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Feb. 22, 2018

Issue Spotlight

Action to address gun violence is long overdue

Last week in Parkland, Florida, 17 students and teachers were murdered. Yet another mass killing. More than a dozen others were seriously injured. The pervasiveness of gun violence and the weapons used in these crimes have changed the way we live. In movie theaters, places of worship, offices, restaurants, night clubs and schools, people today make clear note of escape routes. Schools, including the one attacked yesterday, regularly practice for active shooter situations.

And in emergency departments and trauma centers, we struggle with much more complicated, dangerous injuries inflicted by lethal ammunition fired by military-grade weapons.

At the 2016 AMA Annual Meeting, which began the day after the deadly shooting at the Pulse Nightclub in Orlando, physicians from across the country and at every stage in their career spoke about treating gunshot victims and the scale of violence we are experiencing today. Their stories resonate as much today as they did nearly two years ago.

Gun violence in America today is a public health crisis, one that requires a comprehensive and far-reaching solution. That is the determination of the AMA House of Delegates. With more than 30,000 American men, women and children dying from gun violence and firearm-related accidents each year, the time to act is now.

Today, more than ever before, America's physicians must lend their voice and their considerable political muscle to force lawmakers to examine this urgent health crisis—through federally funded research—and take appropriate steps to address it. We are not talking about Second Amendment rights or restricting your ability to own a firearm. 

We are talking about a public health crisis that our Congress has failed to address. This must end.

Read more at AMA Wire®.

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National Update

Energy and Commerce Committee advances Good Samaritan legislation

On Feb. 14, the House Energy and Commerce Committee unanimously voted to advance H.R. 1876, the Good Samaritan Health Professionals Act of 2018. The AMA strongly supports this bipartisan legislation. The bill, introduced by Reps. Marsha Blackburn (R-TN), Dutch Ruppersberger (D-MD), Ami Bera, MD (D-CA), Phil Roe, MD (R-TN), Larry Bucshon, MD (R-IN), and David Scott (D-GA), would limit the civil liability of volunteer health professionals who provide their services to disaster victims during a federally declared disaster.

The current patchwork of federal and state laws to encourage medical volunteerism during emergencies is inconsistent and often unclear, especially when applied to large-scale disasters that may cross state lines. This has resulted in qualified health care volunteers being turned away during disasters, such as 9/11 and Hurricane Katrina, due to liability concerns, hampering efforts to provide needed care to disaster victims. H.R. 1867 would ensure volunteer health care providers receive clear federal Good Samaritan protection when surges from private citizens are needed.

It is not yet known when the full House of Representatives will consider the measure. Senators Bill Cassidy (R-LA), Angus King (I-ME), and Joe Manchin (D-WV) have introduced the Senate companion bill, S. 781.

Senate Finance Committee seeks stakeholder input on opioid abuse

The AMA sent a letter to Senate Finance Committee Chairman Orrin Hatch (R-UT) and Ranking Member Ron Wyden (D-OR) on Feb. 16, in response to their Feb. 2 letter requesting recommendations in the Committee's jurisdiction to address the opioid epidemic. While there is more work to be done, the letter highlighted that the medical profession's collective efforts are having an impact, with opioid prescriptions in the United States decreasing by 43 million—a nearly 17 percent decrease nationally—from 2013 to 2016. Federal payment and delivery system reforms provide opportunities to better support clinicians' efforts.

The AMA's recommendations to the Committee include:

New electronic clinical quality measure on potential opioid overuse cause for concern

The Centers for Medicare and Medicaid Services (CMS) contracted with Mathematica Policy Research to develop a new electronic clinical quality measure (eCQM) on potential opioid overuse. The agency recently sought comments on the measure, which focuses on the percentage of patients aged 18 years or older who receive opioid therapy for 90 days or longer, and who are prescribed a 90 milligram or greater morphine milligram equivalent (MME) daily dose.

In its comments to CMS, the AMA highlighted that quality measures pertaining to opioid use should focus on how well patient pain is controlled, whether functional improvement goals are met, and what therapies are being used to manage pain. When pain can be well controlled and function improved without high doses of opioids over a long period of time, there is a good indication of high-quality patient care. However, focusing on reducing opioid doses alone, such as opioid prescriptions that exceed 90 or more MME per day, is not an appropriate goal. Daily dose amounts may serve an indicator of whether a patient is at risk of overdose and should be co-prescribed naloxone, but do not signal that a physician provides poor quality care.

In addition, the letter highlighted that calculated MMEs may vary between tools for certain opioids, depending on the algorithm used. These calculations also fail to account for individual patient characteristics and the great potential for patients not receiving necessary care. Furthermore, the AMA highlighted its concern about the feasibility of directly calculating the measure from the electronic health record (EHR) because the measure relies on a function that is not consistently supported by EHR vendors. The AMA will monitor progress on the measure and continue to advocate for changes based on its disagreement over the fundamental premise of the measure.

