April 5, 2018

Issue Spotlight

Physicians ask HHS to withdraw proposed rule on conscience rights in health care

In response to the Notice of Proposed Rulemaking on "Protecting Statutory Conscience Rights in Health Care; Delegations of Authority," the AMA sent a letter to Alex Azar, Secretary of the U.S. Department of Health and Human Services (HHS) to express opposition to the measure, citing concern for vulnerable patient populations and asserting that conscience rights for physicians are not unlimited.

The proposed rule would dramatically expand the discretion that religious or moral objectors have to refuse care without meaningful safeguards to ensure that the rights of those receiving care are protected. The rule is part of a broader White House effort to protect religious rights and follows the announcement in late January of the creation of a new office within the Office of Civil Rights (OCR), the Conscience and Religious Freedom Division.

The rule would require health care providers who participate in Medicare (except those who receive payments only from Part B) and Medicaid to create a set of standards and procedures to protect the religious and moral rights of their employees. The rule covers a wide array of existing federal laws that provide conscience protections including those related to abortion, contraception, sterilization, vaccines, end-of-life care, and care of marginalized groups like LGBTQ patients.

The AMA fears that if implemented, the rule would function as a shield for people asserting objections on religious or moral grounds and could permit them to withhold care from already vulnerable groups and create confusion in health care institutions.

"The proposed rule would undermine patients' access to medical care and information, impose barriers to physicians' and health care institutions' ability to provide treatment, impede advances in biomedical research, and create confusion and uncertainty among physicians, health care professionals, and institutions," AMA Executive Vice President and CEO James L. Madara, MD, wrote in the letter.

While the AMA is committed to conscience protections for physicians and other health professional personnel, the letter states that the exercising of those rights must "be balanced against the fundamental obligations of the medical profession and physicians' paramount responsibility and commitment to serving the needs of their patients."

Thusly, the AMA affirms its position against government interference in the practice of medicine or the use of health care funding mechanisms to deny established and accepted medical care to any segment of the population.

According to the AMA Code of Medical Ethics, the freedom to act according to conscience is not unlimited. Physicians are expected to provide care in emergencies, honor patients' informed decisions to refuse life-sustaining treatment, and respect basic civil liberties and not discriminate against individuals in obligation to patients with whom they have a patient-physician relationship.

This principle is in keeping with many AMA's policies protecting access to care, especially for vulnerable and underserved populations, and its anti-discrimination policy, which opposes any discrimination based on an individual's sex, sexual orientation, gender identity, race, religion, disability, ethnic origin, national origin, or age. Moreover, the letter points out that the proposed rule appears to conflict with OCR's own mission which states that "The mission of the Office for Civil Rights is to improve the health and well-being of people across the nation; to ensure that people have equal access to and the opportunity to participate in and receive services from HHS programs without facing unlawful discrimination."

Similarly the letter expressed concern that the proposed rule could interfere with numerous existing state laws that protect women's access to comprehensive reproductive care, and the rule fails to address how conscience rights of individuals and institutions might apply when emergency situations arise (e.g., under the Emergency Medical Treatment and Labor Act, or EMTALA). Given these concerns and others the AMA recommends that HHS withdraw the proposed rule.

The letter was sent out on March 27, the deadline for the comment period. Since then HHS has received nearly 70,000 letters, with several other medical associations and advocacy organizations like Human Rights Watch joining the AMA in opposition.

Implementation of the rule is expected to cost $312 million in the first year and $125 million annually over the next four years. HHS' Office for Civil Rights said it has seen an increase in religious-related complaints in the past year and a half, logging 34 since November 2016, while only 10 were filed during the entirety of the Obama administration. 

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National Update

Regulatory flexibility needed for controlled substance e-prescribing

In a new letter to senior diversion control officials at the Drug Enforcement Administration (DEA), the AMA is seeking important updates in the DEA rules that govern electronic prescribing of controlled substances (EPCS). Adoption of EPCS can support high-quality patient care and reduce fraud, tampering and diversion of prescription drugs, such as opioid analgesics.

