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May 3, 2019

Issue Spotlight

Physician proposals inspire new HHS payment models for primary careHHS presents new primary care payment models at AMA office

Physician proposals inspire new HHS payment models for primary care

U.S. Department of Health and Human Services (HHS) Secretary Alex Azar unveiled an initiative with five new primary care payment models at the AMA’s Washington office.

Azar said the new models would “radically elevate” the importance of primary care in the U.S. health system, lay the groundwork for better care, and lower costs in the $700 billion Medicare and $580 billion Medicaid programs. The plans, he said, would allow physicians to “focus on the patients in front of them rather than the paperwork we send them.”

The AMA commended HHS for providing potential pathways for physicians providing care to patients with complex and chronic needs.

“Providing adequate financial support for high quality primary care must be an essential element of any strategy to improve the quality and affordability of our country’s health care system,” said Gerald E. Harmon, MD, a family physician and immediate past chair of the AMA Board of Trustees.

Under the new models, Medicare would reward practices for providing more convenient access to care, and start paying for services such as enhanced chronic disease care management, acute care in-home services and palliative care.

Innovative physicians have found that, by providing these services, they can significantly improve quality of care while reducing total health care spending, but most of these efforts were only being financially supported by grant funding. The new models promise predictable monthly payments with bonuses for keeping patients healthy.

“Many primary care physicians have been struggling to deliver the care their patients need and to financially sustain their practices under current Medicare payments,” Dr. Harmon said. “The new primary care payment models announced today will provide practices with more resources and more flexibility to deliver the highest-quality care to their patients.”

More than 200 medical specialty society representatives and other stakeholders attended the announcement, where they also met to discuss primary care delivery. Azar was joined by Seema Verma, Centers for Medicare & Medicaid Services (CMS) administrator, and Adam Boehler, director of the Center for Medicare and Medicaid Innovation (CMMI).

Participation in the models would be voluntary for both patients and physicians. Azar expressed confidence that 25% of Medicare beneficiaries and 25% of the physicians who care for them would benefit from the innovation models.

Azar predicted that physicians would take part because the models offer simplified and predictable payments. Also, the models are designed to encourage state Medicaid programs and commercial insurers to take similar approaches, he said.

Primary Care First (PCF) models are designed for small practices and provide a monthly, flat revenue stream for each patient. Practices could be responsible for downside risk of up to 10% of practice revenue but also be eligible for an “asymmetrical” 50% bonus if patients stay healthy and out of the hospital, Boehler said.

Primary Care First—High Needs Populations will focus on patients with complex and chronic needs and seriously ill populations.

Azar presented three variations on a direct contracting model for larger organizations with at least 5,000 Medicare beneficiaries and experience taking on financial risk with accountable care organizations, Medicare Advantage plans or Medicaid managed care. This included a “geographic” model still in progress and CMS is seeking information to “further refine the design parameters.” Input will be accepted by email at DPC@cms.hhs.gov through May 23.

Plans call for the PCF models to be tested for five years beginning in January 2020, with applications to be available in the next “month or so,” Boehler said. The direct contracting models will also be launched in January and applications will be released in June.

The AMA commended Azar for basing the new payment models on proposals developed by practicing physicians and incorporating recommendations from the Physician-Focused Payment Model Technical Advisory Committee (PTAC).

“Secretary Azar has said that the best ideas for improving outcomes often come from individuals and organizations on the front lines of the health care delivery system, and we agree,” said Dr. Harmon. “PTAC has identified a dozen payment models developed by physicians that it believes merit testing or implementation by HHS, and we hope today’s announcement will be the first of many efforts to implement PTAC’s recommendations.”

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National Update

AMA bolsters physician workforce and supports GME

The Senate Health, Education, Labor and Pensions (HELP) Committee Jan. 29 held a hearing titled, “Access to Care: Health Centers and Providers in Underserved Communities.” The hearing focused on the Sept. 30 expiration of mandatory funding for Community Health Centers (CHC), Teaching Health Centers (THC), National Health Service Corps (NHSC) and Indian Education programs, commonly referred to as the “primary care cliff.”

The AMA has offered its support for S. 192, the “Community and Public Health Programs Extension Act of 2019,” which provides five years of mandatory funding for the NHSC, the Teaching Health Center Graduate Medical Education (THCGME) program, the CHC and Indian Education programs.

