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Federal UpdateJohn T. Supplitt, Sr. Director
February 24, 2017
Agenda
1.Political Environmenta) New Congressb) New Administration
2.Repeal and Replace3.Legislative Advocacy4.Regulatory Policy5.Ensuring Access
Political Environment
The 115th CongressRepublican House Leadership
Speaker of the House: Paul Ryan (R-WI)Majority Leader: Kevin McCarthy (R-CA)Majority Whip: Steve Scalise (R-LA)Conference Chair: Cathy McMorris Rodgers (R-WA)
Republican Senate Leadership• Majority Leader: Mitch McConnell (R-KY)• Whip: John Cornyn (R-TX) • Conference Chairman: John Thune (R-SD) • Policy Committee Chairman: John Barrasso (R-WY) • Conference Vice Chairman: Roy Blunt (R-MO)
The 115th Congress
Committee on FinanceOrrin Hatch, Chairman
Subcommittee on Health CarePat Toomey, Pa., ChairmanChuck Grassley, IowaPat Roberts, Kan.Michael B. Enzi, Wyo.John Thune, S.D.
Richard Burr, N.C.Johnny Isakson, Ga.Rob Portman, OhioDean Heller, Nev.Bill Cassidy, La.
Committee of Jurisdiction for HealthU.S. Senate Republicans
Committee on Health, Education, Labor and PensionsLamar Alexander, Chairman
Michael Enzi, WY Todd Young, INRichard Burr, NC Orrin Hatch, UTJohnny Isakson, GA Pat Roberts, KSRand Paul, KY Lisa Murkowski, AKSusan Collins, ME Tim Scott, SCBill Cassidy, M.D., LA
The 115th Congress
Committee on Ways & MeansKevin Brady TX-8
Subcommittee on HealthPat Tiberi, OH 12, ChairmanSam Johnson, TX 3Devin Nunes, CA 22Peter Roskam, IL 6Vern Buchanan, FL 16Adrian Smith, NE 3Lynn Jenkins, KS 2Kenny Marchant, TX 24Diane Black, TN 6Erik Paulsen, MN 3
Committees of Jurisdiction for HealthU.S. House Republicans
Committee on Energy and CommerceGreg Walden, OR 2
Subcommittee on HealthMichael Burgess, TX 26 - ChairmanBrett Guthrie, KY 2Joe Barton, TX 6Fred Upton, MI 6John Shimkus, IL 15Tim Murphy, PA 18Marsha Blackburn, TN 7Cathy McMorris Rodgers, WA 5Leonard Lance, NJ 7Morgan Griffith, VA 9Gus Bilirakis, FL 12Billy Long, MO 7Larry Bucshon, IN 8Susan Brooks, IN 5Markwayne Mullin, OK 2Richard Hudson, NC 8Chris Collins, NY 27Buddy Carter, GA 1
Tax reform Infrastructure Trade reform Regulatory reform Immigration ACA … repeal and replace
Priorities of the New Administration
The Trump Administration
Rep. Mick Mulvaney, Director OMB Tom Price, M.D., Sec. HHS Seema Verma, Administrator CMS
Fiscal Cliffs and FY 2018Mid-January Congress adopts FY 2017 budget resolution
with reconciliation instructions to repeal ACA
January 27 Committees must report 2017 reconciliation bills
February 20 Target date for reconciliation bill repealing ACA to White House
March 15 DEBT CEILING SUSPENSION EXPIRESApril 28 CONTINUING RESOLUTION EXPIRES
May ?? Pres. Trump sends FY 2018 budget to Congress
June 30 Congress adopts budget resolutionSeptember ?? Committees must report FY 2018
reconciliation billsSeptember 30 FY 2018 reconciliation bill to White HouseOctober 1 FY 2018 begins
2017 Schedule• ACA Repeal & Replace
– 2017 Reconciliation – Replacement Proposals
• 2018 Reconciliation – Tax Reform
• Medicaid• Funding the Government (April 28) • Debt Ceiling (March 15)• CHIP Reauthorization (Sept 30)• Other Priorities - Infrastructure
ProcessReconciliation• FY 2017 instructions• FY 2018 instructions• Byrd rule implications
Procedure Parliamentary rules
Elizabeth MacDonoughSenate Parliamentarian
Power of the Parliamentarian
Repeal & Replace
AHA Principles for ACA Re-examination• Maintain coverage for those covered• Replacement of coverage should be simultaneous
with any repeal, protecting people’s coverage• Any effort to repeal should restore funding
reductions to hospitals • Support continued efforts to transform delivery
system from FFS to FFV using coordinated care and integrated delivery mechanisms
Affordable Care Act
Impact of Repeal on HospitalsThe financial impact on hospitals include: a net negative impact of $165.8 billion regarding
coverage losses; a loss of $289.5 billion in Medicare inflation updates if
the payment reductions in the ACA are not restored; and
suffering $102.9 billion in cuts if the ACA’s Medicare and Medicaid DSH payment reductions are not restored.
