March 23, 2017
Issue SpotlightOutcome of House health reform bill uncertain
House leadership and the Trump Administration are engaged in last-minute negotiations to secure passage of the American Health Care Act (H.R. 1628), a bill that would repeal significant portions of the Affordable Care Act. The bill would provide tax credits for the purchase of insurance and significantly reduce federal funding for Medicaid coverage. The smaller size of the credits relative to current subsidies for lower income families and individuals and Medicaid cuts led the Congressional Budget Office on March 13 to estimate that the number of uninsured Americans would increase by 14 million people in 2018, and by 24 million by 2026.
On March 22, the House Rules Committee approved a Manager's Amendment to the bill that would make changes intended to secure the votes necessary to pass the legislation, including an acceleration of the bill's $880 billion in tax cuts and allowing states to receive reduced Medicaid funding in the form of a block grant. The AMA sent a letter on March 22 urging members of the House of Representatives to vote "no" on the bill because of its negative impact on health insurance coverage and Medicaid funding. At press time, additional changes that include removing essential benefits requirements were under discussion.
National UpdateHealth reform: Website will help patients, physicians take action
A new website will make it easier for patients and physicians to understand where the AMA stands on the health-system reform debate happening in Washington and give them tools to take part in the effort to protect health care coverage for millions of Americans.
The site, Patientsbeforepolitics.org, colorfully delineates the nine objectives that will guide the AMA in its discussions regarding ongoing efforts to improve the nation's health system. The objectives were included in the letter that AMA CEO and Executive Vice President James L. Madara, MD, wrote to Congressional leaders in January. They grow out of the AMA's comprehensive vision for health-system reform.
That vision has been refined over more than two decades by the AMA's House of Delegates, which is composed of representatives of more than 190 state and national specialty medical associations. The new site offers a convenient way for readers to understand the basis for these objectives, through links to relevant AMA Council on Medical Service reports and policy briefs.
The Patientsbeforepolitics.org website makes it easy for patients and physicians to write their elected Congressional representatives and urge them to protect Americans' access to quality care. In the weeks and months to come, the site will be updated to offer more ways to take action on this critical issue.
"Putting patients first is at the heart of everything we do as physicians," said AMA President Andrew W. Gurman, MD. "That's why we are committed to working with leadership in both parties to improve health insurance coverage and health care access so that patients receive timely, high-quality care, preventive services, medications and other necessary treatments. This new website will equip physicians and patients around the country with the information and tools they need so they can join us in urging Congress to ensure Americans have access to affordable, meaningful coverage and high-quality health care."
Read more at AMA Wire®.
The House Judiciary Committee approved H.R. 1215, the "Protecting Access to Care Act (PACA)" on Feb. 28 by a vote of 18-17. This bill is based on the California medical liability reform law and would limit noneconomic damages to a cap of $250,000, while providing unlimited economic damages.
It would also give states the flexibility to increase the cap on noneconomic damages and has language protecting existing state liability reforms. The AMA has policy in favor of limiting noneconomic damages and supports the bill. House Republican leadership considers this measure to be part of its health care reform efforts. The full House is expected to consider H.R. 1215 during the week of March 27.
On March 21, the AMA and 86 state and specialty medical societies sent a letter urging the Centers for Medicare and Medicaid Services (CMS) to adopt relief related to existing Medicare quality reporting programs—the Physician Quality Reporting System (PQRS), Meaningful Use (MU), and the Value-Based Payment Modifier (VM). The Medicare Access and CHIP Reauthorization Act (MACRA) modified and consolidated these three programs into a new Merit-based incentive payment system (MIPS), which addresses a number of problems in the current programs. However, the MACRA-related changes do not affect Medicare payments until 2019. Therefore, in 2018, physicians will still receive payment adjustments associated with MU, PQRS and the VM based on 2016 rules.
The sign-on letter calls for changes that would reduce the likelihood of physicians receiving MU, PQRS and VM penalties in 2018. The suggested changes include increasing the opportunities for hardship exemptions, and protecting physicians who successfully reported at least one PQRS measure from automatic PQRS and VM penalties. Physicians who want to compete for a VM bonus through quality tiering could still do so through an opt-in, voluntary process. These changes are also aligned with the direction CMS is taking as physicians move into MIPS.
State UpdateAMA urges appeals court to block Anthem-Cigna merger
On March 17, the AMA filed its amicus brief with the U. S. Court of Appeals for the District of Columbia asking the court to affirm the lower court's decision to block the proposed Anthem-Cigna merger. The AMA strongly disputes Anthem's claim that the merger is justified because it will give Anthem-Cigna bargaining power to reduce physician and provider payments. In its brief, the AMA emphasizes that:
- Increasing Anthem's bargaining power does not outweigh the anticompetitive effects in the health insurance market that the merger will cause.
- If the merger proceeds, consumer welfare will suffer and could cause quality to degrade and leave consumers deprived of meaningful choices.
- The evidence at trial showing harm to patient care echoed the experiences physicians provided to the AMA and state medical associations as part of the pre-trial strategy.
Of note, at the AMA's suggestion, 27 professors who have expertise in the subjects of health economics, antitrust and/or competition policy also filed their own amicus brief opposing the Anthem-Cigna merger. The professors are from leading academic centers and many are nationally renowned.AMA hosts summit on preventing gun violence
Gun violence in America has reached epidemic proportions. More than 30,000 deaths from gun violence each year underscore the need for a comprehensive public health approach to stem this epidemic.
