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Sept. 7, 2017

Issue Spotlight

"Dreamers" bolster physician workforce, should be allowed to stay

To help alleviate the physician shortage and improve access to care, Congress should move quickly to enact legislation that would allow those granted Deferred Action for Childhood Arrivals (DACA) status—often dubbed "dreamers"—to live and work legally in the U.S. An estimated 5,400 previously ineligible physicians could be introduced into the U.S. health system over the coming decades through a DACA-like legislative fix.

That estimate was cited in a letter to Congressional leaders by AMA Executive Vice President and CEO James L. Madara, MD. He noted there is already a shortage of 8,200 primary care physicians—according to the Health Resources and Services Administration—and that the Association of American Medical Colleges has projected the total physician shortage could grow to as many as 94,700 doctors by 2025.

"Removing those with DACA status will particularly create care shortages for rural and other underserved areas," Dr. Madara wrote. "DACA physicians are more likely to work in high-need areas where communities face challenges in recruiting other physicians. DACA students are also more likely to be bilingual, to come from diverse cultural backgrounds, and to understand challenges in certain ethnic communities. Without these physicians, the AMA is concerned that the quality of care provided in these communities will be negatively impacted and that patient access to care will suffer."

More than 100 students with DACA status applied to U.S. allopathic medical schools last year, he noted.

"Those who enrolled will now face uncertainty about completing their degrees, paying their student loans, and serving patients. Furthermore, if DACA residents are unable to complete their training, which typically spans three to six years after medical school, this could potentially waste graduate medical education funds, leave training slots unfilled, and generally exacerbate the physician shortage our country is facing, especially for our most vulnerable patients," Dr. Madara wrote. "The AMA believes that these DACA recipients should be able to continue to study, work and improve patient access to care without the fear and uncertainty of being deported before their training is completed."

Read more at AMA Wire®.

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National Update

AMA urges HHS Office of Civil Rights to retain sex-nondiscrimination policies

Following reports that the Trump administration may be revising its sex non-discrimination policies, the AMA has urged the HHS Office of Civil Rights (OCR) to retain its current policy of interpreting sex discrimination to include discrimination based on gender identity and sex stereotypes. In a letter to OCR Director Roger Severino, the AMA wrote that it opposes any discrimination based on an individual's sex, sexual orientation, gender identity, race, religion, disability, ethnic origin, national origin or age. AMA policy also supports public and private health insurance coverage for treatment of gender dysphoria as recommended by the patient's physician.

Section 1557 makes it unlawful for any health care provider who receives funding from the federal government to refuse to treat an individual—or to otherwise discriminate against the individual—based on race, color, national origin, sex, age or disability. The OCR has long interpreted Section 1557's sex-discrimination prohibition to extend to claims of discrimination based on gender identity or sex stereotypes and accepted such complaints for investigation. These protections assist some of the populations that have been most vulnerable to discrimination, such as lesbian, gay, bisexual and transgender individuals and those suffering from mental illness, including substance-use disorders, and help provide those populations equal access to health care and health coverage.

Of note, Section 1557 does not force physicians to violate their medical judgment. Rather, covered entities—including insurers—must apply the same neutral, nondiscriminatory criteria used for other conditions when the coverage determination is related to gender transition. The AMA urged OCR to seek input from stakeholders about whether informal guidance may help to clarify misunderstandings of the existing rule.

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State Update

New opioid-related education and treatment resources from ACS, ACOEM

The American College of Surgeons (ACS) and American College of Occupational and Environmental Medicine (ACOEM) have released new resources to help their members reverse the nation's opioid epidemic.

Published in the Bulletin of the American College of Surgeons, "The opioid epidemic: What can surgeons do about it?" provides a range of recommendations for surgeons that focus on preoperative management, inpatient management, outpatient management and health system strategies. The article highlights that surgeons "must be aware of the existing resources to help curb opioid overuse. Current mechanisms for monitoring, counseling and treating patients across the continuum of care can help minimize risk to our patients and our communities."

The ACOEM released a sample opioid treatment agreement that includes information about the risks and benefits of opioids as well as a detailed table for potential adverse opioid effects. The sample agreement identifies responsibilities for both the patient and the physician, including that the patient must agree that opioids are only one part of his or her treatment program. In addition, the sample agreement explains the necessity for safe storage of opioid medications, conditions for drug testing, and communication with other health care professionals.

The new ACS and ACOEM resources also are available on the AMA opioid microsite.

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Judicial Update

Tort reforms facing legal challenges in three states

In contrast with the federal government—where a House-passed medical liability reform bill languishes in the Senate—many states have found success enacting tort reforms that better serve patients and physicians. But court cases are challenging reforms in place in at least three states.

