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MSSNY Fall Legislative Update MOE AUSTER, ESQ. Senior VP, Legislative & Regulatory Affairs mauster@mssny. MSSNY Fall Legislative Update MOE AUSTER, ESQ. Senior VP, Legislative & Regulatory Affairs [email protected] org 1

Medical Society of the State of NY State Budget FY 2016 -17 l l Medical Society of the State of NY State Budget FY 2016 -17 l l l Excess continued at $127. 4 M; preserved coverage for 13, 000 physicians. Defeated Retail Clinic proposal. Defeated Workers comp “reform” proposals Preserved county society role. ¡ Prevented expansion of non-physician role. ¡ Prevented expansion of Workers Comp PPO control of care. ¡

Medical Society of the State of NY State Budget FY 2016 -17 l l Medical Society of the State of NY State Budget FY 2016 -17 l l l Preserved “Prescriber Prevails” protections in FFS Medicaid and Medicaid managed care. Expansion of Doctors Across New York Health Republic Fund Use of “to be determined” settlement monies. ¡ Liquidation process must occur first. ¡

Medical Society of the State of NY State Budget FY 2016 -17 l E-prescribing Medical Society of the State of NY State Budget FY 2016 -17 l E-prescribing waivers for low volume prescriber those writing 25 and under prescriptions per year can certify to DOH to not be subject to eprescribing mandate. ¡ up to 3 “certifications” permitted – will need to be revisited in 2019. ¡

Medical Society of the State of NY Remainder of 2016 Leg Session ¡ Defeated Medical Society of the State of NY Remainder of 2016 Leg Session ¡ Defeated Liability Expansion bills l l ¡ Statute of Limitations (A. 285 and A. 10719/S. 6596 B) Focus of Senate Roundtable in May Continued Dialogue Repeal of Contingency Fee Limitations (S. 4002) Continue to Advance Progressive Liability Reforms l l Certificate of Merit Expert Witnesses Qualifications Peer Review Protections Reasonable Limitation on Awards

Legislative and Physician Advocacy Committee Remainder of 2016 Leg Session ¡ Secured Changes to Legislative and Physician Advocacy Committee Remainder of 2016 Leg Session ¡ Secured Changes to e. Rx mandate § (A 9335, Gottfried/S 6779, Hannon) Signed into Law. § Eliminate requirement for physicians to send DOH information concerning the issuance of a paper script. § (A 9837, Gottfried/S 7334, Hannon) Passed Both Houses, but vetoed. § Allow transmission of e. Rx to centralized site from which it can be downloaded. § (A. 10448, Schimel/S. 7537, Martins) Passed Both Houses. § Transfer e-prescriptions between pharmacies § Gov hinted he may sign

Medical Society of the State of NY Remainder of 2016 Leg Session ¡ Defeated Medical Society of the State of NY Remainder of 2016 Leg Session ¡ Defeated Scope of Practice Bills l l l Optometrist prescribe oral medications- compromise bill introduced (A. 9961, Paulin/S. 7440, Funke) Dentists perform cosmetic procedures in the oral and maxillofacial area (A. 3329, Morelle/ S. 816, Libous) Podiatrists diagnose and treat cutaneous conditions (A. 719 B, Pretlow/ S. 6990, Amedore)

Medical Society of the State of NY Remainder of 2016 Leg Session ¡ Defeated Medical Society of the State of NY Remainder of 2016 Leg Session ¡ Defeated Scope of Practice Bills l l Nurse Anesthetists title bill (A. 140, Paulin/S. 7166, Gallivan) Corporate law changes to allow physicians and nonphysicians to co-own medical practices ¡ ¡ Optometrists: A. 991, Cahill Chiropractors: A. 4391, O’Donnell/S. 215, Martins Psychologists: A. 6925, Weprin Art. VIII providers: A. 8153, People Stokes/S. 5862, La. Valle

Medical Society of the State of NY Remainder of 2016 Leg Session ¡ Defeated Medical Society of the State of NY Remainder of 2016 Leg Session ¡ Defeated Retail Clinic bill (A. 1411, Paulin/S. 5458, Hannon) l l Defeated administration’s budget proposal in March. Last week of Session Assembly Democratic Conference held to discuss bill. ¡ DGA contacted MSSNY and County leadership to call Assembly members. ¡ DGA contacted Primary Care Specialties, Nurses, Retail Council to develop overnight network of Associations engaging in opposition to the bill. ¡ Conference rejected proposal.

