On Friday, October 14, 2015, the Centers for Medicare & Medicaid Services (CMS) displayed the long-anticipated final rule with comment period which sets forth final requirements for implementation of the Quality Payment Program (QPP), authorized by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Eligible clinicians will be able to participate in the QPP by choosing one of two pathways: (1) participation in the Merit-Based Incentive Payment System (MIPS) and (2) participation in Advanced Alternative Payment Models (Advanced APMs) as classified by CMS. CMS anticipates that most clinicians, at least in the QPP's initial year, will participate in MIPS.

The final rule with comment period follows a September 8, 2016 blog post, where Acting Administrator Andy Slavitt announced the agency's plans to provide flexibility in 2017 by offering clinicians four options to participate in the QPP to avoid a penalty in 2019. In the final rule, CMS provides specific requirements for each of the four options:

  • Meeting the Full Reporting Requirements for 2017: CMS finalized reduced requirements for earning an incentive in MIPS, such as:

    • allowing clinicians to report MIPS data for a full 90-day period rather than a full CY;
    • reducing the reporting threshold and eliminating the requirement to report a cross-cutting measure in the quality performance category;
    • reweighting the cost performance category to zero;
    • reducing the number of activities required to earn full points in the improvement activities category; and
    • reducing the number of measures necessary to report to earn a base score in the advancing care information performance category.
    Choosing this option will allow clinicians to earn a positive adjustment. In addition, "exceptional performers” will be eligible for an additional positive adjustment.
  • Participating in an Advanced APM in 2017: In the final rule, CMS stated its intent to "broaden opportunities for clinicians to participate in Advanced APMs.” Advanced APMs Entities with eligible clinicians that meet the Qualifying Participant (QP) participation thresholds will qualify for a 5% bonus incentive payment in 2019 based on all of the 2018 Medicare part B allowables for QPs in the Advanced APM Entity.
  • Avoid the Penalty: According to the final rule, this option allows clinicians to choose to report one measure in the quality performance category; one activity in the improvement activities performance category; or report the required measures of the advancing care information performance category to avoid a penalty in 2019.
  • Partially Participate: Clinicians may be eligible for a small positive adjustment by submitting MIPS data "more than one quality measure, more than one improvement activity, or more than the required measures in the advancing care information performance category” to avoid a penalty in 2019.
These changes from the proposed requirements came in response to feedback provided in 3,875 formal comments submitted by stakeholders on the proposed rule to implement the MACRA. Many commenters, including the Alliance, urged for a decrease in reporting burden and a delay in implementation of the QPP, the performance period of which begins January 1, 2017, as proposed.

While the Alliance of Specialty Medicine is pleased with the flexibilities CMS has finalized to assist eligible clinicians with transitioning to this new system, the Alliance believes that more work must be done to ensure that specialties and subspecialties have the opportunity to participate in the QPP in a clinically relevant and administratively simple manner. For example, while CMS notes that the modifications it made to the Advanced APM requirements would allow for more specialty-specific models, the models approved as Advanced APMs for 2017 are largely focused on primary care. In addition, as CMS did not finalize a virtual group option, CMS will continue to measure group performance at the TIN level, which limits the ability of specialists in larger multi-specialty groups to demonstrate their value to CMS in a meaningful manner. The Alliance is also concerned about the rapid pace at which CMS plans to ramp up requirements in the years following the transition year.

The QPP final rule will be published in the Federal Register on November 4, 2016. Comments on certain provisions of this final rule with comment period are due on December 19, 2016.


Alliance Annual Strategy Meeting December 5th Capitol Hill, Washington, DC

NOTE: Participation in Alliance events is by invitation-only, with some exceptions. To learn more about how you or your organization can participate, please contact your organization's staff liaison to the Alliance or email us at info@specialtydocs.org.


"National Breast Cancer Awareness Month - What Patients Should Know." The Hill's Congress Blog
- October 4, 2016

"Time for Congress to Come Together on 21st Century Cures." Morning Consult.
- June 22, 2016