In Maryland and Michigan, plaintiffs' attorneys are using what is described as "artful pleading" to skirt pre-trial measures that assess the merits of a complaint and its worthiness for going to court. And in Kentucky, a suit has challenged the constitutionality of its new law authorizing medical review boards to assess the merits of a complaint.

The Litigation Center of the American Medical Association has filed amicus briefs in the Maryland and Michigan cases in which patients sued for injuries incurred after falling. By claiming ordinary negligence instead of medical malpractice, the plaintiffs bypassed review processes.

The cases have gone through the trial and appellate courts and are now before the high court in both states.

Read more at AMA Wire.

Suit seeks full VA coverage of transgender vets' gender dysphoria

President Donald Trump last month directed the Pentagon to stop recruiting openly transgender people to serve in the military, and Defense Secretary James Mattis today said he will appoint an expert panel to determine whether to allow trans members currently enlisted to continue their service. Already, the American Civil Liberties Union has filed a lawsuit challenging the president's memorandum on equal-protection and substantive due process grounds.

After the president initially tweeted his intention to ban transgender individuals from serving in the military, the AMA issued a statement saying "there is no medically valid reason" for such action.

Similarly, the AMA has joined an amicus brief with several other health care-related organizations in support of transgender veterans seeking a rule change that would amend or repeal the U.S. Department of Veterans Affairs (VA) policy of not covering sex-reassignment surgery (SRS) for veterans with gender dysphoria.

"AMA policy also supports public and private health insurance coverage for treatment of gender dysphoria as recommended by the patient's physician," AMA President David O. Barbe, MD, said in the Association's response to the president's tweets. "According to the Rand study on the impact of transgender individuals in the military, the financial cost is a rounding error in the defense budget and should not be used as an excuse to deny patriotic Americans an opportunity to serve their country. We should be honoring their service—not trying to end it." 

Another AMA policy affirms that "transgender service members be provided care as determined by patient and physician according to the same medical standards that apply to non-transgender personnel." Together, these policies were included in the amicus brief the AMA joined in the case seeking the VA rule change.

The plaintiffs in the case are transgender veterans Dee Fulcher, a former Marine sergeant, and Giuliano Silva, a former member of the Army, and the Transgender American Veterans Association (TAVA), an organization formed in 2003 that now has some 2,200 members.

Read more at AMA Wire.

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Other News

AMA webinar features expert advice on treatment for opioid-use disorder

The AMA will hold a national webinar next week to emphasize the physician's role in treating opioid-use disorder. Sarah E. Wakeman, MD, medical director of the Substance Use Disorder Initiative and the Addiction Consult Team at Massachusetts General Hospital, will explain the basis of opioid-use disorder and the key attributes of successful treatment. She also will provide examples of how interventions can be applied at various points of patient engagement, and within different clinical practice settings.

The free webinar, funded by a grant from the Provider's Clinical Support System for Opioid Therapies, will take place Sept. 13, noon–1 p.m. CDT. Register.

Inspector general issues ACO report

On Aug. 29, the HHS Office of Inspector General (OIG) issued a report on cost savings and quality of care in Medicare accountable care organizations (ACOs). The report describes findings from an OIG study of all Medicare Shared Savings Program ACOs that participated during the first three years of the program, from 2013 through 2015. The OIG analyzed complex sets of data to provide new information on key areas of spending, utilization of services, quality, composition of ACO participating physicians, and physician-to-patient ratios.

The study found that during the three-year period, a total of 428 Medicare ACOs provided services to 9.7 million patients, with ACO penetration exceeding 40 percent of Medicare fee-for-service beneficiaries in some states. Although most ACOs were able to reduce Medicare spending, only one-third of ACOs reduced spending enough to receive a share of the savings.  Savings from the program were calculated by the OIG to total $1 billion, yet because $1.3 billion was paid to ACOs as shared savings payments, the Medicare program did not actually realize savings.

Performance was very uneven, as half of the total savings achieved, $1.7 billion, was generated by 36 ACOs, and half of the spending that exceeded ACO benchmarks, $1.2 billion, was generated by 38 ACOs. The OIG found that ACO performance on most quality measures improved over time and that ACOs achieved more savings in year three than in year one. At the same time, it is notable that the OIG analyses showed that average per-beneficiary spending for Medicare ACOs is significantly higher than the national average in fee-for-service Medicare. In conclusion, the OIG states that high-performing ACOs are worth a close look to understand the strategies they are employing.

CMS will host call to outline 2016 PQRS results and informal review process

On Sept. 26, 1:30–3 p.m. EDT, the Centers for Medicare & Medicaid Services (CMS) will host a call to discuss and outline the 2016 Physician Quality Reporting System (PQRS) Feedback Reports and Informal Review process. The final data-submission timeframe for reporting 2016 PQRS data to avoid the 2018 PQRS downward payment adjustment was January through March 2017.

