TMA on Monday sent a 27-page formal comment letter to the Centers for Medicare & Medicaid Services (CMS) listing TMA's 50 recommendations to improve the agency's draft rule implementing the Medicare Access and CHIP Reauthorization Act (MACRA).
When Congress passed MACRA last year to replace Medicare's Sustainable Growth Rate (SGR) formula, lawmakers also aimed to simplify and improve Medicare's costly and complex programs — such as PQRS, meaningful use, and value-based purchasing -— that purport to measure the quality of care physicians provide to patients.
TMA says MACRA has fallen far short of that goal.
"If implemented as written, the regulations would dump additional bureaucratic work on physicians and their practices, and would continue to impose onerous federal controls on them — with no data to show that they would improve the quality of or access to care for patients," said TMA President Don R. Read, MD. "The system devised by CMS is far more costly, complex, and confusing than the costly, complex, and confusing programs it is replacing."
The most critical of TMA's 50 recommendations are these three:
- Significantly Expand the Low-Volume Threshold: According to TMA analysis, physicians who bill less than $250,000 in Medicare charges will spend more trying to comply with the MACRA rule than they could ever earn in bonuses — if they hit the hidden quality targets. CMS set the threshold at a paltry $10,000 in Medicare allowed charges. TMA told CMS to set the low-volume threshold at $250,000. That would exempt physicians who have no possibility of a positive return on their investment in the cost of reporting. For physicians with less than $250,000 of Medicare revenue, reporting should be optional, and physicians who attempt compliance should be exempt from any payment penalties.
- Delay the Start: The rule will be finalized around Nov. 1. Practices will have to begin collecting data and making big changes in their operations on Jan. 1. This gives physicians only two months to prepare, and they won't be ready. Support staff won't be ready. Electronic health record vendors won't be ready. TMA told CMS the measurement period for 2017 should be reduced to six months and start no sooner than July 1. (The data collected in 2017 affects physicians' Medicare payments in 2019.)
- Set the Performance Threshold Low: The "performance threshold" is the most important factor affecting MACRA's overall impact on small practices. CMS has complete discretion to set the performance threshold, which is the score a physician must earn to avoid penalties. The threshold also will determine how much MACRA will shift Medicare payments from smaller physician practices to larger groups and health care systems. To reduce the negative impact on small practices, TMA urged CMS to set the performance threshold at 15 percent in the first year of implementation.
For more details on MACRA, see the TMA website. For additional information on TMA's perspective on the draft rule, read Dr. Read's post on the KevinMD blog.
The U.S. Centers for Disease Control and Prevention (CDC) is getting a better indication of just how many pregnant women in the United States and its territories have Zika virus. CDC established the National Zika Pregnancy Registry and is collaborating with state and local health departments to collect information about pregnancy and infant outcomes in women with laboratory evidence of Zika. CDC says it will use the data to update recommendations for clinical care, to plan for services for pregnant women and families affected by Zika virus, and to improve prevention of Zika virus infection during pregnancy.
As of June 16, CDC reports it was monitoring 265 pregnant women in the U.S. states and 216 pregnant women in the U.S. territories with laboratory evidence of possible Zika virus infection. That is a total of 481 pregnant women.
According to CDC, pregnant women in the United States with laboratory evidence of Zika virus infection (positive or equivocal test results, regardless of whether they have symptoms), and periconceptionally, prenatally, or perinatally exposed infants born to these women are eligible for inclusion in the registry. Infants with laboratory evidence of congenital Zika virus infection (positive or equivocal test results, regardless of whether they have symptoms) and their mothers also may be included in the registry.
CDC says physicians can participate in the Zika pregnancy registry by reporting information about pregnant women with laboratory evidence of Zika to their local health department or the Texas Department of State Health Services (DSHS).
To discuss women with laboratory evidence of Zika virus infection, physicians can contact the CDC Zika pregnancy hotline at (770) 488-7100, ZikaMCH[at]cdc[dot]gov, or ZikaPregnancy[at]cdc[dot]gov.
To effectively combat Zika in Texas, Gov. Greg Abbott formally invited CDC to review Texas' Zika Virus Preparedness and Response Plan. Last month, he participated in a conference call hosted by the White House to discuss strategies to address the Zika threat and efforts to combat the virus.
In a letter to CDC Director Thomas R. Frieden, MD, Governor Abbott urged CDC to move swiftly to approve DSHS' funding requests for three projects to assist in funding Texas' Zika response plan:
- $1.5 million to support Zika preparedness and response efforts;
- $360,000 to support Zika-related birth outcomes surveillance; and
- $9.2 million to strengthen epidemiology and laboratory capacity and improve health information systems.
Congress has been dragging its feet on approving a Zika funding package. In a letter to the Texas congressional delegation, TMA President Don Read, MD, wrote it's "only a matter of time before one of those [Aedes aegypti] mosquitoes bites an infected traveler and then passes the disease on to another Texan." The letter stresses the need for federal money to bolster monitoring travelers, keeping Texans informed about the state of the disease, and lab testing — especially of pregnant women.
"We already have waited too long," Dr. Read wrote. "We need that action now. Several months from now will be too late."
In May, CDC began publically reporting the total number of pregnant women with Zika virus infection from two newly established enhanced surveillance systems: the U.S. Zika Pregnancy Registry and the Puerto Rico Zika Active Pregnancy Surveillance System. CDC says the new numbers reflect a broader group of pregnant women — those who have any laboratory evidence of possible Zika virus infection and who may or may not have reported any symptoms.
