December 17, 2015
National UpdateOpioid prescribing guidelines now open for public comment
The AMA and other stakeholders issued serious concern about the lack of transparency and meaningful opportunity for public comment on the initially proposed guidelines for prescribing opioid analgesics developed by the Centers for Disease Control and Prevention (CDC). In response, the CDC has now released a revised proposal and provided a 30-day comment period, which will end Jan. 13.
The CDC has stated that the voluntary guidelines are intended to be used by primary care physicians who treat patients with chronic pain in outpatient settings. While acknowledging the need for physician leadership in addressing opioid misuse, overdose deaths and insufficient access to treatment for substance use disorders, AMA comments on the original draft expressed disappointment that the guidelines lacked a patient-centered view and any real acknowledgement of the problems chronic pain patients may face.
Additionally, the AMA and other key stakeholders opposed the inclusion of quantitative limits in the guidelines—90 morphine milligrams equivalent per day and a three-day supply of opioid analgesics for acute pain—noting the lack of any evidence showing the efficacy of these approaches and their effect on reducing overdose and pain management, as well as the likelihood of unintended consequences.
Preliminary review of the revised CDC proposal suggests that the agency has not changed its recommendations in response to these comments. The AMA plans to develop new comments on the current proposed guidelines.
Last week, the Centers for Medicare & Medicaid Services (CMS) updated and added new quality measure data to the Physician Compare websites. Prior to the release of the information, the AMA voiced concern (log in) over CMS’ proposal to post 2014 Physician Quality Reporting System (PQRS) performance on the Physician Compare website due to widespread problems with 2014 calculations and feedback reports.
Due to the calculation issues, CMS only posted individual physician information on about 40,000 physicians and 275 group practices who successfully reported on a subset of PQRS measures related to preventive care, diabetes and cardiovascular care. Thousands of physicians on Physician Compare do not have quality measure data.
This is the first time CMS has posted individual physician information on Physician Compare through star ratings. For the last couple of years, CMS has posted star ratings for group practices. The AMA will continue to advocate that CMS only post reliable information on Physician Compare and urge for improvements in providing physicians accurate and timely feedback on performance information.
Despite physicians making a good faith effort to participate in the Physician Quality Reporting System (PQRS) and Value Modifier (VM) programs, many may face payment penalties in 2016 as a result of the Centers for Medicare & Medicaid Services’ (CMS) inability to:
- Appropriately analyze 2014 data
- Distribute accurate PQRS Feedback Reports and Quality and Resource Use Reports for the VM
- Provide timely and coherent penalty notification letters
Due to the poor roll-out of 2014 incentive payments and 2016 penalty notifications, the AMA sent a letter to CMS (log in), advocating for the application of a broad “hold harmless” policy that would automatically exempt all physicians who attempted to comply with 2014 PQRS requirements from any PQRS or VM penalties in 2016. Alternatively, the AMA also has asked CMS to extend the informal review deadline into the next calendar year so that physicians can see the impact of any PQRS or VM adjustments on their payments and file for a review, if appropriate.
Note: In 2016, only physicians in practices with 10 or more eligible professionals are subject to potential VM penalties.
As part of its comprehensive strategy to combat the opioid and heroin overdose epidemic, the AMA has offered support (log in) for the Co-Prescribing to Reduce Overdoses Act of 2015 (H.R. 3680). The legislation, which was introduced by Rep. John Sarbanes, D-Md., would create a demonstration project for federally qualified health centers, opioid treatment centers and other providers to encourage the co-prescribing of naloxone for patients at high risk of overdose.
The project funds could be used to train health care providers, purchase opioid overdose reversal drugs, offset co-pays and other cost sharing, conduct community outreach to raise awareness about the issue, and connect patients who have experienced a drug overdose with appropriate treatment.
The bill provides for a second grant program that would allow states or local health departments to develop guidelines on co-prescribing opioid overdose reversal drugs. These guidelines would ensure that naloxone is better integrated into the health care delivery system and covered by insurance.
The Transparent Ratings on Usability and Security to Transform Information Technology Act of 2015 (S. 2141), also called the TRUST IT Act, would allow for greater data exchange among electronic health records (EHR) and other technology by promoting interoperability in certified health information technology, creating greater transparency for EHRs and restricting information blocking.
Introduced by Sens. Bill Cassidy, MD, R-La., and Sheldon Whitehouse, D-R.I., Dec. 9, the TRUST IT Act would create a star rating system to assess the interoperability, usability and security of certified health IT. Read the AMA’s letter of support (log in) for additional information. Companion legislation is expected to be introduced in the U.S. House of Representatives soon.
Issue SpotlightHow meaningful use should work: AMA comment letter shares plan
Physicians said enough is enough and submitted their own revisions to Stage 3 of the electronic health record (EHR) meaningful use program in a letter Tuesday, which would address real-world needs of physicians and patients. The letter outlines several detailed ways the program needs to change in light of the program’s impact on the design of EHRs, the movement toward new payment and delivery models and the quality of patient care.
