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March 7, 2019

Issue Spotlight

AMA and other health groups strongly object to Title X Family Planning Rule

Last year, the AMA filed comments to the Department of Health and Human Services (HHS) to express strong concerns about proposed regulatory changes to the federal family planning program, Title X. On Feb. 22, the Trump administration issued the final rule.

Of significant concern to the AMA, the final federal regulations, if allowed to go into effect, would limit women's access to health care and force physicians to withhold information from patients about all of their health care options. Specifically, federally-funded family planning clinics will no longer be required to give patients access to non-directive counseling on all their options; physicians are permitted to provide non-directive counseling, but are not required to do so. The rule also requires that Title X providers refer all pregnant patients for prenatal care, and prohibits such providers from referring a patient for abortion as a method of family planning; pregnant patients may only be given a list of primary care providers for prenatal care, some of whom may also provide abortion services but may not be identified as such. Moreover, these clinics will have to be organized so that they maintain physical and financial separation between services funded by the government and any organization that provides abortions or referrals for abortions.

The Title X program provides contraceptives, screening and treatment for sexually transmitted diseases and other primary health care services to four million patients each year, many of whom are low-income or uninsured. Planned Parenthood serves about 40 percent of this caseload. In effect, the final regulation will make many currently funded Title X clinics, primarily Planned Parenthood clinics, ineligible for funding, thereby reducing patient access to comprehensive family planning and women's health services. It will also effectively restrict open and direct conversations between physicians and patients about their health care options. Because the final rule includes significant restrictions on physician speech, the AMA has filed a lawsuit in federal court in Oregon along with the Oregon Medical Association and Planned Parenthood.

Read more details in a story by AMA President Barbara A. McAneny, MD.

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National Update

HHS seeks feedback on changing HIPAA to improve care coordination

The HHS Office of Civil Rights (OCR) issued a Request for Information (RFI) in late 2018 asking questions about possible changes to the Health Insurance Portability and Accountability Act (HIPAA) to improve care coordination. The AMA submitted lengthy comments reflecting a commitment to the importance of how protection of patient privacy fosters trust in the physician-patient relationship, as laid out in AMA policy and Code of Medical Ethics.

Some questions in the RFI asked whether the rule should be changed to require (instead of permit) disclosures of patient information. If that shift were to occur, physicians would have to release patient information that they had not previously been required to share. AMA supports care coordination activities and the numerous benefits that can result from coordinated care, however OCR should promote information sharing for these activities through education and positive incentives—not requirements, especially those that value speed over privacy.

Included below is a non-exhaustive list of additional comments:

  • AMA is strongly opposed to any mandate or requirement to disclose protected health information (PHI) to any entity other than the patient. Requiring a physician to share information against a patient's wishes strips patients of control over their own data and potentially overrides medical decision-making. Moreover, policymakers must consider whether relaxing privacy controls will encourage patients to seek care or potentially deter them.
  • Business associates—including health care clearinghouses—should always be required to enter into business associate agreements. A physician is the steward of a patient's health information and has a duty to the patient to protect it.
  • A widespread misperception exists that HIPAA prevents physicians from sharing information—especially related to behavioral health and substance use disorder (SUD)—with families and caretakers. In fact, OCR's own guidance states that HIPAA allows physicians to talk to a patient's family members, friends or others involved in the patient's care and other providers for treatment and care coordination.
  • Technology that tracks patient consent electronically can help physicians manage the sharing of sensitive information (e.g., reproductive health, domestic violence, HIV status and genetic information) while maintaining robust patient privacy protections. Making this technology affordable and accessible for physicians would help to enhance interoperability, support compliance with state privacy laws and bolster trust within a physician-patient relationship by ensuring a patient that his or her sensitive information is private.
  • OCR should help reframe the conversation around securing health information from punitive requirements (e.g., fines and penalties for security failures) by developing positive incentives that encourage ways to bolster practice resilience, protect patient information and promote information sharing about security threats.
  • OCR should remove the presumption of guilt on a physician when patient information is inappropriately used or disclosed. That framework creates potentially unnecessary physician burden, stress and compliance costs. Instead HHS should base the duty to report a breach on a harm threshold.

Physicians urge CMS to address prior authorization in Medicare Advantage

Along with 51 specialty and 45 state societies, the AMA submitted a sign-on letter urging the Centers for Medicare & Medicaid Services (CMS) to provide guidance to Medicare Advantage plans on prior authorization (PA) processes through its 2020 call letter. The letter asked that CMS' guidance direct plans to target PA requirements where they are needed most. Specifically CMS should require Medicare Advantage plans to selectively apply PA requirements and provide examples of criteria to be used for such programs, including ordering/prescribing patterns that align with evidence-based guidelines and historically high PA approval rates.

