Dec. 13, 2018

Issue Spotlight

First national estimate of telemedicine use by physicians

The AMA's Carol Kane, PhD, and Kurt Gillis, PhD, have authored a study documenting the first nationally representative estimates on how physicians use telemedicine, published in Health Affairs. They found that telemedicine is more frequently utilized in larger practices and among certain specialties like emergency medicine and radiology. The use of telemedicine for interactions with other health care professionals is also higher among physicians in nonmetropolitan areas.

By examining a 2016 survey of 3,500 physicians, Kane and Gillis gauged the emergence of telemedicine and its integration into health care delivery, while noting that further legislative and regulatory changes could encourage use in the future.

"There are no nationally representative estimates on its use by physicians across all medical specialties," said Carol K. Kane, study co-author and AMA director of economic and health policy research. "To fill this information gap, the AMA study surveyed 3,500 physicians to provide needed data that will help assess potential barriers and create strategies to promote telemedicine adoption."

The study found that 15.4 percent of physicians worked in practices that used telemedicine for patient interactions, such as diagnosing or treating patients, and following up with or managing patients with chronic conditions. 11.2 percent of physicians worked in practices that used telemedicine for interactions with health care professionals, such as having a specialty consultation or getting a second opinion. Videoconferencing was the most common modality, being utilized in the practice of 12.6 percent of physicians surveyed.

Among specialties, the use of telemedicine for patient interactions ranged from 6.1 percent for the internal medicine subspecialty of allergy/immunology to 39.5 percent for radiology. The use of telemedicine for interactions with other health care professionals ranged from 3.3 percent for allergy/immunology to 38.8 percent for radiology.

More generally, physicians in larger practices and in ones that were not physician owned were more likely to use telemedicine for interactions with both patients and health care professionals. The higher use in nonmetropolitan locations for interactions with health care professionals suggests that physicians are using telemedicine to alleviate access issues when relevant subspecialists are not available. However, the financial burden of implementation still appears to present a problem for smaller and physician-owned practices.

The AMA is committed to making technology an asset, not a burden, and continues to invest in resources that provide physicians with a proven path for integrating telemedicine and digital health technologies into patient care.

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National Update

Proposed rule would penalize immigrants who access health care and other public benefits

In a comment letter the AMA strongly opposed a proposed rule that seeks to significantly expand the number of immigrants who are denied permanent legal status on public charge grounds. The proposed rule would alter the definition of public charge from "primarily dependent" on the government for subsistence to any immigrant who receives "one or more public benefits."

A significantly expanded list of factors to be considered in making a public charge determination, including the Children's Health Insurance Program (CHIP) and Supplemental Nutrition Assistance Program (SNAP), is coupled with the proposed change in definition. The AMA registered its concern that, if finalized, this proposal would lead to poorer health outcomes for the nation by discouraging immigrants from seeking necessary health care. The AMA letter also identified increases in poverty—as immigrants assume more out of pocket health care costs—and negative impacts to public health as foreseeable unintended consequences.

This strong stand against the proposed rule was the result of a clear directive from the AMA House of Delegates to oppose efforts that discourage immigrants from seeking health care.

Trump administration releases new drug pricing rule for Part D drugs

The Trump administration released a new rule proposing changes to the Part D prescription drug benefit and Medicare Advantage programs. The proposed rule includes several potential policy changes impacting Part D protected class drugs, Part B drugs in Medicare Advantage and real-time pharmacy benefit tools at the point of care.

For Part D protected classes, the administration is proposing several changes that may adversely impact patient access to critical drug products. They are proposing to allow Part D plan sponsors to use prior authorization and step therapy protocols, as well as indication-based formulary design, for protected class drugs. Part D plan sponsors would also be able to exclude from their formularies any new formulations of protected class drugs, even if older formulations are no longer available, as well as drugs for which prices have increased beyond the rate of inflation.

Additionally, the administration is moving to formalize an earlier policy change that allows Medicare Advantage plans to use step therapy protocols for Part B drugs. The proposed rule reiterates this policy change, and provides some new parameters for Medicare Advantage plans using step therapy protocols. It would modify adjudication time periods for organization determinations and appeals, bringing them in line with Part D timeframes, and allow step therapy protocols only for new starts, not for existing treatment regimens. The AMA led a sign-on letter to the Centers for Medicare & Medicaid Services (CMS) opposing the earlier step therapy policy change and continues to have serious concerns about the increasing use of utilization management techniques by both public and private payers.

