ACNM Policy Update - 11/2/2014

On Friday, October 31, the Centers for Medicare and Medicaid Services (CMS) released a pre-publication version of the Hospital Outpatient Prospective Payment System (HOPPS) regulation, updating policies and payment rates for 2015. In this regulation, CMS finalized a previously proposed policy change that impacts midwives.

Under a policy that has been in place since October 1, 2013, CMS has required that each inpatient admission for a Medicare patient be accompanied by a certification of the medical necessity of that admission, signed by a physician. The agency drew a clear distinction between the admission order and the certification. It noted that while many different types of providers may order an admission, only physicians can sign a certification. Many hospitals applied this policy across the board with all of their patients, which forced midwives who had previously been admitting patients under their own names to obtain this subsequent physician certification.

In the HOPPS final regulation, CMS responded to comments from ACNM and others and modified its policy so that effective for discharges on or after January 1, 2015 the certification is only required in cases where the inpatient stay extends to 20 or more days in length or results in outlier costs.

Pursuant to this final regulation, CNMs/CMs are encouraged to share this information with hospitals now requiring physician certifications for all admissions and discuss how this requirement can be removed.

ACNM staff will examine the final rule for other issues pertinent to midwives and prepare a detailed summary for later release. The rule will be formally published in the Federal Register on November 10, 2014. CMS also released two fact sheets associated with this rule, available here and here.

On Friday, October 31, the Centers for Medicare and Medicaid Services (CMS) released a pre-publication version of the CY 2015 Medicare Physician Fee Schedule final regulation, containing important policy changes and payment updates applicable to services rendered on or after January 1, 2015.

Of particular interest to midwives are the following issues:

-- CMS indicates that the update factor for physician payments will be kept flat through March 31, 2015, after which current law requires a 21.2% reduction. Congress has repeatedly acted in the past to forestall cuts that would otherwise be required under existing law and we expect them to take action to address the pending cut in the near term.

-- CMS had proposed to remove from the Physician Quality Reporting System (PQRS) a measure related to early elective delivery. The agency took this step because the measure steward, a committee of the AMA, has decided to no longer maintain the measure. ACNM commented on this proposal and encouraged the agency to utilize a similar measure maintained by the NQF. In the final regulation, CMS indicated that it will retain this measure because a new steward had been identified. This is a positive response to ACNM's comments.

-- CMS had proposed to begin applying the physician value based payment modifier to practitioners other than physicians (including CNMs) as of 2017. However, in the final regulation, CMS finalized a policy of applying the modifier to CNMs and other practitioners in 2018 (which means the performance period for that modification will occur in 2016).

-- In this final rule, CMS established a policy of reducing payments for physicians who fail to perform adequately by up to either 2% or 4%, depending on group size. When the modifier is applied to CNMs and others in 2018, that payment reduction may be larger, as the agency has wide discretion to establish the payment adjustment percentage and has indicated in the past that it intends to increase the percentage over time. This reduction is on top of the reduction that occurs for failure to successfully report under PQRS. For more information about the value based payment modifier, visit this page.

The official version of the final regulation will be published in the Federal Register on November 13. ACNM staff will examine the final rule for other issues pertinent to midwives and prepare a detailed summary for later release.

CMS issued three fact sheets in conjunction with the release of the pre-publication version of the rule. They are available here, here and here.

On October 28, ACNM submitted comments to the National Association of Insurance Commissioners (NAIC) with regard to their efforts to revise an 18-year-old model act for states to use in determining managed care plan network adequacy.

ACNM focused its comments on a provision of the existing model act that allows managed care plans to refuse to contract with entire categories of providers. We recommended that the NAIC modify this aspect of the Model Act and based our argument on the provider non-discrimination language of the Public Health Services Act (PHSA) which was added by the Affordable Care Act (ACA). We also provided NAIC with data from our survey of health insurance plans, demonstrating that CNMs/CMs face significant barriers when it comes to participating in marketplace plans and coverage of their services therein.

The NAIC is expected to finalize its revised Model Act in the near future.

ACNM has posted an Issue Brief on the topic of Transition to Practice language that we have seen appear in a number of pieces of legislation that seeks to provide greater practice authority to CNMs/CMs. In some states, midwives and APRNs have struggled to implement full practice authority legislation because of concerns raised by other stakeholders around the appropriateness of such practice. To allay concerns and as a matter of political compromise, some states have included in these bills a requirement that midwives or other APRNs work under the supervision of a physician or experienced midwife for a certain length of time before being granted full practice authority. ACNM's issue brief discusses the known pros and cons of this topic and is a valuable and concise discussion for any ACNM member seeking to understand this issue.

The Kaiser Family Foundation (KFF) recently conducted a survey of state Medicaid programs regarding their plans for 2015. Included in that survey were questions around states' intentions with regard to increased primary care payments. The Affordable Care Act provided funds to help states increase Medicaid payments to certain primary care physicians for certain primary care services. The funding expires as of the end of 2014. KFF asked states what they expected to do once federal funding expired and created a specific fact sheet reporting on the states' responses. Several states plan to continue the increased payments on their own.

ACNM is supporting the Ensuring Access to Primary Care for Women and Children Act - S. 2694, that would extend the federal funding and also expand the set of providers who might qualify for it to include CNMs, among others.

Late in the afternoon of October 28, I received an invitation to attend a White House event with President Obama, on behalf of ACNM. No details were provided about the topic or nature of the event. While I would like to report that midwifery specific concerns prompted the invitation, as it turned out, it was specific to ebola and representatives of many health care organizations were in attendance.

The President of course discussed the disease and the Administration's response, but what was most impressive to me was that with him on the podium were a number of providers who either had been in the affected African countries, or were about to travel there to volunteer their services. Introducing the President was Dr. Kent Brantly who himself contracted ebola while in Liberia.

It is a serious and sober thing to actually exercise that greater love which brings with it the legitimate possibility of laying down one's life for a friend. So while I did not get to discuss midwifery with the President, it was a gift simply to sit in the audience and think quietly about the people on that podium and the choices they had made. I hope my account passes on that gift in some small measure.

As usual, if you know any CNMs/CMs who are not currently ACNM members, please forward this Policy Update to them. We want to be sure they know what the association is doing on their behalf and the kinds of activities that their membership would support.