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March 22, 2018

Issue Spotlight

Survey shows prior authorization's negative impact on timely care

Anecdotes about the patient care delays and practice burdens caused by health plans' onerous prior authorization (PA) requirements are common across organized medicine, but quantitative data to substantiate these stories has been limited until recently. Results from the AMA's new PA physician survey provide strong evidence of the significant impact this burdensome process can have on both patients and physician practices.

Results from the December 2017 survey of 1,000 practicing physicians clearly show the negative effect that PA can have on timely patient care. Among surveyed physicians, 64 percent reported waiting at least one day for PA decisions from health plans, while 30 percent reported waiting at least three business days.

These wait times translate into patient care delays, with 92 percent of physicians saying that PA sometimes, often or always delays access to necessary care. These delays may have more serious implications for patients, as 78 percent of physicians reported that PA can lead to treatment abandonment. Moreover, an overwhelmingly majority (92 percent) of physicians indicated that PA can have a negative impact on patient clinical outcomes.

Beyond these concerning statistics reflecting negative consequences for patients, the survey also addressed the burdens imposed on physicians and their staff by PA. The survey results show that practices complete an average of 29.1 PAs per week per physician, with this PA workload requiring 14.6 hours—nearly two business days—of physician and staff time. Not surprisingly, 84 percent of physicians characterized PA-related burdens as high or extremely high. PA hassles also have been growing over time, with 86 percent of physicians reporting that PA burdens have increased over the past five years.

This data reinforces the need for strong advocacy efforts on PA reform. The AMA has undertaken a major campaign to urge health plans to "right-size" PA programs. In January 2017, the AMA and a coalition of 16 other organizations representing physicians, hospitals, medical groups, pharmacists and patients released a set of 21 Prior Authorization and Utilization Management Reform Principles. These principles, which have been formally supported by over 100 additional provider and patient groups, spurred conversations with health plans about the need for significant reform in PA programs.

As a result of those discussions, the AMA, along with the American Hospital Association, America's Health Insurance Plans, American Pharmacists Association, Blue Cross Blue Shield Association, and Medical Group Management Association, released the Consensus Statement on Improving the Prior Authorization Process in January 2018. This document reflects agreement between provider and health plan organizations to pursue PA reform in several key areas, including reduction in the overall volume of PAs, improved transparency and communication, protection of continuity of care, and automation to increase process efficiency.

State legislative efforts also play a critical role in the AMA's campaign to improve PA processes, and the AMA is working with state and specialty societies to enact legislation. The AMA offers model legislation that continues to serve as the basis for many of the state bills and provides resources and support for these efforts. This year alone, more than twenty states are addressing utilization management reform in their legislatures.

The AMA also offers educational resources to help physicians and their staff reduce the manual burdens associated with PA and transition to automated processes. A new, three-part educational video series describes the current impact of the PA workload on physician practices, demonstrates the workflow improvements and other advantages of implementing pharmacy electronic PA transactions that integrate with electronic health record systems, and offers tips on how practices can start using this technology. Access these videos, along with additional resources and information about the AMA's advocacy efforts on PA reform, by visiting ama-assn.org/prior-auth.

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National Update

Ways and Means Committee holds roundtable on regulatory relief

On March 15, the AMA and several other physicians groups participated in a closed-door "Red Tape Relief Roundtable" held by the House Ways and Means Committee. The roundtable's focus was on the daily administrative burdens of physicians, with the intention of identifying issues that the Committee could address through aggressive oversight of federal agencies rather than through legislation.

AMA Senior Vice President for Advocacy Rich Deem highlighted several steps that the Centers for Medicare and Medicaid Services (CMS) can take now to simplify the complex Merit-based Incentive Payment System (MIPS) scoring system that would allow physicians to spend more time caring for Medicare patients and less time on reporting. These steps include changing advancing care information (ACI) reporting requirements to measure attestation alone, focusing ACI measures on interoperability and patient access, and providing a greater credit for physicians who use clinical data registries. Deem also spoke about reinstating CMS guidance clarifying that physicians do not have to accept payment from insurers via virtual credit card.

The AMA was joined by other groups in describing the need to address prior authorization requirements in Medicare Advantage and Part D prescription drug plans. The roundtable is part of an ongoing effort by Committee leaders to identify and correct regulatory burdens on health care providers in the Medicare program.

AMA recommends strategies to Congress to help address opioid epidemic

The AMA submitted a letter to the House Committee on Ways and Means with recommendations for legislation and policies that it can pursue in an effort to address the opioid epidemic. An array of policies were recommended to increase patients' immediate access to effective treatment for opioid use disorder (OUD), including eliminating prior authorization requirements, extending Medicare coverage for OUD treatments to include methadone, and experimenting with alternative payment models for treatment of OUD.