The NHSC program provides funding for health workforce activities that offers scholarships and loan repayment to clinicians in exchange for their service in health professional shortage areas (HPSA). The THCGME program has helped increase the number of primary care medical and dental residents training in rural and underserved communities by providing graduate medical education funding specifically for training in outpatient health centers. Additionally, CHCs provide invaluable primary care services, largely in areas considered medically underserved.

With regards to GME positions, the Balanced Budget Act of 1997 imposed restrictions on Medicare funding for fellows and residents at existing and future residency training sites. Once established, new programs are subject to a cap-setting process to determine institutional limits on the per-resident funding amount, as well as the total number of positions funded.

The AMA also recently offered support for S. 348, the “Resident Physician Shortage Reduction Act of 2019,” which seeks to address the growing physician shortage and strengthen the nation’s health care system by providing 15,000 additional Medicare-supported GME positions over five years.

In addition, the AMA has offered its support for H.R. 1358, the “Advancing Medical Resident Training in Community Hospitals Act of 2019,” which would close a loophole in GME cap-setting criteria affecting hospitals who host small numbers of residents for temporary training assignments, also known as “resident rotators.”

CDC says misapplication of opioid prescribing guidelines have harmed patients

Three authors of the Centers for Disease Control and Prevention’s (CDC) controversial 2016 guideline on opioid prescribing now say their advice has been misused in ways that can harm patients.

These misapplications “include inflexible application of recommended dosage and duration thresholds and policies that encourage hard limits and abrupt tapering of drug dosages, resulting in sudden opioid discontinuation or dismissal of patients from a physician’s practice,” wrote the CDC’s Deborah Dowell, MD, MPH, Tamara Haegerich, PhD, and Roger Chou, MD, in a New England Journal of Medicine essay, “No Shortcuts to Safer Opioid Prescribing.”

Patrice A. Harris, MD, MA, President-elect of the AMA and chair of the AMA Opioid Task Force, noted in response that the CDC guideline recommendations have been “wrongly treated as hard-and-fast rules, leaving physicians unable to offer the best care for their patients.”

The guideline authors’ essay “underscores that patients with acute or chronic pain can benefit from taking prescription opioid analgesics at doses that may be greater than the guidelines or thresholds” outlined by government agencies, payers, pharmacy chains, pharmacy benefit managers (PBM) or other bodies, she added.

The misapplication of the CDC guideline has been so broad, said Dr. Harris, “that it will be hard to undo the damage.” She said the AMA is calling for a “detailed regulatory review of formulary and benefit design by payers and PBMs to ensure that patients have affordable, timely access to medically appropriate treatment, pharmacologic and nonpharmacologic.”

The AMA also will work with the CDC to help ensure that patients get “multidisciplinary, multimodal pain care based on medical science and effective clinical practice,” Dr. Harris said. The U.S. Agency for Healthcare Research and Quality, with CDC funding, is conducting systematic reviews to gauge the effectiveness of various treatments for acute and chronic pain.

ONC responds to comment deadline concerns

The deadline for comments on the Office of the National Coordinator for Health IT’s (ONC) proposed rule, along with the CMS proposed rule, has been extended by 30 days. Comments are now due June 3. The AMA sent a letter to CMS and ONC cautioning the agencies from moving too quickly with rulemaking. Those concerns were echoed by many other organizations. The proposals will have major impacts on interoperability and how data is exchanged between patients, health providers, payers, technology developers and other health care stakeholders. However, such rapid change in health care policy, technology and business practices may lead to unintended consequences for patient privacy and physician burden. To ensure that the rules are as successful as possible in meeting the administration’s goals, it is vital that stakeholders are given adequate time to provide comprehensive, thoughtful and detailed comments. AMA will share draft comments with the Federation ahead of the deadline.

ONC has also released for public comment draft two of the Trusted Exchange Framework and Common Agreement (TEFCA) to support network-to-network exchange of health information nationally. TEFCA outlines a common set of principles, terms and conditions to support the development of a common agreement to help enable nationwide exchange of electronic health information across disparate health information networks. The AMA provided comments on draft one of the TEFCA. The AMA is reviewing draft two and will be providing additional comments by the deadline on June 17.

