Hampshire’s Medicaid work requirements, Republican Gov. Chris Sununu said the government is committed to helping Granite Staters enter the workforce, adding that it is critical to the “economy as a whole.” Despite spearheading a controversial topic in a politically centrist state, Sununu has not trailed against his Democratic opponent Molly Kelly in any poll throughout the midterm elections.

Arkansas: Similarly, Arkansas Gov. Asa Hutchinson, is running in a race where he has held a sizable lead over his Democratic challenger Jared Henderson. Since enacting the work requirements over the summer, the state has conducted two waves where it dropped more than 8,000 enrollees.

Wisconsin: The most vulnerable Republican governor of a state with approved Medicaid work requirements is Wisconsin Gov. Scott Walker, who has been neck and neck with Democratic nominee Tony Evers. While the Badger state only received approval for its Medicaid work requirements last week, healthcare has been a central issue of the campaign as Walker, a longtime opponent of the ACA, works to address premium costs in the state and defend his record on preexisting conditions.

Indiana and Kentucky: Indiana Gov. Eric Holcomb and Kentucky Gov. Matt Bevin are not on the ballot this year.

When HealthLeaders issued its first list in April of the healthcare leaders running for public office during the primaries, there were more than 60 candidates with relevant healthcare backgrounds out on the campaign trail.

Now, for the general election, that list has nearly been halved, with 35 candidates still remaining. 

This collection of healthcare leaders includes registered nurses, former insurance company executives, physicians, and former government health policy leaders.

U.S. Senate: Running for the Senate are Florida Gov. Rick Scott, former Tennessee Gov. Phil Bredesen, former Celgene CEO Bob Hugin, and State Sen. Leah Vukmir.

U.S. House: Among those aiming to join the House are Lauren Underwood, RN, former HHS Secretary Donna Shalala, and Dr. Kim Schrier.

 

 

Pre-existing conditions: Does any GOP proposal match the ACA?

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , , , , , , , , , • Leave a comment

https://www.politifact.com/truth-o-meter/article/2018/oct/17/pre-existing-conditions-does-any-gop-proposal-matc/?fbclid=IwAR2QXSwiwRryxaHWJVgO3evTUtJPk6QcV1HkxkaI2qq3iPWqsrXqGA0qPeY

From a routine visit to a critical exam, the stethoscope remains one of the most common physician tools. (Alex Proimos, via Flickr Creative Commons)

In race after race, Democrats have been pummeling Republicans on the most popular piece of Obamacare, protections for pre-existing conditions. No matter how sick someone might be, today’s law says insurance companies must cover them.

Republican efforts to repeal and replace Obamacare have all aimed to retain the guarantee that past health would be no bar to new coverage.

Democrats aren’t buying it.

In campaign ads in Nevada, Indiana, Florida, North Dakota, and more, Democrats charged their opponents with either nixing guaranteed coverage outright or putting those with pre-existing conditions at risk. The claims might exaggerate, but they all have had a dose of truth.

Republican proposals are not as air tight as Obamacare.

We’ll walk you through why.

The current guarantee

In the old days, insurance companies had ways to avoid selling policies to people who were likely to cost more than insurers wanted to spend. They might deny them coverage outright, or exclude coverage for a known condition, or charge so much that insurance became unaffordable.

The Affordable Care Act boxes out the old insurance practices with a package of legal moves. First, it says point-blank that carriers “may not impose any preexisting condition exclusion.” It backs that up with another section that says they “may not establish rules for eligibility” based on health status, medical condition, claims experience or medical history.

Those two provisions apply to all plans. The third –– community rating –– targets insurance sold to individuals and small groups (about 7 percent of the total) and limits the factors that go into setting prices. In particular, while insurers can charge older people more, they can’t charge them more than three times what they charge a 21-year-old policy holder.

Wrapped around all that is a fourth measure that lists the essential health benefits that every plan, except grandfathered ones, must offer. A trip to the emergency room, surgery, maternity care and more all fall under this provision. This prevents insurers from discouraging people who might need expensive services by crafting plans that don’t offer them.

At rally after rally for Republicans, President Donald Trump has been telling voters “pre-existing conditions will always be taken care of by us.” At an event in Mississippi, he faulted Democrats, saying, “they have no plan,” which ignores that Democrats already voted for the Obamacare guarantees.

At different times last year, Trump voiced support for Republican bills to replace Obamacare. The White House said the House’s American Health Care Act “protects the most vulnerable Americans, including those with pre-existing conditions.” A fact sheet cited $120 billion for states to keep plans affordable, along with other facets in the bill.