The letter noted that the PA process can be burdensome for all involved and can adversely affect patient health outcomes by delaying the start or continuation of necessary treatment. It drew on concepts outlined in the Consensus Statement on Improving the Prior Authorization Process, issued by the AMA, the American Hospital Association, America's Health Insurance Plans, the American Pharmacists Association, Blue Cross Blue Shield Association and the Medical Group Management Association in January 2018.

This letter is only the latest AMA effort to #FixPriorAuth in the federal space. AMA has also opposed additional utilization management requirements on the six protected classes under Part D, made recommendations to CMS to reduce the impact of PA as a way to increase efficiencies in the Medicare and Medicaid programs, expressed serious concern about Government Accountability Office (GAO) recommendations to increase PA in Medicare and brought together nearly 100 medical societies to oppose increased use of step therapy for Part B drugs.

How Medicare Advantage and Part D policies can help address the opioid epidemic

Also in response to the draft 2020 call letter outlining proposed Medicare Advantage and Part D policies, the AMA submitted separate comments that strongly support CMS proposals to improve patient access to evidence-based treatment for opioid use disorder, non-opioid therapies for pain and naloxone. The AMA recommended that CMS go further and require that plans eliminate any prior authorization requirements for medication-assisted treatment (MAT) and urge Part D sponsors to ensure that patients have access to MAT options in all drug classes at the lowest cost-sharing tier.

AMA answers call for solutions to rising health care costs

Following a series of hearings in 2018, the Senate Health, Education, Labor and Pensions (HELP) Committee Chairman Lamar Alexander (R-TN) wrote health care stakeholders to request information on what steps Congress should take to address rising health care costs. Alexander noted that he was "interested in trying to bring to the health care system the discipline and cost saving benefits of a real market. Too many barriers to innovation drive up costs. And most Americans have no idea of the true price of the health care services they buy – which also drives up costs." Stakeholder responses were requested by March 1, 2019.

In response, the AMA highlighted a number of areas where Congress or the administration could take specific steps to lower overall health care costs. High on that list were proposals to address the cost and time burdens administrative requirements place on physicians and their staffs. Eight percent of U.S. health care spending goes toward "administration and governance" activities. In addition to payment systems, this burden also includes prior authorization which, according to a recent AMA survey, consumes nearly two full days (14.9 hours) of physician and staff time per week, per physician.

Greater scrutiny of these practices by Congress, including addressing the burdens placed on physicians by public payers, could significantly reduce unnecessary costs in the health care system. The AMA letter also addressed the growing cost of prescription drugs, the need to increase pricing transparency, and the potential of value-based insurance design to align clinical and financial incentives among stakeholders and foster a legal and regulatory environment where innovative plan designs can be explored. Other recommendations included stepped-up efforts to support alternative payment models and lowering health care costs with increased attention on prevention, including the AMA-led focus on preventing diabetes and controlling hypertension. Combined, these two conditions account for almost $280 billion in annual health care expenditures and $110 billion in lost productivity.

The AMA remains engaged with Sen. Alexander and the HELP Committee on this important topic and is encouraged that the committee is focusing on addressing this growing burden on taxpayers, employers and families in partnership with physicians and other health care providers and stakeholders.

VA proposes permanent replacement to the Veterans Choice Program

On Feb. 22, the Department of Veterans Affairs (VA) issued a proposed rule that would establish the Community Care Program as a permanent replacement to the Veterans Choice Program. New eligibility criteria and access standards would increase veterans' access to community-based care. The current distance-based standard (veterans must live at least 40 miles away from the nearest VA facility) will be replaced with average drive time and appointment wait times. The VA is proposing a 30-minute average time standard and a 20-day appointment wait time for primary care and mental health care. For specialty care, the access standard will be 60 minutes and 28 days respectively. Payment rates to non-VA providers would not exceed Medicare and future rulemaking will define the VA's contractual relationship with eligible providers. The rule includes a 30-day comment period—March 25 is the deadline.