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State Update

Arkansas removes prior authorization for treatment of opioid use disorder

The AMA and Arkansas Medical Society (AMS) applauded Arkansas Governor Asa Hutchinson and the Arkansas General Assembly last week for putting an end to senseless administrative barriers to evidence-based treatment for opioid use disorder (OUD). Arkansas Act 964 requires all health insurers and the Arkansas Medicaid program to remove prior authorization to FDA-approved medications—including buprenorphine, methadone and naltrexone—that have been shown to support recovery, reduce health care costs and save lives. These medications are part of what is commonly referred to as medication-assisted treatment (MAT), considered the gold standard for treating OUD, according to the U.S. Surgeon General.

The new law also requires that these medications must be on the lowest cost-sharing tier, which the AMA believes is critical to increase availability and affordability of MAT. “I commend Governor Hutchinson, Representative Deborah Ferguson and Senator Cecile Bledsoe for their leadership on this critical issue,” said AMA President-elect Patrice A. Harris, MD, MA, chair of the AMA Opioid Task Force.

“The Arkansas Medical Society championed this bill because we’ve seen firsthand how delays and denials of care because of prior authorization harm our patients,” said Gene Shelby, MD, an addiction medicine physician who represents AMS on the AMA Opioid Task Force. “This bill received unanimous support because all stakeholders came to see that the status quo has to change if the epidemic is to end. Removing prior authorization for MAT is an important step in that direction.” Arkansas, which saw a 10% increase in the opioid-related overdose death rate from 2016 to 2017, is the first state this year to enact this type of legislation, based in part, on AMA model legislation.

For more information about the AMA model bill, please contact Daniel Blaney-Koen of the AMA.

Four states join the Interstate Medical Licensure Compact

Georgia, Kentucky, North Dakota and Oklahoma have adopted legislation this year to join the Interstate Medical Licensure Compact, bringing the total number of states in the Compact to 29, plus DC and Guam. The IMLC is a pathway to expedite the licensure of physicians already licensed to practice medicine in one state who wish to practice in multiple states. The AMA supports the compact as a means to modernize the state licensure system, provide uniformity in requirements for state licensure and offer pluralistic approaches to verification of credentials for licensure.

Advance practice registered nurses bill defeated in Indiana

The Indiana State Medical Association (ISMA) defeated bill S.B. 394 that would have allowed advance practice registered nurses to practice independently. ISMA worked closely with fellow members of organized medicine including the AMA and Indiana Osteopathic Association to defeat this legislation.

Montana Medical Association defeats multiple scope bills in 2019

The Montana Medical Association (MMA) defeated several scope of practice bills this session. Due to MMA’s strong lobbying efforts, they successfully defeated a psychologist prescribing bill (S.B. 106), as well as prevented a bill that would have allowed physician assistants to practice independently from moving beyond the drafting stage. 
 
MMA was also instrumental in securing an important amendment to H.B. 231, which as drafted, would have allowed pharmacists to administer vaccines to children as young as seven years of age. As a result of MMA’s strong advocacy efforts, an amendment was added to only allow this practice within a collaborative practice agreement with a physician.

The AMA Scope of Practice Partnership was proud to award MMA with a grant to support their efforts to defeat these bills and protect the health and safety of patients in Montana.

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Judicial Update

Judge says AMA is right: Title X gag rule violates medical ethics

“This is madness,” wrote U.S. District Judge Michael McShane in Portland, Oregon, in a scathing rebuke of the Trump administration’s new Title X regulations that includes a gag rule dictating what physicians must and must not say to their patients in the Title X program about family planning.

“The gag rule prevents doctors from behaving like informed professionals,” McShane wrote. “At the heart of this rule is the arrogant assumption that government is better suited to direct the health care of women than their medical providers.”

McShane’s ruling detailed how the regulations would violate the AMA Code of Medical Ethics, damage public health and state economies with it, and violate provisions of the Affordable Care Act and Administrative Procedure Act without explaining what problem the new regulations seek to address.

The Oregon lawsuit was led by the AMA, Planned Parenthood and its local affiliates, and the Oregon Medical Association, but the case was consolidated with another lawsuit and the ruling covers the plaintiffs in both cases. That includes 20 states, the District of Columbia and individual health professionals.

McShane said a nationwide ban was appropriate because Planned Parenthood operates in 48 states, AMA members reside in all 50 states, AMA members provide counseling to pregnant women served by the Title X program, and that there was “ample evidence” of potential harm to public health across the nation.

Read more here.