Medical Society of the State of NY Remainder of 2016 Leg Session ¡ Secured Medical Society of the State of NY Remainder of 2016 Leg Session ¡ Secured Several Changes to Opioid Package l CME Mandate on Pain Management- prescribers must take 3 hour course by 7/1/17 and every 3 yrs thereafter. ¡ Course can be taken online. ¡ Exception process: l Physicians for whose practice such a course is not applicable. l Physicians who have already taken a course. ¡ MSSNY has course online. Will seek recognition (Need to add palliative care component).

Medical Society of the State of NY Remainder of 2016 Leg Session ¡ Secured Medical Society of the State of NY Remainder of 2016 Leg Session ¡ Secured Several Changes to Opioid Package l l Limits Initial Prescription Of Schedule II, IV Opioid For Treatment Of Acute Pain To A Seven-Day Supply. MSSNY secured flexibility to enable prescriber after subsequent consultation for same pain to issue renewal, refill or new prescription. ¡ Consultation does not require examination; may be phone conversation with patient.

Medical Society of the State of NY Remainder of 2016 Leg Session ¡ Secured Medical Society of the State of NY Remainder of 2016 Leg Session ¡ Secured Several Changes to Opioid Package l l l Defeated a proposal that would have placed a duty on a prescriber to provide consultation regarding the addictive nature of opioids Defeated a proposal to require the patient sign a form attesting that they received such counseling from their prescriber. Defeated a proposal to require Emergency Room Physicians to Consult PMP.

Medical Society of the State of NY Remainder of 2016 Leg Session ¡ Secured Medical Society of the State of NY Remainder of 2016 Leg Session ¡ Secured Several Changes to Require Extend Hours For Mammography l Defeated a proposal that would have imposed the extended hours requirements beyond hospitals and extension clinics to private physician practices.

Medical Society of the State of NY Remainder of 2016 Leg Session o Secured Medical Society of the State of NY Remainder of 2016 Leg Session o Secured Passage By Both Houses of Key Health Insurance Administrative Simplification Proposals: • Permit override of a health plan step therapy prescription protocols (A 2834 -B, Titone/S 3419 -B, Young); • Directs DFS/DOH to establish a standard prior authorization form for requesting medication coverage (A 6983, Mc. Donald/S 4721, Hannon); • Reduces timeframe for plan credentialing of new physicians from 90 to 60 days (A. 501, Cusick/S 2545, Lanza)

Medical Society of the State of NY 2017 Legislative Session- Ongoing Issues ¡ Impact Medical Society of the State of NY 2017 Legislative Session- Ongoing Issues ¡ Impact of Election- Who controls NYS Senate? GOP? Dems? GOP-IDC Bi-Partisan Majority? ¡ ¡ ¡ Effect of MLMIC Demutualization on Excess and Regressive Legislation? Impact of VBP on ability to leverage Collective Negotiation? Impact of DSRIP-SHIP-MIPS-APMs on Physician Practices?

Medical Society of the State of NY Federal Issues ¡ Implementation of MIPS-APMs l Medical Society of the State of NY Federal Issues ¡ Implementation of MIPS-APMs l l l Penalties/Bonuses starting in 2019, but based on 2017 actions Rules to be Finalized Soon CMS/Slavitt Flexibility Announcement ¡ CMS Rule on Medicare Part B Medication Reimbursement ¡ Changes to the ACA? 16

Medical Society of the State of NY Implementation of MIPS-APMs ¡ Part of MACRA Medical Society of the State of NY Implementation of MIPS-APMs ¡ Part of MACRA law enacted in 2015 to repeal SGR ¡ Goal of MIPS is to consolidate existing MU, PQRS and Value-Based Modifier Into One Value Program ¡ Bonus/Penalties Begin in 2019, but are based on 2017 care delivery to Medicare patients 17

