Feb. 9, 2017

Issue Spotlight

Fighting together, physicians foil insurance Goliaths

An AMA Viewpoints from AMA President Andrew W. Gurman, MD

Both decisions are in and trial courts have blocked Anthem's acquisition of Cigna and Aetna's acquisition of Humana, deeming them a threat to the affordability, accessibility and quality of health care. These rulings are victories of great magnitude for our patients and the health care system. They are the result of one important factor—that physicians came together to protect patients, our profession and our health care system from further consolidation.

These attempted health insurance mergers reflect the industry-held belief that by joining together, insurers can gain added negotiating leverage over physicians and hospitals. In Anthem, the court concluded that an enhanced ability to coerce physicians to accept lower reimbursement is not an efficiency defense, would not benefit patients, and "would erode the relationship between insurers and providers" and "reduce the collaboration" that is essential to innovation in payment and delivery.

I testified before the House Judiciary Committee on Sept. 29, 2015, when the proposition of the mergers was only beginning to meet the resistance that would carry through the next 15 months.

At the beginning of the hearing, the committee chair read the biographies of the witnesses into the record. There wasn't much attention paid to this process. I was the fourth of six witnesses that day, and when the chairman said, "And representing the American Medical Association …" everyone looked up. They wanted to know who was the doctor in the room. And that goes to show you that, when physicians are in a position to speak up for our patients and ourselves, people listen.

It is difficult for individual physicians to battle with industry giants alone, to have our voices outweigh theirs. But when we create a unified voice through the AMA and other medical societies, we have the depth and breadth of expertise to accumulate the facts necessary to support our position.

The AMA's annual analysis of competition in the marketplace was pivotal in backing up the testimony that I and several other physicians delivered during that time.

These past 18 months are also a time when many claimed that our country was divided. But for this cause—to defend our patients and protect our health care system—physicians came together. In the Aetna-Humana case, we secured a decision that the merger would greatly erode competition in the sale of individual Medicare Advantage plans in 364 counties. U.S. District Judge John D. Bates also set a notable legal precedent by recognizing Medicare Advantage as a separate and distinct market that is not in competition with traditional Medicare—a major focus of our efforts.

Don't ever forget that this major win for patients, physicians and the entire health care system was a result of a physician coalition led by the AMA and several other representative medical societies. When we physicians put our minds toward a cause, we can make a difference.

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National Update

Don't deport our "dreamers"; DACA bill earns physician support

The AMA has expressed its support for the "Bar Removal of Individuals who Dream and Grow our Economy Act" (BRIDGE Act), a bipartisan, bicameral bill that would provide protection from deportation for undocumented young immigrants—often called "dreamers"—who have Deferred Action for Childhood Arrivals (DACA) status.

The letter was sent Monday to the U.S. Senate sponsors of the bill (S. 128), Illinois Democrat Richard Durbin and South Carolina Republican Lindsey Graham. Reps. Mike Coffman, R-Colo., and Luis Gutierrez, D-Ill., who also received a letter, have introduced the bill in the House (H.R. 496).

"I do not believe we should pull the rug out and push these young men and women—who came out of the shadows and registered with the federal government—back into the darkness," Graham said in a press release.

The BRIDGE Act would offer people who meet certain requirements the opportunity to apply for protected legal status and work authorization for three years. The bill would "provide important protection and stability until a permanent solution on lawful immigration status for DACA recipients is implemented," AMA Executive Vice President and CEO James L. Madara, MD, wrote.

DACA's impact has been felt in medicine. More than 60 medical schools considered applications from students with DACA status for the 2016 – 2017 academic year, according to the Association of American Medical Colleges. In the coming decades, DACA protections could enable as many as 5,400 previously ineligible people to join the U.S. physician workforce, the AMA's letter says.

Read more at AMA Wire®.

Dr. Price's nomination to be HHS Secretary advances

The Senate Committee on Finance Feb. 1 reported out the nomination of Representative Tom Price, MD, R-Ga., to be Secretary of the U.S. Department of Health and Human Services  by a vote of 14-0, with all Republicans supporting the nomination.

Democrats on the committee did not attend the nomination vote, which came following a week of procedural machinations that affected several nominations. The full Senate is likely to vote on Dr. Price's nomination later this week.

