March 9, 2017

Issue Spotlight

American Health Care Act does not align with AMA health reform principles

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

The American Health Care Act (AHCA), released by Congress this week, is intended to repeal and replace the Affordable Care Act (ACA). But as introduced, it does not align with the health reform principles that the AMA set forth in January to protect patients. While the ACA is imperfect, the current version of the AHCA is not legislation we can support.

The replacement bill, as written, would reverse the coverage gains achieved under the ACA, causing many Americans to lose the health care coverage they have come to depend upon.

In a letter sent this week to leaders of the House committees that will mark up the AHCA, AMA CEO and Executive Vice President James L. Madara, MD, wrote that the proposed changes to Medicaid would limit states' ability to respond to changes in service demands and threaten coverage for people with low incomes. Dr. Madara also noted that the proposed changes in tax credits and subsidies to help patients purchase private health insurance coverage are expected to result in fewer Americans with insurance coverage.

Policymakers and stakeholders are awaiting budgetary and coverage projections from the nonpartisan Congressional Budget Office. The ratings and analytics firm S&P Global Ratings has estimated that as many as 10 million Americans could lose coverage if this bill becomes law, saying that between 2 million and 4 million people could lose the insurance they purchased in the individual health exchanges under the ACA, and between 4 million and 6 million could lose their coverage under Medicaid.

That just won't do.

We all know that our health system is highly complex, but our core commitment to the patients is firm. As the AMA has previously stated, members of Congress must keep top of mind the potentially life-altering impact their policy decisions will have.

We physicians often see patients at their most vulnerable moments, from the first time they set eyes on a newborn child to the last time they squeeze a dying loved one's hand. We don't want to see any of our patients, now insured, exposed to the financial and medical uncertainties that would come with losing that coverage.

That is, above all, why physicians must be involved in this debate.

Editor's note: In the coming weeks, a series of AMA Wire® articles will explore policies that form the basis of the AMA's advocacy on health reform. Read parts one ("Protecting insurance gains is priority No. 1") and two ("No going back on key market protections").

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National Update

AMA urges stronger network-adequacy standards, fewer prior-auth demands

In response to the 2018 Advance Notice for Medicare Advantage (MA) and Part D prescription drug plans (PDPs), the AMA submitted comments to the Centers for Medicare and Medicaid Services (CMS) urging continued oversight of MA plan compliance with network adequacy and directory accuracy requirements. In addition to information CMS currently requires plans to collect on network physicians' addresses, contact information and hours, up-to-date information should be maintained on physicians' specialties and subspecialties. 

The letter also urges CMS to require MA and PDPs to sharply curtail their use of prior authorization and other drug-utilization management requirements, and to ease the processes for physicians to obtain required authorizations. In particular, the AMA advocates transparency of these requirements and for electronic health record (EHR) vendors to support transactions that allow physicians to complete prior authorizations as part of the electronic prescribing process. 

The comments address several other MA and PDP policy issues, including seeking policy to promote annual wellness visits by an MA patient's regular physician instead of as a one-time-only service from an outside vendor.

Flexibility needed in EHR adoption

The AMA and 104 medical specialty and state societies sent a letter to CMS and the Office of the National Coordinator for Health Information Technology (ONC) requesting that physicians be permitted to continue using their current EHR version though at least 2018. 

Under the Quality Payment Program (QPP) and Meaningful Use (MU), physicians must upgrade or purchase 2015 Edition EHRs to participate. Many EHR vendors have yet to make their new products available and physicians who have upgraded were charged significant fees by their vendors.

The AMA has been a vocal proponent for reducing the physician burden caused by EHRs and is concerned CMS' current EHR requirement will result in rushed upgrades, installations, a lack of user training and an overall disruption to physicians' practices.  Physicians should identify their own 2015 Edition-rollout timeline independent of federal regulation.

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State Update

AMA provides comments on CMS proposed rule on market stabilization

The AMA provided comments this week on CMS' proposed rule on market stabilization. While the proposed rule was identified by CMS as an effort to stabilize the individual and small group markets, the AMA expressed concerns about the negative impact the changes could have on patients and their physicians.  

For example, by significantly reducing the annual enrollment period and limiting special enrollment opportunities, the rule could lead to many individuals finding themselves without coverage. Likewise, proposals that would loosen network-adequacy requirements and reduce the percentage of essential community providers with whom payers must contract would undoubtedly hinder access to care for many of the most vulnerable patient populations. 