In addition to the protected class and step therapy proposals, CMS is proposing to require Part D plan sponsors to implement an electronic benefit tool to provide prescribers with access to real-time pharmacy benefit information for patients. The AMA has supported calls for this information to be available at the point of prescribing.

Administration releases new report on choice and competition in health care

The Trump administration released a long-awaited report titled "Reforming America's Healthcare System Through Choice and Competition." The report aims to examine and discuss the influence of current state and federal policies on choice and competition in health care markets and makes recommendations to both state and federal lawmakers to "develop a better functioning health care market."

It discusses a significant number of topics, including scope of practice, telemedicine, graduate medical education funding, non-compete clauses in employment contracts, foreign-trained physicians, the Affordable Care Act, the system of third-party payment for health care services, health information technology and others. While the report is not open for public comment, the AMA will closely monitor policymakers at both the state and federal levels to see what, if any, actions are taken on the report's recommendations.

HHS issues draft burden reduction strategy

The U.S. Department of Health and Human Services' (HHS) Office of the National Coordinator for Health Information Technology (ONC) is seeking comments on a draft strategy regarding reducing regulatory and administrative burdens related to the use of electronic health records (EHR). The 21st Century Cures Act instructed HHS to identify, through consultation with stakeholders, ways to reduce regulatory and administrative burdens relating to EHR use.

The draft report outlines three overarching goals: reduce the effort and time required to record health information in EHRs; reduce the effort and time required to meet regulatory reporting requirements; and improve EHR functionality and ease of use. The AMA has advocated for reducing the burdens of health information technology and welcomes this opportunity to work with HHS to improve regulations around EHR use and design. ONC is seeking public feedback on the draft burden reduction strategy, and the AMA will be providing comments.

AMA urges CMS to exempt educational material from Open Payments reporting

The AMA and 81 state medical and specialty societies signed on to a letter urging CMS to exempt journal reprints and medical textbooks from Open Payments reporting using a preexisting statutory exclusion for "educational materials that directly benefit patients." The letter was drafted in response to a CMS request for feedback regarding the Open Payments reporting requirements. The letter also notes ongoing challenges with manufacturers reporting independent continuing medical education—this is not required unless the manufacturer requires, instructs, directs or otherwise causes the third party to provide the payment or transfer of value, in whole or in part, to a covered recipient—and it urges the agency to play a more proactive role in the reporting process by working with stakeholders on a common set of definitions of what is reportable.

Open Payments year-end reminder: Physicians who review their data and find potential errors can file disputes with the appropriate reporting entity (drug makers and Group Purchasing Organizations) through Dec. 31.

Learn more about reviewing and disputing public data.

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State Update

Spotlight analysis shows how Pennsylvania is responding to the opioid epidemic—and what else is needed

The AMA, Pennsylvania Medical Society (PAMED) and Manatt Health today released the first study of a state's response to the opioid epidemic. Focusing on Pennsylvania, the spotlight analysis found that considerable progress is being made to increase access to evidence-based treatment for substance use disorders. This includes the landmark agreement last month between the Governor's administration and the seven largest insurers in the state, fully removing prior authorization requirements for medication-assisted treatment (MAT) to treat substance use disorder.

"We conducted this analysis because it's essential that policymakers know what is working, and where additional progress can be made," said Dr. Patrice Harris, AMA president-elect and Chair of the AMA Opioid Task Force, in a video. "There is long way to go to fully end the epidemic in Pennsylvania and across the nation, but it's clear that Pennsylvania's policymakers are employing multiple strategies that are showing promise."

The spotlight analysis reviewed how well Pennsylvania is making progress in three main areas:

  • Increasing access to high-quality, evidence-based care for substance use disorders
  • Providing comprehensive care to patients with pain
  • Enhancing access to naloxone

Based on available data, review of key policies, and discussions with key policymakers, the spotlight analysis found that there were four key areas where the Commonwealth was succeeding:

  • Comprehensive support for MAT
  • Enforcement of mental health and substance use disorder parity laws through detailed market conduct examinations of health insurance companies
  • Comprehensive naloxone access policies
  • Medically-based oversight for Medicaid patients with careful review of care plans for patients with an opioid use disorder as well as for patients with chronic pain

Pennsylvania has been hit hard by the opioid epidemic with prescription opioid-related overdose growing in the early 2000s and more recently, high volumes of heroin and fentanyl coursing through the Commonwealth. The challenges faced by the Commonwealth make for an ideal case study for other states of how strong leadership can make a difference—even if the fight is not over yet.