ASE is Working to Ensure Patients Have the Right Information to Make the Right Choices
The American Society of Echocardiography is working to encourage patient-physician conversations about making the right healthcare choices and ask the right questions. ASE wants patients to feel informed about their healthcare options and most importantly understand the safety and usefulness of cardiovascular ultrasound when undergoing treatment for illnesses like cancer. Chemotherapy and radiation can increase the odds for curing the cancer, but they may also adversely affect the heart, leaving many cancer survivors at risk for cardiac disability. Several chemotherapeutic agents can have detrimental effects on heart function and radiation can also potentially damage the heart and lungs, as well as weaken the rib bones making them more prone to fracture. ASE member Juan Carlos Plana, MD, FASE, Chief of Clinical Operations of the Section of Cardiology, Department of Medicine at Baylor College of Medicine, Director of the Cardio-Oncology Center, and co-Director of the Center for Advanced Cardiac Imaging at Baylor St. Luke's Medical Center, produced patient focused videos, one in English and one in Spanish, encouraging women who are going through treatment for breast cancer to ask certain questions of their doctor. Dr. Plana was the chair of the writing group for the ASE guideline, Expert Consensus for Multimodality Imaging Evaluation of Adult Patients during and after Cancer Therapy: A Report from the American Society of Echocardiography and the European Association of Cardiovascular Imaging, September 2014, which helps doctors learn the protocol for treating patients. ASE has also created a Patient Information Sheet that outlines the importance of taking care of your heart during cancer therapies.

ASE member Sangeeta Shah, MD, FASE, Co-Director, Adult Congenital Heart Program and Director, Cardiovascular MRI at Ochsner Heart and Vascular Institute, produced a Stress Echocardiography video for patients explaining what a stress echo is, how to prepare for the test, and what to expect when having a stress echo. This video helps ASE's work to make sure patients have the information they need. It also provides patients with important information to have a voice in their healthcare and understand their choices.


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AGA Advocates to CMS for GI APMs
American Gastroenterological Association (AGA) leaders Larry Kosinski, MD, MBA, AGAF, clinical councillor, AGA Institute, and Joel V. Brill, MD, AGAF, AGA CPT advisor, met in September 2016 with high ranking officials from CMS and the Center for Medicare and Medicaid Innovation (CMMI) to advocate for the inclusion of specialty alternative payment models (APMs) in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). AGA asked CMS that GI payment models that demonstrate positive clinical and fiscal results, such as Project Sonar, be recognized as a Clinical Practice Improvement Activity (CPIA) and represent a path to qualify as an APM in 2018.

CMS issued the MACRA final rule on Oct. 14, 2016, which seeks to provide more flexibility to physicians to qualify as advanced APMs by expanding the definition of the type of risk the entity would need to bear. Initially, CMS defined an advanced APM as those entities that take on downside risk. The final rule expanded the type of risk, but also provided a path for private payor APMs to qualify as advanced APMS. Although it is not clear at this point whether Project Sonar would qualify as an advanced APM, a letter of intent is being submitted seeking approval and, at a minimum, we hope it will qualify as an APM under MIPS.

During the meeting with CMS and CMMI, Dr. Brill provided an overview of AGA's bundle and episode payment models for gastroenterological issues, including colonoscopy screening and surveillance, gastroesophageal reflux disease, viral hepatitis, and obesity, to help gastroenterologists prepare for success in the new value-driven reimbursement environment. These APMs reward providers for identifying efficiency gains, effectively coordinating care and improving quality. Dr. Brill stressed to CMS officials that gastroenterologists who participate in these risk-bearing models covering at least 50 percent of Medicare beneficiaries should be eligible as a qualified APM under MACRA.

Dr. Kosinski highlighted the importance of population health, value-based payments and patient engagement under APMs. Project Sonar, founded by Dr. Kosinski and built on AGA IBD quality measures, is an intensive medical home developed in conjunction with Blue Cross and Blue Shield of Illinois, which demonstrated that use of patient engagement tools can result in significant reduction in unnecessary emergency department visits, inpatient hospitalizations and costs of care, while improving medication adherence and health outcomes for patients with Crohn's disease.

Drs. Brill and Kosinski stressed that Project Sonar has components similar to the CMS Oncology Care Model, including care pathways for proactive management of the patient, medication reconciliation and appropriate use, a monthly management fee tied to results, and downside risk. Given these similarities, Project Sonar and other GI payment models that demonstrate these results should be recognized as a CPIA and represent a path to qualify as an alternative payment model in 2018.

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U.S. Dept. of Health and Human Services Implements ASPS's BCPEA
Almost one year after President Obama signed the Breast Cancer Patient Education Act (BCPEA) into law, the U.S. Department of Health and Human Services (HHS) launched their implementation of the BCPEA in conjunction with national Breast Reconstruction Awareness Day. As the national sponsor of Breast Reconstruction Awareness Day and the Breast Reconstruction Awareness Campaign, October 19 was a particularly momentous day for the American Society of Plastic Surgeons (ASPS) in its continuing effort to raise greater awareness about a patient’s right to reconstructive surgery following mastectomy, or their choice for prosthesis and breast forms.