The current rules, which have been unchanged since 2010, prevent user-friendly devices that are widely available in medical practices from being deployed to meet the multifactor authentication standards DEA now requires. The AMA letter outlines specific changes that are needed in the regulations for biometric devices in order to make it simpler and less expensive for physicians to adopt EPCS and have it integrated into their practice workflows.

These requests are consistent with a recommendation from the President's Commission on Combating Drug Addiction and the Opioid Crisis that the DEA should increase EPCS to prevent diversion and forgery.

HHS Secretary urged to adopt new alternative payment models

At its March 26–27 meeting in Washington, the Physician-Focused Payment Model Technical Advisory Committee (PTAC) reviewed four alternative payment model (APM) proposals and voted to recommend all of them to the Secretary of the U.S. Department of Health and Human Services for testing or implementation.

Two of the proposals aim to improve the availability of palliative care for Medicare patients with advanced illness, including a model developed by the American Academy of Hospice and Palliative Medicine that supports interdisciplinary palliative care teams. These teams would be available to patients and caregivers 24/7 to help ensure issues associated with the patient's health conditions and functional limitations are managed in the most efficient way in alignment with the patient's wishes.

In public comments supporting the palliative care model, the AMA reinforced the importance of legislation recently passed by Congress in response to AMA advocacy that clarifies the PTAC's authority to provide feedback to proposal developers to help them refine and improve their proposals. Another model that the PTAC adopted would improve care for nursing home patients by offering around-the-clock intensive care management services from geriatrician-led multidisciplinary teams via telemedicine. The APM would help on-site medical and nursing staff better manage care transitions and prevent patients from cycling back and forth between nursing homes and hospitals.

CMS urged to reissue guidance to clarify permissible electronic payments

The AMA wrote to the Centers for Medicare & Medicaid Services (CMS) on March 26 to express concerns over unfair business practices with respect to electronic payments to physicians, including the use of virtual credit cards.

The letter urged CMS to republish frequently asked questions issued last summer, since removed from the CMS website, which endorsed honest, fair business in the health care industry by enabling physicians to make informed, independent choices regarding the appropriate payment method for their practice.

AMA objects to new limits on transgender military service

In a letter to Defense Secretary James N. Mattis sent on April 3, the AMA expressed its concern about recently announced policies that would impose limits on transgender individuals serving in the military.  There is a wide body of peer-reviewed research on the effectiveness of transgender medical care, which formed the basis of policy adopted by the AMA's House of Delegates in 2015 that there is no medically valid reason to exclude these individuals from military service. 

The AMA further expressed its support for public and private health insurance coverage for treatment of gender dysphoria and its support for a RAND study's conclusion that the financial cost of transgender individuals in the military is negligible.

AMA hearing statement highlights improvements made and needed to MACRA

The AMA submitted testimony for the record for the March 21 House Ways and Means Health Subcommittee hearing that examined implementation of the 2015 Medicare Access and CHIP Reauthorization Act's (MACRA) physician payment policy.

The AMA was supportive of MACRA since it replaced the flawed, target-based sustainable growth rate (SGR) formula with a new payment system and addressed problems found in existing physician reporting programs. Under prior law, possible combined penalties for the legacy pay-for-reporting programs could have been up to negative 11 percent in 2019. Under the Merit-based Incentive Payment System (MIPS), the maximum penalty physicians could receive in 2019 was negative four percent.

AMA testimony included comments on recent changes made to MACRA. Under the Bipartisan Budget Agreement of 2018, Medicare Part B drug costs were excluded from MIPS payment adjustments, flexibility was provided for the Centers for Medicare & Medicaid Services (CMS) to reweight the cost performance category to not less than ten percent for the third, fourth, and fifth years of MIPS. Allowing three additional years for the cost score to be weighted at ten percent will allow additional time for CMS build on its ongoing initiative to use panels of physicians to develop, test and refine resource use measures. The law also allows CMS flexibility in setting the performance threshold for three additional years.

