March 8, 2018

Issue Spotlight

AMA, Anthem try new tack: Working together to improve health care

The AMA and Anthem announced last week they are working together to figure out mutually agreeable ways to improve patients' access to health care that is timely, high quality and affordable. This year, the AMA and Anthem—whose health plans cover more than 40 million people—will pursue collaboration in four key areas to:

"Physicians caring for patients across the country have many ideas about how we can reduce health care costs and administrative burdens while improving clinical outcomes, and collaboration with  Anthem and other  health plans can produce wins for patients, physicians and payers.," AMA Board Chair Gerald E. Harmon, MD, said. "The AMA looks forward to finding common ground on ways to improve the delivery of affordable, high-quality, patient-centered care."

Anthem Chief Clinical Officer Craig Samitt, MD, said collaboration between physicians and payers "is critical in order to evolve and advance our health care system to one that is simpler, more accessible and more affordable for our consumers."

This collaboration signals a new type of dialogue and engagement between insurers and physicians. In a letter to the AMA last week, Anthem's Dr. Samitt announced the insurer's decision to not proceed with a planned cut in payments for significant, separately identifiable evaluation-and-management (E/M) services billed with a Current Procedural Terminology modifier 25 that are provided on the same day as a procedure or a wellness exam. This policy was set to take effect March 1, but Anthem reconsidered following strong advocacy efforts by the AMA and other physician organizations.

Of note, Dr. Samitt's letter also expressed a commitment to continuing work with the AMA, state medical associations and national medical specialty societies to address physician concerns with other policies and guidelines. Organized medicine has raised concerns regarding Anthem's policies on the retrospective denial of payment for emergency department visits, restrictions on advanced imaging in hospital outpatient facilities and the denial of payment for monitored anesthesia care or general anesthesia for cataract surgery.

Read more at AMA Wire®.

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National Update

Congress should closely scrutinize proposed CVS-Aetna merger

The AMA last week asked Congress to closely scrutinize the massive proposed merger of CVS Health and Aetna because of the potential negative impact it poses to American health care consumers. The AMA submitted a statement to the House Judiciary Subcommittee on Regulatory Reform, Commercial and Antitrust Law in anticipation of a Feb. 27 hearing entitled "Competition in the Pharmaceutical Supply Chain: The Proposed Merger of CVS Health and Aetna."

The statement expresses the AMA's concerns that the proposed merger has the potential to worsen competition (or reduce hopes for amelioration) in three poorly performing markets: pharmacy benefit manager (PBM) services; local health insurance markets; and many local retail pharmacy markets.

Since CVS-Aetna announced the deal in early December, the AMA has been proactively analyzing the merger. Unlike health insurance mergers, which involve merging of competitors, the CVS-Aetna merger is largely a merger of non-competitors, i.e., a "vertical merger." It is much harder to analyze and predict the anticompetitive effect of a vertical merger than a horizontal merger. The merger itself is in its early stages, and the AMA will continue to evaluate the merger's likely effect on competition in health insurance, PBM, and retail pharmacy markets, as well as the impact that the merger might have on physician practices and patient care.

In its investigation and review of the proposed CVS-Aetna merger, the AMA is following the same evidence-based, joint AMA-Federation model that proved so effective in opposing the Anthem-Cigna and Aetna-Humana mergers. Evidence-based merger advocacy is essential for the AMA  to protect and build on the well-earned reputation for credibility that it achieved when opposing the health insurer mega-mergers. 

The AMA has already built a coalition of all state medical associations in markets that might be affected by the CVS-Aetna merger, as well as interested national medical specialty societies. The AMA is also reaching out to nationally known health economists and other antitrust experts, and communicating with other potential advocacy allies. The AMA will continue to work with these medical societies, experts and allies to maximize ways to persuade state regulators to closely scrutinize the CVS-Aetna merger and make available to the AMA and Federation as much merger data as possible via public hearings and other public proceedings.

Health groups call for action on firearm violence prevention

The AMA joined 74 other national medical, health, public health, and research organizations in letters sent to the House and Senate on Feb. 22, urging Congress to find a bipartisan path toward enacting commonsense solutions to the public health threat of firearm-related injuries and fatalities. In particular, the organizations recommended strengthening firearm background-check systems and supporting public health surveillance. Research is needed to build the evidence base on the causes of firearm violence and on the effectiveness of intervention and prevention strategies.

