Oct. 18, 2018

Issue Spotlight

Pennsylvania removes prior authorization for opioid treatment

Pennsylvania Gov. Tom Wolf announced a landmark agreement last week with seven major insurers to end prior authorization for medication-assisted treatment (MAT) for substance-use disorders (SUDs). Insurers also committed to including a comprehensive range of medications to treat SUDs on the lowest cost-sharing tier of a health plan's pharmacy benefit. The AMA is extremely pleased with this result.

"We have long advocated for the removal of prior authorization and other barriers to increase access to medication-assisted treatment for substance-use disorders," said AMA President-elect Patrice A. Harris, MD. "The leadership shown by the governor and his administration to reach this agreement should act as a call for all states to demonstrate that they support patients' access to care over needless administrative burdens."

The AMA and medical society efforts have included direct advocacy with key policymakers within the state, national-level advocacy with payers and national policymaking groups, and federal advocacy in support of removing barriers to high-quality, evidence-based care. Now that payers in Pennsylvania have recognized the importance of removing prior authorization and other barriers to MAT, the AMA will encourage payers in every state to show similar leadership.

"We commend the governor for his leadership in bringing together all major stakeholders in reaching this agreement," said Pennsylvania Medical Society President Theodore A. Christopher, MD, FACEP. "Today's agreement will bring much-needed certainty and clarity to physician practices when we are helping our patients access treatment for a substance-use disorder."

Prior authorization—sometimes called precertification or prior approval—is a process by which patients, physicians or other health care providers must obtain advance approval from a health plan to qualify for payment before a specific service or treatment is delivered to the patient. Applying prior authorization to patients with SUDs can have deadly consequences if patients are forced to delay care or have that care denied.

MAT is the evidence-based standard for treating people with opioid-use disorder to help sustain recovery and save lives. In the past year, nearly 15,000 physicians have become certified to provide MAT—a 42 percent increase nationwide.

To learn about the Pennsylvania Medical Society efforts to help reverse the epidemic, visit

To learn about the AMA's work to end the nation's opioid epidemic, visit

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National Update

CMS proposes requiring drug prices be listed in TV commercials

The Trump administration released a proposed rule on Oct. 15 that would require pharmaceutical manufacturers to disclose the list prices of their products in direct-to-consumer television commercials. The proposal would mandate that brand manufacturers clearly state in all television advertisements the wholesale acquisition cost (WAC) of either a 30-day regimen or "typical" treatment regimen of any drug where that price is over $35.

The proposal would not require disclosure in print, radio or social media ads. The move, which follows calls from the AMA to include this information in direct-to-consumer advertising efforts, is expected to be challenged by the pharmaceutical industry.

In addition, the Centers for Medicare & Medicaid Services (CMS) is seeking comment on other approaches that could be utilized by the agency to increase transparency, including creation of a new drug-pricing counseling payment code for use by physicians and use of artificial intelligence methods to help beneficiaries select the lowest cost Part D drug plans. The proposal is open for public comment until Dec. 17.

10 takeaways from the Surgeon General's opioid report

In a new report on the opioid epidemic, Surgeon General Jerome Adams, MD, highlights the need for a cultural shift in the nation's perception of substance-abuse disorders (SUDs). He emphasizes that SUDs are chronic-but-treatable diseases.

To remedy the problem, Dr. Adams, an AMA member, suggests that physicians and policymakers focus on evidence-based treatments— both medications and behavioral therapies—that can save lives and restore people's health and wellbeing. The AMA agreed that there is a great need to recognize that patients suffering "require medical intervention, not moral judgment." Here are ten major takeaways from the report:

