CMS Announces New Payment Model

On Tuesday, 1/9/18, the Centers for Medicare and Medicaid (CMS) announced a new voluntary bundled-payment model that will be considered an advanced alternative payment model under Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (1). The new model is the first advanced Alternative Payment Model (APM) to be introduced by the Trump administration. The Trump administration has been a vocal advocate of reducing administrative burden for clinicians and has touted voluntary models as a solution (2). The new, voluntary model comes less than two months after the CMS officially decided to eliminate two mandatory bundled-payment models created during the Obama administration.

Under the model, clinician payment will be based on quality measures during a 90-day episode of care. Participants must select at least one of the 32 clinical episodes to apply to the model. The inpatient clinical episodes are listed in Table 1 (3).

Table 1. Clinical inpatient episodes under proposed payment model.

• Acute myocardial infarction
• Back & neck except spinal fusion
• Cardiac arrhythmia
• Cardiac defibrillator
• Cardiac valve
• Cellulitis
• Cervical spinal fusion
• COPD, bronchitis, asthma
• Combined anterior posterior spinal fusion
• Congestive heart failure
• Coronary artery bypass graft
• Double joint replacement of the lower extremity
• Fractures of the femur and hip or pelvis
• Gastrointestinal hemorrhage
• Gastrointestinal obstruction
• Hip & femur procedures except major joint
• Lower extremity/humerus procedure except hip, foot, femur
• Major bowel procedure
• Major joint replacement of the lower extremity
• Major joint replacement of the upper extremity
• Pacemaker
• Percutaneous coronary intervention
• Renal failure
• Sepsis
• Simple pneumonia and respiratory infections
• Spinal fusion (non-cervical)
• Stroke
• Urinary tract infection

Providers will be eligible for bonuses based on their performance. For more information about the model and its requirements, or to download a Request for Applications document (RFA), the application template, and the necessary attachments, please visit: https://innovation.cms.gov/initiatives/bpci-advanced. Applications must be submitted via the Application Portal, which will close on 11:59 pm EST on March 12, 2018. Applications submitted via email will not be accepted.

The CMS Innovation Center will hold a Q&A Open Forum on Tuesday, January 30, 2018 from 12 pm – 1 pm EDT. This event is open to those who are interested in learning more about the model and how to apply. Please register in advance here - https://preaward.adobeconnect.com/e3cdwg6hgx9f/event/registration.html.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Centers for Medicare and Medicaid Services. CMS announces new payment model to improve quality, coordination, and cost-effectiveness for both inpatient and outpatient care. January 9, 2018. Available at: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2018-Press-releases-items/2018-01-09.html (accessed 1/10/18).
2. Castellucci M. CMS launches new voluntary bundled-payment model. Modern Healthcare. January 9, 2018. http://www.modernhealthcare.com/article/20180109/NEWS/180109905 (accessed 1/10/18).
3. Centers for Medicare and Medicaid Services. BPCI Advanced. January 9, 2018. Available at: https://innovation.cms.gov/initiatives/bpci-advanced (accessed 1/10/18).

Cite as: Robbins RA. CMS announces new payment model. Southwest J Pulm Crit Care. 2018;16(1):29-30. doi: https://doi.org/10.13175/swjpcc006-18 PDF 

Varenicline (Chantix®) Associated with Increased Cardiovascular Events

Researchers from Canada published on-line a study linking varenicline with increased cardiovascular events on December 20, 2017 in the American Journal of Respiratory and Critical Care Medicine (1). They found new varenicline users had a statistically significant 34% increased incidence of cardiovascular hospitalizations and emergency department visits while taking the medication.