RACs now required to reimburse physicians for the cost of pulling medical records

In a policy reversal, the Centers for Medicare and Medicaid Services (CMS) directed the Recovery Audit Contractors (RAC) to reimburse physicians for the cost of printing and mailing medical record documentation. CMS indicated that it is working on a change to the Program Integrity Manual (PIM) language to reflect this new policy.

This is how one RAC contractor explained the change in a question and answer on its website:
"Per CMS and the PIM guidelines, institutional providers will receive 0.12 cents per page + 1st class postage and non-PPS providers receive 0.15 cents per page + 1st class postage. An additional $2 is added for esMD submissions in lieu of postage. The maximum payment to a provider per medical record shall not exceed $25. Performant."

The AMA has long sought this policy change and continues to advocate that other CMS contractors reimburse physicians for the cost of pulling medical records.

New proposed RAC review topics posted to CMS website

The Centers for Medicare and Medicaid Services (CMS) has posted nine proposed Recovery Audit Contractor (RAC) Review Topics to its website. This was the result of a recommendation made by the AMA and medical specialty societies to provide feedback on possible RAC review. Medical societies and physicians now get to provide input before CMS approves a topic as appropriate for the RACs to audit.

Below are the titles of the nine proposed RAC review topics:

The proposed topics were posted to the CMS website at the following URL on Feb. 14 and will be available for comment for 30 days. After 30 days, CMS will evaluate whether to allow the RACs to proceed with the audits. If CMS approves the topics, the RAC(s) will post them to their respective RAC websites for an additional 14 days, prior to beginning the reviews.

AMA suggests areas of study to improve CMS's readmission reduction program

The AMA recently sent a letter to CMS recommending further study of the Hospital Readmission Reduction Program (HRRP) in order to improve the program. The letter was sent in response to an article recently published in the JAMA Cardiology in which the authors described an association between implementation of the Centers for Medicare and Medicaid Services (CMS) HRRP and an increase in mortality for fee-for service Medicare beneficiaries discharged after a heart failure admission.

To better understand the significance of the authors' findings within the larger body of literature on readmissions, and out of concern that a government-sponsored program might be leading to negative unintended consequences, the AMA performed a literature search to evaluate whether the article's conclusions could be replicated. Because the published literature uses inconsistent data sources and varying versions of the CMS readmission measures, the results of the AMA's literature search to confirm the study's findings were inconclusive. However, the results did raise additional questions that the AMA urged CMS to review and study. The AMA will continue to monitor the HRRP and advocate for changes in the program so the healthcare system, including physicians and providers, have better tools for discriminating between necessary or unnecessary admissions.

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State Update

Aetna's prior authorization program under scrutiny

Last week, CNN published a story, shining light on Aetna's problematic utilization management programs. The story highlights courtroom testimony from a former Aetna medical director in California in which he states that he never reviewed medical records when deciding whether to authorize or deny care. California Insurance Commissioner David Jones, as well as the California Department of Managed Health Care, launched an immediate investigation into Aetna's practices and has been followed by Insurance Commissioners in Colorado, Connecticut and Washington. 

Insurers' prior authorization and other utilization management programs continue to be the major barriers to care for patients and major administrative burdens to physicians. Reported negative clinical impacts, patient care delays, and interference with clinical expertise reflect the daily experiences of both patients and physicians navigating health insurers' prior authorization systems.

As illustrated by the CNN reporting, companies are increasingly determining the course of treatment, even though physicians have the clinical expertise, years of training, and first-hand knowledge of the patient necessary to recommend the most appropriate care in each individual case. The AMA has a number of resources available to medical societies interested in addressing prior authorization and other utilization management programs, including principles, model legislation, survey data, and videos on electronic prior authorization. 

Additionally, a recently released consensus statement developed by the AMA, AHA, AHIP, APhA, BCBSA, and MGMA on improving the prior authorization process is available to you to help in your prior authorization efforts. 

MAT helps reduce post-incarceration fatal opioid-related overdoses

A statewide substance use disorder treatment program in Rhode Island focused on people released from prison was a driving factor in reducing opioid-related mortality across the state, according to a new study in JAMA Psychiatry.

The program emphasized screening individuals for opioid use disorder and initiating them on or maintaining their medication assisted treatment (MAT—including methadone, buprenorphine or naltrexone) regimen throughout incarceration. Upon release, the Rhode Island Department of Corrections worked to connect patients to the established community-located Centers of Excellence in MAT to help ensure continuity of care.