Medical Society of the State of NY MIPS Bonus/Penalties Year Bonus/Penalty 2019 2020 2021 Medical Society of the State of NY MIPS Bonus/Penalties Year Bonus/Penalty 2019 2020 2021 2022 +/- 4% +/- 5% +/- 7% +/- 9% 18

Medical Society of the State of NY Impact of Laws Prior to MACRA (According Medical Society of the State of NY Impact of Laws Prior to MACRA (According to AMA) Year 2019 2020 2021 Potential Cumulative Impact of MU/PQRS/VBP -11% or More 19

Medical Society of the State of NY MIPS Scoring (2017) Component Quality Performance Advancing Medical Society of the State of NY MIPS Scoring (2017) Component Quality Performance Advancing Care Information Clinical Practice Improvement Resource Use Replaces PQRS % of Score 60% (up from 50% in proposed rule) MU 25% New 15% Replaces Value. Based Modifier 0% (had been 10% in proposed rule) 20

Medical Society of the State of NY MSSNY/AMA Concerns with MACRA Regs ¡ Exemption Medical Society of the State of NY MSSNY/AMA Concerns with MACRA Regs ¡ Exemption threshold of $10, 000 Medicare revenue/100 Medicare patients too low – raised to $30, 000 in final rule ¡ Full-year reporting for MU too difficult – permits 90 -day reporting and reduced number of measures to report ¡ Need earlier feedback (2019 payment based upon 2017 activity; 2020 payment based upon 2018 activity, etc. ) ¡ Reduce the 90% patient threshold for reporting quality measures – reduced to 50% of patients in final rule 21

Medical Society of the State of NY MSSNY/Coalition of State Medical Societies Letter to Medical Society of the State of NY MSSNY/Coalition of State Medical Societies Letter to CMS ¡ “…the overwhelming complexity of this proposed regulation is not what Congress intended when it passed MACRA. ” ¡ “Because the cost of reporting is so high for small practices and…threat of penalties or inadequate bonus payments do not cover the costs to report, few small practices can participate. ” 22

Medical Society of the State of NY CMS 9/8 Blog Post – Good News! Medical Society of the State of NY CMS 9/8 Blog Post – Good News! Options to Avoid 2019 Cuts 1. Report some data (before 3/31/18) – No Medicare Cuts 2. 90 -day reporting – “Small Positive Adjustment” 3. Full Year Reporting - “Modest Positive Adjustment” 4. Participate in an APM 23

Medical Society of the State of NY Alternative Payment Models (APMs) ¡ Alternative to Medical Society of the State of NY Alternative Payment Models (APMs) ¡ Alternative to Participating in MIPS ¡ 5% Bonus but must take on significant risk ¡ Does not include Track 1 ACO participation (but may be permitted in 2018) ¡ Risk based upon entire Medicare spending for patient, not just Part B expenses 24

Medical Society of the State of NY Resources for MACRA Compliance ¡ AMA Payment Medical Society of the State of NY Resources for MACRA Compliance ¡ AMA Payment Evaluator – to determine how practices will be impacted by MACRA ¡ AMA Steps Forward – Practice Improvement Strategies, including: l l Implementing Team Based Care EHR Selection and Implementation Quality Reporting Preparing practices for Value Based Care 25

Medical Society of the State of NY Important Dates ¡ January 4, 2017: Opening Medical Society of the State of NY Important Dates ¡ January 4, 2017: Opening Day of Session ¡ January 18, 2017: Proposed Budget Announced (? ) ¡ February 27 -28 – AMA Nat’l Advocacy Conference ¡ March 7 & 8, 2017 – MSSNY Legislative Day ¡ April 1, 2017: Budget Due Date ¡ June 16, 2017: End of Session (Anticipated)

Medical Society of the State of NY JOIN MSSNYPAC!! The Few Cannot Continue to Medical Society of the State of NY JOIN MSSNYPAC!! The Few Cannot Continue to Support the Many!! 27

Medical Society of the State of NY Thank You! Medical Society of the State of NY Thank You!