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Oct. 4, 2019

Issue Spotlight

Highlights of CMS' 2020 physician fee schedule and QPP proposed rule

The AMA has submitted comments to the Centers for Medicare & Medicaid Services (CMS) on the 2020 physician fee schedule and quality payment program (QPP) proposed rule. AMA comments focus primarily on two issues. First, while the AMA greatly appreciates CMS' proposal to align the previously finalized office visit coding changes with the framework adopted by the Current Procedural Terminology® (CPT) Editorial Panel, the AMA urges CMS to finalize the CPT codes and guidelines and AMA/Specialty Society RVS Update Committee (RUC) recommendations exactly as implemented by the CPT Editorial Panel and submitted by the RUC. Second, the AMA commends CMS for responding to the AMA's recommendations in crafting its Merit-based Incentive Payment System (MIPS) value pathways (MVP) proposal. Modifications will be needed to ensure that the MVP is voluntary, is a more holistic track for physicians than the current MIPS program, and provides a minimum point floor for those who report via this track.

In addition to the above, principal recommendations on the 2020 proposed rule are as follows:

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National Update

Congressional oversight on health IT rules urged as administration plans implementation

The AMA and six other organizations have asked two congressional committees to use their oversight of the 21st Century Cures Act to improve interoperability and empower patients with meaningful health information while ensuring data is safe and secure. The letter arrives as the administration is drawing up its plans to implement the law and adopt information blocking rules. The AMA appreciates several of the administration's proposals, particularly related to electronic health record (EHR) certification, EHR application programming interfaces (API), and modifying EHR vendor business practices and behaviors.

The AMA is, however, expressing concern with the overall complexity of the proposed rules. Rather than supporting the goals Congress outlined in the Cures Act, many of the administration's proposals will dramatically affect patient privacy and safety as well as data security. The AMA has also advised that proposals will add to physician burden and burnout. The letter recommends four specific actions the administration should take to improve its rule:

  • Additional rulemaking prior to finalization: To ensure a sufficient level of industry review and to appropriately respond to stakeholder feedback, the Office of the National Coordinator for Health IT (ONC) should issue a supplemental rulemaking to address outstanding questions and concerns.
  • Enhanced privacy and security: The proposed rule does not sufficiently address Cures' directives to protect patient data privacy and ensure health IT security. Further, it is imperative that the Committee continue its oversight of privacy and security issues that fall outside of the Health Insurance Portability and Accountability Act (HIPAA) regulatory framework.
  • Appropriate implementation timelines: ONC should establish reasonable timelines for any new EHR requirements. Physicians must be given sufficient time to deploy and test these systems, which must take into account competing regulatory mandates.
  • Revised enforcement: The U.S. Department of Health and Human Services (HHS) should use discretion in its initial enforcement of the data blocking provisions of the regulation, prioritizing education and corrective action plans over monetary penalties.

The AMA will continue to engage with Congress and the administration to implement these needed changes. The final rule is expected later this year or early in 2020.

AMA opposes the expansion of law enforcement access to substance use disorder records

The AMA recently wrote to the Substance Abuse and Mental Health Services Administration (SAMHSA) to oppose a proposed rule that would expand the circumstances in which a court could authorize disclosure of a patient's substance use disorder (SUD) records under 42 CFR Part 2. The proposal would permit a court to authorize disclosure of a patient's confidential communications when the disclosure is necessary in connection with investigation or prosecution of an extremely serious crime, even if the extremely serious crime was not allegedly committed by the patient.

SAMHSA believes the change would help crack down on "rogue doctors and pill mills that have contributed to the opioid crisis," but it does not provide any evidence for this claim. The AMA stated in its comments that the change is contrary to the purpose of the underlying Part 2 law and would expose the confidential communications of hundreds of thousands of individuals, including those seeking treatment for alcohol—not drug—use. The AMA urged SAMHSA to withdraw its proposal.

House to advance legislation that will lower prescription drug costs

On Sept. 19, House Energy and Commerce Committee Chairman Frank Pallone, Jr. (D-NJ) introduced H.R. 3, the Lower Drug Costs Now Act of 2019, along with Ways and Means Committee Chairman Richard E. Neal (D-MA) and Education and Labor Committee Chairman Bobby Scott (D-VA). 

