May 31, 2018

Issue Spotlight

AMA fights to preserve the sanctity of the patient-physician relationship

In response to the administration's plan to withhold federal family planning funding from Planned Parenthood and other entities AMA has issued a statement strongly objecting to the policy change, asserting that it interferes with patient-physician relationships and negatively affects quality of care.

"High-quality medical care relies on honest, unfiltered conversations between patients and their physicians," said AMA President David Barbe in a statement released last week. "Gag orders that restrict the ability of physicians to explain all options to their patients and refer them—whatever their health care needs—compromise this relationship and force physicians and nurses to withhold information that their patients need to make decisions about their care."

The U.S. Department of Health and Human Services announcement specifically notes that the regulation update "would prohibit referral for abortion as a method of family planning."

The new proposal would also endanger access to care that the Title X program has helped to facilitate. Title X has helped to expand access to basic reproductive health care like birth control, cancer screenings, STI testing and treatment, and exams. The program serves roughly 4 million people every year, many of whom would otherwise be unable to access care.

"Title X is popular, successful, and has had bipartisan support for decades," said Barbe. "We are at a 30-year low for unintended pregnancy and a historic low for pregnancy among teenagers -- largely because of expanded access to birth control. We should not be walking that progress back."

The AMA's stance on this issue is in keeping with its longstanding position on maintaining patient choice and physician freedom to practice in the setting they choose, and reflects a broader commitment to protecting free communication between patients and physicians.

Read more at AMA Wire®.

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National Update

Trump administration releases plan to lower drug prices 

On May 11, the Trump administration released its much-anticipated plan to lower drug prices and federal drug spending. Titled "American Patients First: The Trump Administration's Blueprint to Lower Drug Prices and Reduce Out-of-Pocket Costs," the plan builds on proposals released by the administration earlier in 2018, attempting to lay out a multifaceted approach to tackle high drug costs. 

The blueprint includes a significant number of proposals including: 

While a number of proposals were included in the plan, significant detail on how the administration plans to implement the proposed changes is lacking. It is likely that many of the suggestions would require regulatory changes or new legislative action. 

The AMA is reviewing the blueprint and the accompanying request for information and is planning to submit detailed comments to the administration. Comments are due July 16. 

House and Senate committees act on legislation to address opioid abuse

Multiple committees in the House and Senate approved legislation during the weeks of May 14 and May 21 to address opioid abuse.
In the House, on May 16, the Committee on Ways and Means considered and approved several bipartisan bills to address the opioid epidemic in the context of the Medicare program. In a letter to the committee, the AMA expressed support for several of the provisions in these bills while also making recommendations to improve other provisions. 

The Energy and Commerce Committee held its second markup on May 17 to consider an additional 32 bills to address the opioid epidemic. The AMA submitted a letter for the record highlighting our position on many of the bills. In total, the Energy and Commerce Committee approved 57 bills—53 by voice vote—during its two markups. The House is expected to vote on legislation that was considered in various committees during the week of June 11.

In the Senate, the Committee on Commerce, Science and Transportation and the Committee on the Judiciary each approved multiple measures on a bipartisan basis on May 22 and 24, respectively, to address the opioid abuse crisis. Additionally, on May 23, the Committee on Finance announced the introduction of 22 bipartisan bills by members of the Committee to address the opioid epidemic. 

The Finance Committee is expected to markup these measures during June. The AMA is continuing to engage in the process in both the House and Senate to ensure that effective policies are adopted to address this national crisis.

AMA comments on FDA draft guidance for compounding from bulk substances

On May 25, the AMA submitted comments on the U.S. Food and Drug Administration's (FDA) draft guidance, "Evaluation of Bulk Substances Nominated for Use in Compounding Under Section 503B of the Federal Food, Drug, and Cosmetic Act."

The draft guidance, which was released earlier in 2018, lays out the FDA's plan to consider when an outsourcing facility may appropriately compound from bulk substances as opposed to an FDA-approved product. The Drug Quality and Security Act permitted compounding from bulk substances in cases where there is a "clinical need" for the product.

The draft guidance proposed that the FDA would make determinations of clinical need and would also determine if FDA-approved products were "medically unsuitable" for certain patients. In its comments, AMA noted concern with the FDA's proposal to make determinations of clinical need and medical suitability of certain drug products without designating a role for physicians and their specialty societies in those determinations.

The AMA strongly urged the FDA to work with physicians and specialty societies to develop a process for making those determinations in collaboration. 