The spotlight analysis also found areas where additional progress could be made, including continued enforcement and refinement of tools to identify parity violations, expanding efforts in emergency departments and law enforcement to link efforts to coordinate patients' access to high quality, evidence-based treatment, and more.

Visit the AMA's End the Epidemic website to access the full report.

Keynote speaker for State Advocacy Summit just announced

Dec. 18 is the last day to register and book your hotel room for the AMA State Advocacy Summit, Jan. 10-12, in Scottsdale, Arizona. Ashish K. Jha, MD, MPH, director of the Harvard Global Health Institute, who earlier this year authored a widely read and cited study of health care costs published in JAMA, is the keynote speaker.

Key topics to be debated and discussed at the meeting include:

  • Pharmacy benefit managers: What do they do?
  • Managing Medicaid priorities in 2019
  • A thousand cuts and a thousand opportunities: How states can restore and improve access to care in the individual market

AMA, OMA voice concerns for proposed Oregon pain policy

The AMA and Oregon Medical Association (OMA) joined together to voice concerns over a new Oregon proposal that could interfere with the ability of pain patients to receive individualized care. The proposal aims to have all patients receiving opioid therapy tapered to zero opioid exposure.

The AMA and OMA wrote in a joint statement, "We request that recommendations be written with an acknowledgment of the fact that there may be patients who never reach zero use due to medical complexities and diagnosis, among other factors. And we further request inclusion of language stating that neither patients nor physicians should ever be forced into nonconsensual tapering protocols by payers or the state that contravene the treatment plan prescribed by the provider."

The medical societies' concerns were echoed by many national pain experts. "There is no demarcation or line in the sand where this dose of opioids is unsafe and this dose of opioids is safe," said Dr. Sean Mackey, a pain medicine specialist at Stanford University to the Bend Bulletin.

Dr. Mackey and other national pain experts detailed their concerns in a letter to the Oregon Health Authority. The Oregon proposal must pass at least two additional Oregon committees before it would go into effect.

For more information, please contact the OMA's Aaron Ragan-Fore.

New AAP quality improvement course on substance use in adolescence

The American Academy of Pediatrics (AAP) is offering complimentary access (for a limited time) to a new course for pediatricians and other interested physicians to help with adolescent substance use screening, brief intervention and referral to treatment (SBIRT).  The course will help physicians identify and close gaps in their practice related to SBIRT using practical tools, while earning continuing medical education credit and meeting part 4 (performance in practice) maintenance of certification credits. To access more AAP resources, visit the AMA opioid microsite.

PCSS offering free, 8-hour online MAT waiver course

The Providers Clinical Support System (PCSS) has developed a new eight-hour MAT waiver course that is entirely online. After taking the course, physicians and other health care professionals eligible for an MAT waiver should be able to:

  • Review addiction identification and evidence-based treatments
  • Discuss the pharmacology of opioids as it relates to treatment of opioid use disorder (OUD) patients
  • Describe the fundamentals of office-based opioid treatment including the treatment of the co-morbid patient
  • Explain the process of buprenorphine induction as well as stabilization and maintenance
  • Discuss other approved antagonist and agonist medications to treat OUD
  • Discuss basic office protocols including medical record documentation and confidentially
  • Utilize evidence-based resources to ensure providers have the confidence to prescribe buprenorphine for patients with OUD
  • Apply for a MAT Waiver Training Certificate to begin treating patients with OUD

See more PCSS resources at the AMA opioid microsite.

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Judicial Update

Top Kentucky court strikes down law on medical review panels

Kentucky physicians will continue to face meritless lawsuits thanks to a recent commonwealth high court ruling.

The Supreme Court of Kentucky has struck down a 2017 state law that created a medical review panel, a group of experts who were to evaluate medical liability claims to ensure they had merit before a plaintiff filed a lawsuit against a health care provider.

The Litigation Center of the American Medical Association and State Medical Societies and the Kentucky Medical Association (KMA) filed an amicus brief that urged the Kentucky Supreme Court to keep the law intact after a patient seeking to file a claim challenged the law shortly after it was passed. The Litigation Center also helped offset the expenses the KMA incurred in the trial court.