North Dakota Supreme Court upholds state’s cap on noneconomic damages

On May 29, 2012, Chenille Condon gave birth to a child at St. Alexius Medical Center.After birth, she experienced complications that required follow up surgery. During the procedure an injury occurred which caused bleeding and ultimately lead to Condon suffering from a stroke. Condon filed a medical malpractice claim against the physician and medical center and the jury returned a verdict finding negligence and awarding Condon $265,000 in past economic loss, $ 1.735-million in future economic loss, $150,000 in past noneconomic loss and $1.350-million in future noneconomic loss.

Dr. Booth sought a reduction of noneconomic damages under N.D.C.C. § 32-42-02, and a reduction of the past economic damages pursuant to the collateral-source rule, which allows expenses to be reduced if they were paid by a third-party (e.g. an insurance policy). Condon opposed the reductions and challenged the constitutionality of the statute. The district court granted Dr. Booth’s motion with regard to the collateral-source reduction, but found that N.D.C.C. § 32-42-02 was unconstitutional on equal protection grounds.

On April 22, 2019 the North Dakota Supreme Court reversed the lower court decision, finding that N.D.C.C. § 33-42-02 does not violate the Equal Protection Clause because there is a sufficiently “close correspondence between the damage cap at issue in this case and legitimate legislative goals to satisfy the intermediate level of scrutiny” under the North Dakota Constitution.

An AMA Litigation Center brief was successful in raising the important role that N.D.C.C. § 33-42-02 plays in making affordable professional liability insurance available for North Dakota health care providers while also curbing the impact that such cost increases would have on the affordability and availability of health care for North Dakotans. The brief also empirically demonstrated that “states that limit noneconomic damages generally experience increases in physician supply per capita compared to states without caps.”

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Other News

AMA is committed to a diverse physician workforce

From AMA President Barbara L. McAneny, MD

The strength of our medical workforce—and our nation—is rooted in diversity. One requirement to advance health equity is to promote greater diversity among medical school applicants and enrollees. We know from research and experience that all patients, but particularly those from marginalized communities, benefit from a diverse physician workforce and are even likely to see improved outcomes. Diversity also enhances students’ learning environments and fosters greater innovation.

Achieving diversity within the physician community, especially racial equity, has been historically challenging and has not yet reached levels that are representative of our nation’s racial and ethnic diversity. Census data shows that less than 10% of physicians are African Americans, Latinos, Native Americans and Alaska Natives combined.

That’s why we’re concerned any time actions occur that may undermine these efforts, such as the agreement reached between the Texas Tech University Health Sciences Center School of Medicine and the U.S. Department of Education Office of Civil Rights to no longer consider race in making admissions decisions.

While this agreement does not set a legal precedent, it does require the Trump administration to clarify policy changes. More importantly, while there is still much more to be done, we cherish the progress our country has made to ensure the civil and human rights of people—and we do not want to see further voluntary acts or agreements removing race considerations from the admissions process. Removing race further raises questions about whether medicine can and will recruit the best students from all backgrounds.

The AMA has been a part of this debate before. As the AMA stated in an amicus brief in Fisher v. University of Texas at Austin, a 2016 decision by the U.S. Supreme Court that further upheld this practice: “Removing the ability of medical schools to consider applicants’ race and ethnicity as one of many personal attributes would undermine their ability to assess the entirety of each individual’s background, thus frustrating the goal of best serving the public’s health.”

Read more here.

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Upcoming Events

Thriving in practice webinar: A physician’s APM journey

May 22: A long-time physician will share her practice’s journey through the phases of transformation and how both the struggles and the triumphs have prepared the practice team for operating and succeeding in an APM. Register now for the webinar at 1:00 p.m. Eastern time.

The campaign trail starts here: Register for AMA Campaign School by June 21

Open to AMA members, their spouses, medical students, residents and state medical association staff who want to become more involved in campaigning process, the 2019 AMPAC Campaign School will be held Sept. 26-29 at the AMA offices in Washington, D.C. The Campaign School is designed to provide participants with the skills and strategic approach they need to run a successful political campaign.

During the two-and-a-half day in-person portion of the program, under the direction of AMA political experts, participants will be broken into campaign staff teams to run a simulated congressional campaign using what they have learned during group sessions on strategy, vote targeting, social media, advertising and more. Faculty, materials and all meals during the meeting are covered by the AMA. Participants are responsible for the registration fee and hotel accommodations at the Hyatt Regency Washington on Capitol Hill.

The deadline to register is June 21. For more information or to apply visit: www.ampaconline.org/apply or contact politicaleducation@ama-assn.org.

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