As of June 17, Texas had reported to the CDC one confirmed case of Zika in a pregnant woman who traveled abroad to an area with Zika transmission. DSHS says there have been 20 additional pregnancies in Texas with laboratory evidence of Zika infection since tracking and testing for Zika began, but all 20 had no symptoms and do not meet the CDC's Zika case definition. Texas provides the data to the CDC's pregnancy registry weekly.
DSHS reports that as of June 24, Texas had 47 reported cases of Zika virus disease. Of those, 46 were in travelers infected abroad and diagnosed after they returned home; one of those travelers was a pregnant woman. One case involved a Dallas County resident who had sexual contact with someone who acquired the Zika infection while traveling abroad. Nationally, as reported by CDC, 820 people in the continental United States, and 1,860 in U.S. territories had tested positive for the virus as of June 22.
DSHS is testing for Zika virus at its public health lab in Austin. DSHS encourages Texas physicians to report suspected Zika virus cases to DSHS or their local health department.
According to DSHS, Aedes aegypti mosquitoes can be found in Texas, particularly in urban areas in the south and southeast portions of the state. While there is no evidence of local transmission by Texas mosquitoes yet, state health officials have implemented Zika virus prevention plans in anticipation of increased mosquito activity and the potential for local mosquito transmission.
You can help educate patients on preventing the spread of Zika by downloading and printing educational materials to display in your office from the DSHS Zika toolkit. The toolkit features posters, push cards, and fact sheets, as well as TV and radio spots and graphics you can share and post via social media. DSHS also developed flyers and door hangers (available in English and Spanish) you can use in your office to educate your patients on protecting themselves from the disease.
To help ensure Texas physicians have all they need to know about the virus, the texaszika.org website features a supplemental testing information form and polymerase chain reaction (PCR) and serology specimen criteria form. The PCR test can confirm the presence of Zika virus. Serologic testing can detect Zika infection in people who may not have had symptoms, and the test can be conducted up to 12 weeks after infection. DSHS says a positive serologic test result requires confirmatory testing to pinpoint Zika because it can cross-react with other flaviviruses, such as dengue.
The disease can cause fever, rash, muscle and joint aches, and red eyes, and also has been linked to the birth defect microcephaly and other poor birth outcomes in some women infected during their pregnancy.
You can learn more about Zika by viewing this informative video by Houston obstetrician Catherine Eppes, MD, who delves into what physicians need to know about Zika. In May, Dr. Eppes, whose high-risk pregnancy clinic has been overrun by women concerned about Zika infection, told the Senate Health and Human Services Committee Texas needs to find more ways to screen pregnant women for the Zika virus. "The combination of a relatively new but profoundly significant disease with little knowledge about the exact timing and rates of transmission, and complex, often inaccessible testing options leaves pregnant women and physicians frustrated," the member of the TMA Committee on Maternal and Perinatal Health said. "I think doctors would benefit from statewide dissemination of the options and costs for testing within our state and city health departments."
Dr. Eppes also recommended Texas Medicaid and the Women's Health Program be authorized to support the screening and testing of their eligible populations.
TMA and the Texas Association of Obstetricians and Gynecologists have prepared guidance for physicians on the Zika virus and pregnant patients.
Read more about Zika preparedness and prevention in the August Texas Medicine cover story, "Confronting Zika."
General information about Zika virus
Update: Interim Guidance for Prevention of Sexual Transmission of Zika Virus — United States, 2016
Information for clinicians
Protection against mosquitoes
Zika virus travel notices
DSHS Zika toolkit
The Texas Pharmacy Association (TPA) implemented an expansive physician-authorized "standing order" regarding the dispensing of naloxone/narcan, a fast-acting antidote that can be administered to someone who is overdosing on opioids. Effective Aug. 1, the standing order will allow qualified Texas pharmacists to dispense naloxone to patients and/or family members or friends of patients who have a medical need.
Pharmacists will be authorized to act under the standing order only after they have completed a one-hour course accredited by the Accreditation Council for Pharmacy Education and in coordination with TPA.
During the 2015 session of the Texas Legislature, TMA strongly supported passage of Senate Bill 1462 by Sen. Royce West (D-Dallas). SB 1462 gives physicians authority to prescribe the lifesaving opioid antagonist naloxone not only to patients but also to family members or friends of those who may be at risk of an overdose. The law also allows a person or organization acting under a standing order to distribute an opioid antagonist and allows pharmacies to dispense the drug.
"The new law will save lives in Texas as it has done in other states," said Dallas anesthesiologist and pain medicine specialist C.M. Schade, MD. "When you have an overdose situation, timing is critical. The naloxone needs to be in the hands of first responders, family members, and friends to rescue the patient."
The new law provides liability protection for prescribers who, acting in good faith with reasonable care, prescribe an opioid antagonist.
The American Medical Association Task Force to Reduce Opioid Abuse updated the AMA website to include tools and resources to help physicians in co-prescribing naloxone to patients at risk for overdose.
The U.S. Centers for Disease Control and Prevention has guidance on prescribing opioids for chronic pain. Visit Prescribe to Prevent to access guidance for clinicians, information on naloxone products, and links to training for consumers.
For more information, read "A True Antidote" in the October 2015 issue of Texas Medicine.