KMA leaders said they were "extremely disappointed" in the ruling in Commonwealth of Kentucky v. Claycomb.

"Kentucky now remains one of the few states in the country with no meaningful tort reform, including medical liability reform, making our system more susceptible to higher costs and frivolous lawsuits," the KMA said in a statement after the ruling.

Implementation of medical review panels dates back to 1975, when Indiana began using them to weed out frivolous lawsuits before physicians and the health care system had to spend money to defend meritless claims. More than a dozen states now have laws that require some form of a medical review panel that must give an OK before a medical liability lawsuit is filed, according to the National Conference of State Legislatures.

Read more.

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Other News

Listen now: 5 ways the midterms shook up the U.S. health care agenda for 2019

Polls said health care was the top issue on voters' minds, but whether a divided Congress can work with President Donald Trump to address the public's concerns remains to be seen—though some issues, such as curbing drug prices, have bipartisan appeal.

That is the well-considered view of AMA experts such as Richard Deem, the AMA's senior vice president for advocacy, and Todd Askew, AMA director of congressional affairs.

Askew and Deem, who took part in an AMA Council on Legislation educational session at the 2018 AMA Interim Meeting noted five areas in which the election results could shape the nation's health care agenda. Listen to a podcast of the session, which discussed:

ACA repeal efforts. While some Republicans may want to continue down the repeal-and-replace path, Democrats in the House will stop them. Likewise, Democrats may try to reverse some of the actions Republicans took to dismantle the ACA.

Deem noted that "previous bipartisan proposals to help stabilize the individual health insurance marketplace may be resurrected"—such as funding for cost-sharing reduction payments.

Prescription drug prices: While approaches may vary, some sort of limited action could occur as both sides have an interest in the issue. Patent reform or more price transparency may have bipartisan appeal.

Gun violence: While some proposals may get through the House, efforts may stall in the Senate. Askew noted that Democrats could schedule hearings on measures to address the public health threat of gun violence and seek to renew CDC funding for gun violence research as step in a broader prevention strategy

The opioid epidemic: More states will follow Pennsylvania's lead and adopt policies opposing prior authorization for medication-assisted treatment for opioid-use disorder, Deem predicted. The AMA has engaged with insurance regulators, Medicaid directors and behavioral health providers to develop a playbook to share with other states. Read more on this advocacy in the state section above.

Changing committee leadership's effect: Leadership lineups are being shuffled in both chambers by both parties. This could affect how heavily health care legislation is promoted. Most notably, Sen. Charles Grassley, R-Iowa, is giving up his chairmanship of the Judiciary Committee to chair the Finance Committee, which deals with Medicare and Medicaid. Grassley previously led the panel from January 2003 to January 2007, and let it be known he was open to taxing nonprofit hospitals.

Health care impact of the border-wall debate: A "big fight is likely" over funding of a wall on the U.S. border with Mexico that could consume the attention of Congress, the money available for other needs and possibly even lead to a government shutdown, Askew said.
"Our priorities haven't changed," Deem said. "Clearly, we are going to continue to advocate very firmly for expanding coverage, maintaining the safety-net programs, and making sure that there is better health equity in this nation."

Read the full story here.

Physician Compare preview period is open

The Physician Compare 30-day preview period is open as of Nov. 30. Physicians can now preview their 2017 Quality Payment Program performance information as it will appear on Physician Compare in early 2019. The secured measure preview can be accessed through the Quality Payment Program website. To learn more about the 2017 Quality Payment Program performance information and 2016 clinician utilization data that are available for preview, download the following documents from the Physician Compare Initiative page:

Clinician Performance Information on Physician Compare: Performance Year 2017 Preview Period

Group Performance Information on Physician Compare: Performance Year 2017 Preview Period

The 30-day preview period will close on Dec. 31 at 8:00 p.m. Eastern time. CMS advises that those who have questions about Physician Compare, public reporting or the 30-day preview period should contact the agency at

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Upcoming Events

Register now for both 2019 advocacy conferences

Register for the 2019 AMA State Advocacy Summit (formerly the State Legislative Strategy Conference) by Dec. 18, and save 20 percent when you register for both the State Advocacy Summit and National Advocacy Conference. The State Advocacy Summit will be held Jan 10-12 in Scottsdale, Arizona, and the National Advocacy Conference will be held Feb. 11-13 at the Grand Hyatt in Washington, D.C.

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