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Feb. 23, 2017

Issue Spotlight

Clinical technology in the age of the QPP

With a new Medicare payment system in place this year, the Quality Payment Program (QPP), health care technology could be a physician's best friend—if it is designed in a way that works in everyday clinical practice. The question is: What are those things that take away from a physician's ability to provide that care to patients?

"Physicians are dissatisfied with anything that takes away from providing high-quality patient care," said Michael Tutty, PhD, AMA vice president of professional satisfaction and practice sustainability, speaking at the Healthcare Information and Management Systems Society's annual conference in Orlando, Fla. When it comes to electronic health record (EHR) systems, the "frustration that physicians experience with EHRs, in many cases—whether it be from government regulation or with [the] technology's design—is that the amount of time it takes to do documentation increases, taking valuable time away from direct patient care.

Insurance and government regulations, internal bureaucracy within an organization and frustration with EHRs are just a few of the factors in play, he said.

The AMA funded a study published last fall in the Annals of Internal Medicine that was conducted to better understand how the typical day of a physician is spent. "What was interesting … is that for every hour that physicians spend with their patients, they spend almost two additional hours doing EHR and desk work," Dr. Tutty said.

The study also found that physicians spend an additional one to two hours accomplishing this clerical work at home. "No matter how you slice this, it seems like this is not the best use of physicians' time," he said. "And this time pressure is leading to physician burnout."

One of the coping mechanisms for this time struggle is for physicians to cut back on their hours, Dr. Tutty said. "And in an era where there are predictions that we will be short 25,000 physicians by 2025, having physicians cut back on their [hours] is not a good solution."

"If you think about technology and you think about the laws that are going to impact physicians, and you're in the technology space … this is the environment facing our physician workforce," he said.

The Medicare Access and CHIP Reauthorization Act (MACRA) was enacted two years ago and is a bipartisan success story, said Rich Deem, AMA senior vice president of physician advocacy. The implementation of MACRA started this year under the QPP.

"Government and stakeholders worked together to implement a new payment framework. ... CMS conducted numerous engagements to listen to people on the front lines of care about their concerns," Deem said. Andy Slavitt, immediate-past administrator of the Centers for Medicare and Medicaid Services (CMS) and many others at CMS, "rolled up their sleeves to work with the AMA to make things works better for practicing physicians."

"I hope this process with CMS and with [the Office of the National Coordinator for Health Information Technology] continues, where people get out from behind their desks [and] they continue  to engage front-line caregivers," Deem said.  

The MACRA legislation had overwhelming bipartisan backing.

"We don't see that kind of bipartisan support too often these days, unfortunately," Deem said. "There's a lot of confusion about what's in the QPP," but physicians can visit the AMA's Medicare Payment and Delivery Changes webpage to make sure they are up to date on what they need to know.

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National Update

CMS awards contracts to provide technical assistance to small practices with QPP

The Centers for Medicare and Medicaid Services (CMS) awarded $20 million to 11 organizations for the first year of a five-year program to provide training and education about the Quality Payment Program (QPP) for clinicians in individual or small group practices of 15 or fewer. CMS will award a total of $100 million over the five years.

The AMA supported this technical assistance when the Medicare Access and CHIP Reauthorization Act (MACRA) was being drafted and has been urging the administration to award these funds. For no charge, awardees will assist practices with the following types of activities:

CMS issued a press release to provide more information.

AMA agrees with maternal and infant health strategy

In comments on the Substance Abuse and Mental Health Services Administration (SAMHSA) draft strategy to prevent and treat opioid use disorder in pregnant women and its postpartum impact on families, as required by the "Protecting Our Infants Act," the AMA stated its strong agreement with the SAMHSA report's focus on the need to overcome prejudice against pregnant women and mothers with substance use disorders.

The AMA's comments stressed that pregnant women and mothers with substance use disorders often cannot find a safe environment to seek treatment for pain and/or addiction, and urged that education and awareness campaigns focus on opportunities to treat pain, not just substance use disorders. The same types of barriers, such as coverage limits and prior-authorization requirements that impede access to addiction treatment also limit access to non-opioid and non-pharmacologic treatments for pain.

The AMA is also encouraged by the strategy's focus on achieving healthy families and examining the consequences of removing children from their parents due to prenatal substance exposure.