  1. Only 1 in 4 people, (28.6 percent) with opioid-use disorder (OUD) received specialty treatment for illicit drug use in the past year, 45.5 percent of people with a SUD also have a mental disorder, but only half (51.0 percent) receive treatment for either disorder.
  2. Individuals receiving buprenorphine with counseling have significantly lower total health care costs than individuals receiving little or no treatment for their OUD ($13,578 compared to $31,055). As of September 2018, 44,968 physicians and 8,825 nurse practitioners and physician assistants, are approved to prescribe buprenorphine.
  3. Research has found that, for every dollar spent on prevention programs, the program returns between $0.62 and $64.18 in reduced costs.
  4. Incorporating treatment for multiple SUDs can be beneficial and is associated with a 25 percent increase in the likelihood of maintaining long-term abstinence from alcohol and drug misuse.
  5. Evaluation studies have clearly shown that syringe services programs are effective in reducing HIV and HCV transmission and do not increase rates of community drug use. They help individuals engage in treatment to reduce, manage, and stop their substance use when appropriate.
  6. The introduction of illicitly manufactured fentanyl and other highly potent synthetic opioids to the drug supply makes immediate access to naloxone crucial to effective overdose death prevention. Although regulations vary, most states have passed laws expanding access to naloxone without a patient-specific prescription.
  7. Multiple factors create barriers to widespread use of MAT. These include provider, public, and client attitudes and beliefs about MAT; lack of an appropriate infrastructure for providing medications; payment policies; need for staff training and development; and legislation, policies, and regulations that limit MAT implementation.
  8. An abstinence-only philosophy that avoids the use of medications for opioid treatment is not scientifically supported. Research clearly demonstrates that opioid-agonist therapy leads to better treatment outcomes compared to behavioral treatments alone. Decades of research have shown that the benefits of opioid agonist therapy greatly outweigh the risks associated with diversion.
  9. A public health approach to the opioid crisis will also reduce other harmful consequences, such as infectious disease transmission and neonatal abstinence syndrome.
  10. Effective integration of prevention, treatment, and recovery services across health care systems is key to addressing opioid misuse and its consequences, and it represents the most promising way to improve access to and quality of treatment.

Sports medicine licensure bill enacted

President Trump signed into law on Oct. 5, the FAA Reauthorization Act of 2018 (P.L. 115-254), which included the "Sports Medicine Licensure Clarity Act of 2018." The bill, which was supported by the AMA, extends the malpractice insurance coverage of a state-licensed medical professional to another state when the professional provides medical services to an athlete, athletic team or team staff member pursuant to a written agreement.

Prior to providing such services, the medical professional must disclose to the malpractice insurer the nature and extent of the service. This extension of malpractice coverage does not apply at a health care facility or while a medical professional is transporting the injured individual to a health care facility.

Athletes include individuals participating in a sporting event for which the individual may be paid, participating in a sporting event that is sponsored or sanctioned by a national governing body, or for whom a high school or university provides a medical professional.

FLMA should be expanded to include "blood or affinity" model

A letter was sent to Labor Department Sec. Alexander Acosta requesting that his department consider changes to the Family and Medical Leave Act (FMLA) regulations, expanding the categories of individuals for whom an employee may use leave. New policy was adopted at the 2018 AMA House of Delegates Annual Meeting that advocated for the "blood or affinity model," which allows FMLA-equivalent benefits for chosen family, domestic partners, and individuals who are dependent or mutually interdependent on the employed individual.

This policy reflects the needs and realities of today's diverse workforce, specifically as it pertains to LGBTQ employees. Several states, including Arizona, Hawaii, Maine, New York, and Oregon, as well as the District of Columbia, have expanded FMLA regulations in favor of the "blood or affinity" model and the AMA believes that FLMA regulations and policies should be likewise expanded at the federal level.

AMA urges CMS to retain shared savings ACO model

In a comment letter responding to the "Pathways to Success" proposed rule for Medicare accountable care organizations (ACOs), the AMA urged CMS not to retire the Track 1 shared savings-only ACO model, as it has proposed. Under the CMS proposal, all ACOs would be required to take two-sided risk after a short period of time as a shared savings-only model.

The AMA letter points out that, in every year since the Medicare ACO program was first created, the majority of Track 1 ACOs have reduced Medicare spending relative to CMS benchmarks without being subject to downside risk. In 2017, the total net savings generated by the 433 Track 1 ACOs was 12 times the net savings generated by Track 2 and 3 ACOs.