“We’re excited that the Department of Health and Human Services (HHS) is implementing the Breast Cancer Patient Education Act,” said ASPS president Debra Johnson, MD. “ASPS worked for years to pass the legislation and has been at the ready since the bill’s passage to assist in implementation any way we can. We applaud HHS for making this important new policy a reality.”

Numerous offices within HHS have been tasked with executing the BCPEA and spreading greater awareness among their distinct audiences. The National Cancer Institute updated their website to include more robust information about breast reconstruction after mastectomy. The new fact sheet will also be incorporated within the breast cancer awareness materials on sister organization sites, including the Office of Minority Health. The Director of Program Innovation for the Office of Women’s Health, Beth A. Collins Sharp, Ph.D., R.N., FAAN, also published a blog post to launch the campaign.

Throughout the months of October and November, the Office of Women’s Health (OWH) will use social media to engage patients and providers and spread greater awareness on breast reconstruction and prosthesis. Campaigns have been created via social media including #ChoicetoRebuild, which is focused on patient awareness, and the #Right2Reconstruct, which is targeted at health care professionals who are involved in the team-based approach for treatment. Sister offices, including the Office of Minority Health and the National Cancer Institute, have actively participated in promoting these social media campaigns.

Support from the Office of Minority Health is paramount in spreading greater awareness about access to reconstruction. While some eligible women with breast cancer undergo breast reconstruction, insufficient information about care options is a more serious problem for women in racial and ethnic minority groups. This is particularly concerning as African-American women under the age of 40 have a greater incidence of breast cancer than Caucasian women of the same age. Additionally, the Office of Women’s Health (@womenshealth)) has reached out to Spanish-speaking audiences through their @SaludDLaMujer@SaludDLaMujer handle, which is particularly important as breast cancer is the most common cancer among Hispanic women.

ASPS has acted as a liaison between the Department of Health, members of the ASPS-founded BCPEA Coalition and industry supporters to further promote these campaigns and ensure that all invested parties continue to share this important message with their unique audiences. Through these communications, ASPS informed partners about the Office of Women’s Health and the Office of Minority Health’s Twitter chat on October 26, which focused on a woman’s #ChoicetoRebuild.

ASPS is working closely with Office of Women’s Health, which is slated to host a webinar in November with participating partner federal agencies to educate health care professionals about reconstructive rights. Unlike the patient-focused Twitter chat, this webinar is specifically targeted at providers within the team-based approach for breast cancer treatment. Educating these health care providers is another important step in closing the loop, as less than half of all women requiring a mastectomy are currently offered breast reconstruction surgery. ASPS believes this webinar is a vital opportunity to further educate other providers in the cancer team about the positive impact breast reconstruction can have on patients suffering from the disease.

ASPS advocated for the passage of the BCPEA from 2012-2015 and promoted this important legislation during the eight ASPS Fly-Ins that took place during that time. ASPS also founded the Breast Cancer Patient Education Act Coalition, which received unprecedented support in 2015 with 40 coalition members, including 26 medical societies, 11 cancer advocacy organizations and three women’s health foundations. ASPS will continue to work with the U.S. Department of Health to identify opportunities to further educate patients and providers in 2017.

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Faces of Neurosurgery: TRACK-ing Progress in Traumatic Brain Injury
By now many have grown numb to the statistics regarding traumatic brain injury (TBI) in the United States. Over two million people see a medical professional for symptoms related to a traumatic head injury each year. If these numbers only make the problem seem unreal, then consider the more personal side of traumatic head injury:
  • A sixty-year-old woman slips down the stairs in her home, falling into a deep coma. She is found to have a large intracranial hemorrhage. Emergency surgery is performed, but it fails to improve her neurologic status.
  • A ten-year-old boy is involved in a high-speed automobile accident on the freeway. His entire brain swells dangerously, threatening to progress to complete loss of blood flow to the brain, the result of which is brain death. He undergoes emergency surgery to have both sides of his skull removed and then is placed in a pharmacologic coma. After several weeks in the intensive care unit, followed by a prolonged stay in a rehabilitation hospital, he walks home with his mother and father and siblings.
  • A twenty-four-year-old man, who had too much to drink while at a lake outing, crashes a jet ski into the dock. He comes into the hospital with a severe skull fracture that has lacerated the linings around his brain and has bruised the brain itself. He undergoes surgery to have the fractured bone fragments removed and goes home several days after his injury.
TBI is not a faceless public health issue that impacts people on the other side of the world. It is agnostic to your race, your gender, your age and your socioeconomic status. Its effects are felt on any number of people in your life: your neighbor, your child, your cousin, your grandmother. Despite its far-reaching effects, TBI is still a very poorly understood disease process. As General Peter Chiarelli cogently pointed out in his blog post, there is a lack of consensus regarding how to diagnose, how to treat, and how to assess treatments for TBI. It is hard to fight an enemy when you don't even know what to call it.