Repeal and ReplaceThe emerging GOP blueprint includes Republican mainstays like: • expanding Health
Savings Accounts• enacting high-risk
insurance pools• reforming Medicaid• tax credits to help
Americans buy insurance policies.
Repeal and Replace
Legislative Advocacy
Five objectives:1. Reduce the regulatory
burden;2. Enhance affordability and
value;3. Continue to promote
quality and patient safety;4. Ensure access to care and
coverage; and 5. Continue to advance health
system transformation and innovation.
Letters to the President-elect
Make Medicare extensions from SGR permanent:• Medicare-dependent Hospital
(MDH) program; • Enhanced adjustment for
certain low-volume hospitals• Ambulance add-on payments
for ground ambulance and super-rural areas,
• Therapy cap exceptions process, and
• Rural home-health add-on
2017 AHA Rural Advocacy Agenda
2017 Rural Advocacy AgendaReintroduce fixes for rural hospitals:• Extend enforcement
moratorium for direct supervision (S. 243/H.R. 741)
• Remove the 96-hour condition of payment
• 340B program stabilization• IT and meaningful use stage 3• Care coordination• Vulnerable community models
Telehealth. Expand Medicare coverage and payment and support research
Behavioral Health. Improve access to services, address workforce issues; and improve parity.
Medicare DSH. Relieve hospitals from cuts to Medicare disproportionate share hospitals.
CAH payments. Ensure CAHs are paid 101 percent of costs by Medicare and are paid at least the same by Medicare Advantage plans.
CAH designation. Maintain CAH designation, as currently defined.
IPAB. Exempt CAHs from the Independent Payment Advisory Board.
Provider taxes. Allow claim the full cost of provider taxes as allowable costs.
2017 AHA Rural Advocacy Agenda
Rural Advocacy Resources
Rural Advocacy Agenda
Rural Infographics
Action Alerts
Social Media
www.aha.org/RuralAdvocacy
41 U.S. Senators sent a letter to HHS Secretary Tom Price regarding health care in rural America.
Senators Highlight Need for Quality Health Care in Rural America
Rural hospitals play a critical role in communities across this country.
We hope you remain dedicated to ensuring all Americans—no matter where they live—have access to quality, affordable care. We look forward to continuing to work with you as we move forward to improve health care in rural America.
Congrats, and remember rural!
AdvocacyUseful Tips
• Coordinate with your Government Relations Representative if a system hospital and State Association if independent
• Tell Your Hospital Story• Use Hospital-Specific Data• Useful Anecdotes that Help Make the Case• Build a Relationship with the Congressional
Staff• Offer Yourself and the Hospital Team as a
Resource
Rural Hospital Policy Forum 2017July 20, 2017
Annual AHA Rural Hospital Policy Forum on Capitol Hill
Regulatory Policy and Advocacy
AHA identified 33 rules including;• Suspending star ratings,• Canceling stage 3 of
meaningful use,• Rescind 96-hour rule,• Allow visiting specialists
to share space in HOPDs,• Suspend e-CQM• Remove faulty quality
measures• Expand telehealth
coverage
Regulatory Relief Actions
Regulatory Highlights1. Two-midnight policy 2. ALJ litigation decision3. Medicare Outpatient Observation Notice4. MACRA Final Rule5. Site Neutral Regulations6. Hospital Co-Location Issue7. ACA Section 15578. Medicare Conditions of Participation9. Emergency Preparedness Plans10. 340B Program 11. CJR and Cardiac Bundles12. Anti-Kickback Statute and Safe Harbors
Two-midnight policy• Eliminates two-midnight cut
– Prospective and retrospective elimination provides $3.1 Billion to hospitals over 10 years
• Policy changes, effective Jan. 1, 2016– Stays expected to cross at least two midnights are
inpatient– No changes to two-midnight presumption or benchmark– Stays less than two midnights may now be payable as
inpatient “based on the clinical judgment of the admitting physician and medical record support for that determination”
Regulatory Highlights
ALJ litigation decision• Decision issued on Dec. 5, 2016• HHS ordered to eliminate the backlog
of Medicare claims appeals pending at the ALJ level within four years – 30% by Dec. 31, 2017; – 60% by Dec. 31, 2018; – 90% by Dec. 31, 2019; and – 100% by Dec. 31, 2020
• Court upholds timeline on Feb. 9• Appeals settlement reopened
Regulatory Highlights
Medicare Outpatient Observation Notice
Outpatient Observation Services
MACRA abolished the SGR formula for Medicare physician payment and replaced it with:• Stable payment updates
physician fee schedule• Two-track payment system
effective in 2019:1. Merit-Based Incentive
Payment System (MIPS), and
2. The Alternative Payment Model (APM) track
Medicare Access & CHIP Reauthorization Act
AHA MACRA resources: http://www.aha.org/macra
Quality Payment ProgramMACRA Final Rule
• Started Jan. 1, 2017, clinicians “pick their own pace”• Few advanced APMs qualify for incentives in 2017 • More data reported in 2017 means better chance of payment
increase• Fewer clinicians than expected subject to MIPS in the first year• Expectations will ramp up over time
Site Neutral Regulations• Outpatient PPS final rule implements site-
neutral provisions – Establishes site-neutral payment rates for certain off-
campus provider-based hospital outpatient departments (HOPDs)
– In 2017, these HOPDs will be paid under the physician fee schedule at newly established rates (generally 50 percent of the outpatient PPS rate)
• Legislative extension for effective date for some HOPDs
• Does not apply to CAHs
Regulatory Highlights
Hospital Co-Location Issue• A number of current regulations affect how
hospitals may share:
• Space• Services• Staff
• CMS has expressed several precise interpretations of these rules that differ from prior understanding
• Status update
Satellite rules, HwH, CoPs, provider-based rules
These rules lack specificity
Regulatory Highlights
Regulatory HighlightsNondiscrimination in Health Programs and Activities
Section 1557 of the Affordable Care Act (ACA) of 20101. prohibits discrimination on the basis of race, color, national
origin, sex, age, or disability in certain health programs or activities
2. has been in effect since signed into law.Obligations under Section 1557 include: posting information telling consumers about their rights telling consumers with disabilities and consumers with limited
English proficiency (LEP) about the right to receive communication assistance
posting taglines in the top 15 languages spoken by individuals with LEP, and
advising consumers of the availability of free language assistance services.