Congress examines the ACA landscape

Both chambers of Congress last week held several hearings to examine the current landscape of the Affordable Care Act (ACA). Among the panels holding hearings, the House Energy & Commerce Committee examined potential changes to the Medicaid program as well as opportunities to strengthen the ACA exchange insurance market.

The Senate Health, Education, Labor and Pensions (HELP) Committee also held a hearing to seek immediate solutions to stabilize the individual health insurance market. Congress will continue to examine issues surrounding the ACA, although it is not yet clear when legislative activity related to the ACA will occur.

IPAB repeal legislation introduced in the House and Senate

Legislation to repeal the Independent Payment Advisory Board (IPAB) last week was introduced on a bipartisan and bicameral basis. Representatives Phil Roe, MD, R-Tenn., and Rep. Raul Ruiz, D-Calif., introduced H.R. 849, while Senators John Cornyn, R-Texas, and Ron Wyden, D-Ore., introduced S. 260 and S. 251, respectively.

Separately, the same members last week introduced resolutions in the House (H.J. Res. 51) and Senate (S.J. Res. 16 and S.J. Res. 17) that would discontinue automatic implementation of IPAB recommendations. These resolutions, which were prescribed by provisions in the Affordable Care Act, enjoy several procedural protections relative to the standard repeal legislation.

It is not yet known when or how the House and Senate will consider this issue. The AMA continues to strongly support repealing the IPAB and will be working with the House and Senate in this effort.

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State Update

Attorneys General urged to help end prior authorization for MAT

The AMA last week urged the nation's attorneys general to help end insurance company policies that delay or deny care for substance use disorders. As part of an agreement to resolve an investigation by New York Attorney General Eric Schneiderman of Anthem and Cigna's prior authorization and network adequacy policies, the two health insurance plans agreed to end their policies of prior authorization for medication-assisted treatment (MAT) in New York and the rest of the nation.

In a letter to the National Association of Attorneys General (NAAG), the AMA strongly supported the agreement and pledged its support to NAAG with reaching similar agreements with other payers across the nation. The AMA highlighted that more than 33,000 Americans died in 2015 due to an opioid-related overdose, two million had a substance use disorder involving opioid analgesics, and nearly 600,000 people have a substance use disorder involving heroin.

In addition to ending prior-authorization policies that delay care for patients, the AMA also called on all payers "to end policies that require patients to repeat step therapy protocols or retry therapies failed under other benefit plans before qualifying for coverage of a current effective therapy for substance use disorders."

Increasing access to MAT is one of the key recommendations of the AMA Task Force to Reduce Opioid Abuse.

Rhode Island releases opioid educational toolbox

The AMA and the Rhode Island Medical Society (RIMS) recently released a Rhode Island specific "toolbox" to provide physicians and other health care professionals with data, resources and information designed to help reverse the state's opioid epidemic. The toolbox, which is being promoted throughout Rhode Island, includes details about new state laws, resources on referrals for patients with a substance use disorder, information for co-prescribing naloxone and more.

"Rhode Island physicians have made important strides in making more judicious prescribing decisions, supporting access to treatment and making naloxone more widely available," said Patrice A. Harris, MD, and Chair of the AMA Board of Trustees. "This toolbox will complement those efforts by providing data, tools and practical resources that can increase awareness, enhance education and help patients."

The AMA also worked with the Medical Association of the State of Alabama to produce an Alabama-specific toolbox. The AMA will be working with medical societies to evaluate the toolbox resources and revise them based on the findings.

For more information, please contact Daniel Blaney-Koen of the AMA.

Funding for this initiative was made possible (in part) by Providers' Clinical Support System for Opioid Therapies (grant no. 5H79TI025595) from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

ASAM holding public comment period for drug testing appropriateness document

The American Society of Addiction Medicine (ASAM) is inviting public comment on a draft of a drug-testing appropriateness document that seeks to provide guidance on the use of drug testing in the diagnosis, treatment and promotion of recovery for patients with, or at risk for, addiction.

The draft document is now open for external review. The deadline for responses is Feb. 28, at 5 p.m. Eastern time. ASAM asks that the recommendations in its draft manuscript are still draft and should not be copied, disseminated or implemented until final publication. All comments can be submitted through an online tool, which also includes a conflict of interest form that must be completed in order to finalize submission.

If you have any questions regarding the document please contact ASAM at by Feb. 28.