The letter also notes that the many physicians who use their Track 1 ACO participation as a means of participating in the Merit-based Incentive Payment System (MIPS) would lose this option under the proposed rule. The AMA recommends several potential modifications to Track 1 that could increase Medicare savings from the ACO program without requiring all ACOs to take downside financial risk. These include allowing ACOs to take accountability for the specific types of spending they can control instead of total Medicare spending on their assigned patient population.

Other recommended changes from the CMS proposal include:

  • Linking risk requirements to the services that ACO participants deliver or order themselves instead of arbitrary classifications of low-revenue and high-revenue ACOs
  • Providing additional upfront payments to ACO participants
  • Excluding MIPS incentive payments from calculations of ACO savings and losses
  • Focusing quality measures intended to help end the opioid epidemic on the quality of pain management and substance-use care instead of the dose of prescribed opioid analgesics

Comments sought on ambulatory BP monitoring coverage

In response to a joint request from the AMA and the American Heart Association, CMS has reopened the Medicare coverage policy on ambulatory blood pressure monitoring (ABPM) coverage and is seeking public comments until Nov. 8. Current Medicare policy only covers ABPM for patients with suspected white coat hypertension.

The request urged CMS to align its policy with the 2016 recommendation of the U.S. Preventive Services Task Force (USPSTF) by covering ABPM as the reference standard for diagnosis of hypertension. The USPSTF found convincing evidence that ABPM is the best method for diagnosing hypertension. Although the criteria for establishing hypertension varied across studies, there was significant discordance between the office diagnosis of hypertension and 12- and 24-hour average blood pressures using ABPM, with significantly fewer patients requiring treatment based on ABPM. The AMA encourages other medical societies to submit comments in support of expanding Medicare coverage for ABPM.

AMA to CMS: Fund quality measures developed by physicians

Recently, CMS announced private-sector cooperative agreements to partner with the agency in developing quality measures for Medicare's Quality Payment Program (QPP). These cooperative agreements, authorized under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), represent the first funding initiative supporting public-private efforts to develop measures for the QPP.

The AMA was instrumental in ensuring MACRA included funding authorization for quality measure development. However, the AMA is extremely disappointed that CMS only issued a single announcement, funding only seven projects. Some of the awards were given to large provider systems and existing Medicare contractors, rather than adhering to the intent of the law and being given physician-led specialty organizations and PCPI®. In addition, much of the work involves re-specifying and/or re-tooling existing measures, which is traditionally work handled by CMS' existing measure development and support contractors.

Therefore, the AMA sent a letter to CMS Administrator Seema Verma voicing physician concern and urging the administrator to issue additional cooperative agreements that would focus on small projects by physician-led organizations. The AMA also requests that CMS ensure that current and future projects are coordinated with specialty societies and that practicing physicians are actively involved during the development, specification and testing of the measures. Key to achieving MACRA's goals is the availability of an adequate portfolio of appropriate quality measures that allows for all physicians, regardless of specialty or subspecialty, to meaningfully participate in the program.

CMS should reject report's recommendations to continue prior auth

The AMA wrote to CMS in response to a recent report on the topic of prior authorization (PA) prepared for CMS by the Government Accountability Office (GAO). The report recommended that CMS continue PA by extending current demonstrations and expanding PA to additional items and services to decrease program costs.

The AMA urged CMS to not follow the report's recommendations, but rather to carefully consider the care delays associated with PA and the resulting impact on the health of beneficiaries when evaluating any additional PA requirements for Medicare. It included stories from both patients and physicians around the country about how prior authorization affects patients, which the AMA has collected on its grassroots website

The AMA will continue to urge CMS to refrain from expanding Medicare PA or demonstrations before carefully considering the evidence that the process harms patients and burdens health care professionals.