The AMA strongly advocated for Congress to clarify the MACRA statute so that the Physician-focused Payment Model Technical Advisory Committee can provide data and technical assistance to individuals and organizations developing alternative payment model proposals going forward. This will significantly enhance the quality of the submitted proposals and greatly increase the likelihood of their testing and implementation.

The AMA also made suggestions for further improvement. The overarching goals in MACRA regulations should be choice, flexibility, simplicity and feasibility. The MIPS scoring system could be simplified by harmonizing the scoring across the four separate components of MIPS so that physicians can more easily calculate their progress toward achieving success and increasing opportunities for physician reporting to be counted across multiple categories in a more coherent payment system.

The AMA argued that advancing care information (ACI) MIPS performance should require only attestation by reporting physicians and CMS should focus ACI measures on interoperability and patient access. Additionally, MIPS needs to transition from using prescriptive measures to using cases and outcomes.

Billions approved for fight to end opioid epidemic

Nearly $4 billion to support a multifaceted approach to combating the opioid epidemic is included in the $1.3 trillion omnibus budget bill signed into law on March 23. The money will pay for law-enforcement programs directed at opioid trafficking as well as medical programs aimed at preventing and treating opioid-use disorder.

Most of the money will go to Health and Human Services agencies such as the Substance Abuse and Mental Health Services Administration, which will get $1 billion to fund State Opioid Response Grants (this is in addition to the $500 million provided in the 21st Century Cures Act); $84 million for the Medication Assisted Treatment-Prescription Drug and Opioid Addiction state grant program; and $50 million dedicated for health programs for Native Americans.

Read more at AMA Wire®.

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State Update

Chair of AMA Opioid Task Force details steps needed to end the opioid epidemic

Patrice A. Harris, MD, chair of the American Medical Association's Opioid Task Force, spoke at the nation's largest drug abuse summit, the National Rx Drug Abuse and Heroin Summit, on April 3 in Atlanta. During her session, "More PDMPs, More CME, Fewer Opioids—So Why Is the Epidemic Worse?" Dr. Harris detailed critical steps policymakers must take in order to end the nation's ongoing opioid epidemic.

"Physicians are leading a significant effort to end the opioid epidemic, fueling increased use of prescription drug monitoring programs, reducing opioid prescriptions by more than 22 percent since 2013, and increasing co-prescribing of naloxone," said Dr. Harris prior to the summit. "The foundation to end the epidemic has been poured. But unless and until policymakers and payers work with us to remove barriers to treatment for pain and substance use disorders, this epidemic will continue. We look forward to highlighting solutions at this Summit."

The Rx Summit is the largest national convention of researchers, health care professionals, and policymakers, who meet in hopes of working together to address the national opioid crisis. Keynote speakers for the conference include President Bill Clinton and United States Surgeon General Jerome M Adams, MD.

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Other News

New Medicare beneficiary identification cards go into effect on April 1

As noted in previous editions of AMA Advocacy Update (May 18, 2017; July 27, 2017) and highlighted on the AMA's website, the Centers for Medicare & Medicaid Services (CMS) is issuing new Medicare cards to beneficiaries starting April 1, 2018. The new Medicare cards replace the Health Insurance Claim Number (HICN) with a Medicare Beneficiary Identifier (MBI) that is not based on the beneficiary's social security number.

The AMA was instrumental in successfully urging CMS to create a look-up tool for patients' new MBIs in the event that patients do not bring their new cards with them to their office visits. The portal is anticipated to be ready in June 2018. In addition, the AMA arranged for a CMS briefing on the new Medicare card. A recording of the webinar is available here. Also, see this AMA Wire story, "9 steps to welcoming the new Medicare card in your practice."

Medicare rolls out Diabetes Prevention Program expanded model nationally

Physicians now have another tool to prevent the onset of type 2 diabetes. Beginning April 1, Medicare patients with prediabetes can be referred to a Centers for Disease Control and Prevention (CDC)-recognized Diabetes Prevention Program (DPP) for group sessions with a lifestyle change coach.