Fix the present before planning the future
Earlier this year, Stage 3 of the meaningful use program was finalized against the recommendations of the physician community. In response, the AMA submitted a comment letter (log in) Tuesday to the Centers for Medicare & Medicaid Services (CMS), outlining a framework for a more practical meaningful use program.
The comment letter seeks to alleviate meaningful use burdens and revise the program to improve flexibility, expand patient engagement, and clear the way for increased health IT interoperability and innovation.
The recommended changes would improve the program for both physicians and patients. They include:
- Provide flexibility and eliminate the program’s pass-fail design
- Expand measures to promote patient engagement and interoperability
- Remove requirements that are beyond physicians’ control
- Reorient measures away from process-based tasks to highlight goals that are useful to patients and physicians
- Focus certification on new technology functions rather than placing requirements on physicians that may not be feasible yet
- Support the reuse of data to reduce the physicians’ documentation burden
The letter points out that new payment systems, such as the Merit-Based Incentive Payment System (MIPS) and alternative payment models (APM) established in the Medicare Access and CHIP Reauthorization Act (MACRA), will not work under the current pass-fail design, in which physicians are penalized for failure to meet just one of many requirements and are held accountable for measures not in their control. Increasing flexibility should ensure more successful participation and ease the implementation of new payment models in the future, the letter states.
Interactions with patients (beyond data) should count
It’s no surprise that patient engagement is a major focus of the recommended revisions as well. The outline calls for broadening patient engagement measures to include the “numerous innovative ways that patients and physicians can communicate and connect with one another.”
“Instead of having multiple measures that overlap,” the letter states, “we urge CMS to adopt a single expanded measure that would include activities beyond viewing, downloading and transmitting data.”
A revision of Stage 3 could include measures focused on reviewing clinical notes; accessing information about labs, tests and prescriptions; viewing cost information; and scheduling appointments and paying for services electronically. The measure should not dictate which type of technology must be used, the letter urges. “We believe such criteria stifle new approaches and will become quickly outdated.”
Enhancing quality reporting and data entry
The recommended revisions focus on what EHR technology should accomplish, rather than on data entry requirements.
The requirements for computerized provider order entry and clinical decision support, which currently are focused on counting data entry, can add ongoing challenges to practice work flow. Although CMS tried to mitigate some of these problems in Stage 3 requirements, the measures still need greater flexibility to remove these work flow challenges and ensure relevance to all physicians.
The AMA proposed the following revised measure:
- Physician-designated staff should be allowed to electronically enter medication, lab and radiology orders. These orders should be processed electronically without intervention.
- Physicians should have a choice in selecting at least one clinical decision support tool and the information that is taken into account. Clinical decision support should not only be tied to quality measures and should not be required for the entire EHR reporting period.
“Changing the focus away from data entry and toward actual processing of the order will help ameliorate [some] concerns and improve productivity,” the letter states. However, this will require advancements in interoperability. As a solution, the letter urges the Office of the National Coordinator for Health IT (ONC) to establish a more focused approach for testing the interoperability of health IT at the point of development to promote better user-centered design.
Also flagged for revision are the qualified clinical data registry measures. The framework recommends that physicians, particularly specialists, who participate in a qualified clinical data registry should be deemed as successfully meeting the meaningful use quality requirements.
Additionally, because CMS has not updated the electronic clinical quality measures list in years and does not plan to do so again until 2017, the AMA recommends scaling down the number of quality measures required to report until there are enough electronic clinical quality measures that work for all physician specialties.
For additional reading: Learn about some of the provisions in the recently released Stage 3 rule or find out how EHRs and meaningful use tied up physicians’ time in 2015.
State UpdateNeurosurgeons confront the stigma of substance use disorder
The American Association of Neurological Surgeons and Congress of Neurological Surgeons (AANS/CNS) is urging its members to help remove the stigma of substance use disorder and support increased access to overdose prevention and treatment.
In an editorial, the AANS/CNS highlighted that organized neurosurgery “is committed to identifying the best practices to combat this public health crisis to help patients with substance use disorders.”
“Stigmatizing patients helps no one,” the article said. “Our goal is to treat patients and help them live as fully functional members of society.”
The editorial, which is part of the work of the AMA Task Force to Reduce Opioid Abuse, focused on three specific areas in which physicians can make a difference:
- Change the conversation about what it means to have a substance use disorder and increase access to evidence-based treatments.
- Encourage physicians, dentists and other prescribers of controlled substances to register for and use prescription drug monitoring programs as one tool to identify when a patient may need counseling and treatment for a substance use disorder.
- Consider that we must do a better job with prevention. This includes intervening early with teens who initiate alcohol and/or marijuana use as well as efforts to encourage safe storage and disposal.