Overall, the proposed rule has the potential to raise premiums, out-of-pocket costs or both for moderate-income families, and would make it more difficult for eligible individuals to enroll in health insurance coverage and access needed care. 

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Judicial Update

Appeals court OKs salt-shaker sodium warnings at chain restaurants

An Empire State appeals court has upheld the New York City health-department rule requiring chain restaurants to warn customers about menu items exceeding the 2,300 mg daily recommended sodium limit. The decision allows the regulation that took effect in 2015 to stay in place, offering critical information to the nearly 2 million New Yorkers diagnosed with hypertension.

The Appellate Division of the Supreme Court of the State of New York ruled 5 – 0 to uphold the New York City Department of Health and Mental Hygiene rule, which requires that chain restaurants that disclose nutritional information and offer standardized menu items display a salt-shaker icon next to menu items that surpass the recommended daily limit of sodium.

The National Restaurant Association sued the department, arguing that the regulation was arbitrary and capricious, preempted by federal law on food labeling, and violated the principle of separation of powers and the First Amendment. The Appellate Division rejected each of these arguments. In the unanimous opinion, Associate Justice Ellen Gesmer opened by noting, "Salt is both an essential ingredient of our diet and, when consumed in excess, a significant health hazard."

The restaurant trade group had challenged that notion, citing methodologically suspect research published in recent years. In an amicus brief filed with the court, the AMA, the American Heart Association (AHA) and 12 other organizations supported the widely held view that the federal government recommended daily limit on sodium is appropriate.

"There exists no medical or scientific controversy about the content of the warning," the brief says. "The 'total daily recommended limit' of sodium intake is in fact 2,300 mg, and 'high sodium intake' in fact 'can increase blood pressure and risk of heart disease and stroke.'"

The brief filed by the AMA Litigation Center and others cited data showing that excess sodium consumption poses a high risk to people older than 51 and those who have hypertension, diabetes or kidney disease. A majority of New York City's population falls into one or more of these "vulnerable groups who are in particular need of the warnings" about sodium intake.

"The sodium rule is a necessary, scientifically sound, and legally well-grounded measure, carefully designed to work within the boundaries of New York law and the federal Constitution, as well as to coordinate with the city's larger effort to reduce hypertension among its residents," the brief says.

Gesmer cited the medical organizations' brief in her decision upholding the New York City sodium-warning rule, which she said can be justified by health considerations such as the fact that Americans get nearly one-third of their sodium from restaurant meals. Twenty percent of meals in fast-food restaurants, she noted, contain more than 2,300 mg of sodium. The unanimous ruling added that the regulation does not violate the First Amendment because, while it compels commercial speech, the content of that speech "is factual, accurate and uncontroversial."

The National Restaurant Association could appeal to the state's highest court, the New York Court of Appeals.

Read more at AMA Wire.

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Other News

Health system reform highlights advocacy conference agenda

At the AMA National Advocacy Conference in Washington, D.C., last week, industry experts, Congressmen and AMA leadership spoke with physicians about bipartisanship, fighting for patients and what can be expected in the coming weeks as the debate on health care reform heats up.

The AMA's core priority in health care reform is maintaining the coverage gains of the Affordable Care Act (ACA). AMA President Andrew W. Gurman, MD, discussed why physicians are in a unique position to advocate for their patients to make sure the health care coverage they have come to depend upon is not lost.

The AMA's Rich Deem, senior vice president of advocacy, talked with industry experts about what can be expected of the coming bill, released this week, and the markups that follow.

The annual Dr. Nathan Davis Awards commended former CMS Administrator Andy Slavitt for his work to bring the physician voice to the design of the Medicare Access and CHIP Reauthorization Act. The AMA also honored longtime AMA members Sen. John Barrasso, MD, for his leadership in repealing the SGR formula and for shaping the Quality Payment Program, and Rep. Phil Roe, MD, for his effort to improve access to care for senior citizens, veterans, military families and people with disabilities.

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Upcoming Events

April 9–11:
The AMA and the Medical Group Management Association will hold their Collaborate in Practice Conference at the Sheraton Grand Hotel in Chicago. The conference honors physicians and administrators as partners in leading medical practices to enhance patient experience, improve population health, cut costs and improve the work life of health professionals. Learn more and register.

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