The results of the study found a decrease in overdose deaths from 26 of 179 individuals released from Jan. 1 to June 30, 2016, to 9 of 157 individuals from Jan. 1 to June 30, 2017—a 60 percent reduction in mortality.

"We have known for a long time that MAT works and that people leaving the incarcerated setting are at extremely high risk for fatal overdose," said Josiah "Jody" Rich, MD, MPH, Professor of Medicine and Epidemiology at Brown University and one of the authors of the study. "We now know that, even in the face of a devastating fentanyl-laced epidemic, that prompt implementation of MAT can lead to a dramatic drop in overdose deaths. Communities concerned about fatal overdose in their population now have an effective strategy to pursue- implement comprehensive screening, initiation of MAT with linkage to effective community treatment programs for people passing through correctional facilities."

"Focusing on incarceration and the overdose risk post-incarceration reduces the harm of the life-altering social consequences of incarceration while treating a health condition that is clearly responsive to effective treatment," said Traci C. Green, PhD, MSc, Department of Emergency Medicine, Brown University, and the study's lead author. "This approach is an investment that works, saves lives, and reduces overdose in the community." 

The Rhode Island Medical Society noted that the program is one of several innovative approaches in the state that has been developed with Governor Gina Raimondo's Overdose Prevention and Intervention Task Force that includes RIMS and many other stakeholders.

The AMA strongly supports increased access to post-incarceration MAT and advocates for "correctional facilities to increase access to evidence-based treatment of opioid use disorder, including initiation and continuation of [MAT] in conjunction with counseling, in correctional facilities within the United States and that this apply to all incarcerated individuals including pregnant women." Visit the AMA's End the Opioid Epidemic microsite to learn more.

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Other News

10 key issues where physicians can help move medicine in 2018

A recent article in AMA Wire by AMA President David O. Barbe, MD, MHA, highlights 10 key issues included in the AMA's agenda for 2018, including protecting and expanding access to coverage, targeting inefficient prior authorization policies, and encouraging transparency in pharmaceutical pricing.

Dr. Barbe also discusses these issues in a new video series available on the AMA website.

New podcasts help physicians navigate the Quality Payment Program in 2018

Physicians can stay up to date with the latest developments in the Centers for Medicare and Medicaid (CMS) Quality Payment Program (QPP) by listening to new podcasts in the AMA series on ReachMD, "Inside Medicare's New Payment System."

These 15-minute podcasts are now available to download and listen to on demand:

Transcripts are also available. Stay tuned for additional podcasts coming soon, and visit the AMA website for additional resources on the QPP.

To succeed as a physician advocate, share your story

Today's political climate may be unlike anything the seasoned physician advocates who gathered in Washington, D.C., for the recent AMA National Advocacy Conference have ever experienced. But the fundamentals of promoting the interests of their patients and profession remain the same: Use facts and personal stories while building relationships and serving as a resource.

Read more at AMA Wire.

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Upcoming Events

Feb. 26:
The Center for Medicare & Medicaid Innovation (CMMI) recently announced the administration's first new Medicare alternative payment model, Bundled Payments for Care Improvement Advanced, a voluntary model that includes 32 clinical episodes. The AMA is hosting a free 1-hour webinar on the model from 8:00 to 9:00 p.m. Eastern time, featuring CMMI's Dr. Steven Farmer, who is a cardiologist, senior advisor and medical officer. Applications to participate in the model are due two weeks after the webinar. Click here to register and click here for more information about the model.

Through Feb. 28:
Join this digital community discussion, "IMG Visa Discussion Series: Part II, During Residency," to learn more about what type of visa you need before, during, and after residency. Part two of this IMG Visa Discussion Series will focus on visa issues after you have been accepted into a residency program, including a basic review of the J-1 and H-1B sponsored visas and what you and your family can and cannot do while on these specific visas. This overview will prepare you for your residency program visa compliance requirements, renewals, change of status and traveling guidelines.

March 28:
Recognizing that practice transformation is a journey of many steps, the AMA has developed a webinar miniseries, "Reinventing medical practice: A step-wise approach." The overall series is intended to help practices meet their aims and understand the drivers of practice transformation, as supported by a portfolio of helpful resources from both the AMA, as well as other partners.

This webinar, held at 1:00 p.m. Eastern time, will also include an overview of the future webinar topics and what changes can be made to transform your clinical practice. Ashley Cummings, MBA, CRCR, Project Administrator, and Meghan Kwiatkowski, MAIO, Senior Practice Transformation Advisor, will be presenting. Register here.

April 2:
Physicians and practice staff are invited to join the AMA and HITRUST at a cybersecurity workshop on April 2 from 6:00 to 8:30 p.m. Eastern time in Cleveland, Ohio. Dinner will be provided. Learn more and register today.

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