FDA drug shortages task force meets with physician groups

The AMA participated in a listening session on drug shortages held Oct. 12 by the Drug Shortages Task Force that was newly convened by the Food and Drug Administration (FDA). Staff from the FDA, CMS, Defense Department, and other federal agencies convened a number of stakeholders over the course of several days to provide input as to how drug shortages are impacting clinical practice. They also heard recommendations on how the FDA and other agencies can craft solutions that may help mitigate and alleviate shortages.

The AMA provided a statement on the breadth of the impact of drug shortages, noting that a significant number of providers are impacted by at least one drug shortage every day. The AMA also provided information on how patient care is compromised by ongoing shortages of critical drug products and offered a number of policy recommendations.

The task force will host its first public meeting to receive input on drug shortage policy Nov. 27 in Washington, D.C. The FDA will be accepting public comments on this issue until Jan. 11.

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State Update

AMA calls for greater enforcement of Mental Health Parity Act

Ten years after the passing of the Mental Health Parity and Addiction Equity Act (MHPA), the AMA is calling for greater enforcement and oversight of this landmark legislation as physicians face challenges related to the opioid epidemic.

The MHPA was signed into law by President George W. Bush in October 2008, and it requires that annual and lifetime dollar limits on mental health benefits be no lower than any such dollar limits for medical and surgical benefits offered by a group health plan or health insurance issuer.

Prior to its passing, insurers were not required to cover mental health care, which limited access. "The law's much-needed reforms improved opportunities for care and reduced the stigma of having a mental health or substance-use disorder," said AMA President-elect Patrice A. Harris, MD. "Yet, an overwhelming number of people needing treatment for an addiction are not receiving it. Clearly, we have a long way to go."

The 2017 National Survey on Drug Use and Health found that 92 percent, or 19.7 million people, with an SUD receive no treatment, and 57 percent, or 46.6 million people, with a mental illness receive no treatment.

"Insurers need to be held accountable for complying with their legal obligations," Dr. Harris said. "This means that health insurance companies must have addiction medicine and psychiatric physicians not only in the network but accepting new patients." 

Physicians and policymakers can learn more about parity, including how to file a complaint, from resources developed by the American Psychiatric Association (APA) and the American Society of Addiction Medicine (ASAM). The APA and ASAM are member organizations of the AMA Opioid Task Force.

AMA president returns to Iowa

The Iowa Medical Society (IMS) hosted AMA President Barbara L. McAneny, MD, in Iowa City, Iowa, where she had the opportunity to interact with health care leaders and professionals from across the state. Dr. McAneny, an alumnus of the University of Iowa (UI) Carver College of Medicine, visited the UI medical campus along with IMS President Michael Romano, MD, and Marygrace Elson, MD, IMS President-elect.

They met with Carver faculty and students as well as hospital administrators and health care providers at the University of Iowa Hospital to discuss a variety of topics, including the state of health care in Iowa and the importance of being involved in organized medicine at the state and national levels.

She also delivered the Grand Rounds at the Holden Comprehensive Cancer Center and visited the impressive Stead Family Children's Hospital, one of just two comprehensive children's hospitals in Iowa.

Dr. McAneny capped off her trip by addressing the IMS Board of Directors meeting where her remarks focused on physician leadership in the future of health care, emphasizing that physicians bring tremendous economic and cultural benefits to communities, but are operating under difficult conditions.

She stressed the need to put patients and physicians first by removing the obstacles and burdens that interfere with patient care, confronting the increasing chronic disease burden, reimagining medical education, training, and lifelong learning, and protecting coverage for all Americans.

"The decisions we make today will have a lasting impact on generations to come, and they're counting on us to get it right," Dr. McAneny said.

Dr. McAneny speaks with Dr. Daniel Berg (center) and Dr. Francois Abboud following her grand rounds presentation at the Holden Comprehensive Cancer Center. Dr. Abboud was one of Dr. McAneny's professors at the University of Iowa Carver College of Medicine.

