Focus Winter 2016

ACADEMY NEWS Volume 14 No. 4 December 2016

Pennsylvania Ophthalmology News

President’s Message

By Joanna M. Fisher, MD As 2016 comes to a close, it is natural to reflect on the year that was. While national politics were overly dramatic, with one of the most contentious presidential campaigns in history, you might have thought that state politics, particularly the PAO’s longstanding efforts to define ophthalmic surgery, were rather quiet. This was definitely not the case.

Throughout the 2015-2016 legislative session, PAO leaders and our lobbyist were hard at work talking to legislators and sitting down at the table with optometry in an effort to identify acceptable terms to pass both our bill and optometry’s scope bill. We consistently and firmly drew a bright line at surgery, insisting that only trained physicians and surgeons can perform this invasive procedure. In the end, neither bill moved, which means there was no expansion of optometric scope in Pennsylvania, proving once again that a good offense is the best defense! Look for more legislative activity in 2017 and be sure to join us in May in Harrisburg for Advocacy Day.

777 East Park Drive, PO Box 8820 Harrisburg, PA 17105-8820 Phone: (717) 558-7750, ext. 1518 Fax: (717) 558-7841 Email: pao@pamedsoc.org www.paeyemds.org

2016 also saw the continued rise in the cost of drugs. This is an issue that deeply concerns the PAO, Pennsylvania Medical Society, and other specialties. Look for joint efforts to address this escalating problem in 2017.

Be sure to read David Silbert’s report on the Pennsylvania Medical Society’s decision to create a Clinically Integrated Network in

Pennsylvania. David attended PAMED’s House of Delegates, where the proposal to pursue a CIN was unanimously approved. After listening to the presentations about the plan, as well as debate on the floor of the House, he sees a tremendous opportunity for Ophthalmology.

Read more on page 2.

The PAO Board of Directors held a strategic planning session in September to discuss the future of the organization, including how we can provide more value for our members.

Look for increased communications in 2017 on relevant and timely topics. We also plan to engage our Young Ophthalmologists by hosting regional networking events. We would love to hear your ideas on how the PAO can help you in your practice. Email our Executive Director, Jennifer Keeler, at jkeeler@pamedsoc.org with your suggestions.

Finally, we are planning a joint meeting with the West Virginia Academy of Eye Physicians and Surgeons at Nemacolin Woodlands Resort on April 28-30, 2017. This is our first foray into clinical education in more than a decade.

I hope you join us for a weekend of learning and socializing with our colleagues from West Virginia. Look for more information in the coming weeks.

As physicians, we are faced with many professional uncertainties in the New Year. The PAO stands ready to help our members deal with whatever comes our way.

I wish you much joy and prosperity in 2017!

ACADEMY NEWS

2016 House of Delegates & Annual Education Conference Update By: David Silbert, MD, FAAP Definition of Acronyms: MACRA: Medicare Access and CHIP Reauthorization Act MIPS:

The Merit-based Incentive Payment System

APM:

Advanced Alternative Payment Models

CIN:

Clinically integrated Network

MSO:

Management Services Organization

PAMED: Pennsylvania Medical Society ACA:

Affordable Care Act

TID:

Tax ID number

CMS:

Center for Medicare and Medicaid Services

EHR:

Electronic Health Records

After months of planning, extended information sessions and debate, the Pennsylvania Medical Society (PAMED) voted unanimously to proceed with the development of a Management Services Organization (MSO) and begin to develop physician-run Clinically Integrated Networks (CINs) in the Commonwealth. This decision has the potential to transform the way that medical care is delivered in the Commonwealth by providing higher quality healthcare at lower cost, while maintaining physician control.

2

Over the course of the weekend at the House of Delegates meeting, the decision to proceed with the MSO and CIN took center stage. Scott Shapiro the outgoing president of PAMED, as well as two physician consultants and an accountant from Deloitte, laid out the options for PAMED through a number of presentations and Q&A sessions. Ultimately, there was a unanimous decision by the House of Delegates to provide up to $15 million dollars of seed money from the PAMED endowment to begin the development of physician run organization that has the potential to reshape for generations how care is provided to our patients. The decision gives hope that physicians will once again be able to have a seat at the table in determining how to provide the most cost efficient, high quality, and physiciancentered care to Pennsylvanians.

Background on MACRA Under MACRA performance rules, January 1, 2017 will start defining how we will be paid. PAO in partnership with PAMED is working to make sure that we as physicians can be restored to

the driver’s seat in healthcare. Alternate payment methods are coming and it is foolhardy to try to ignore them. On the bright side, this is the first time in years that physicians, through groups like these, may be able to help control their own future. Of note, Hospitals are already 30% Alternate Payment Models (APMs).

