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SlitLamp provides illuminating e-news for Colorado ophthalmologists. It keeps you in the know on the evolving Colorado health care scene by detailing the latest legislative and regulatory happenings. It also spotlights the information and resources you need for your practice.

 

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Executive director's update: Tectonics

Posted By Chet Seward, Friday, November 22, 2019

Chet Seward,
Executive Director
Maybe it is because the end of the year is approaching faster than my to-do list would like, but these days it seems like there are a ton of important things in motion. Health reform changes that are underway and planned in Colorado have caught the attention of the nation. Indeed, at a recent conference I heard Colorado referred to as the hot bed of health policy changes. Last year’s Democrat sweep of every state office continues to be felt as Governor Polis and legislative leaders have embraced activist roles and demonstrated a willingness to shake things up. Given the continuing impact of recently passed legislation all signs point to another very interesting legislative session in 2020 where ophthalmology will need to be both thoughtfully prepared and actively engaged.

Consider just a few of the bills that rocked the Colorado health policy world last year including the creation of a state reinsurance for the individual insurance market that has decreased premiums up to 20%, capping physician out of network fees associated with surprise bills, directing the creation of a public option plan (see Capitol View story above), and a string of skunk-works mission bills to uncover more hospital and pharmaceutical pricing and cost data that can be used to drive other seismic bills in the future. While decreasing the cost of care is a priority in Colorado, it’s critical to note the continued push throughout the states, including our immediate neighbors, by the optometric community to expand their scope of practice. The projections are that approximately 20 states in 2020 will see surgical scope expansion battles and Colorado ophthalmology must be on firm footing and ready to respond.

The CSEPS board grappled with the opportunities and challenges of these tectonic shifts during their October board meeting as they set aggressive plans for the coming year to protect and advance ophthalmology’s priorities. This is where you come in – by remaining a CSEPS member, staying informed about our work, and taking steps (small and large) to get engaged by meeting with your legislator or serving as a volunteer with CSEPS.

Even when the world moves unexpectedly there are ways to stay safe, to make sense of things and to move forward prosperously. When it comes to advocacy, information and professional connectivity I hope that CSEPS serves these foundational needs for you, your practice and your patients.

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Pueblo eyeMDs meet with Sen. Garcia

Posted By Chet Seward, Friday, November 22, 2019

From left Eric Blom, MD, Anak Shrestha, MD, Ron Pelton, MD, PhD, Sen. Leroy Garcia and James Luu, MD

One of the most impactful and important advocacy actions that ophthalmologists can take is to get to know their local legislator. Policymakers welcome these interactions and with a quick phone call you can create lasting strong relationships with the people that profoundly affect your practice. Leaders from the Pueblo area recently met with Colorado State Senate President Leroy Garcia. They learned about Sen. Garcia’s service as a marine and his work as a paramedic and an emergency medical services teacher at Pueblo Community College. The group discussed the importance of surgery being done by surgeons and other health care issues. If you need help setting up a meeting with your legislators just contact CSEPS.

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Urge Congress to support positive payment update for physicians

Posted By Chet Seward, Friday, November 22, 2019

CSEPS is engaged in fighting a scheduled six-year pay freeze that is set to go into effect on January 1, 2020. Please join us in urging Congress to support a positive payment update for physicians.

 

Urge Your Elected Representatives to Support a Positive Payment Update for Physicians

 

The Medicare Access and CHIP Reauthorization Act (MACRA) provided for modest payment increases for the first five years of the new law. But even with these increases, payment rates still have not kept up with inflation. The cost of running a medical practice increased 32 percent between 2001 and 2018, or 1.7 percent per year far outpacing the 0.4 percent on average increase in Medicare physician pay over the last decade and a half. By contrast, other Medicare providers such as hospitals and skilled nursing facilities have seen their pay increased by 50 percent or more over the same time period.

Under MACRA, physicians will receive zero percent payment updates for years 2020-2025. CSEPS, the American Academy of Ophthalmology, the American Medical Association and other physician organizations have launched a campaign to stop the six-year freeze on physicians' annual pay increase, which begins in January 2020. To stop this pay freeze, Congress must be convinced to act via changes to MACRA, a challenging process that could cost billions of dollars. If Congress doesn’t act, many physicians who see Medicare patients will be negatively affected. Use the American Academy of Ophthalmology’s online advocacy tool to tell your federal lawmaker to join the effort.

