My talk is entitled Current Legislative and Regulatory Issues. I have no financial relationships with commercial support to disclose. So I would like to start off by the first polling question. Which of the following is true? MACRA was enacted in 2015. MACRA includes MIPS and alternative payment models. MACRA replaces sustained growth, SGR, all of the above, or none of the above? Yeah, so the results are on the screen. It looks like 80% of you got the answer right. So that means I should just pack up and go home. You guys know all the answers already. But without further ado, let's go and talk. So the current issues I'd like to discuss today are the rising cost of health care, the case for a shift from fee-for-service to value-based care, modernizing Stark Law, and development of alternative payment models and how the two are related, efforts to increase colon cancer screening. I would like to talk about the CDC's colorectal cancer prevention program, the Congressional Colorectal Cancer Caucus. And briefly, I would like to touch base on certain legislation that's in the United States Congress that somewhat, that definitely pertains to practice of GI endoscopy and GI practice, but not necessarily to a GI unit. But this includes the SAFE Step Act and the Improving Seniors' Timely Access to Care Act. I want to also touch base on fighting Medicare sequestration. And I also finally want to touch base a little bit about surprise billing, because all of you will be encountering this. So let's talk about fee-for-service to value-based care. 3.65 trillion spent in health care costs in 2018, 3.81 trillion spent in 2019. In 2020, cost dipped for the first time in 60 years, secondary to the COVID pandemic. That was only a 2% dip. Approximately $12,000 are spent per person, and 59% of this goes to hospitals and clinical services, 4.4% increase since 2017. There's an estimated 5.5% increase per annum. So what does this mean? This means that at this rate in 2027, health care costs will roughly encompass more than 20% of the GDP. This is, again, a cartoon, a slide that basically shows the steady rising rate of U.S. national health expenditures as a share of the GDP. You look at 1960, it was rated barely 5%, and now we're close to 20%. It's a little bit of an older slide, but it shows that steady rise and that steady increase. This slide basically compares us to all the other countries and how their health care spending is compared to ours. As you can see, our per capita health care spending is more than twice than the average of other developed countries. So problem is, if we don't do anything, Medicare will be insolvent, experts say, by 2034, and this is because of uncontained costs, increasing overhead, increasing number of retirees and longer lifespans. So how did this happen? It happened because of unchecked expenses and cost shifting. Cost shifting is basically reliance on overcharging for other sources of revenue in an attempt to make up on financial losses. It's the reliance on private payers to make up for lost revenue from other sources. It's basically artificial suppression of the problem. Basically to make up from cuts from Medicare or Medicaid and uninsured patient population, where services are overcharged that could be done at a lower cost. This in turn raises private insurance premium. And what happens is the problem is not fixed, but it's simply pushed to another source. And like I said earlier, systems rely on overcharging for revenue that can be done at a lower cost to make up for losses. For example, increased cost of colonoscopy in one set versus another, increased cost of labs and imaging in one set compared to another. So how is the system trying to compensate? One is a hard stop on how much we spend, and that's called the sequestration of funds. And I'll explain that in my talk in a little bit. The other is accountability, value-based care, the rewarding quality over quantity by alternative payment models, and a shift from fee-for-service to value-based care. So this cartoon sort of explains fee-for-service and value-based care. This, you know, was predominantly present in the 1960s, and today we're moving more towards value-based care. We're aligning reimbursements with people that are providing value, whereas previously it was how many people we saw and how much billing and charges we submitted. So what are professional societies supporting? We're basically supporting legislative agendas that reduce stark regulation, thereby promoting innovative partnerships that promote value, promoting the development of alternative payment models that promote value, delaying sequestration, which is the mandatory cuts until we're successfully able to put all this in place, supporting policies that improve access for patients, supporting policies that promote colon cancer screening. So let's talk a little bit about MACRA. This is old, but I think it's for those of you in the audience that are unaware, when Congress enacted the Medicare Access and CHIP Reauthorization Act of 2015, which is also known as MACRA, SGR was replaced with a program that basically promoted value-based care delivery. This basically had two arms. One was MIPS, which is the Merit-Based Incentive Payment System, and the other one was alternative payment models. I still remember when MACRA was enacted, everybody wanted to learn about ACOs, and it was all new, and we were Googling it, and we were trying to learn about it. And for those of you that don't know, the Medicare SGR, the sustainable growth rate, was a method used by centers for Medicare and Medicaid services in the United States to control spending by Medicare on physician services. For example, if the expenditures were less than expended, the conversion factor would increase the payments to physicians for the next year. Conversely, if they were greater than expected, then it would decrease that payment. So the MIPS pathway was sort of an easier pathway to follow. So a lot of solo providers or providers that were in smaller groups that did not have advanced or more integrated healthcare delivery systems could follow a value-based system, and they wouldn't be knocked out of the box. Basically, MIPS, the Merit-Based Incentive Payment System, basically looked at some physician quality reporting metrics, and this differed from specialty to specialty. Some GI-based physician quality metrics that were looked at were documentation of the bowel prep, photo documentation of the cecum, documentation of the incidence of perforation, but basically a provider's performance was based on certain parameters, and providers received a score, and the payments to the provider were adjusted based on that score, and the use of EHR was also one of the part of MIPS. Alternative payment models, on the other hand, which were much more complex and required a larger infrastructure, for example, the Medicare Shared Savings Program, and these included ACOs, there was a significant financial risk to providers, but the upside was