Payment model committee to review its first proposals

The Physician-focused Payment Models Technical Advisory Committee (PTAC) has now received five proposals for review and has scheduled four days of meetings in March and April to discuss and consider recommending these proposals to the U.S. Department of Health and Human Services (HHS) for implementation.

The American College of Surgeons submitted a proposal for an episode-based model that reflects input and review of the clinical content of the episodes by many different specialties. The SonarMD model for management of patients with Crohn's disease, utilizing a care pathway and clinical decision tool developed by the American Gastroenterological Association, has already been implemented in 20 medical practices.

In addition, a model focusing on colorectal cancer screening, diagnosis and surveillance was submitted by the Digestive Health Network. The most recent proposal submitted is for treatment of patients with advanced illness and includes care management, team-based care, concurrent curative and palliative treatment, advance care planning and shared decision making.

More information on these proposals is available on HHS' website.

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State Update

Aetna ends prior authorization for treatment of substance use disorders 

The AMA last week commended Aetna for joining other health insurers in eliminating prior authorization for treatment of substance use disorders as of March 1.

"Patient lives will be saved by Aetna's decision to remove prior authorization for treatment of substance use disorders," said Dr. Patrice A. Harris, MD, chair of the AMA board of trustees and chair of the AMA Task Force to Reduce Opioid Abuse.

"The AMA has advocated strongly for removing this hurdle, and we are pleased by Aetna's announcement," Dr. Harris said. "Increasing access to treatment is crucial to reversing the nation's opioid epidemic, and we urge all payers to show the leadership that Aetna has taken to make patient care a priority over administrative hurdles."  

The New York Attorney General recently announced an agreement with insurers Anthem and Cigna to end their policies of prior authorization for medication-assisted treatment in New York and the rest of the nation.

In a follow-up letter to the National Association of Attorneys General (NAAG), the AMA urged other state attorneys general to help end insurance company policies that delay or deny care for substance use disorders.

The AMA strongly supported the New York agreement and pledged its support to NAAG with reaching similar agreements with other payers across the nation. The letter noted that more than 33,000 Americans died in 2015 due to an opioid-related overdose, 2 million had a substance use disorder involving opioid analgesics, and nearly 600,000 people have a substance use disorder involving heroin.

Massachusetts encourages gun safety discussions with patients

In partnership with the Massachusetts Attorney General, the Massachusetts Medical Society has developed materials and resources for physicians and other health care providers who wish to engage their patients in discussions about gun safety.

Guns are a leading cause of death and injury, particularly among children, adolescents, and young adults, and studies show that patients who received physician counseling on firearm safety are more likely to adopt one or more safe gun-storage practices.

The resources clarify state and federal laws regarding physician speech related to firearms and provide clinical information on how to begin a conversation with patients about firearms or respond to patient concerns. Available materials, including brochures for physicians and patients and an online educational video, are available on the Massachusetts Medical Society website.

Longstanding AMA policy encourages physicians to routinely ask patients about firearm ownership and educate them on the dangers posed to children by firearms that are not safely secured.

For additional information about state gun laws, please contact Annalia Michelman of the AMA.

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Judicial Update

Florida 'gun gag law' ruled unconstitutional

The 11th U.S. Circuit Court of Appeals struck down provisions of the Florida Firearms Owners' Privacy Act (FOPA) that prohibited health care providers from asking patients about gun ownership and safe firearm storage. Citing AMA policy, the court determined that "the applicable standard of care encourages doctors to ask questions about firearms (and other potential safety hazards)," and that health care providers "must be able to speak frankly and openly to patients." The court noted that "Florida may generally believe that doctors and medical professionals should not ask about, nor express views hostile to, firearm ownership, but it may not burden the speech of others in order to tilt the public debate in a preferred direction."

The AMA strongly opposed FOPA and along with the American Academy of Pediatrics and seven other medical specialty societies urged the court to uphold a lower court decision that ruled the law unconstitutional. Joint amicus briefs filed by the medical societies stressed that lawmakers should not insert the state into the patient-physician relationship by dictating, prohibiting, or threatening open communication between patients and physicians.

AMA President Andrew Gurman praised the decision by stating that "open communication between patients and physicians is essential to medical care and must be protected from legislative gag orders. The court ruling is a clear victory against censorship of private medical discussions between patients and physicians. The State of Florida cannot ignore constitutional rights by limiting the free speech necessary for the practice of medicine."