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Other News

ONC and OCR release updates to Security Risk Assessment tool

The Health Information Portability and Accountability Act (HIPAA) requires physician practices to conduct Security Risk Assessments (SRAs) to evaluate compliance with HIPAA's rules about the privacy and security of patients' protected health information (PHI).

In honor of National Cybersecurity Month, the Office of the National Coordinator for Health Information Technology (ONC) and the Health and Human Services Department's Office of Civil Rights (OCR) have released a new version of their SRA Tool. ONC states that the updates are to make the tool more user-friendly and to more broadly consider a practice's risks to privacy, security, availability and integrity of protected health information.

While not perfect, the new version of the tool provides improved education and guidance to clinicians as they conduct an SRA. It also provides physicians with a summary of where the practice's risk is and with a detailed SRA to help physicians understand the results of the assessment. This documentation is important for physicians in the event that they are ever audited by the OCR, which is the agency that enforces HIPAA.

The AMA has advocated for more clarity on how HIPAA relates to physicians and has created toolkits to help elucidate HIPAA's privacy and security requirements.

How practices can prepare for public release of 2017 MIPS data

CMS will host a national provider call about Physician Compare and the public reporting of 2017 Quality Payment Program performance information on Oct. 30 from 1:30 to 3:00 p.m. Physicians will have the opportunity to review their 2017 MIPS public reporting data before it goes live on Physician Compare during the 30-day preview period. The AMA continues to advocate for changes in Physician Compare, including alignment between the MIPS quality measure-calculation policies and Physician Compare performance calculations.

The webinar will cover what to expect during the upcoming 30-day preview period and how to navigate previewing performance information.

There will be a question and answer session after the presentation. Register today. For information, please contact

Free CME programs on drug diversion offered in two states

The Drug Enforcement Administration (DEA) will be hosting two regional one-day Practitioner Diversion Awareness Conferences for physicians in Nashville, Tennessee, on Nov. 18-19, and in Hershey, Pennsylvania, on Dec. 17-18. The same conference will be held both days in each location and both are open to all DEA-registered practitioners in those states.

Several years ago, the DEA organized conferences like this around the country for pharmacists and the AMA recommended that they do something similar for physicians, so this is a welcomed development. Almost all the presenters are DEA officials. They will speak on the opioid epidemic, drugs of abuse, prescription drug monitoring programs, drug disposal and telemedicine. Each conference runs from 8 a.m. to 5 p.m. Attendance is free and attendees will receive a certificate from the Federation of State Medical Boards that can be used to obtain continuing education credits. To register or learn more visit this page.

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Upcoming Events

Register now for 2019 advocacy conferences to save on registration
Registration is now open for the 2019 American Medical Association State Advocacy Summit (formerly the State Legislative Strategy Conference) and the National Advocacy Conference. Register for both events today and get 20 percent off. SAS will be held Jan. 10-12 in Scottsdale, Arizona. NAC will be held Feb. 11-13 in Washington, D.C.

Oct. 24: Prior authorization – overview of AMA advocacy strategy
Register to attend an informative discussion of the AMA's multi-faceted advocacy campaign for prior authorization reform, and learn about resources available to help streamline the PA process. The webinar takes place from noon to 1 p.m. CST. Register now.

Oct. 24: Panel discussion on the new RAND study results
Register to attend this educational event from 9:30 a.m. to noon Oct. 24 in Washington, D.C., that will highlight the findings of the AMA-RAND follow-up study on payment models. Panel discussions will cover how the challenges still experienced, improvements realized and strategies implemented affect the shift to value-based care. AMA President Barbara L. McAneny, MD, will give opening remarks. Space is limited so reserve a spot now and be the first to hear the research results. 

Oct. 30, Nov. 15: Climate impact on health and emergency medicine
In this webinar series emergency medicine experts will explore the health impacts of climate change and opportunities to advance solutions that address human health and our health system. Participating physicians can earn one CME credit per webinar. Topics are "Preparing for climate emergencies" on Oct. 30 at 1 p.m. EST, and "Delivering climate-smart health care" on Nov. 15 at 1 p.m. EST. Register now.

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