But the protections in the GOP plans are not as strong as Obamacare. One independent analysis found that the bill left over 6 million people exposed to much higher premiums for at least one year. We’ll get to the congressional action next, but as things stand, the latest official move by the administration has been to agree that the guarantees in the Affordable Care Act should go. It said that in a Texas lawsuit tied to the individual mandate.

The individual mandate is the evil twin of guaranteed coverage. If companies were forced to cover everyone, the government would force everyone (with some exceptions) to have insurance, in order to balance out the sick with the healthy. In the 2017 tax cut law, Congress zeroed out the penalty for not having coverage. A few months later, a group of 20 states looked at that change and sued to overturn the entire law.

In particular, they argued that with a toothless mandate, the judge should terminate protections for pre-existing conditions.

The U.S. Justice Department agreed, writing in its filing “the individual mandate is not severable from the ACA’s guaranteed-issue and community-rating requirements.”

So, if the mandate goes, so does guaranteed-issue.

The judge has yet to rule.

Latest Republican plan has holes

In August, a group of 10 Republican senators introduced a bill with a title designed to neutralize criticism that Republicans don’t care about this issue. It’s called Ensuring Coverage for Patients with Pre-Existing Conditions. (A House Republican later introduced a similar bill.)

The legislation borrows words directly from the Affordable Care Act, saying insurers “may not establish rules for eligibility” based on health status, medical condition, claims experience or medical history.

But there’s an out.

The bill adds an option for companies to deny certain coverage if “it will not have the capacity to deliver services adequately.”

To Allison Hoffman, a law professor at the University of Pennsylvania, that’s a big loophole.

“Insurers could exclude someone’s preexisting conditions from coverage, even if they offered her a policy,” Hoffman said. “That fact alone sinks any claims that this law offers pre-existing condition protection.”

The limit here is that insurers must apply such a rule across the board to every employer and individual plan. They couldn’t cherry pick.

But the bill also gives companies broad leeway in setting premiums. While they can’t set rates based on health status, there’s no limit on how much premiums could vary based on other factors.

The Affordable Care Act had an outside limit of 3 to 1 based on age. That’s not in this bill. And Hoffman told us the flexibility doesn’t stop there.

“They could charge people in less healthy communities or occupations way more than others,” Hoffman said. “Just guaranteeing that everyone can get a policy has no meaning if the premiums are unaffordable for people more likely to need medical care.”

Rodney Whitlock, a health policy expert who worked for Republicans in Congress, told us those criticisms are valid.

“Insurers will use the rules available to them to take in more in premiums than they pay out in claims,” Whitlock said. “If you see a loophole and think insurers will use it, that’s probably true.”

Past Republican plans also had holes

Whitlock said more broadly that Republicans have struggled at every point to say they are providing the same level of protection as in the Affordable Care Act.

“And they are not,” Whitlock said. “It is 100 percent true that Republicans are not meeting the Affordable Care Act standard. And they are not trying to.”

The House American Health Care Act and the Senate Better Care Reconciliation Act allowed premiums to vary five fold, compared to the three fold limit in the Affordable Care Act. Both bills, and then later the Graham-Cassidy bill, included waivers or block grants that offered states wide latitude over rates.

Graham-Cassidy also gave states leeway to redefine the core benefits that every plan had to provide. Health law professor Wendy Netter Epstein at DePaul University said that could play out badly.

“It means that insurers could sell very bare-bones plans with low premiums that will be attractive to healthy people, and then the plans that provide the coverage that sicker people need will become very expensive,” Epstein said.

Insurance is always about sharing risk. Whether through premiums or taxes, healthy people cover the costs of taking care of sick people. Right now, Whitlock said, the political process is doing a poor job of resolving how that applies to the people most likely to need care.

“The Affordable Care Act set up a system where people without pre-existing conditions pay more to protect people who have them,” Whitlock said. “Somewhere between the Affordable Care Act standard and no protections at all is a legitimate debate about the right tradeoff. We are not engaged in that debate.”

 

 

How Will the Midterm Elections Impact Healthcare?

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , , , , , , • Leave a comment

https://mailchi.mp/burroughshealthcare/pc9ctbv4ft-1586513?e=7d3f834d2f

Image result for 2018 Midterm Elections Impact Healthcare

With the midterms less than a week away,  a new poll published October 18th by the non-partisan Kaiser Family Foundation got a lot of attention. Over seventy percent of voters say health care is a very important issue in deciding who to vote for. 

But exactly what happens to key healthcare initiatives, especially the Affordable Care Act including expansion of Medicaid in many states—which tends to be more popular among Democratic lawmakers than Republicans–depends on whether it’s the Democrats or Republicans who get control of the House, says Eric Feigl-Ding, MPH, Ph.D., a health economist and visiting scientist at the Harvard Chan School of Public Health in Cambridge, Mass.