Court rules patient-safety info subject to litigation discovery

Physicians and hospitals share medical incident reports for quality improvement efforts to increase patient safety through patient safety organizations (PSO). When that information is not protected from disclosure in medical liability cases, it can stifle the sharing. The Supreme Court of Florida reversed a District Court of Appeal decision, deeming this information unprotected from litigation discovery.

In Charles v. Southern Baptist Hospital of Florida, a trial court had ordered the hospital to produce medical documents that were being used for patient safety and quality improvement efforts.

A Florida appeals court in 2015 overturned the trial court's decision and upheld the protection of medical information being used for patient safety efforts. The appellate court held that the federal Patient Safety and Quality Improvement Act of 2005 (PSQIA) preempted a provision in the Florida constitution, which might otherwise have required the recovery of the information.

The PSQIA, passed by Congress and signed into law by President George W. Bush with AMA support, offers physicians and hospitals a way to share medical information used for quality improvement through a PSO. Under the law, the confidentiality of data within these systems is protected if that data unless requested by a state administrative agency.

These patient-safety systems were created to allow hospitals and practices nationwide to share information about safety issues and incidents in order to improve quality and patient safety without the fear that this information could be used against health professionals in a medical liability case.

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."

But, despite the need for protections, the Supreme Court of Florida has reversed the district court's decision concluding that a "health care provider or facility … cannot shield documents not privileged under state law or the state constitution by virtue of its unilateral decision of where to place the documents under the voluntary reporting system created by the [PSQIA]."

"[The PSQIA] was for the voluntary reporting system to function harmoniously within existing state reporting and discovery laws," the decision says. "[The PSQIA] was intended by Congress to improve the overall health care in this system, not to act as a shield to providers."

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Other News

New York BCBS plans reduce prior-authorization requirements

Recent announcements from two BlueCross BlueShield (BCBS) plans in New York may signal an emerging willingness among health plans to reform burdensome prior-authorization (PA) programs. BCBS of Western New York announced that it will be eliminating PA requirements for over 200 medical services, including certain surgeries, physical therapy, skilled nursing services for home health care and power wheelchairs.

BlueShield of Northeastern New York issued a similar statement shortly thereafter, indicating that it would remove PA requirements on over 200 medical services across 20 medical protocols. Both plans stated that their review of PA requirements would be ongoing and that additional services may be removed from their PA programs in the future.

The announcements followed strong advocacy efforts by the Erie County Medical Society and the Medical Society of the State of New York urging regional health insurers to refine PA programs, as well as the recent release of the Prior Authorization and Utilization Management Reform Principles by the AMA and 16 other physician, hospital, pharmacist, and patient organizations.

While the two plans cover a limited part of New York, these announcements may spur other health plans in the state and elsewhere to consider changes in their utilization management programs.

AMPAC hosts 2017 Candidate Workshop in Washington, D.C.

Last week 21 participants took part in the two-day AMPAC Candidate Workshop at the Washington, D.C. office of the AMA. Participants came from all over the country to learn what it takes to be a successful candidate for public office.

Over the course of the workshop all the elements of a competitive political campaign were discussed by a bipartisan team of campaign experts. The topics included campaign plan and messaging, polling, grassroots organization, leveraging direct mail, internet and social media, how to leverage television and radio ads and fundraising.

The annual workshop provides intensive political training to AMA members, spouses and state medical society staff members. For more information on the workshop or other political education programs, please visit the AMPAC website.

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Upcoming Events

Feb. 27 – March 1, 2017:
The 2016 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.

March 20:
With the MACRA Quality Payment Program starting this year and the new Physician-focused Payment Model Technical Advisory Committee (PTAC) reviewing specialties' Alternative Payment Model (APM) proposals, now is the time to join your colleagues at the AMA's APM Workshop, to be held Monday, March 20, in Washington, D.C. Physicians who are working on APMs or interested in learning more about them should register now to: share how your organization is designing APMs; learn about physician-focused APMs that others are proposing; and develop solutions to challenges in APM design, such as risk adjustment and patient attribution. Participants will also have opportunities to inform policymakers 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 ela.cameron@ama-assn.org with your name, email address, organization, city and state. There is no charge to attend, but space is limited.

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