AMA raises concerns about proposed association health plans

The AMA provided comments on the Department of Labor's (DOL) proposed rule regarding Association Health Plans (AHP) that stemmed from President Trump's Executive Order on Promoting Healthcare Choice and Competition Across the United States.  The AMA supports efforts to maximize health plan choices for individuals and small businesses seeking coverage in the individual and small group markets.  However, the AMA opposed the expansion of AHPs as defined by and outlined in the proposed rule.  The AMA urged DOL to withdraw the proposed rule and work with state insurance commissioners and health care stakeholders to seek a solution that would expand affordable insurance coverage options through AHPs without undermining state authority to regulated AHPs to protect patients and physicians against such things as fraud and insurer solvency.

The AMA also warned that without proper oversight to account for insolvency and fraud, AHPs have the potential to increase already-high insurance premiums and overall health care costs, while threatening patients' health and financial security and the financial stability of physician practices.  AMA recommended that DOL take the following steps to prevent potential insolvent and fraudulent AHPs:

AMA submits letter on Medicare Advantage risk adjustment model changes

On March 1, the AMA submitted a letter to the Centers for Medicare and Medicaid Services (CMS) on the Advanced Notice of Methodological Changes for CY 2019 for the Medicare Advantage CMS-Hierarchal Condition Categories (HCC) Risk Adjustment Model Notification. 

The AMA has consistently expressed to CMS that a key element of success of the Medicare Advantage program is ensuring that payments to plans reflect the relative risk of beneficiaries who enroll. Therefore, the AMA supported many of the improvements to the risk adjustment methodology proposed by CMS.  However, the AMA also cautioned CMS to ensure that any improved risk adjustment methodology does not increase physician reporting burden in the Medicare Advantage program. The AMA will continue to work with CMS to make improvements to risk adjustment methodology in the Medicare Advantage and other Medicare programs going forward.

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State Update

Bills would up access to medication-assisted treatment for opioid-use disorder

The AMA, California Medical Association (CMA) and Vermont Medical Society (VMS) are supporting bills that would increase access to medication-assisted treatment (MAT) and remove barriers to care for patients with substance use disorders throughout the state.

California Assembly Bill 2384 would remove administrative barriers—such as prior authorization and step therapy—for MAT as well as ensuring that formularies used by health insurance companies and public payers include all forms of MAT. It also would:

"The CMA is committed to helping patients obtain timely treatment for opioid use disorder, which can immediately save lives," said CMA President Theodore M. Mazer, M.D. "California is leading the country in reducing overdose deaths from prescription opioids, and we must now seize the chance to lead in providing critical Medication Assisted Therapy (MAT), as well as non-medication services to assist recovery. By removing barriers to some of the most effective and innovative treatment of substance use disorders, AB 2384 will continue California's commitment to reverse the opioid epidemic while addressing real needs of patients with chronic or acute pain."

"A.B. 2384 will unquestionably help save many lives," said James L. Madara, MD, AMA Executive Vice President and CEO in a letter to the bill's sponsor, California Assemblyman Joaquin Arambula, MD.

The AMA also is supporting Vermont Senate Bill 166 (scroll to page 51), which would increase access to MAT for those who are incarcerated, including helping identify those with an opioid use disorder, and ensuring that a person currently receiving medication assisted treatment (MAT) remains on MAT; or that a person who has an opioid use disorder can begin treatment with MAT when entering jail or prison.

"The AMA and VMS are particularly pleased to see that Vermont will further enhance its nationally-recognized 'hub and spoke' model for increasing access to treatment for opioid use disorder by working collaboratively with the health care community and opioid treatment programs throughout the state," wrote Dr. Madara and Trey Dobson, M.D., President, Vermont Medical Society.

A slightly amended version of S. 166 passed the Vermont Senate last week and is heading to the House.

For more information on AB 2384, please contact CMA's Megan Allred; and for more information about S. 166, please contact VMS's Jessa Barnard.

Colorado emergency physicians' opioid prescribing guidelines having positive effect

A 10-hospital pilot led by Colorado's emergency medicine community to improve pain care and reduce the state's opioid supply available for diversion recently reported a 36 percent decrease in opioid prescribing during the 6-month pilot study. The study relied heavily on guidelines developed by the Colorado chapter of the American College of Emergency Physicians (COACEP).