The AMA also encouraged the Committee to help eliminate barriers to multimodal treatment for pain and to support physician-led, team-based efforts to improve pain care that the AMA recommends be at the heart of efforts to reduce opioid-related harms. In addition, the letter reinforced the AMA's longstanding concern that Drug Enforcement Administration requirements for biometric devices used in multifactor authentication prohibit user-friendly electronics already found in physicians' offices such as fingerprint readers on laptop computers and mobile phones, from being used for electronic prescribing of controlled substances and sought the Committee's help to secure modifications to these rules.

House of Representatives urged to address gun violence

The AMA wrote a letter to House Speaker Paul Ryan and Democratic Leader Nancy Pelosi on March 12, urging action on common-sense solutions to reduce the epidemic of gun violence in America. While supportive of plans to vote on the STOP School Violence Act of 2018 (H.R. 4909), which passed the House on March 14, the letter recommended a more comprehensive approach to this public health problem.

Specifically, the AMA urged them to consider:

HHS urged to reconsider Title X family planning changes

The AMA wrote a letter to Secretary of Health and Human Services Alex Azar on March 12, regarding new grant application guidelines for awarding Title X family planning funds. A Funding Opportunity Announcement issued several weeks ago made major changes to the program's priorities.

Specifically, it removed references to Quality Family Planning recommendations—nationally recognized clinical standards for the provision of high-quality family planning and sexual health care services. It also removed references to ensuring access to the 18 contraceptive methods approved by the Food and Drug Administration. Instead, the funding formula favors certain grantee characteristics, giving preference to faith-based clinics and those that offer natural family planning services and abstinence-only counseling for teenagers. The letter urges the Secretary to reconsider these changes.

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State Update

AMA urges Connecticut legislature to oppose physician assistant bill

Last week, the AMA submitted testimony to the Connecticut Senate Public Health Committee in opposition to Senate Bill 300. This bill would remove requirements that physician assistants practice pursuant to physician supervision, instead allowing physician assistants to practice in collaboration with one or more physicians. Because of the potential for this bill to fragment the health care team, the AMA urged defeat of S.B. 300.

How your medical society can co-brand a new MAT advocacy document

As part of the AMA's efforts to increase access to medication assisted treatment (MAT) for the treatment of substance use disorder, the AMA is urging medical societies to co-brand a new advocacy document highlighting the benefits of MAT. If you are interested in co-branding this document with the AMA, please contact the AMA's Daniel Blaney-Koen.

Step-by-step naloxone education video now available

As part of its efforts to help educate physicians and others about the opioid overdose reversal medication, naloxone, the AMA released a new step-by-step video showing how to administer the four main forms of naloxone: Narcan nasal spray, Evzio auto-injector into the thigh, a yellow cap nasal spray, and an intramuscular needle syringe. The video is available on the AMA opioid microsite.

In the first eight weeks of 2017 the number of naloxone prescriptions written by physicians increased 340 percent compared to the same eight week period in 2016, and the number of physicians prescribing the drug increased by 475 percent. A study published by the National Bureau of Economic research found that in states where laws have been enacted to increase access to naloxone, there has been a 9 to 11 percent reduction in opioid-related deaths. More than 1,200 law enforcement programs across the United States now equip their personnel with naloxone, resulting in thousands of lives saved.

While the use of naloxone does not guarantee an overdose reversal, it does present many patients with the best tangible option if they are experiencing an opioid overdose. Co-prescribing naloxone is supported by a broad range of health agencies, such as the World Health Organization, the Centers for Disease Control and Prevention, the Substance Abuse and Mental Health Services Administration, state departments of health, and a variety of consumer and advocacy groups.

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Judicial Update

Pregnant women deserve to get the whole truth on their options

The U.S. Supreme Court heard oral arguments Tuesday in a controversial case that has drawn attention because it touches on the hot-button questions related to abortion and freedom of speech.

But the real issues at stake in National Institute of Family and Life Advocates v. Becerra are medical ethics and a patient's right to informed consent, according to an amicus brief filed by the Litigation Center of the American Medical Association and State Medical Societies. In its brief, the AMA argues that laws seeking to compel or restrict physician speech should be subject to strict constitutional scrutiny and concludes that a California law aimed at ending deceptive pregnancy counseling meets that high bar.

The National Institute of Family and Life Advocates is seeking a preliminary injunction against enforcement of California's Reproductive Freedom, Accountability, Comprehensive Care and Transparency Act, which took effect Jan. 1, 2016. The state law requires licensed pregnancy-related clinics to disseminate information on available, publicly funded family-planning services, including contraception and abortion. It also mandates that unlicensed facilities post a notice stating that they are not licensed by the state of California.