Senate Passes VA Choice Reform Bill; Floor Consideration Expected This Week

On May 23, the Senate passed S. 2372, the "Department of Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks (VA MISSION) Act," by a 92–5 vote. It had previously passed the House on May 16 by a vote of 347–70. The president is expected to sign the measure into law shortly.

This bill streamlines the VA's various community care programs into a single, cohesive program, ensuring that veterans have continuity of care external to the VA's medical network. It also invests in the modernization of VA medical care facilities, expands veterans' access to clinically validated telehealth services within the VA, and authorizes $5.2 billion in urgently needed funds to prevent interruption of veterans using the Choice Program.

In addition, the bill will continue to fund vital programs to recruit and retain health care professionals to provide quality care for veterans. The bill establishes a loan repayment program for medical residents who are training in specialties deemed by the VA to be experiencing a shortage. It also will fund scholarships to medical students in exchange for service to the VA following residency training.

Two-sided ACO risk models result in higher spending

A new report from the Center for Healthcare Quality and Payment Reform's CEO Harold Miller deconstructs performance data on Medicare Shared Savings Program accountable care organizations (ACOs). The report shows that, on average, ACOs in two-sided risk models have higher per-beneficiary spending than those in upside-only models.

The report suggests that the methodologies used to set ACO benchmarks, adjust for patient risk factors, and measure quality all tend to distort assessments of ACO performance. Miller recommends that Medicare replace the shared savings approach that it has been using to date with patient-centered alternative payment models that provide the resources physicians need to successfully address their patients' health care needs while holding them accountable for those aspects of spending and quality they can control.

AMA commends outreach on direct provider contracting

In a letter to the Center for Medicare and Medicaid Innovation (CMMI), the AMA offered detailed feedback on 22 questions posed by the CMMI in a request for information on its plans for a Direct Provider Contracting alternative payment model.

The AMA has long supported private contracts between patients and their physicians and views the Direct Provider Contracting model as an innovative approach with the potential to promote high levels of patient engagement and improve patient health outcomes. The comment letter urged the CMMI to adopt an array   of Direct Provider Contracting models including primary care, specialty and multispecialty pilots, and to use the Direct Provider Contracting model as a means of testing the 10 models that have been recommended by the Physician-focused Payment Model Advisory Committee.

The AMA also recommended that the CMMI employ the new model as a means to reduce physician regulatory burdens due to prior authorization requirements and ensure that the model does not impose unnecessary new administrative burdens. 

In addition, the AMA called on the CMMI to support practices' efforts to improve patient engagement by educating them about how best to utilize their services, which may include more timely appointment scheduling, after-hours and between visit phone call or email consultations, improved communication and coordination with other professionals and providers such as emergency departments, and services like remote patient monitoring and home visits.

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State Update

Report details physicians' progress in reversing the opioid epidemic

The AMA has issued a new report outlining how physician leadership is advancing to fight the opioid epidemic. The report found:

"While this progress report shows physician leadership and action to help reverse the epidemic, such progress is tempered by the fact that every day, more than 115 people in the United States die from an opioid-related overdose," said Patrice A. Harris, MD, chair of the AMA Opioid Task Force. "What is needed now is a concerted effort to greatly expand access to high quality care for pain and for substance use disorders. Unless and until we do that, this epidemic will not end."

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Judicial Update

U.S. Supreme Court case could limit physician referral power

A case before the U.S. Supreme Court on how antitrust laws are enforced has the potential to affect health care in a way that would harm patient care and interfere with a physician's duty to a patient to provide the best medical care.

The case before the nation's highest court, State of Ohio et al. v. American Express Company et al., involves how a credit card company operates, although this may seem far removed from the practice of medicine, the underlying issue the justices are considering is how federal antitrust laws are applied. Their ruling could upend how the courts determine whether anti-steering provisions are violated under the Sherman Act.

If the nation's highest court upholds a ruling by the 2nd U.S. Circuit Court of Appeals, it would mean dominant health insurers or dominant hospital systems could create contracts that include anti-referral rules that prohibit physicians from referring patients to out-of-network specialists for innovative or medically-necessary tests that would provide the patient with the best care. So argues an amicus brief the Litigation Center for the American Medical Association and State Medical Societies and the Ohio State Medical Association filed with the U.S. Supreme Court.