Contact Dash Delan, the American Academy of Ophthalmology’s grassroots coordinator, with questions or concerns.

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Save the date: CSEPS legislative reception – January 22, 2019

Posted By Chet Seward, Friday, November 22, 2019

Mark your calendar to the annual CSEPS legislative reception on January 22 from 7:30-8:45am at the University Club in Denver. This is your chance to make an impact on the future of ophthalmology. With a push of a button to vote on a bill, state legislators can radically change where and how you can practice ophthalmology. Look no further than the optometric scope of practice battles sweeping the nation, including recent pushes in Wyoming and Utah, and you will understand the importance of having strong relationships with legislators. 

 

Plan on starting your morning off strong that day by meeting legislators, learn more about how public policy is affecting your practice and your patients, and build lasting relationships with policymakers. Consider it an investment on behalf of your patients and your profession. Register now for this free event.

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New local guidance on billing for Avastin

Posted By Chet Seward, Friday, November 22, 2019

David Johnson, MD

Attention all CSEPS members who use Avastin (bevacizumab) for treatment of eye disease. Please read the following article on the CMS.gov website regarding changes in how to bill for Avastin (bevacizumab), using code J7999:

 

Article A53121 Information Regarding Uses, Including Off-Label Uses, of Anti-Vascular Endothelial Growth Factor (anti-VEGF), for The Treatment of Ophthalmological Diseases.

 

Novitas representatives informed AAO staff and regional Contractor Advisory Committee (CAC) members, in a phone conference on 11/13/19, that they now request an invoice from the Avastin source/compounding pharmacy, along with billing the correct J code, in order to determine proper reimbursement. The AAO has suggested the benchmark of $97.00 per syringe, which is currently in place with contractor Noridian. Stay tuned for further developments!

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Executive Director's Update: It's Getting Hot in Here

Posted By Chet Seward, Tuesday, August 13, 2019

Chet Seward,
Executive Director
With the dog days of summer, the heat is definitely on and I’m not talking about the temperatures in August. I’m talking about Colorado’s activist policy environment on health care issues. 

Concerns about the cost of and access to quality health care are growing in magnitude and they are being voiced by Republicans, Democrats and Independents. Interim legislative committees, a new Polis Administration Office of Saving People Money in Healthcare, and myriad regulatory bodies make for a red-hot environment that offers both opportunities and challenges for ophthalmology.

At CSEPS we know that you depend on us to advocate for your priorities and those of the patients you serve. Collectively across our senior management and lobby team we have almost four decades of experience championing critical public policies. The power of our team also lies in your hands as a member of CSEPS. As a dues-paying member you help provide the resources and content expertise to make sure that our advocacy efforts are prioritized and focused. When things get hot, like they are now, more is needed and the number one means of driving great advocacy efforts is a personal relationship with legislators. Whether you invite them to your practice to see a surgery, meet them for a cup of coffee or just trade a few getting-to-know-you emails or phone calls, investing the time to build and nurture trusting relationships with your state senator and representative is critical. We can help coordinate so just ask. Money also helps and that is why we strongly encourage you to donate to EYEPAC and the CSEPS Small Donor Committee so that we can support policymakers that support ophthalmology’s priorities like ensuring surgery is only done by surgeons. 

Enjoy the final days of summer vacations and lingering high temps. Let’s put this public policy heat to good use.

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The unmet demand for specialty care in Colorado

Posted By Chet Seward, Tuesday, August 13, 2019
Alex Caldwell

new report from the Colorado Health Institute (CHI) finds that there is a significant demand for specialty care in Colorado that is not being met.

Colorado medical specialists would need to provide an additional 634,000 visits annually to meet the unmet demand for care by uninsured people and Medicaid members. CHI determined that Medicaid enrollees are missing out on 99,000 ophthalmology visits, and uninsured Coloradans are forgoing 57,000 visits.

There are limitations to the data: CHI created estimates based on data from the Behavioral Risk Factor Surveillance System and the Medical Expenditure Panel Survey (MEPS) to identify rates of utilization by payer, which may make some gaps appear smaller or larger than they are. And CHI was unable to use local hospital referral rates to check its analysis because hospital system data are not collected with the purpose of estimating unmet demand for specialty care. Still, the data offers a glimpse of differences between Medicaid members and uninsured Coloradans.