A three-judge panel of the 9th U.S. Circuit Court of Appeals unanimously upheld a lower-court ruling denying the injunction sought by NIFLA, a Virginia-based corporation with—at the time of the decision—73 licensed and 38 unlicensed facilities located in California. Two other parties to the lawsuit against California Attorney General Xavier Becerra are Pregnancy Care Clinic, which is licensed by the state, and the Fallbrook Pregnancy Center, which is not licensed.

The judges rejected the petitioners' arguments that the law violated their rights to free speech.

"The act is a content-based regulation that does not discriminate based on viewpoint," wrote Senior Circuit Judge Dorothy Nelson, explaining how the law applied to all clinics regardless of their stance on abortion or contraception.

Arguing on behalf of the respondents in NIFLA v. Becerra, the brief lists three reasons for the AMA's interest in the case. They are to ensure that physicians:

Read more at AMA Wire®.

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Other News

Teaching physicians may now use medical student documentation

Last October, the Centers for Medicare and Medicaid Services (CMS) administrator launched the "Patients Over Paperwork" initiative which focuses on reducing administrative burdens in the Medicare program.

As part of this effort, CMS recently revised its Medicare Claims Processing Manual to allow teaching physicians to use medical student documentation, including: history, physical exam and/or medical student decision-making of the evaluation and management (E/M) service. The teaching physician must personally perform or re-perform the physical exam and medical decision-making of the E/M service and verify the student's documentation.

This is a welcome change. However, there are still some outstanding questions for which the AMA is working to secure answers.

Open Payments reminder: 45-day review-and-dispute period starts April 1

The Centers for Medicare and Medicaid Services (CMS) is required to publicly report, on an annual basis, items of value that are given to physicians and teaching hospitals by drug and device companies. Before the public data release, physicians are given a brief window of time, which typically begins in early April, to review their data and dispute errors.

Physicians planning to review their 2017 Open Payments Data should test their CMS Enterprise Portal (EIDM) logon credentials beforehand. Locked accounts and other logon issues can be fixed before the beginning of the review and dispute period by visiting Frequently Asked Questions for EIDM Users. For answers to additional questions, please email Medicare's Open Payment Help Desk at openpayments@cms.hhs.gov, or call (855) 326-8366.

AMPAC hosts 2018 Candidate Workshop in Washington, DC

Ever wonder how doctors get elected to Congress or your state legislature? On March 2-4, a collection of physicians, physician spouses, residents and medical students from around the country came to Washington, DC, to find out. Attendees of the two-day Candidate Workshop were taught the ins and outs of how to run a winning political campaign. 

The agenda included a bevy of bi-partisan political and campaign veterans who spoke from years of experience on topics such as the secret of effective fundraising, the importance of developing a disciplined campaign plan and message, and how to handle the inevitable crises that emerge.

The Candidate Workshop is just one of the political education programs that AMPAC provides for physicians, spouses and state medical society staff who have ever entertained running for public office. For more information on these programs please visit AMPAConline.org.

Refreshed Physicians' Grassroots Network site now available

The AMA recently launched a refresh of the Physicians' Grassroots Network site. This includes revised content, fresh visuals and a new way to experience the content. There is also an updated list of key advocacy issues where physicians can learn more about what is facing medicine today and what the AMA is doing to make sure the concerns of physicians are being heard on Capitol Hill.

As physicians navigate the new site, they can share their own stories or take action on the issues that matter most to their practice. Physicians can even refer colleagues to sign up for the Very Influential Physician program online, helping the AMA amplify the voice of medicine.

Video series covers access to care, Medicare payment and insurer issues

In a new video series, AMA President David O. Barbe, MD, outlines the AMA's top advocacy priorities for 2018, paying special attention to issues surrounding access to care, Medicare physician payment reform, and insurer issues, among others.

Access to care will remain at the top of the AMA's priorities by way of maintaining the strength of Medicaid, the Children's Health Insurance Program (CHIP), preserving patient protections and stabilizing the individual insurance markets. The AMA has taken a stand against Medicaid work requirements, and supports extending cost-sharing reduction (CSR) payments. It is estimated that at least 6 million people had their cost of care lowered by a CSR at an annual cost to the federal government of around $7 billion.

Medicare physician payment reform also remains an important topic, as better support is needed for coordinated, high value care. The AMA advocates for simplification of administrative requirements in payment systems and is developing reliable educational materials to help physicians succeed under new payment models.

The AMA is committed to maintaining insurance enrollment gains, addressing increased market consolidation advocating to health insurers to change short-sighted policies that adversely affect patients and physicians.

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Upcoming Events

March 28: New webinar series on reinventing medical practice
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.
 
March 29–April 6: Physician online branding discussion
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.

April 2: Cybersecurity workshop
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: Qualified Clinical Data Registry webinar
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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