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Other News

AMA prior authorization survey shows burdens and impact

The AMA last December surveyed 1,000 practicing physicians on the burdens associated with prior authorization (PA) for medical services and prescriptions.

Among the most notable survey findings was that, on average, a medical practice completes an average of 37 PAs per physician per week, which takes a physician and their staff an average of 16 hours, or the equivalent of two business days, to process. Given this PA workload, it is not surprising that 75 percent of surveyed physicians described PA burdens as high or extremely high. In addition to taxing practices, PA requirements can also impact patients: nearly 90 percent of surveyed physicians reported that PA sometimes, often, or always delays access to care.

The 24-question, web-based survey was conducted with the assistance of M3 and involved 600 specialists and 400 primary care physicians. Participating physicians were screened to ensure that they provide 20 or more hours of patient care and complete PAs during a typical week of practice.

The survey results highlight the need for improvements in the PA process. A coalition including the AMA and 16 other organizations recently released a set of 21 principles aimed at effecting positive changes in health plans' utilization management programs. The AMA encourages state medical associations and specialty medical societies to use the survey results and the principles in advocacy efforts on this challenging issue.

CMS extends deadline for 2016 Meaningful Use reporting

The Centers for Medicare and Medicaid Services (CMS) has given physicians an extra two weeks to submit meaningful use data from 2016, extending the deadline to March 13. The original deadline was Feb. 28. The reporting period for returning participants is a minimum of any continuous 90-day period between Jan. 1 and Dec. 31, 2016.

CMS extends deadline for 2016 PQRS electronic submissions

The Centers for Medicare and Medicaid Services (CMS) is extending the deadline for submission of 2016 Physician Quality Reporting System (PQRS) data through all mechanisms except claims—including reports submitted through electronic health records (EHR), qualified registries and qualified clinical data registries.

The original submission deadline was Feb. 28, and claims-based reporters still must submit all their claims by that date. Eligible professionals (EPs) who do not satisfactorily report 2016 quality measure data to meet the 2016 PQRS requirements will be subject to a downward PQRS payment adjustment on all Medicare Part B Physician Fee Schedule (PFS) services rendered in 2018.

A complete list of 2016 data submission timeframes is below. Submission ends at 8 p.m. Eastern Time on the end date listed.

March 13 deadlines:

March 17 deadline:

March 31 deadlines:

An Enterprise Identity Management (EIDM) account with the "Submitter Role" is required for these PQRS data submission methods. If reporting through the EHR, it is highly recommended that practices work with their EHR vendor to submit data on practices' behalf and not for practices to submit data directly to CMS. Please see the EIDM System Toolkit for additional information.

For questions, please contact the QualityNet Help Desk at (866) 288-8912 or via email at from 8 a.m. - 8 p.m. Eastern Time. Complete information about PQRS is available on CMS' website.

Register to attend alternative payment model (APM) workshop

With the Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program starting this year and the new Physician-focused Payment Model Technical Advisory Committee (PTAC) reviewing specialties' APM proposals, now is the time to join your colleagues at the AMA's APM Workshop, to be held Mon., March 20, in Washington, D.C.

Physicians who are working on APMs or interested in learning more about them should register now to:

Participants will also have opportunities to inform policy makers about the data, technical assistance, registries and information technology needed for APMs. Discussion leaders for the APM Workshop include physician leaders from the American College of Surgeons, the Centers for Medicare and Medicaid Services and the AMA, as well as a PTAC member.

To register, contact Ela Cameron at with your name, email address, organization, city and state. There is no charge to attend, but space is limited.

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Upcoming Events

Feb. 17 – 19, 2017:
Whether you want to run for public office or campaign for a candidate who supports issues that are important to medicine, AMPAC (the AMA's bipartisan political action committee) offers the hands-on training you need. The Candidate Workshop is designed to help you make the leap from the exam room to the campaign trail and give you the skills and strategic approach you will need to make a run for public office. Please note participants are responsible for their registration fee, hotel accommodations at the Hyatt Regency Washington on Capitol Hill and travel to and from Washington, DC. Faculty, materials and all meals during the meeting are covered by the AMA. Learn more or apply today.

Feb. 27 – March 1, 2017:
The 2017 National Advocacy Conference will take place in Washington, D.C. Participants in this year's conference will gain important insights from industry experts, political insiders and members of Congress. Conference participants will leave more well informed and empowered to advocate for patients, the medical profession and the future of health care. Learn more and register today.

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