Dr. Geoff Manley has set out to change that.

Geoffrey T. Manley, MD, PhD, FAANS, is Vice Chairman of Neurological Surgery at the University of California, San Francisco. He is Chief of Neurosurgery at San Francisco General Hospital and the Co-Director of the UCSF Brain and Spinal Injury Center (BASIC). He is also one of the principal investigators of a radical new National Institutes of Health-National Institute of Neurological Disorders and Stroke (NIH-NINDS) sponsored trial called TRACK-TBI. The goal of TRACK-TBI is to transform clinical research in TBI. It is the first precision medicine effort in TBI research, with a goal to collect clinical, blood/biospecimen, radiologic and outcome data from three thousand TBI patients nationwide. At present, the trial is over halfway to its goal, with over sixteen hundred patients enrolled. The data collected will be stored in an accessible data repository, with the goal not only to gain further insight into the TBI disease process, but also to help in designing future clinical trials. As Dr. Manley points out,the current understanding of TBI is "as an event, not a process." Currently, there is no way even to confirm a diagnosis of TBI in many patients with milder injuries, such as concussion. But with data collected from studies such as TRACK-TBI, we may be even closer to a combination of blood test and imaging study that could confirm the diagnosis and, as a result, lead to new treatments. With newly tested and validated treatments there will be ways to track outcomes and improve the quality of care for patients with all levels of TB I-- from mild concussion to more severe traumatic injuries.

Dr. Manley has always had a passion for neurosciences and neurosurgery. He obtained his MD and PhD in the Medical Scientist Training Program while at Cornell University in New York. During his neurosurgery training at UCSF, he immediately saw the opportunity to make a clinical impact by studying traumatic injuries of the brain and spinal cord. He is passionate not only about the science of TBI, but also the day-to-day care of patients with traumatic injuries. There are few surgeries a neurosurgeon can perform where the immediate result is saving a life; however, may neurotrauma cases, such as removing a large traumatic hemorrhage that is compressing the brain, offer the neurosurgeon such a gratifying opportunity. Dr. Manley believes that the field of neurotrauma is wide open to neurosurgeons, with so little known regarding a disease process that has such a significant public health impact. To date, many patients who sustain a TBI are an orphaned population, with no clinics or specialists available to help them deal with the aftermath and recovery from their injury. Dr. Manley asserts that neurosurgeons are best suited to be leaders in the field of TBI.

We salute Dr. Geoff Manley, with his passion and scholarship, as a face of neurosurgery who is pushing TBI research and patient care forward.

This post originally appeared on Neurosurgery Blog which is a publication of The American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS). It was authored by Kristopher T. Kimmell, MD, a neurosurgical resident from Rochester, NY.

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Join the most powerful group of specialty physicians!
Joining forces with specialty doctors from across the country helps amplify the concerns specialty doctors share. By working together, specialty medical organizations can work more effectively to influence health care policy and ensure our primary goal: to continue to provide our patients the optimal care they need. As a part of the non-partisan umbrella organization representing all of specialty medicine, your organization will:

  • Promote specialty specific issues as part of a larger coalition, increasing visibility and understanding of issues.
  • Help increase exposure for specialty medical care.
  • Gain access to insider information, background materials and research on health policy initiatives and the political landscape.
  • Receive expert analysis on proposed legislation.
  • Caucus with other specialty organizations at the AMA House of Delegates and other forums to promote key issues that are important to specialty physicians.
  • Coordinate physician and patient grassroots efforts through a large and robust network.
  • Participate in future Alliance Fly-In events in Washington, D.C. Past events have included Capitol Hill visits and presentations by health policy experts.
For information on joining the Alliance of Specialty Medicine, visit our website at www.specialtydocs.org or contact Vicki Hart at vhart@hhs.com

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