https://www.hhs.gov/civil-rights/for-providers/index.html
Hospital/CAH Conditions of Participation
• Implement antibiotic stewardship programs• Augment infection prevention and control
regulation• Update QAPI requirements, including QAPI for
CAHs;• Make changes related to the content of hospital
medical records;• Allow qualified dieticians/nutrition professionals in
CAHs to order patient diets• Require hospitals and CAHs to implement written
policies to prohibit discrimination and to inform patients of their right to be free from discrimination.
Regulatory Highlights
Conduct risk assessments using an all-hazards approach; Develop emergency preparedness plans, policies, and
Procedures, including distinct communications plans; and establish training and testing programs Emergency and standby power systems that reflect their
emergency plans Implementation date of November 15, 2017.
340B Program
CJR and Cardiac BundlesComprehensive Care for Joint Replacement
(CJR) Cardiac Bundle Payment Models• Acute care hospitals control the bundle• Required of most hospitals in certain markets• Hospitals would be responsible for
quality and costs for all Medicare PartA & B services for 90 days post discharge
• Heart attack and cardiac bypass surgery services• Surgical treatments for hip and femur fractures
beyond hip replacement• New bundles go into effect July 2017
Anti-Kickback Statute and Safe HarborsProtection for certain cost-sharing waivers, including:• pharmacy waivers of cost-sharing • waivers of cost-sharing for emergency ambulance
services furnished by State- or municipality-owned ambulance service;
• protection for certain remuneration between Medicare Advantage (MA) organizations and FQHCs;
• protection for discounts by manufacturers on drugs furnished to beneficiaries under the Medicare Coverage Gap Discount Program; and
• protection for free or discounted local transportationservices.
Office of Inspector General
2017 Regulatory Outlook
• Regulatory freeze- New regulations- Regulations currently at Federal Register- Those that have not taken effect
• Regulatory relief- One in, Two out
Executive Orders
Regulatory Tracker
Ensuring Access to
Health Care
Confirm the characteristics and parameters of vulnerable rural and urban communities
Identify emerging strategies, delivery models and payment models for health care services in rural and urban areas
Identify policies/issues at the federal level that impede, or could create, an appropriate climate for transitioning
AHA Board Task Force ReportEnsuring Access to Health Care
in Vulnerable Communities Task Force
AHA Board Task Force Report
AHA Board Task Force Report
Public Policy Changes• Creation of new Medicare payment methodologies and
transitional payments;• Creation of new and expansion of existing federal
demonstration projects; • Modification of existing Medicare Conditions of Participation to
allow for the formation of the strategies;• Modification of laws that prevent integration of health care
providers and the provision of health services;• Modification of the existing Medicare payment rules that
stymie health care providers’ to coordinate care; and• Expansion of Medicare coverage and payment for telehealth.
To learn more about the work of the AHA Task Force on Ensuring Access in Vulnerable Communities, please visit www.aha.org/ensuringaccess.
AHA Board Task Force Report
Task Force Action Plan
Draft schedule for the release of new tools:
• Jan – Indian Health Service• Feb – Inpatient/Outpatient Transformation Model• Mar – EMC/FSED• April – Virtual care strategies• May – Social determinants of health• June – Global budgets• July – Frontier health system• Aug – Rural hospital – Rural health clinic• Sept – Urgent care
Task Force Action Plan
Discussion
Questions and Comments
Contact Information
John SupplittSenior Director
AHA Constituency Sections312-422-3306
jsupplitt@aha.org
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