This finding was consistent in numerous subgroup and sensitivity analyses with different types of patients, different outcome definitions and different risk and control intervals. They also observed a questionably clinically significant 6% increase in the incidence of neuropsychiatric hospitalizations. The cardiovascular findings are in contrast to previous studies which reported no difference or a decrease in cardiovascular events (2,3). The authors advise weighing the health benefits of smoking cessation against any potential cardiovascular events related to varenicline.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Gershon AS, Campitelli MA, Hawken S, Victor C, Sproule BA, Kurdyak P, Selby P. Cardiovascular and neuropsychiatric events following varenicline use for smoking cessation. Am J Respir Crit Care Med. 2017 Dec 20. [Epub ahead of print]. [CrossRef] [PubMed]
2. Kotz D, Viechtbauer W, Simpson C, van Schayck OC, West R, Sheikh A. Cardiovascular and neuropsychiatric risks of varenicline: a retrospective cohort study. Lancet Respir Med. 2015; 3(10):761-8. [CrossRef] [PubMed]
3. Sterling LH, Windle SB, Filion KB, Touma L, Eisenberg MJ. Varenicline and adverse cardiovascular events: a systematic review and meta-analysis of randomized controlled trials. J Am Heart Assoc. 2016; 5(2). pii: e002849. [CrossRef] [PubMed]

Cite as: Robbins RA. Varenicline (Chantix®) associated with increased cardiovascular events. Southwest J Pulm Crit Care. 2018;16(1):15. doi: https://doi.org/10.13175/swjpcc003-18 PDF 

Tax Cuts Could Threaten Physicians

Today (December 13) members of the House and Senate will meet to reconcile differences between their two tax reform proposals. Congress is expected to complete work on the bill before the Christmas recess. Although many are overjoyed by a tax cut, there are potential pitfalls to the tax cut that might adversely affect physicians.

Under a rule in the Senate known as Pay as You Go (PAYGO), legislation that increases the deficit results in automatic spending cuts. The Congressional Budget Office (CBO) estimates that tax cuts could lead to automatic cuts of $136 billion in fiscal 2018, $25 billion of which would come from Medicare. PAYGO cuts would reduce Medicare payments to physicians by 4% in 2018 according to the American College of Physicians (ACP) (1). PAYGO would also lead to cuts to graduate medical education, lab fees, and hospital payments and would cut or entirely eliminate hundreds of other federal programs, including programs within the Centers for Disease Control and Prevention, the Health Resources and Services Administration, and the Prevention and Public Health Fund, according to the ACP.

Senate Republicans want to essentially repeal the penalty that accompanies the mandate that all Americans buy health insurance. It seems likely that House Republicans will go along. The CBO estimates that this would decrease the number of people with health insurance by 4 million by 2019 and premiums in the nongroup market by about 10% in almost each year for the next 10 years. The American Association of Retired Persons (AARP) says that 64-year-olds could see their premiums increase by an average of $1490 a year (2).

The medical expense tax deduction has been targeted for elimination by the House. The Senate version, however, would keep the deduction. The AARP says that in 2015, 8.8 million Americans used the deduction and that more than half were older than 65 (2). Nearly three quarters are 50 years old or older and live with a chronic condition or illness, and 70% of those who claimed the medical expense deduction have income below $75,000, according to the AARP. However, the tax deduction seems likely to survive. Rep. Kevin Brady (R-TX) who heads the reconciliation said he's willing to consider scrapping the proposal to eliminate the deduction (3).

The House is proposing to eliminate a tax credit that has been used as an incentive for pharmaceutical companies to develop therapies for orphan diseases. The Senate is reducing that credit. Not surprisingly, the National Organization for Rare Disorders and 160 other organizations representing patients with rare conditions oppose any reduction (4). They argue that eliminating the tax cut would deincentivize pharmaceutical companies to develop therapies for orphan diseases where the market is usually small.