In 2017 and 2018 all physicians will be scored. This will lead to a 4% bonus to physicians above the mean and a 4% decrease to those below the mean for the vast majority of physicians who are subject to MIPS reporting.

The proposed MSO will allow the aggregation of data, the first step toward any of the goals. Data aggregation would be far too expensive for any one single practice. The MSO will initially help practices with MIPS reporting and costs but will also lead toward the development of Clinically Integrated Networks (CINs), which have the potential to put physicians in charge of medical care.

The Affordable Care Act (ACA) specifically authorized Clinically Integrated Networks (CINs) in order to help improve quality of care while bending the cost curve. While it is unclear what changes will be made to the ACA in the Trump administration, CINs will likely survive, as they are the only marketbased approach to control costs. Regulations allow CINs made up of groups of physicians from separate practices with separate Tax ID numbers (TIDs) to combine together in order to improve quality and decrease costs. Prior to these rules this behavior would be viewed as anticompetitive, but in the context of a CIN is meant to decrease costs and improve quality.

Through MACRA, physicians will need to report through MIPS or via Alternate Payment Models (APMs). To be involved in APMs, physicians will need to be involved in a CIN. These are already being set up by Hospital Systems and by nature the hospital networks are exclusionary. While primary care specialists must choose involvement in only one CIN, specialists may be involved in multiple CINs. For ophthalmologists who wish to continue with things the way they are, reporting through MIPS, taking whatever penalty and not becoming involved in Alternate Payment Methods (APMs) is an option. CMS however, is disincentivizing this approach. First, it will be very difficult for physicians to get the 4% bonus without being involved in an organization like this or the IRIS registry, but further, there will be no positive payment updates beyond 2019, so payments will stay stagnant. This is by design, as CMS is trying to push us all toward APMs and CINs. Developing the organization envisioned will have immediate positive results, but if fully actualized will lead to an environment where CINs controlled by physician practices can, in essence, place physician-run CINs on par with hospital systems by allowing direct contracting with employers and insurance companies to decrease cost and increase quality of care, while sharing in the savings. This will be happening in the Medicare and private payer environments. Over time it is anticipated that more and more lives will be controlled by alternate payments models relying on CINs. In light of this, Medicare as we know it will likely change dramatically. An organization like the one being developed by PAMED may be the only way to preserve a private practice option. Of note, there are already large physician run CINs forming continued on page 6

www.paeyemds.org

ACADEMY NEWS

Legislative Update: Nothing New- Participation Required By: Kenneth Cheng, MD, PAO Secretary of Legislation and Representation Our profession of ophthalmology is continually under assault across the country with legislative efforts by the optometric profession to expand their scope of practice into surgery. This isn’t a new development – it’s been going on for more than 25 years.

As you know, we saw an optometric scope of practice bill here in Pennsylvania this past year, SB 1012. The bill included injections and lid procedures as well as other expansions of optometric scope. In 2016, legislative battles also occurred in Alaska, California, Delaware, Illinois, Iowa, Massachusetts, and Puerto Rico. Thankfully, our fight and all of the rest of these battles to defend patient safety and to stop optometric surgery were won. Pause for a moment to think about what it took to achieve that. It took a tremendous amount of work by ophthalmologists working with their

state ophthalmology societies to accomplish those victories. It required participation.

Large numbers of ophthalmologists making contact with their legislators, maintaining their membership in their state societies, participating with their state PAC’s, and contributing to the AAO’s Surgical Scope Fund.

It required participation by ophthalmologists like you.

Optometry will certainly be back again in 2017 with their scope of practice bill, since SB 1012 was stopped in the Senate Professional Licensure Committee at the end of the session.

We will certainly be back again with our bill in 2017. To “draw the line in the sand” and stop this yearly battle over our profession and the safety of patients, we will be asking for your help again. Develop relationships with your legislators (a great way would be to attend our Advocacy Day which we are planning for May 2017 – Keep an eye out for details). Donate to the PA Ophthalmology PAC. Maintain your

membership in the PAO. Help fight scope battles across the country by donating to the AAO Surgical Scope Fund (a loss anywhere in the country makes the battle all that much harder here at home in PA). Nothing newparticipation required.

This is our opportunity to do something for our profession to ensure the continued ability to practice as we do now. This is our opportunity to do something to help ensure that future generations of ophthalmologists have the opportunities that we have benefited from and enjoyed. Most importantly, this is our opportunity to protect our patients from surgery performed by optometrists who have not had the necessary education and training.

2016 was a good year. No optometric surgical scope bills passed here or anywhere else.

Nothing new. Let’s make 2017 an even better year. Let’s get our Definition of Ophthalmic Surgery Bill passed. Participation required.

