Congress Repeals Sustainable Growth Rate Formula and Advances Medicare Payment for Quality

On April 14, 2015, Congress ended over a decade of repeated “doc fixes” which temporarily suspended scheduled Medicare provider reimbursement cuts, by passing the Medicare Access and CHIP Reauthorization Act (the “Act”).  If signed by President Obama, the Act would permanently end the Centers for Medicare & Medicaid Services’ (“CMS”) use of the physician payment formula known as the “Sustainable Growth Rate” (“SGR”). Without the approval of the Act, or the passage of a doc fix, providers would have seen Medicare reimbursement rates drop by 21 percent starting on April 15, 2015. Continue Reading

Full Speed Ahead for Meaningful Use

On Friday, March 20, 2015, the Centers for Medicare and Medicaid Services (“CMS”) issued a proposed rule (available here) which would make significant changes to the federal Medicare and Medicaid Electronic Health Records (“EHR”) Incentive Programs (collectively the “Meaningful Use Program”).  Continue Reading

More Risk for All and “Free” Care?

While the Supreme Court continues to debate the outcome of King v. Burwell in their chambers, stakeholders must be prepared for the potential fallout the nine justices’ ruling may have.  Two weeks ago, we summarized the underpinnings of the case (read about it here) and last week, we reviewed the impact of a ruling against the government on individuals (read about it here).  Today, we will take aim at two other groups of stakeholders who are sure to be impacted by a ruling against the government: (i) healthcare providers; and (ii) third party payors.  These two groups have seen a significant benefit in the form of new patients/enrollees from the exchanges and are likely to take the most significant hit to their businesses if the Supreme Court rules against the government and limits tax subsidies under the Affordable Care Act (“ACA”) currently available to consumers on both federal exchanges and state run exchanges to only those consumers on the state run exchanges. Continue Reading

Stripping the ACA of Both the Carrot and the Stick: Sticking it to Consumers On and Off the Federal Exchange

Even as we write and you read, the Supreme Court in King v. Burwell is considering whether qualifying (often low income) individuals and families who have an opportunity to purchase healthcare coverage through the Affordable Care Act’s (“ACA’s”) federal exchange also have the right to federal premium subsidies/tax credits when determining the premium costs associated with the actual purchase of such coverage.  While it is obvious that the King decision will be of great importance to those who need the discounts created by the subsidies/credits to make the cost of purchasing coverage on the federal exchange affordable, the King decision could also have a significant impact on those individuals and families who purchase insurance coverage outside of the federal exchange. Continue Reading

Medicare ACO v. 3.0—More Risk, More Money?

The Centers for Medicare and Medicaid (CMS) announced on March 10, 2015 that it is adding a new Accountable Care Organization (ACO) model to its cadre of innovative models.[1] Titled the “Next Generation ACO Model,” CMS’ new ACO model allows provider groups to assume higher levels of financial risk and reward than currently available under its Pioneer Model and Shared Savings Program model. CMS noted that the goal of the Next Generation ACO Model (Next Generation) is to “test whether strong financial incentives for ACOs can improve health outcomes and lower expenditures for Original Medicare fee-for-service (FFS) beneficiaries.”[2] Continue Reading

Time is Running Out to Avoid the Negative Effects of 2016 Value-Based Physician Payment Modifiers: CMS Releases Results of Medicare’s Value-Based Payment Modifier for 2015 as Final PQRS Participation Deadlines for 2016 Adjustments Approach

CMS recently released results of Medicare’s value-based payment modifier for 2015.[1]  This is the first year in which physicians are subject to adjustments under the payment system and, in this first phase of implementation, only affects practices with 100 or more eligible professionals.   Continue Reading

Round and Round and Round She Goes, and Where She Lands, Nobody Knows: The Future of Obamacare and Why King v. Burwell Matters – A Five-Part Series

Last week, on Wednesday, March 4, the U.S. Supreme Court heard oral argument in the highly publicized case of King. v. Burwell—a lawsuit challenging the Affordable Care Act or “Obamacare” based upon what many would call the most pernicious of statutory problems – poor drafting.

The exact issue presented to the Supreme Court by the King petition is “whether the IRS may permissibly promulgate regulations to extend tax-credit subsidies to healthcare coverage purchased through Exchanges established by the federal government under section 1321 of the ACA.”[1]  At first glance (and maybe even at the second, third, and fourth glance), this may seem to be a highly-technical issue of tax and administrative law.  However, for every professional and armchair constitutional law pundit out there, the issue – Federalism – goes to the core of who we are as a country.
Continue Reading

Medicare Advantage Insurers May See Positive Growth in 2016 Despite CMS’ 0.95% Payment Rate Cut Announcement

The Centers for Medicare and Medicaid Services (CMS) proposed a 0.95 percent decrease in Medicare Advantage payment rates for 2016 in its Advance Notice and Draft Call Letter released on February 20, 2015.[1] Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare. Unlike “original Medicare,” in which the government pays for Medicare benefits when a beneficiary receives them, Medicare pays these private companies to cover beneficiaries’ Medicare benefits based on a risk-adjusted, per-patient payment formula that varies annually.[2] Continue Reading

Oral Argument in King v. Burwell Concludes; Debates Ensue

At approximately 10:00am EST this morning, the Justices of the U.S. Supreme Court heard oral argument in King v. Burwell – the highly publicized case whose final decision may “end Obamacare as we know it!” (as one excitable healthcare “talking head” noted during a morning newscast).   Although an audio recording of today’s event will not be available for download or streaming until this Friday, the transcript is currently available at The Sheppard Mullin healthcare team is now mining the text to provide blog readers with our insights and predictions regarding the case and the future of the Affordable Care Act.  Moreover, on Friday, we will be listening closely to the audio recording of the argument.  Although avoiding the temptation to make “much ado about nothing,” auditory clues can often provide insight into an argument’s strengths and weakness and the possible outcome of a case based upon the tones and inflections coming from the Bench and coming from the presenting attorneys.  We look forward to providing our commentary to you in the days and weeks to come.