CHI's model projects that providing specialty care to fill the unmet demand would cost up to $93 million a year, if reimbursed at the rates private insurers pay providers. However, the report suggests several strategies to provide and fund specialty care, including using telehealth and offering social impact bonds to finance an improved system.

Colorado has made great gains in access to care in recent years, but we know there's still a lot of work to do, especially for people with the most complex health conditions and people who already face barriers to accessing care. This report helps quantify the problem and identify potential solutions.

Read the specialty care access report here.

Alex Caldwell is a director at CHI and lead author of the report.

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Lowering health care premiums: State reinsurance and public option plans

Posted By Chet Seward, Tuesday, August 13, 2019

High health care insurance bills have prompted a flurry of activity in Colorado to bring relief to especially hard-hit areas and groups like the mountain communities and consumers and businesses on the individual and small group health insurance markets.

Gov. Polis recently announced the federal approval of a reinsurance plan aimed at consumers on the individual market that purchase insurance on the state health insurance exchange. The program will enable the state to cover the most expensive medical claims for these patients on the individual market which will help private insurers to lower rates by an expected 18%. The Colorado legislature passed HB19-1168 during the 2019 session to authorize the development of the plan.

Another bill passed in the legislature this year also has the potential to shake up Colorado’s health insurance marketplace. As directed by HB19-1004, the state is in the middle of an aggressive stakeholder process under an ambitious timeline to develop and submit a proposal to the General Assembly concerning the design, costs, benefits, and implementation of a state “public option” for health care coverage. The plan, which must be submitted to the legislature by November 15, 2019, offers opportunities and threats for ophthalmology. A state public option may provide a vehicle to decrease health plan administrative burdens and complexities (i.e. standardizing prior authorizations, benefit plans and contracts) that drive ophthalmology practices crazy, and it could be used to advance the importance of eye care and surgery being done only by surgeons. Efforts to control plan costs could also drive toward more concerning things like provider rate setting and mandatory participation. CSEPS is actively working with other medical societies to shape the final proposal. Watch for more details.

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Out of network bills: New state law and regulation development

Posted By Chet Seward, Tuesday, August 13, 2019

Surprise medical bills from out of network providers continue to be a hot issue nationally and in Colorado. During the last legislative session the General Assembly passed HB 19-1174 which aims to limit the impact of these bills on patients. While CSEPS joined in the fight to help make important changes to narrow the scope of this bill and add arbitration, the final bill creates a payment benchmark. For covered services at an in-network facility from an out-of-network provider, the carrier will pay the provider directly the greater of 110 percent of the carrier’s in-network reimbursement rate for the same service in the same geographic area or the 60th percentile of the in-network reimbursement rate for the same service in the same geographic area for the prior year based on commercial claims data from the all-payer claims database (APCD).

According to the state, the Colorado Division of Insurance (DOI) is developing rules to implement HB 19-1174 along five tracks:

  1. Emergency ambulance services reimbursement methodology regulation
  2. Consumer disclosures regulation
  3. Arbitration program process and arbitrator selection regulation
  4. Center for Improving Value in Health Care (CIVHC)/carrier data concerning payment methodologies for out-of-network providers
  5. Out-of-network utilization reporting and terminology regulation   

The current timeline for these regulations is as follows:

  • DOI intends to have drafts ready to circulate to stakeholders by the end of August
  • DOI will hold/coordinate stakeholder meetings on these regulations in September and October
  • DOI will work to finalize the regulations throughout November
  • DOI will issue these regulations as emergency regulations in December to ensure they are in place before January 1

CIVHC has developed an FAQ regarding the latest information and timeline related to the methodology that will be used and the data elements that will be available to the DOI. Ophthalmologists that bill out of network are encouraged to review this information.

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Have you met with your state representative or senator lately?

Posted By Chet Seward, Tuesday, August 13, 2019

One of the best ways to build relationships with the policymakers that can radically change your practice with a quick vote is to meet with them regularly. Legislators face myriad policy issues and having someone that they know and trust to help them figure out how to vote on topics ranging from general health care to the merits of surgery only being done by surgeons is invaluable. Whether you meet them at the capitol, a coffee shop or even at your practice making the effort is worthwhile. CSEPS can help! Contact Chet Seward in the CSEPS offices to learn more. Summertime is a great time to connect with your legislator. Act now.

Pictured above: Oculoplastic surgeon Michael McCracken, MD, from Parker, wraps up a visit with Rep. Kim Ransom.

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