The COACEP Guidelines are a comprehensive approach to pain management and harm reduction strategies, including multiple sections with practice recommendations, use of non-opioid medications as well as policy recommendations. The guidelines were developed by a multidisciplinary panel of emergency physicians, addiction and harm reduction specialists, pharmacists, paramedics, emergency department nurses, and medical students. According to COACEP, "These guidelines are not meant to replace clinical judgment, but rather inform and augment it. Although we acknowledge the value of opioids in certain clinical situations, including the treatment of cancer pain or hospice patients, we advocate extreme caution in all cases."

For more information about the guidelines, please contact Barb Burgess, Executive Director, Colorado Chapter, American College of Emergency Physicians, at (303) 255-2715.

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Other News

USP announces new timeline for completion of compounding chapter revisions

The AMA has been urging the United States Pharmacopoeia (USP) to allow for more physician input into the revisions to its standards for sterile and non-sterile drug compounding. USP, a non-governmental, non-profit organization that sets standards for drug quality and safety, has been in the process of updating its sterile and non-sterile compounding standards since 2015. 

The AMA has made headway with USP. According to the newly-released timeline, USP will release a new draft of the Chapter 795 standards for non-sterile compounding on March 30, 2018, while a new draft Chapter 797 for sterile compounding will be released on July 27, 2018. Both chapters will be open for public comment for three months. USP will also be allowing members of the public to provide in-person comment at open microphone sessions—a new addition to the USP process for which the AMA has advocated. USP is planning to publish final chapters on Dec. 1, 2019. More information is available on the USP website.

The AMA has been working closely with USP and a number of physician specialty organizations throughout the revision process to ensure that any changes do not adversely impact a physician's ability to prepare sterile and non-sterile drug products in their offices. The AMA has also been working closely with the Food and Drug Administration, which recently announced intentions to make accommodations for preparation of drug products by physicians. 

AMA asks OIG for cybersecurity and alternative payment model safe harbors

The AMA recently sent a letter to the Office of Inspector General (OIG) outlining two additional safe harbor provisions that promote innovation and allow physicians to modernize our nation's health care system. First, the AMA recommended that OIG create a safe harbor that allows for the sharing of cybersecurity items and services. The AMA expressed its deep concern that our nation's health care providers have been insufficiently prepared to meet the cybersecurity challenges of an increasingly digital health care system. The AMA firmly believes that this is a national priority and that physicians and other health care providers need tools to secure sensitive patient information in the digital sphere. 

Second, the AMA urged OIG to create a safe harbor to facilitate coordinated care and promote well-designed alternative payment models.  The fraud and abuse laws—including the Anti-Kickback Statute—can stand in the way of payment and delivery system innovation.  Fostering improvements in the delivery of care has necessitated reviewing and, in some situations, relaxing fraud and abuse laws to ensure that they do not impede the development of alternative payment models that link payments to quality, efficiency, and patient health outcomes.  The potential safe harbor should be broad, cover both the development and operation of a model, and provide adequate protection for the entire care delivery process to include downstream entities and manufacturers who are linking outcomes and value to the services or products provided.

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Upcoming Events

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.

March 29–April 6: Would you like a more impactful way to inform current and prospective patients about the unique skills and contributions you and your practice offer, collaborate with colleagues from around the world, and educate your community about health issues? Learn how a personal brand can help you achieve these aims and much more. With 70-85 percent of patients accessing health care information online, it is no longer a question of whether physicians should engage in personal branding but rather how to do so. Join a discussion in the AMA's Reinventing Medical Practice Community to learn how to mitigate negative feelings about personal branding and fully embrace this strategy to help you take control of how you are perceived by your peers, patients and community, and how branding can help you positively impact patients, collaborate with peers from around the world and stay relevant.

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.

April 11:
The Medicare Access and CHIP Reauthorization Act (MACRA) shifts physician payment from relying solely on the payments made for each service to increasing or decreasing payment rates in the Merit-based Incentive Payment System (MIPS) based on cost, quality, advancing care information measures and improvement activities. The Quality Payment Program (QPP) provides for multiple methods for reporting an individual or group's measures. 

Qualified Clinical Data Registries (QCDR) are one method for reporting to the Centers for Medicare and Medicaid Services (CMS). Held at 1:00 p.m. Eastern time, this webinar "Finding a QCDR" will identify the components of a QCDR, differentiate between the different types of QCDRs, provide tools for groups to select a QCDR partner, and highlight methods to be successful reporting via a QCDR.  It will also discuss how to leverage your QCDR data beyond MIPS reporting – credentialing, licensure, and certification. Lance Mueller, AMA Healthcare Quality Manager will be presenting.

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