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State Update

AMA advocates for elimination of nonmedical vaccine exemptions

Following outbreaks of measles in Washington and Oregon that have, to date, sickened 74 individuals, lawmakers in many states are considering bills to change childhood vaccination laws. The AMA is very concerned about the action in some states to allow nonmedical exemptions and is working to change these laws. All states require certain vaccines for children attending school. All but three states (California, Mississippi and West Virginia) allow parents to opt out of vaccines for their children for personal, philosophical or religious reasons, though specific exemptions vary by state. This year state legislatures across the country are considering bills that would either expand or eliminate nonmedical exemptions.

Nonmedical exemptions are a barrier to the high immunization rates necessary for herd immunity and work against the establishment of a successful vaccination program. The AMA supports eliminating all non-medical exemptions from required childhood vaccines and has submitted testimony on legislation in Arizona, Maine, Oregon and Washington. Similar legislation is currently pending in several other states and the AMA continues to work with state medical associations on those bills.

For assistance with immunization laws in your state, contact the AMA Advocacy Resource Center.

Massachusetts Insurance Commissioner issues naloxone bulletin

Life insurance carriers need to be more careful in underwriting when there is a prescription for naloxone or other medications not relevant to an individual's health condition, the Massachusetts Insurance Commissioner said in a recent bulletin. The bulletin was issued after widespread concerns were sparked by a recent story where a nurse employed by an addiction treatment program at Boston Medical Center had a standing order for naloxone and was denied life insurance as a result. "It would defeat the Commonwealth's important public health efforts if applications for individual accident and sickness insurance policies, life insurance policies and annuity contracts, were unfavorably impacted solely because the applicant had obtained naloxone or some other opioid antagonist to address opioid overdoses of other persons or had a prescription to prevent illness or disease," said the Feb. 1 bulletin The Massachusetts Medical Society was among many in the Commonwealth urging the commissioner to issue the bulletin.

State medical societies working to remove prior authorization for MAT

Medical societies in Kentucky, Montana and Vermont are among the first states in 2019 working to enact legislation that would remove prior authorization requirements for medication-assisted treatment (MAT) for opioid use disorder. The state societies, AMA and American Society of Addiction Medicine are working closely to help legislators understand that the best time for patients to receive treatment is when the patient expresses the desire to receive treatment—and that any delay or denial of care due to a prior authorization requirement could have fatal consequences. In Kentucky, HB 121 unanimously passed the House but has not yet been scheduled for a hearing. In Montana, SB 280 did not move out of committee but may be attached to legislation going to the Senate. And in Vermont, S. 43 passed out of the Senate and is awaiting a hearing in the House.

For more information, please contact the AMA's Daniel Blaney-Koen.

Free CME for physicians registered with DEA in Ohio

The diversion of pharmaceutical controlled substances is a growing problem. To help registered practitioners in identifying and preventing diversion activity, the Drug Enforcement Administration (DEA) will be hosting two regional free one-day Practitioner Diversion Awareness Conferences (PDAC) March 18 and 19 in Cleveland. There is no registration fee and the conference is open to all DEA Registered Practitioners in Ohio. The same program will be held both days; participants can attend either day. Attendees will receive a certificate from the Federation of State Medical Boards which they can present to their appropriate boards/associations for possible continuing educational credits. The Federation of State Medical Boards designates this live activity for a maximum of 6.5 AMA PRA Category 1 Credits™.

Topics covered include:

  • The Ohio Automated RX Reporting System (OARRS)
  • Prescriptions for controlled substances
  • Methods of diversion and effective controls for controlled substances
  • Telemedicine
  • Disposal, return of patient medications and options for patients

The conferences will be held in at the Renaissance Cleveland Hotel. Learn more by reading the full agenda and register now.

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Other News

Slowdown in health spending growth continues

A new AMA Policy Research Perspective provides a detailed examination of U.S. National Health Expenditures (NHE) through 2017 using data released by CMS. In 2017 health spending in the U.S. was $3.5 trillion or $10,739 per capita. Health spending as a share of GDP decreased from 18.0 percent in 2016 to 17.9 percent in 2017. Spending grew more slowly in 2017 (3.9 percent) than in 2016 and 2015 (4.8 percent and 5.8 percent). This slowdown was evident across most payers and types of spending, reflecting the stabilized enrollment and spending rates after the initial years of Affordable Care Act implementation. In particular, physician spending growth was low and stable over the 10-year period ending in 2017 (3.8 percent per year on average).


Learn more in an AMA News story.

New survey shows decline in physician burnout

For the first time since 2011, the physician burnout rate has dropped below 50 percent among physicians in the United States, according to a new triennial study. While the decrease in the physician burnout rate might suggest that health systems are on the right track, more work still needs to be done. 