To explore workable solutions to reducing gun violence in our communities, the AMA has joined with the American Bar Association to host Preventing Gun Violence: Moving from Crisis to Action on March 24 in Chicago. At this critical half-day program, expert speakers will examine what it means to take a public health approach to the gun violence crisis, evidence-based interventions being implemented in Chicago, potential policy interventions to limit high-risk individuals' access to guns and strategies physicians can use to promote gun safety.
Learn more about this event.
State legislatures continued to pursue legislation—many consistent with the model AMA Telemedicine Act—laying the ground work for the adoption of safe and effective telemedicine. Arkansas and Colorado passed legislation requiring coverage of medical care delivered through telemedicine. Arkansas' legislation also clarified the steps by which physicians can establish a relationship with a new patient via telemedicine. Legislation passed in Virginia will allow physicians to prescribe controlled substances based on an exam conducted through telemedicine, so long as certain clinical standards are met. Finally, states including Arizona, Hawaii, Indiana, Michigan, Montana, North Dakota, Oklahoma, Utah, Washington, West Virginia and Wyoming have passed telemedicine legislation through at least one chamber.
The AMA is working with these and other state medical associations as part of a state telemedicine advocacy campaign that provides advocacy materials focused on the various telemedicine issues above. Advocates can contact Kristin Schleiter of the AMA for more information.
In a recent survey, three out of five physicians in Ohio treating patients with substance-use disorders said that they have experienced administrative interference from private insurers and Medicaid.
The AMA and Ohio State Medical Association (OSMA) conducted the survey earlier this year to gain a better understanding of the barriers patients and physicians face when attempting to access treatment for substance use disorders. 47 of 165 physicians responding said that they treat patients with a substance use disorder (28 percent).
The summary findings also included:
- Administrative barriers, such as prior authorization, limit patients' access to care.
- Physicians who treat patients with a substance-use disorder commonly recommend or prescribe multimodal care, including mental health care.
- A lack of coverage and high cost are burdens for patients to access treatment for substance use disorders.
- It is difficult for many physicians who do not treat substance-use disorders to find another provider who does.
The full survey results are available upon request, and medical societies interested in conducting this survey in their state should contact Daniel Blaney-Koen of the AMA.Alabama medical board issues new opioid prescribing rule, CME mandate
The Alabama State Board of Medical Examiners recently issued new "Risk and Abuse Mitigation Strategies by Prescribing Physicians." The new rule, which took effect March 9, set forth several requirements concerning mandatory use of the state prescription drug monitoring program (PDMP) that correspond to the total morphine milligram equivalency (MME) prescribed to a patient.
Among the requirements:
- For controlled substance prescriptions totaling 30 MME or less per day, physicians are expected to use the PDMP in a manner consistent with good clinical practice.
- When prescribing a patient controlled substances of more than 30 MME per day, physicians shall review that patient's prescribing history through the PDMP at least two times per year, and each physician is responsible for documenting the use of risk and abuse mitigation strategies in the patient's medical record.
- Physicians shall query the PDMP to review a patient's prescribing history every time a prescription for more than 90 MME per day is written, on the same day the prescription is written.
The PDMP requirements do not apply to physicians writing controlled substance prescriptions for:
- Nursing home patients.
- Hospice patients, where the prescription indicates hospice on the physical prescription.
- When treating a patient for active, malignant pain.
- Intra-operative patient care.
The board also will require, effective Jan. 1, 2018, that each holder of an Alabama Controlled Substances Certificate shall acquire two credits of continuing medical education (CME) in controlled substance prescribing every two years as part of the licensee's yearly CME requirement. The controlled substance prescribing education shall include instruction on controlled substance prescribing practices, recognizing signs of the abuse or misuse of controlled substances, or controlled substance prescribing for chronic pain management.
A detailed FAQ is available here.
Other NewsChallenges and solutions explored at recent alternative payment model workshop
On March 20, more than 150 attendees from specialty and state medical societies participated in an AMA workshop led by AMA President-elect David Barbe, MD, MHA, to learn about and develop solutions to challenging issues in the design and implementation of alternative payment models (APM). Participants included physicians from more than 40 specialties who are on the cutting edge of APM design and implementation, including several who submitted the first proposals to the federal physician-focused APM advisory committee.
The workshop included an energetic discussion with Harold Miller from the Center for Healthcare Quality and Payment Reform about how APMs can support more accurate diagnosis and provide support for services that are not separately payable under fee-for-service. Frank Opelka, MD, from the American College of Surgeons and his colleagues from Brandeis University led a lively discussion of their work to develop APMs for hundreds of different episodes. The AMA's Kathleen Blake, MD, facilitated a discussion of key issues in implementing APMs, such as clinical and cost data needs, quality registries, coding and practice recruitment.
A highlight of the workshop was a dynamic question-and-answer session with Patrick Conway, MD, deputy administrator, innovation and quality, and director, Center for Medicare and Medicaid Innovation, CMS.. The AMA plans to develop a report based on the workshop outlining the challenges facing physician-focused APMs and the solutions offered by the workshop participants. Learn more about APMs by listening to a new podcast from the AMA, "What are physician-focused payment models?" and visiting the AMA's APM website.
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.