if you could do it right, there was a significant financial gain. Basically, large healthcare delivery systems would be provided a certain amount of dollars by the government, and they would be responsible for utilizing those dollars and providing care to a certain patient population. Whatever money that was saved would be shared savings, and that would get spit back out to the system and to the providers, and conversely, if you went over, there would be a risk to providers. So, Stark Law, it's important to talk about. It was enacted more than 20 years ago, and it was designed to prevent physician self-referrals. The alternative payment models and ACOs, they inevitably link payments to the volume or value of physician referrals, so Stark restriction impedes better management of a physician's referral patterns, the utilization of ancillary services in collaboration with high-quality or cost-efficient partners. People are afraid to start developing different alternative payment models because it may violate Stark Law. So, GI societies are supporting legislation that would modernize Stark Law, that would provide CMS the same authority to waive Stark and anti-kickback laws that was provided to ACOs, that remove the value or volume prohibition in the Stark Law so that practices can incentivize physicians to abide by best practices and succeed in new value-based alternative payment models. The protection would only apply to practices that are developing or operating an alternative payment model. So, something else that I want to touch base on that's going on on a legislative level is we are trying to promote and secure increased funding for the CDC's colorectal cancer control program. We're trying to promote the newly formed Congressional Colorectal Cancer Caucus. And briefly, I would like to touch base on the SAFE Step Act and the Improving Seniors' Timely Access to Care Act. So, the CDC's colorectal cancer control program works with health systems in 35 states, including clinics, hospitals, and other health care organizations to use and strengthen strategies that increase quality screening. CRCCP-funded strategies include patient navigation, provider reminders, provider assessment and feedback, and removing structural barriers such as transporting the patient to and from the test, providing means of this to the patients that don't have this. Among clinics recruited in the first year of the program, screening rates increased from a mean of 42.9% in 2016 to 52.6% in 2018. CRCCP funding has been flat-funded since fiscal year 2011 at $43 million. ASGE has been pushing for increased funding for this program in fiscal year 2022 at $70 million. Increased funding will allow more patients access to colon cancer screening. SAFE Step Act, although this doesn't really affect the GI unit, it's important that since we're having a talk on the legislative landscape, that you are all aware of the SAFE Step Act. This is a legislation that's on the Congressional floor that basically outlines situations in which a group health plan must grant an exception to fail-first protocols, including if an application clearly demonstrates that patient already tried and failed on the required drug, the required drug is reasonably expected to be ineffective, the required drug will cause harm to the patient, the required drug will prevent a patient from working or fulfilling daily activities, and the patient is stable on his or her current medication, and if they have an insurance switch, they don't have to go through the step protocol again. This is another piece of legislation called the Improving Seniors' Timely Access to Care Act that increases transparency and streamlines prior authorization in the Medicare Advantage Program, and the way it does this is by establishing an electronic prior authorization program. It standardizes and streamlines the prior authorization process so your office staff is not fighting back and forth with the insurance company. It ensures that prior authorization requests are reviewed by qualified medical personnel that are familiar with the care. It increases transparency in the prior authorization process, and it speeds it up so your patients are not left without care. Fighting Medicare sequestration. Now, as we're putting all these things into place, Medicare sequestration is a big problem. It's a process of automatic, largely across-the-board spending reductions under which budgetary resources are permanently canceled to enforce budget policy goals. Every year, physician reimbursements, unfortunately, are also at risk. Medicare benefits account for 90 percent of all Medicare and non-Medicare resources available to be sequestered. Of the funds, interestingly, of the funds that are sequestered, Medicare benefit payments are estimated to account for 74 percent of the combined mandatory defense and non-defense sequestered funds. So ASGE partners with other societies in the broader House of Medicine to delay these cuts. Finally, I think no talk about the legislative landscape would be complete without talking about a slide on surprise billing legislation. This does not affect an outpatient GI unit, but it is important that all you know about the No Surprises Act of 2021. This basically forbids patients from receiving surprise medical bills when seeking emergency services or certain services from out-of-network providers at in-network facilities. So if you're rounding in a hospital and a patient gets admitted and you're asked to consult on that patient, and the insurance is in-network with the patient's insurance, but you're out-of-network with the patient's insurance, you can't surprise bill the patient. So Congress has settled on a process that allows providers and insurers to initiate an open negotiation period if either party believes that an out-of-network medical bill or payment is unreasonable. The parties can pursue an independent resolution process by a certified independent dispute resolution entity. What's concerning is that the current interim final rule instructs the certified entity to start with the presumption that the median in-network rate is the appropriate payment giving payers and insurers the upper hand. ASGE and the broader House of Medicine are actively working with lawmakers in both the House and the Senate to help make this a process in which this rule is fair to the providers. So practice pearls. I think it's very important that we understand the issues. We have to get involved with our local societies and know the pertinent legislation. We have to support legislation that is beneficial to our patients and to our practice by contacting our local Congress people and senators. We have to focus on systems improvement and practice that provides quality and value over quantity and overall practices that improve disease process. We have to drive the change and not let the change drive us. Thank you.

healthcare legislation

value-based care

alternative payment models

colon cancer screening

surprise billing