3

ACADEMY NEWS

NOTICES: DEPARTMENT OF HEALTH Amendments to Charges for Medical Records [46 Pa.B. 7598] In the notice published at 45 Pa.B. 6934 (December 5, 2015), the Department of Health (Department)published the guidelines and fees that a health care provider or facility may charge in response to a request for production of medical charts or records. This notice updates the notice published at 45 Pa.B. 6934.

Under 42 Pa.C.S. §§ 6152, 6152.1 and 6155 (relating to subpoena of records; limit on charges; and rights of patients), a health care provider or facility is allowed to charge a fee in response to a request for medical charts or records. The Secretary of Health (Secretary), under 42 Pa.C.S. §§ 6152 and 6152.1, is directed to adjust annually the amounts which may be charged by the health care provider or facility.

The Secretary is directed to base these adjustments on the most recent changes in the Consumer Price Index reported annually by the Bureau of Labor Statistics of the United States Department of Labor. For the annual period of October 31, 2015, through October 31, 2016, the Consumer Price Index was 1.6%. Accordingly, effective January 1, 2017, the following fees may be charged by a health care facility or health care provider in response to a request for production of medical charts or records:

Not to Exceed

Amount charged per page for pages 1—20

$1.48

Amount charged per page for pages 21—60

$1.10

Amount charged per page for pages 61—end

$0.37

Amount charged per page for microfilm copies

$2.19

Flat fee for production of records to support any claim under Social Security or any Federal or State financial needs based program

$27.92

Flat fee for supplying records requested by a district attorney

$22.04

* Search and retrieval of records

$22.04

The previously listed fees shall apply for paper copies or reproductions on electronic media whether the records are stored on paper or in electronic format.

In addition to the amounts listed previously, charges may also be assessed for the actual cost of postage, shipping and delivery of the requested records.

The Department is not authorized to enforce these charges.

The previous charges, however, are subject to the following exceptions:

4

(1) An insurer shall not be required to pay for copies of medical records required to validate medical services for which reimbursement is sought under an insurance contract, except as provided in: (a) the Workers’ Compensation Act (77 P.S. §§ 1—1041.4 and 2501—2506) and the regulations promulgated thereunder; (b) 75 Pa.C.S. Chapter 17 (relating to Motor Vehicle Financial Responsibility Law) and the regulations promulgated thereunder; or (c) a contract between an insurer and any other party.

(2) The charges listed in this notice do not apply to an X-ray film or any other portion of a medical record which is not susceptible to photostatic reproduction.

www.paeyemds.org

(3) The charges for the production of medical records by a health care provider in response to a request made by either an individual who is the subject of the health information or the individual’s personal representative is governed by the Health Insurance Portability and Accountability Act (HIPAA) and Federal regulations enacted under HIPAA, including 42 U.S.C.A. § 17935(e) and 45 CFR 164.524 (relating to access of individuals to protected health information), as follows: a. Electronic health record. Under 42 U.S.C.A. § 17935(e), if a health care provider uses or maintains health records in an electronic format with respect to protected health information of an individual, the individual shall have a right to obtain from the health care provider a copy of the information in an electronic format. The individual also has a choice to direct the health care provider to transmit electronically a copy of the health record directly to an entity or person designated by the individual, provided that any choice is clear, conspicuous and specific. Any fee that the health care provider may impose for providing the information (or a summary or explanation of the information) in an electronic format shall not be greater than the labor costs in responding to the request. The United States Department of Health and Human Services has stated that the labor costs may not include costs associated with searching for and retrieving the requested information. b. Health record used or maintained in other types of format (for example, paper). Under 45 CFR 164.524(c)(4), if the individual requests a copy of the protected health information or agrees to a summary or explanation of the information, the covered entity may impose a reasonable, cost-based fee, provided that the fee includes only the cost of: (1) labor for copying the protected health information requested by the individual, whether in paper or electronic form; (2) supplies for creating the paper copy or electronic media if the

ACADEMY NEWS individual requests that the electronic copy be provided on portable media; (3) postage, when the individual has requested the copy, or the summary or explanation, be mailed; and (4) preparing an explanation or summary of the protected health information, if the individual agrees in advance to a summary or explanation and the fees to be imposed, in accordance to 45 CFR 164.524(c)(2)(iii). Similarly, the labor costs under 45 CFR 164.524(c)(4) shall not include the cost attributable to search and retrieval of the records.

Academy Honors David S.C. Pao, MD, for 40-Plus Years of Patient-Centered Advocacy

Inquiries for further clarification on this exception should be directed to the Office of Civil Rights, United States Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington, DC 20201, (866) 627-7748, http://www.hhs.gov/ocr/office/about/contactus/ index.html.

Questions or inquiries concerning this notice should be sent to the Department of Health, Office of Legal Counsel, Room 825, Health and Welfare Building, 625 Forster Street, Harrisburg, PA 17120, (717) 783-2500.