This legislation, largely spearheaded by House Speaker Nancy Pelosi (D-CA), would give HHS the power to negotiate prices for prescription drugs without generic or biosimilar competition. Negotiated prices would be available to all payers, including the commercial market.  The maximum negotiated price would be set at no more than 120 percent of an international price index, called the "Average International Market" price. The bill would also create a $2,000 out-of-pocket spending cap for Medicare beneficiaries. 

The House Energy and Commerce, Ways and Means, and Education and Labor Committees are expected to mark up this legislation, followed by a vote before the full House, in late October. The legislation is expected to pass the House along party lines with opposition from House Republicans.

On Sept. 24, the AMA sent a letter regarding H.R. 3 to the chairs of the aforementioned committees expressing appreciation for the efforts to address the high cost of prescription medications.

Price increases for brand pharmaceuticals and biologicals continue to outpace the rate of inflation, limiting affordability and access for our patients.  Furthermore, higher prices lead to insurers using increasingly onerous utilization management programs that erect additional barriers to access, raise patient out-of-pocket costs, and add administrative hurdles for both patients and already-stressed physician practices.

The AMA's letter urges Congress to pass meaningful legislation this year to ensure that patients have access to affordable medications. 

AMA supports presidential effort to combat veteran suicide

In a joint statement, the AMA pledged to support the efforts of the President's Roadmap to Empower Veterans and End a National Tragedy of Suicide (PREVENTS) Task Force. This cabinet-level task force is charged with bringing together federal, state and local governments, along with non-governmental organizations and the veteran community to create a broad-based national public health effort to prevent veteran suicide.

The AMA's support for PREVENTS follows the participation of AMA board members Bobby Mukkamala, MD, and Jesse M. Ehrenfeld, MD, MPH, in White House meetings regarding how best to combat the epidemic of veteran suicides.

New analysis explains Medicare's major new primary care pay model

Medicare's alternative payment models (APM) for primary care practices are works in progress, with the recently announced Primary Cares initiative coming in response to physician-developed proposals. A new analysis takes a point-by-point approach to explain what physicians should know about it in comparison with Medicare's current APM demonstration project.

Primary Cares, shaped with substantial physician input, was unveiled in April by HHS Secretary Alex Azar at the AMA's Washington office.
"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," Gerald E. Harmon, MD, said at the time. Dr. Harmon is a family physician and a member of the AMA Board of Trustees.

The initiative introduces Primary Care First (PCF), a streamlined, potentially higher-paying APM that provides an alternative to the current five-year demonstration project, Comprehensive Primary Care Plus (CPC+) that was launched in 2017.

PCF is scheduled to be available in January 2020, and ultimately will be offered in 26 states and metropolitan regions, eight more than CPC+. Practices in CPC+ regions will have to wait a year before they can apply for PCF. Primary Cares also creates a direct contracting option, but the qualification threshold—at least 5,000 Medicare patients—places it out of reach for solo and small practices.

The AMA's analysis, "Medicare Alternative Payment Models for Primary Care," is one in a set of AMA resources that provide detailed, physician-focused insights on Medicare APMs and the APM-enabling Medicare Access and CHIP Reauthorization Act.

Read the full story here.  

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State Update

Governors take executive action to protect youth from e-cigarettes

Amid a growing crisis of vaping-related illnesses and deaths, states are taking bold action to protect youth from e-cigarettes. Governors in Michigan, New York, and Rhode Island have taken executive action in recent weeks to prohibit the sale of flavored vaping products in their states. Massachusetts has banned the sale of all e-cigarette products.

Flavored e-cigarettes play a significant role in drawing young people to vaping as these products are often perceived to be "safer" and young users enjoy the candy, fruit and mint flavorings. Deliberate marketing of these qualities to young people has been disturbingly successful, and the numbers of America's youth using e-cigarette products is soaring. In addition to the harm that can be caused by e-cigarette use directly – which has been tragically demonstrated in recent weeks by the hundreds of people who have fallen ill with serious or fatal lung illnesses linked to vaping – e-cigarettes have the potential to undermine the public health gains that have been made over the years in combatting the smoking epidemic. Evidence has demonstrated that youths who use e-cigarettes are at greater risk of subsequently initiating tobacco use.