“The AANS/CNS Neurosurgical Pain Section strongly supports the efforts of the AMA Opioid Task Force and is proud to be a part of such an important endeavor to improve awareness, safety and treatment options among prescribers and patients alike,” said Jennifer A. Sweet, MD, a neurosurgeon from Cleveland and the AANS/CNS representative on the task force.FSMB revisits opioid treatment guidelines
In response to urging from the AMA, the American Osteopathic Association and other medical associations, the Federation of State Medical Boards (FSMB) this week convened a select workgroup to consider revisions to its 2013 Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain.
At the meeting, AMA Chair-Elect Patrice A. Harris, MD, emphasized that the AMA supports the FSMB’s efforts to develop responsible, balanced policies that help guide physicians when they treat patients with chronic pain. The AMA remains concerned, however, with some aspects of the 2013 model policy, including the addition of more than 60 uses of what physicians “should” do for every patient.
Dr. Harris recommended increased focus on:
- The need for individualizing treatment
- Recognizing the challenges faced when treating patients with chronic non-cancer pain
- New information on co-prescribing naloxone
- Understanding the limitations of drug screening and patient treatment agreements
The FSMB did not indicate a date for revisions to the model policy. The AMA will remain engaged and provide further updates as warranted. Questions can be emailed to Daniel Blaney-Koen of the AMA.
Learn more about previous AMA concerns outlined in letters from June and September 2013 (log in) sent to the FSMB.
A new report from the National Conference of State Legislators, “Telehealth: Policy trends and consideration,” focuses on the following three primary policy issues related to telehealth:
- 1. Coverage and payment
- 2. Licensure
- 3. Safety and security
The report offers a checklist and summary of considerations for legislators interested in pursuing telemedicine legislation in their state.
The product of a yearlong effort involving state lawmakers, staff and industry representatives, including the AMA, many of the report’s recommendations and focus areas align with AMA model state legislation on telemedicine.
Email Kristin Schleiter of the AMA for information and resources related to telemedicine state legislation and regulation.
Judicial UpdateCourt decides: Is patient safety information protected?
A Florida district court of appeal recently considered whether patient safety information is protected from disclosure under a federal act in a medical liability case against a hospital and its physicians.
In Southern Baptist Hospital of Florida, Inc. v. Charles, a trial court had ordered the hospital to produce medical documents that were being used for patient safety and quality improvement efforts.
The Patient Safety and Quality Improvement Act of 2005 (PSQIA) offers physicians and hospitals a way to share medical information used for quality improvement through a patient safety organization (PSO). Under the PSQIA, the confidentiality of data within these systems is protected if that data is not requested by a state administrative agency.
As the Litigation Center of the AMA and State Medical Societies noted in an amicus brief filed in support of the hospital’s appeal of the trial court’s ruling, the purpose of the PSQIA and PSOs is to “improve patient care and reduce risk through collective action.”
“The trial court’s decision threaten[ed] to undo … progress and undermine the valuable work that has been done by PSOs,” the brief said. “Patients, who are the ultimate beneficiaries of the PSQIA, will suffer.”
A few weeks ago, a Florida district court of appeal overturned the trial court’s decision and upheld the protection of medical information being used for patient safety efforts. It held that the PSQIA preempted a provision in the Florida constitution, which might otherwise have required the recovery of the information.
Read more at AMA Wire®.
Other NewsWebinar about prior authorization now available for on-demand viewing
Prior authorization tops the list of administrative burdens for many physician practices. “Break through the prior authorization roadblock,” an educational webinar presented by AMA staff, is now available for on-demand viewing and offers physicians and their staff a wealth of helpful information on this frustrating issue.
The webinar covers the following topics related to prior authorization:
- An overview of prior authorization, including a discussion of the current industry landscape related to prior authorization automation
- Tips to help practices reduce prior authorization burden
- The future of prior authorization: Remaining work needed for true automation and practice workflow changes required to support a prospective prior authorization process
To access the new AMA prior authorization resources presented during the webinar, visit the AMA’s prior authorization Web page.Now is the time to register for 2016 political education programs
Registration is open for the 2016 programs of the AMA Candidate Workshop and Campaign School. Applications are reviewed on a rolling basis for each program, so physicians should apply now to secure their places.
Visit the AMPAC website to complete applications for the Candidate Workshop (Feb. 19-21) and Campaign School (April 13-17). AMPAC covers all program costs for active AMA members (including room, meals, faculty and materials), except transportation to the Washington, D.C. These programs are available to AMA member physicians and their spouses.
For more information, email Jim Wilson of the AMA.
Jan. 7–9: State Legislative Strategy Conference
Don't miss the opportunity to meet colleagues from across the country and share ideas about the toughest state-level issues in health care today. Hosted by the AMA Advocacy Resource Center, the State Legislative Strategy Conference will cover telemedicine, opioids, state-based delivery and payment reform, provider networks and more. Learn more at the meeting Web page or email Wendy Holmes of the AMA with any questions. Also, the room block closes Dec. 21, so make your hotel reservation today.
Feb. 22–24: National Advocacy Conference
Join the AMA in Washington, D.C., at the 2016 National Advocacy Conference, which empowers physicians to advocate for patients, the medical profession and the future of health care. Register today.