This follows several years of advocacy by the AMA in partnership with the YMCA to demonstrate that the DPP reduces costs and improves health outcomes. The AMA strongly advocated for flexibility in how the Medicare DPP is structured and services are delivered to ensure access to as many Medicare patients as possible. The AMA's advocacy continues as Medicare builds the national supplier and referral networks that are essential to ensure access to care.

To be eligible for the program, a Medicare patient must have a body mass index of 25 or greater and have a blood lab value in the prediabetes range. The program consists of up to two years of regular coaching sessions that are designed to help people lose weight and increase physical activity. The program is based on the national DPP randomized control trial that showed a 71 percent reduced risk of developing type 2 diabetes in adults 60 and older compared to placebo.

Medicare DPP suppliers are paid based on the number of sessions that beneficiaries attend and weight loss goals achieved. Medicare has indicated that its focus is on building the supplier and referral networks that will be necessary to scale the Medicare DPP nationally. Physicians who are interested in referring their patients to the Medicare DPP should check on the Medicare DPP website for information about suppliers in their area.

Prior authorization among the AMA's top priorities

In a new video series AMA President David Barbe, MD, highlights the AMA's top priorities in 2018, including reforming the prior authorization process. According to a recent AMA survey more than nine in 10 physicians say that prior authorizations programs have a negative impact on patient clinical outcomes. The survey results further bolster a growing recognition across the entire health sector that prior authorization programs must be reformed.

Learn about the steps the AMA is taking to combat the overuse and time-consuming process of prior authorization by watching a short video. "Fixing Prior Authorization" is also the focus of the Advocating for Patients and Physicians topic page.  

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Upcoming Events

Through April 6: Perfect your online brand
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 best 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 11: How to benefit from a Qualified Clinical Data Registry
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 & 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.

April 12–April 19: Global health volunteer opportunities for med students
Join five medical student panelists in a digital community discussion on "Public & Global Health: Make A Difference During Medical Training." There you can discover unique volunteer opportunities and learn how you can impact public and global health while in medical school and residency. You will have the chance to hear about the personal experience of panelists, ask questions, and get advice on how to identify opportunities that will make the biggest difference.

April 18–April 24: Advice for IMGs on visas
Join the digital community for "IMG Visa Discussion Series: Part III, Post Residency" to learn more about what type of visa you need before, during, and after residency. Part three of this series will focus on how to transition into practice from a J-1 or H1-B visa.

You will learn about the various waivers that will allow you to stay and work in the United States, learn about the Conrad 30 program, and other immigration issues you may face when trying to practice in the U.S. and accommodate your family members. Ask questions about immigration requirements, practicing in medically underserved areas, changing your immigration status and discover what immigration pitfalls to avoid.

April 25: Integrated community approach to diabetes prevention
Health reform initiatives are increasingly shifting financial risk to clinicians. In order to manage risk in this volatile health care market, physicians must begin to adopt a population health approach to the practice of medicine.

The skyrocketing costs associated with diabetes expose this patient population to greater risk of increased expenditures. In order to achieve success with alternative payment model efforts, it is imperative that physicians adopt a population health strategy to address the population at risk or currently diagnosed with diabetes.

In this 90-minute webinar at 1 p.m. EDT, "Population Health Management: Addressing the Diabetes Epidemic with an Integrated Community-based Intervention," attendees will learn how Mission Health, a member of a large Accountable Care Organization (ACO), established a partnership with the YMCA of Western North Carolina to expand access to diabetes prevention, diabetes self-management, and lifestyle modification coaching to successfully improve their diabetes outcomes, while reducing the total cost of care for the target population.

The webinar will detail the steps the partners undertook to target the population, establish baseline performance metrics, solidify community-level YMCA access points, integrate ambulatory and community YMCA operations, define outcome tracking, and strategy for long-term financial sustainability of the model.

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