"Material interference with physicians' medical judgments threatens physician autonomy, damages the doctor-patient relationship, decreases medical innovation and lowers the overall quality of patient care," the Litigation Center brief states. "The antitrust laws have historically played an instrumental role in preventing such outcomes. This court should ensure that antitrust law's vital role in health care continues."

Read more at AMA Wire.

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Other News

Reach MD podcast series debut

The first in a series of six podcasts produced in partnership with Reach MD will be released biweekly beginning May 31. The debut episode will be an interview with AMA lobbyist Koryn Rubin on quality reporting options.

Future topics will include ACI hardship exemptions, understanding cost categories, physician-focused APMs, and what hospital employed physicians neeed to know about MIPS.

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Upcoming Events

May 29–June 8: Telemedicine in practice
Telemedicine is transforming the way health care is delivered and is a strategy for many physician practices and health systems to provide more immediate access to care, improve care coordination, and decrease overall costs to organizations and their patients. If you are thinking about implementing telemedicine in your practice, this AMA Reinventing Medical Practice Community discussion is for you. Not only will you learn about relevant laws and licensure status; we will also focus on how to implement telemedicine in your practice by discussing such issues as cybersecurity, adoption and reimbursement. Join this discussion to learn more about implementing telemedicine in practice and where to go for resources to keep up with the latest legislative and payment changes in this space. Visit discussion page.

June 11, 8 a.m.: Value-based contracting
While at the 2018 AMA Annual Meeting, learn about the latest evolution of value-based payment contracts that include cost and quality metrics and risk-based payments. Through a presentation and dialogue moderated by an expert in health care legal and management consulting, this CME activity will enable you to learn from experienced physicians about the strategies used to ensure these arrangements work for your patients and your practice. This session qualifies for 1.0 AMA PRA Category 1 Credit™ and will take place on Monday, 8 a.m. CDT, in Crystal Ballroom A. 

June 11, 9 a.m.: Transforming Clinical Practice: A step-wise approach
In this interactive session, we will describe the Transforming Clinical Practice initiative (TCPI), AMA's efforts and tools to help attendees assess their practice capabilities and identify pain points and to provide information/resources they can use in their practices. We will hear from a physician/practice on the front-lines of transformation who can share their performance story and offer valuable and practical tips for moving to VBC. Hosted by AMA's Professional Satisfaction and Practice Sustainability Strategy Group and held in Crystal Ballroom A.

June 11, 10 a.m.: Cost-sharing and preventive interventions
In this session, you will learn about the methods and processes used by the US Preventive Services Task Force (USPSTF) in making evidenced-based recommendations for preventive services and the ways insurance design can be used to align incentives. Coverage of preventive services was expanded under the Affordable Care Act (ACA) to include coverage, without cost sharing, of services rated as "A" or "B" by the USPSTF. Nevertheless, valuable preventive interventions are often outside the scope of the ACA preventive coverage and out-of-pocket costs can be a barrier for patients. A more precise benefit design can enhance patient-centered outcomes, while reducing the harm associated with high cost-sharing. Value-Based Insurance Design, consistent with AMA policy, applies the principle of "clinical nuance," to align patient cost-sharing with the value of the care to a specific patient. Crystal Ballroom A.

June 20: Health literacy solutions
There is a growing need to understand the socioeconomic issues surrounding patients and the lack of resources and assets on the topic of health literacy. In this AMA webinar, Dr. Mary Reeves, TCPI National Faculty, as well as several team members from HealthCare Dynamics International, will define health literacy and how it can have an impact on reporting and your practice overall, as well as discuss tools and resources that address clinician concerns regarding the social factors affecting their patient population and the impact of these factors on clinical outcomes. Register.

June 27: Digital health ecosystem
This webinar, noon–1 p.m. CDT—will provide an overview of the digital health ecosystem and the AMA initiatives that support and drive health care innovation. Attendees will learn about physicians' key requirements for adopting digital health in practice, facilitators and barriers to the adoption of digital health, and how physicians and practices can get involved in influencing and accelerating innovation in health care technology. Register.

July 25: EHRs—Usability and optimization
Electronic health records have transformed health care over the last decade. While they have improved some aspects of clinical practice, they are still often associated with physician burnout and patient safety concerns. This webinar, noon–1 p.m. CDT—will provide an overview of the AMA's initiatives focused on improving the usability of EHRs through research, guiding principles and collaboration. It will also cover resources and best practices available to physicians and practices to support optimization. Register.

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