Read more in AMA News and the press release

Xcertia releases new mHealth app guidelines, adding three categories 

Xcertia, the nonprofit organization launched in 2016 by the Healthcare Information and Management Systems Society (HIMSS), American Medical Association, American Heart Association and the DHX Group, unveiled new mobile health (mHealth) app guidelines at the recent HIMSS conference and exhibition in Orlando. The group is gathering public comments on the guidelines through May 15. Learn more on the Xcertia website.

Contribute to new AMA-RAND research on behavioral health

The RAND Corporation and AMA are conducting research to better understand and describe how physician practices in a variety of specialties and practice arrangements have integrated behavioral health care into the range of services they offer. If you have integrated behavioral health care in your practice, whether you are in the early stages or have a well-established program, please consider participating in this research project. This phone interview-based research will enable the AMA to provide physicians with training and resources needed to effectively implement and manage behavioral health care in their practices.

Contact Mark Friedberg, MD, MPP, RAND senior physician policy researcher, to participate.

New regulatory clarification reduces administrative burden on physicians

The newest addition to the AMA's ongoing series on debunking regulatory myths, which seeks to provide physicians with resources to reduce guesswork and administrative burden, addresses ancillary staff and/or patient documentation. This resource seeks to answer the question: who on the care team can document components of E/M services and what is the physician required to do? Physicians do not need to re-document chief complaints or history recorded in the medical record by the patient himself or ancillary staff. Physicians can now review the information in the record, update or supplement it as necessary and indicate in the medical record that they have done so.

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Upcoming Events

Thriving in practice: A TCPI graduation performance story

March 13: In a new AMA webinar on March 13 at 1 p.m. Eastern time, the team from Heartland Health Services will be sharing how their journey through the Transforming Clinical Practice Initiative (TCPI) led them to successfully complete all five phases of the program and helped them strengthen their practice. The team will share specific instances of their successes, barriers and how they overcame them.

Meeting quality goals with behavioral health integration

March 20: Integrating behavioral health services within primary care can improve outcomes by directly addressing common issues such as depression, anxiety and stress and providing appropriate psychotherapeutic treatment. In addition, these services have been shown to have a direct positive impact on other important quality measures such as blood pressure, glycosylated hemoglobin, patient satisfaction and total cost of care. In a new AMA webinar on March 20 at 1 p.m. Eastern time, data will be presented from clinical trials of this approach, and suggestions will be made on how to incorporate these types of services in a primary care practice.

Ending the opioid epidemic: How to change policy in your state.

March 27: Join AMA president-elect Patrice A. Harris, MD, MA, for a webinar on March 27 at 1 p.m. Eastern time to hear how you can advocate in your state for policies to help end the opioid epidemic. Dr. Harris will be joined by state regulators to discuss specific state-focused strategies that are helping reduce the epidemic and improving patient care. By attending this webinar, you will get an insider's look at policymaking and how your experiences can impact the advocacy of your state medical society, regulators and the AMA. Stories like these have already been shared with the AMA and are being used to effect change:

  • "When someone decides they are ready for treatment, time is critical. Time spent waiting for a service authorization makes it more difficult for the individual who initiates treatment to remain engaged in treatment." – John Gallagher, MD, Pennsylvania
  • "Until you can give me a policy by which physical therapy, occupational therapy, massage therapy, acupuncture, biofeedback and behavioral health are as cheap as a five-dollar prescription for [an opioid] each month, I'm going to have problems." – Rachel Franklin, MD, Oklahoma
  • "Ninety-nine percent of the time prior authorization requests are approved, so the delay is a senseless bureaucratic hurdle that can be the difference between continued recovery and relapse for vulnerable patient populations." – Yngvild Olsen, MD, MPH, Maryland

2019 Rx Drug Abuse and Heroin Summit

Apr. 22-25: The Rx Drug Abuse & Heroin Summit is the largest and most-recognized conference committed to addressing the opioid crisis. Government officials, first responders, law enforcement personnel, clinicians, physicians, nurses, educators, public health and prevention officials, and families and people in recovery are represented. The conference agenda is designed with timely and relevant information to address what is working in prevention, treatment and law enforcement. AMA Trustee S. Bobby Mukkamala, MD, will be representing the AMA, giving a presentation April 24, "Moving slowly to treatment: policymaker, payer and physician leadership to end the epidemic."

The 2019 Summit returns to the Hyatt Regency in Atlanta.

Visit www.rx-summit.com to explore the agenda and register.

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