The AMA has long recognized that the use of products containing nicotine in any form among youth, including e-cigarettes, is unsafe and the AMA House of Delegates has declared the skyrocketing use of e-cigarettes to be an "urgent public health epidemic." The AMA applauds state efforts to keep harmful e-cigarette products out of the hands of young people and prevent another generation from becoming dependent on nicotine.

Pennsylvania House committee makes right decision to pull bill from consideration

After direct advocacy from many different medical organizations, the Pennsylvania House Human Services Committee did not consider a bill that would have added additional barriers to care for patients with a substance use disorder. The Pennsylvania Medical Society, Pennsylvania Society of Addiction Medicine, AMA and multiple other state and national medical organizations strongly opposed Senate Bill 675.

The bill proposed to levy additional fees for certification of buprenorphine office-based prescribers and impose multiple additional regulatory requirements on physicians. It also would have imposed requirements on patients to prove, for example, that they were already being treated in a state-licensed addiction treatment facility before an office-based buprenorphine provider could treat a patient.

At a time when Pennsylvania is seeing decreases in opioid-related mortality, the AMA urged policymakers to continue to removebarriers to evidence-based care rather than take a step backward. The AMA strongly urged a "No" vote on S.B. 675 to protect access to medication-assisted treatment for patients with opioid use disorder, and on Sept. 19 the bill was pulled from consideration.

Fighting stigma and building a career treating substance use disorders

When Alena Balasanova, MD, began her psychiatry residency at Boston University, she encountered patients with SUD the way all too many people do—with judgment: "I wanted to treat patients with depression and anxiety—I didn't sign up to treat people with a drug addiction, I held some very stigmatizing beliefs."

Tani Malhotra, MD

Alena Balasanova, MD

Over the course of her residency, however, she started working with patients who are on medication assisted treatment (MAT) and saw firsthand the transformation that occurs when a patient comes in the door very ill, is provided evidence-based care and begins to heal. Her perspective shifted drastically.

"My patients receiving MAT were repairing relationships, finding jobs, and becoming healthier," Dr. Balasanova said. "I began to understand how remarkable it was that I could participate in helping a patient turn his or her life around."

After completing her residency, Dr. Balasanova moved to Nebraska, where she was raised, because she saw an opportunity to improve the lives for patients with SUDs.

"There are so few MAT treatment providers in Nebraska," she said. "I wanted to fill that gap."

Filling the gap meant working to develop an outpatient addiction psychiatric clinic at the University of Nebraska Medical Center in 2017, where patients with SUD could get medication while also having their other psychiatric conditions treated. After the clinic was up and running, Dr. Balasanova then set her sights on something even bigger: an inpatient addiction psychiatry service where patients with SUDs could be seen in the hospital and medical intervention could begin immediately while clinic follow-ups are scheduled.

Dr. Balasanova did not stop there.

These new programs needed knowledgeable medical staff to run them, so she worked to develop a new rotation for psychiatry residents—Longitudinal Integrated MH/SUD Outpatient Clinic (LIMSOC). During the rotation, which lasts a year with a half a day per week in the clinic, residents learn how to use different treatment modalities and are encouraged to get their buprenorphine waivers. This means that no matter where residents choose to go after their residency, they are equipped to treat patients with SUDs.

"The journey I've taken has opened my eyes," said Dr. Balasanova. "But there is so much more work to do."

One of the biggest impediments to care for patients with SUDs Dr. Balasanova has faced is prior authorization for MAT. "Prior authorization for MAT has been a big problem for me and my residents. It's something we deal with on a regular basis," Dr. Balasanova said, "but it shouldn't be—MAT is evidence-based but the insurance companies don't seem to get that."

Looking ahead, Dr. Balasanova is encouraged that she is helping train another generation of physicians to treat SUDs. "I am very lucky to be back in my home state to literally help my neighbors, and I hope all my residents go on to help end the epidemic where they can as well."