Persons with a disability who require an alternative format of this notice (for example, large print, audiotape, Braille) should contact the Department of Health, Office of Legal Counsel at the address or phone number listed previously, or for speech and/or hearing impaired persons V/TT (717) 783-6514 or the Pennsylvania AT&T Relay Service at (800) 654-5984.

The newest inductee to the Secretariat for State Affairs’ Hall of Fame is an ardent champion of ophthalmology’s commitment to quality patient care David S.C. Pao, MD, one of the Academy’s best and longest advocates for ophthalmology, is the newest member of the Secretariat for State Affairs’ Hall of Fame. Dr. Pao, who was honored at AAO 2016 in Chicago, is a visionary leader in organized medicine, serving to further our Academy’s commitment to advocating on behalf of our patients and profession.

“Dr. Pao’s career epitomizes the ideals represented by the Hall of Fame Award: a lifelong commitment to advocacy for quality patient care and for our profession,” said Academy Secretary for State Affairs Kurt F. Heitman, MD. “Perhaps equally impressive to his work is that after more than forty years, Dr. Pao remains passionate about meeting this charge on our patients’ behalf.”

Dr. Pao is an active member of the Pennsylvania Academy of Ophthalmology, having held numerous advocacy-related leadership roles. His past titles include Secretary of Legislation and Representation, Academy Councilor, and PAO President. He is active in the Pennsylvania Medical Society, where he has served on the Pennsylvania Medical Political Action Committee board. He also served as president of his county medical society.

Admission into the Hall of Fame is done in recognition of Dr. Pao’s 40-plus years of advocacy work. In addition to this honor, Dr. Pao is a past recipient of the PAO’s Distinguished Service Award, presented in 2011, and PAMPAC’s Alexander Award in 2010. He is extraordinarily active in local, state, and federal politics, allowing him to develop close working relationships with elected officials in Harrisburg, Pa., and Washington, D.C. Lawmakers say they can trust Dr. Pao to provide an honest assessment, peppered with his trademark humor, of how health policies will impact physicians and patients.

5

ACADEMY NEWS 2016 House of Delegates continued from page 2 in the state including in Philadelphia and Harrisburg region. It is anticipated that PAMED would work to help these organizations and others that would form.

The savings from the CINs come from two sources, the ability to contract directly with employers, thus cutting out the middleman, and from site of service savings. Site of Service savings move testing, procedures, etc., into low-cost environments (out of hospitals).

Aggregation of data allows the practices in the CIN to share data and eliminate unnecessary testing and studies. It will also allow reporting of efficiencies when contracting.

Comments on PAMED investment to develop MSOs and CINs: • 15 million dollars will be placed in an account to draw from for startup costs.

It will not be spent immediately. This is a small fraction of the 180 million dollars in resources that PAMED has in its endowment.

• Risk of inaction is that PAMED will become nonviable over time as hospitals and insurers continue to dominate healthcare.

The PAO faces the same risk.

• Strategic partners are willing to invest in these networks and will put in much of the money (Venture Capitalists).

• MSO will become a source of revenue for PAMED. • These networks provide options to physicians as to how they wish to practice and provide a private practice option.

• Now is the time to act. The opportunity is unprecedented. In a year or two it will be too late to get started. This may be the last opportunity for physicians to take back a leadership role in medicine.

The Pennsylvania Academy of Ophthalmology Received State Affair’s Star Award

Recommendations from Deliotte: • CIN with MSO is the best structure for PAMED as the MSO will create revenue, which will help sustain the enterprise.

• Best place to set up CIN in the Lehigh/ Capital Regions.

• PAMED plans to help CINs in other regions later.

• PAMED will help groups set up CINs. • Specialists can be involved in more than one CIN. Action Items for PAO: • PAO is actively working with PAMED in the initiatives to set up CINs. • PAO will help ophthalmologists partner with the developing CINs

Save the Date for 2017Annual Scientific Meeting

The PAO was announced as a 2016 State Affairs Star Award recipient for our Patient Testimonial Video. This video is used as an online educational resource for ophthalmologists, legislators, and the public. The video features real ophthalmic surgery patients talking about why they believe only trained ophthalmologists should perform eye surgery. Currently, the video is featured on our website (https://www.paeyemds.org/ pages/safe-eye-surgery.aspx)

Hosted by the West Virginia Academy of Eye Physicians & Surgeons and the Pennsylvania Academy of Ophthalmology

April 28-30, 2017 6

Nemacolin Woodlands Resort

Don’t forget to renew your membership for 2017

For more information and to register, visit www.paeyemds.org

Pay Online at www.paeyemds.org www.paeyemds.org

ACADEMY NEWS

7

PRSRT STD U.S. POSTAGE PAID HARRISBURG PA PERMIT NO. 922

777 East Park Drive P.O. Box 8820 Harrisburg, PA 17105-8820