Based on multiple polls, the New York Times reported on October 23 that a likely outcome is that Democrats will gain the majority in the House of Representatives and the Republicans will keep the majority in the Senate. But the Times and many other news outlets continually point out that many factors including the news of each day make it difficult to predict the outcome.

Feigl-Ding says having opposing parties in the House, Senate and White House could make it harder to pass national legislation. Changes can still happen to the ACA, however, because the President can continue to make certain executive level decision such as ending the penalty for not having health insurance which he did last year. That change takes effect in 2019.

In terms of new legislation, Feigl-Ding says a split Congress and White House means that passing legislation will be difficult because what comes from the House side, if most members are Democrats in the next sessions, could be more liberal and the corresponding bills from the Senate, likely to remain Republican, could be more conservative. So, says Feigl-Ding, either a bill won’t pass at all, or there will have to be much more of a compromise. “And assuming they would get to compromise is a big assumption, that then requires the president to agree to sign that legislation,” adds Feigl-Ding.

A report this week by strategy and policy group Manatt Health, based in Washington, DC lists the health care issues the firm thinks will dominate in states and the federal government after the elections:

  • The role of Medicaid as either a welfare program or health insurance for low-income Americans: While Democrats generally support continued expansion of Medicaid with no cost or work requirements for low-income adults, Republican governors in a number of states—with the approval of the Trump administration– have introduced premiums, work requirements, increased paperwork and penalties for falling off on requirements those that can keep many adults from applying for or remaining on Medicaid.
  • Differences in states about expanding and stabilizing the Affordable Care Act (ACA) Marketplace or promoting non-ACA coverage: The ACA allows states to open their own health insurance marketplaces or simply offer access to the federal marketplace. According to 2017 data from the National Academy for State Health Policy, more consumers sign up for health care coverage in states that run their own marketplaces
  • Drug prices: According to the Organization for Economic Development, an international forum with 36-member countries, consumers in the U.S. spend just over $1,100 on prescription drugs each year, more than consumers in any other country. President Trump has promised to help lower drug prices and on October 25 he released a plan that would tie some drug prices for patients on Medicare to an index based on international prices. Those prices are often far lower than Americans pay. PhRMA, the largest drug trade association announced its opposition to the plan the same day it was announced.

According to the report what states do will depend on the election outcomes for governors in more than a dozen states and many of those races are as impossible to predict as the Congressional races.

Other important health care issues for 2019-20120 include:

Pre-Existing Conditions 

Listening to ads for some Republicans candidates for Congress makes it appears protecting pre-existing conditions will be a top priority for some Republicans, even among some who voted against them previously. But Feigl-Ding says keeping coverage for preexisting conditions in health insurance plans also requires figuring out how to pay for it. Under the original ACA legislation, the hope was that a financial penalty for not having health coverage would keep more healthy people in the plans—along with the prohibition against letting insurers “cherry pick” only healthy consumers. But that penalty is now gone. “Take that away and you probably can’t sustain the preexisting conditions, says Feigl-Ding.

Medicaid Work Requirements and Other Conditions of Eligibility.

Legal challenges in several states could impact the implementation of work requirements. Some governors have said they’ll cut the number of state Medicaid beneficiaries to save money if work requirements are overturned.

ACA Repeal. Twenty states are challenging the constitutionality of the ACA in Texas v. The U.S., a case that could make it to the Supreme Court.

Association Health Plans and Short-Term Plans. Several Democratic state attorneys general have filed a lawsuit against the administration’s rule promoting association health plans that allow individuals and small businesses to join to purchase health care coverage and short-term plans. The suit argues that the new rules for both avoid protection for people with pre-existing conditions, according to Manatt.

No one has a crystal ball for what will happen, but everyone has hindsight. According to the Manatt report, in 2010 Republicans replaced Democratic governors in eleven states, and all but one of those states ended plans to establish a state-based health insurance marketplace (SBM). In five states where Democrats replaced Republicans, all those states set up those marketplaces.

And whatever the outcome of the 2018 elections, their impact on healthcare may only be short lived. At a foundation briefing on the midterm elections earlier this week Mollyann Brody, Executive Director, Public Opinion and Survey Research at the Kaiser Family Foundation reminded the crowd that “the day the 2018 elections are over the 2020 campaign starts.”