Hospitals are alarmed about the House proposal to eliminate tax-exempt private activity bonds used by nonprofit hospitals and academic medical centers. The Senate bill would continue to allow that tax-exempt financing. This is opposed by both the Association of American Medical Colleges and the American Hospital Association (5,6).  The AHA’s Thomas P. Nickels states, "The ability to obtain tax-exempt financing is a key benefit of hospital tax-exemption that works to make access to vital hospital services available in communities large and small across America." (6).  Locally several medical centers have large bonds and loss of the exemption might have significant consequences.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Ende J. Letter to Mitch McConnell and Charles Schumer. November 30,2017. Available at: https://www.acponline.org/acp_policy/letters/senate_tax_cuts_and_jobs_act_2017.pdf (accessed 12/13/17).
2. Strauss G. AARP opposes senate tax bill. November 30, 2017. Available at: https://www.aarp.org/politics-society/advocacy/info-2017/senate-letter-tax-fd.html?intcmp=AE-HP-FLXSLDR-SLIDE1?intcmp=AE-HP-FLXSLDR-SLIDE1-RL1 (accessed 12/13/17).
3. Ault A. Five things in the GOP tax plan that threaten medicine. Medscape. December 12, 2017. Available at: https://www.medscape.com/viewarticle/889947?nlid=119526_4502&src=wnl_dne_171213_mscpedit&uac=9273DT&impID=1507630&faf=1#vp_2 (accessed 12/13/17).
4. Letter to Congress. December 7, 2017. Available at: https://rarediseases.org/wp-content/uploads/2017/12/Orphan-Drug-Tax-Credit-Conferee-Letter-Final.pdf (accessed 12/13/17).
5. AAMC. AAMC statement on house tax reform legislation. https://news.aamc.org/press-releases/article/house_tax_reform_11092017/ (accessed 12/13/17).
6. Nickels TP. Letter to Rep. Kevin Brady. December 8, 2017. Available at: http://www.aha.org/advocacy-issues/letter/2017/171208-letter-taxbill-conferees.pdf (accessed 12/13/17).

Cite as: Robbins RA. Tax cuts could threaten physicians. Southwest J Pulm Crit Care. 2017;15(6):280-1. doi: https://doi.org/10.13175/swjpcc153-17 PDF 

Trump Nominates Former Pharmaceutical Executive as HHS Secretary

President Trump on Monday announced Alex Azar, a former pharmaceutical executive, as his choice to succeed Dr. Tom Price as secretary of Health & Human Services (HHS) (1). HHS is an 80,000-employee federal agency that oversees the Centers for Medicare and Medicaid Services, the Food and Drug Administration, the National Institutes of Health, and the Centers for Disease Control and Prevention. Price resigned in September following reports of his extensive use of government and charter air travel.

Azar, a lawyer, formerly headed Eli Lilly & Co.'s U.S. division. Before that, he served as HHS general counsel and deputy secretary during the George W. Bush administration. During that stint, he received praise for his management competence. Azar "will be a star for better healthcare and lower drug prices!" Trump tweeted.

Andy Slavitt, CMS administrator under the Obama administration, also a lawyer and former United Healthcare executive, offered cautious praise for Azar. "I have reason to hope he would make a good HHS secretary," Slavitt said in a written statement. "He ... has real-world experience enough to be pragmatic, and will hopefully avoid repeating the mistakes of his predecessor in over-politicizing Americans' access to healthcare."

If confirmed, Azar would inherit an agency currently torn by political and policy divisions in the wake of Price's departure (2). He will have to make key decisions to avoid further disruption in the individual health insurance market; how much leeway to give states to make big changes in their Medicaid expansion program; and face pressure to address rising prescription drug costs. One management issue Azar would quickly face is how to deal with Price's ambitious Reimagine HHS initiative to streamline the department's operations and with the White House’s proposal to slash the HHS' budget for 2018 by 18%.

Azar has been a sharp critic of the Affordable Care Act, saying in May that the ACA is "fundamentally broken" and "circling the drain." In June, he envisioned the Trump administration shifting the ACA in a more conservative direction even without repeal and replacement of the law. He also has opposed reducing prescription drug prices or allowing purchasing drugs from other countries where prices are lower.