To hear more from Dr. Balasanova, watch this video. To learn more about what physicians are doing to fight the opioid epidemic please visit the AMA End the Epidemic website.

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Judicial Update

Top court: In medical liability cases, expert testimony is a must

A recent Supreme Court of Kentucky decision makes clear that juries must hear from—and base decisions on testimony from—medical experts in medical malpractice cases involving complex conditions such as strokes instead of relying on "common knowledge" when rendering decisions.

The high court's opinion helps ensure physicians will be less likely to face jury prejudice or practice defensive medicine to protect themselves from spurious lawsuits. Those were two concerns the Litigation Center of the American Medical Association and State Medical Societies, along with the Kentucky Medical Association, expressed to the court in a joint amicus brief filed in the caseLewis v. Shackelford/Ashland Hospital v. Lewis.

The worry that the legal landscape for physicians could change in Kentucky arose after an appellate court said a patient, David Shackelford, could go forward with a lawsuit against a physician and a hospital that alleged the man would have suffered less harm from a stroke had it been detected earlier. The claim was allowed even though no experts testified that the physician or hospital took any action—or failed to take any action—that caused the patient harm.

The appellate court reversed the trial-court decision and ruled the claim could go forward because it is "common knowledge" that promptly identifying stroke and treating the condition is important. The AMA Litigation Center and the KMA warned the standard would be "a recipe for imposing liability for harm that physician did not cause and could not have prevented based on the accepted standards of care."

Read the full story here.

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Other News

Value-based care podcast series now available

A new podcast series from the AMA and ReachMD, "Reaching the potential of value-based care," provides physicians with real-world insight from experts in advancing value in health care to improve quality and promote cost-effective care for patients. As the move to value intensifies, it will be even more important for physicians to have access to pathways that encourage changes they consider valuable.

Tune in to hear Griffin Myers, MD, of Oak Street Health, a network of primary care practices for adults on Medicare, and Barbara Spivak, MD, from the Mount Auburn Cambridge Independent Practice Association (MACIPA), a physician membership organization, regarding their experience working in the Medicare Advantage space. Topics of discussion include effects on how care is delivered and associated challenges, as well as the impact on patient outcomes and overall practice sustainability.

2020 IPCH call for abstracts now open through Jan. 31

The International Conference on Physician Health (ICPH), which is being hosted by the American Medical Association, British Medical Association and the Canadian Medical Association, is being held Sept. 14-16, 2020, at the IET London: Savoy Place in London, England. Authors are invited to submit abstracts for consideration as part of the 2020 ICPH. Submissions will be accepted from Oct. 1 to Jan. 31.

Visit the "call for abstracts" section on the British Medical Association website to review important details and instructions for submitting abstracts. Submissions will be accepted through the online ICPH Abstract Submission System, which can be accessed here.

Email icph2020@bma.org.uk with any questions or requests for further information.

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Upcoming Events

Online discussion on how AI in health care will affect students, resident and young physicians

Oct. 28 – Nov. 3: Join an online discussion hosted by the AMA's Physician Innovation Network (PIN) on what augmented intelligence (AI) in health care means for medical students, residents and young physicians. Join the discussion about the consequences of AI, and learn how to engage with the technology and prepare it for clinical practice. 

Register now for 2020 AMA advocacy conferences and save 20%

The 2020 AMA State Advocacy Summit will be held in Bonita Springs, Florida, at the Hyatt Regency Coconut Point Resort and Spa, Jan. 9-11. The 2020 AMA National Advocacy Conference will be held in Washington, D.C., at the Grand Hyatt, Feb. 10-12. Register now for both meetings and use the code "SASNAC20" to save 20% on dual registration.  

Register today for the Rx Drug Abuse and Heroin Summit

April 13-16: The Rx Drug Abuse and Heroin Summit will take place in Nashville, TN, April 13-16. Next year for the first time a Maximum Access Package is being offered; a great option for attendees who want to access sessions they missed while on-site. With the Maximum Access Package, nearly every session from the summit will be available on-demand for 12 months.

Register today for the lowest possible rate and save an additional $50 with code ALUM.

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