Still the end of the week also brought a glimmer of hope. In response to President Trumps remarks on October 25thabout his administration’s plan to test new drug pricing models in Medicare Part B help to lower drug prices Frederick Isasi, executive director of FamiliesUSA, a liberal leaning health insurance advocacy group, released a statement that said, in part, “I hope this is a serious policy that will be formally proposed and finalized by the Trump administration. If so, it is an important step forward for our nation’s seniors and taxpayers.”

 

 

A Blues plan (finally) deals a health system in on full risk

Posted on by • Posted in Uncategorized • Tagged , , , , , , , , , • Leave a comment

Image result for global capitation

Blue Cross Blue Shield of Massachusetts (BCBS-MA) announced this week that it plans to launch a new extension of its long-standing value-based payment program, the Alternative Quality Contract (AQC), which ties physician payments to the total cost of care delivered to their patients. In the first arrangement of its kind in the AQC program, BCBS-MA will pilot a similar, capitation-like approach with South Weymouth, MA-based South Shore Health, an independent health system serving southeastern Massachusetts.

As we described in a blog post on the AQC earlier this year, the broader program is structured around physician networks and their primary care practices, which bear two-way, upside-downside risk for the cost of care for patients attributed to them. Participating practices also have the ability to earn sizeable bonuses based on their performance on a number of quality metrics. The new approach is intended to experiment with putting the hospital directly at risk, encouraging it to reduce unnecessary admissions and other high-cost care by collaborating with physicians and other care providers.

While full details of the plan were not released, the agreement was described as a pilot program, to test the model of so-called “global budgeting” for hospitals. A similar approach to paying hospitals has been in place in Maryland for several years, as part of that state’s Federal waiver program. Notably, the CEO of South Shore Health, Dr. Gene Green, previously served as President of Suburban Hospital in Bethesda, MD, and in a press release stated, “What’s so encouraging about this partnership is that the provider and the payer are finally coming together at the same table with the same goal: drive down costs without affecting quality of care”.

The move is noteworthy because health plans—and particularly BCBS carriers—have historically been reluctant to share true risk with hospitals, for a variety of reasons. Some have claimed that hospitals lack the ability to manage commercial risk, while others have worried about the strategic implications of enabling health systems to move into the commercial risk market, fearing new competition for employer contracting.

For the most part, carriers have preferred to limit risk-based programs to physician practices, encouraging doctors to manage total cost of care by limiting referrals to high-cost specialists and hospitals. To the extent health plans have “shared risk” with hospitals, it has typically been in the form of performance-based bonuses added onto fee-for-service payments.

That phenomenon has served to stall the broader transition to provider risk envisioned by the authors of the Affordable Care Act (ACA) in creating the Medicare Shared Savings Program (MSSP) and its much-debated accountable care organizations (ACOs). The new BCBS-MA pilot with South Shore Health will be closely watched by BCBS leaders across the country.

It’s no accident that the first such pilot in the AQC program is with a smaller, independent system that operates in the shadow of the dominant Partners Healthcare system, an arrangement unlikely to raise competitive concerns among BCBS-MA executives.

Bowing to physician pressure, CMS delays visit code changes

Posted on by • Posted in Uncategorized • Tagged , , , , , , • Leave a comment

Related image

Yesterday the Center for Medicare & Medicaid Services (CMS) finalized the 2019 Physician Fee Schedule (PFS), announcing they will delay implementation of changes to physician evaluation and management (E&M) codes until 2021. CMS had proposed to collapse five E&M codes into two, and to streamline physician documentation requirements.

The delay is a win for the thousands of physicians who submitted comments opposing the changes, complaining that the proposal would penalize doctors who see more complex patients. Doctors also expressed concern that the rates assigned to the proposed codes were too low, discouraging doctors from seeing Medicare patients and creating access challenges.

Along with the two-year delay, CMS also raised base rates, and created an additional code for complex visits. These changes are a win for doctors—and provide time for continued lobbying to permanently forestall implementation.

The 2019 rule also includes several other noteworthy changes that were largely lost in hubbub surrounding E&M visit coding, most of which will be well-received by doctors.

At the top of our list: CMS significantly expanded telemedicine coverage, and will now reimburse for telemedicine and telephone visits for brief check-ins, evaluation of patient-submitted images or remote monitoring data, as well as more comprehensive and preventive care visits. This is a substantial step toward increasing access for the two-thirds of Medicare beneficiaries who are ineligible for telemedicine coverage today. 

We will be continuing to make our way through the details of the rule, and sharing our thoughts on its impact for doctors and health systems. In the longer term, it is worth watching whether continued pressure from doctors postpones further action, and whether the administration will enact changes that could upset the physician base—significantly, the 2021 PFS rule will likely drop in the weeks just before the 2020 Presidential election.