Due to AMA and Federation advocacy efforts, CMS has proposed in the 2018 Physician Fee Schedule Proposed Rule to reduce the 2016 PQRS requirements to align with the 2017 Merit-based Incentive Payment System (MIPS) quality category requirements. If finalized, the 2016 PQRS reporting requirements will be based off of six quality measures, as opposed to nine measures, and the domain and cross-cutting measure requirements will be eliminated. The AMA believes the reduced PQRS-reporting requirements will better ensure physician success with avoiding a 2018 PQRS penalty.

Keep in mind, 2016 was the last year of the PQRS program and any payment adjustment a physician may receive in 2018 is related to PQRS, not MIPS. The first MIPS performance period is Jan. 1, 2017, through Dec. 31, 2017. For more information on MIPS, visit the CMS Quality Payment Program website or the AMA's Quality Payment Program tools.

To find out more about the call and to register, visit the CMS website.

Learn more about Physician Compare in an upcoming webinar

On Sept. 28, 1:30–3 p.m. EDT, CMS will host a webinar to discuss the upcoming 30-day Physician Compare preview period on 2016 Physician Quality Reporting System (PQRS) performance data for release in December 2017. On the call, CMS will outline how a physician and practice can review their 2016 performance information and contest any inaccuracies with their data before it is published.

CMS will also discuss the future of public reporting on the call. Given that 2016 is the final year for PQRS, the AMA continues to urge CMS not to move forward with expanding Physician Compare. Instead, the AMA believes that CMS and physicians' efforts would be better spent focusing on how to best present future MIPS data so it accurately reflects physicians' performance. Consistent with other years, CMS will only publicly post PQRS data if a physician or practice successfully participated in PQRS.

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Upcoming Events

Through Sept. 15:
Join key stakeholders to discuss topics such as usability and optimization, share best practices, and learn from each other in the digital community discussion, "Electronic Health Records: Impact, Optimization, and Usability." Held as part of the AMA Running Your Practice Community, the discussion will include insights from a number of panelists:

Sept. 12:
On Sept. 12, noon CDT, the AMA will host "How to Position Yourself as a Physician Leader" (1.0 AMA PRA Category 1 Credits™), a timely and empowering webinar for women physicians. Despite the increasing number of women in medicine, women physicians continue to hold a smaller proportion of leadership positions. Author, researcher and educator Vineet Arora, MD, will share strategies on how women physicians can better position themselves as leaders. Dr. Arora will discuss highly relevant topics including contract and salary negotiations, and career advancement strategies. Registration is open until Sept. 10.

Sept. 13:
Both HIPAA and the Advancing Care Information (ACI) component of the Quality Payment Program under MACRA require physicians to protect their patient information by conducting a security-risk analysis. In fact, physicians cannot score any points in the ACI category if their security risk analysis is insufficient. This task can be complex, but a clear understanding of the security risk analysis components can help make the process more manageable. In this one-hour webinar, "AMA SAN QPP/MIPS/ACI Webinar—Security Risk Analysis," held from 1–2 p.m. EDT, attendees will learn about the security-risk analysis process under HIPAA and how to scope a quality improvement project to achieve success. Laura G. Hoffman, JD, will be the presenter. Register.

Oct. 27–29:
Apply by Sept. 8 to attend the Candidate Campaign School and become an advocacy expert at the AMA office in Washington, D.C. The school is geared toward AMA members, their spouses, residents, medical students and medical society staff who want to become more involved in the campaign process. Faculty, materials and meals are covered by AMPAC. Participants are responsible for the registration fee ($350 for AMA Members / $1000 for non-members), airfare and hotel accommodations. Learn more or apply, or email politicaleducation@ama-assn.org for more information.

Nov. 29:
Without an understanding of what is really driving poor quality or performance, it is difficult to improve. Root-cause analysis is a critical tool in the quality-improvement tool box that allows professionals to understand what's at the heart of the problem, and then develop improvement ideas that can make a difference. How can you improve if you do not understand the challenge and the contributing factors?

In this one-hour webinar, "AMA SAN Quality Improvement Webinar—Root-cause analysis: Digging deep to improve," held from 1–2 p.m. EDT, Physician Consortium for Performance Improvement Director of Quality Improvement Stephen L. Davidow will cover three common forms of root-cause analysis. He also will discuss the advantages of applying these methods to different circumstances and environments, and how root-cause analysis is used as the basis for creating and implementing ideas that lead to robust improvement. Register.

Jan. 4–6, 2018:
The AMA State Legislative Strategy Conference takes place at the Sanibel Harbour Marriott Resort and Spa near Fort Myers Beach in Florida. Email events@ama-assn.org for more details.

Feb. 12–14, 2018:
The AMA National Advocacy Conference will be held in Washington, D.C. at the Grand Hyatt Washington. Email events@ama-assn.org for more details.

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