If confirmed, Azar will represent a return to the recent tradition of selecting Secretaries of HHS with no medical background. Before, Price, only Dr. Otis Bowen (1985-9) and Dr. Louis Sullivan (1989-93) were physicians of the 11 non-interim Secretaries.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Meyer H. Can Trump's pick to lead HHS navigate the churning political waters of healthcare? Modern Healthcare. November 13, 2017. Available at: http://www.modernhealthcare.com/article/20171113/NEWS/171119968?utm_source=modernhealthcare&utm_medium=email&utm_content=20171113-NEWS-171119968&utm_campaign=am (accessed 11/14/17).
2. Pradhan R, Diamond D. Price investigation continues to roil HHS. Politico. November 13, 2017. Available at: https://www.politico.com/story/2017/11/13/tom-price-private-jets-probe-hhs-244793 (accessed 11/14/17).

Cite as: Robbins RA. Trump nominates former pharmaceutical executive as HHS secretary. Southwest J Pulm Crit Care. 2017;15(5):221-2. doi: https://doi.org/10.13175/swjpcc140-17 PDF

Arizona Averages Over 25 Opioid Overdoses Per Day

An Arizona Republic article and the Arizona Department of Health Services Director's blog, Dr. Cara Christ, brings the opioid crisis home (1,2). Christ states that over 3200 opioid overdoses with over 400 deaths occurred between June 15 and October 17 in Arizona. This averages to over 25 overdoses and 3 deaths per day.

Some of the data from Christ’s blog are below:

• Males 25-29 have the highest rates of suspected opioid overdoses.
• 37% of people experiencing a suspected opioid overdose had an opioid prescription in the two months prior to their overdose.
• The majority of overdoses occur at home.
• The most commonly cited pre-existing health conditions of those with suspected overdoses was chronic pain. Depression and other behavioral health conditions were also common health conditions noted.
• Meth and heroin were the most frequently cited drugs involved in reported neonatal abstinence syndrome.
• About 40% of people experiencing suspected opioid overdoses who had a prescription in the Controlled Substances Prescription Monitoring Program had been prescribed both benzodiazepines and opioids in 2017. When these medications are combined, it is so dangerous that the FDA gives it a “black box” warning.
• About 40% of people experiencing a suspected overdose that had prescription history in the Controlled Substances Prescription Monitoring Program (CSPMP) had received opioid prescriptions from 10 or more providers.
• Only about 25% of clinicians prescribing controlled substances checked the CSPMP prior to prescribing.

On October 16, a new mandate went into effect that requires clinicians to check the CSPMP prior to prescribing an opioid or benzodiazepine. Other states implementing such mandates have experienced reductions in people with 4 or more prescribers or pharmacies, reductions in opioid prescribing, and reductions in Morphine Milligram Equivalent daily doses.

The CSPMP requires registration and login but is relatively easy to use (3). You can search not only in Arizona but other states as well. Personally, as a pulmonary consultant I infrequently prescribe opioids or benzodiazepines. However, I have used the website once to check a benzodiazepam prescription for a patient I suspect might be addicted. No other prescriptions were found. It at least gave me some assurance that he was not obtaining prescriptions from multiple practioners while we attempt to wean him off this medication.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. McCrory C. More than 400 opioid-overdose deaths reported in Arizona since June 15. Arizona Republic. October 27, 2017. Available at: http://www.azcentral.com/story/news/local/arizona/2017/10/27/more-than-400-opioid-overdose-deaths-reported-arizona-since-june-15/809157001/ (accessed 10/28/17).
2. Christ CM. Opioid update: latest data and emergency rules update. October 17, 2017. Available at: http://directorsblog.health.azdhs.gov/opioid-update-latest-data-and-emergency-rules-update/ (accessed 10/28/17).
3. Arizona Board of Pharmacy. Arizona PMP Aware. Available at: https://pharmacypmp.az.gov/ (accessed 10/28/17).

Cite as: Robbins RA. Arizona averages over 25 opioid overdoses per day. Southwest J Pulm Crit Care. 2017;15(4):179-80. doi: https://doi.org/10.13175/swjpcc133-17 PDF