Dec. 6, 2019

National Update

Two rules aim at transparency in health care pricing

Following an Executive Order on health care price transparency released earlier this year, on Nov.15 the administration released two rules, one final and one proposed, aimed at increasing transparency in health care pricing. The first, a proposed rule, includes two key proposals—one aimed at providing patients with estimates of out-of-pocket costs, the other proposing to require insurers to make public payment rates negotiated with providers, as well as historic out-of-network allowable rates. The out-of-pocket cost estimator proposal would require insurers to provide consumers with a tool that would produce estimates of expected costs for which they would be responsible for procedures covered under their health plan. It would also provide information regarding coverage of procedures, as well as information regarding any prerequisites to coverage. The administration expects this will help consumers better manage their health care expenditures as well as provide information allowing them to "shop" for medical services.

According to the administration, the second proposal, which would require public disclosure of rates negotiated with in-network providers as well as out-of-network allowable amounts, is aimed at driving down payment rates of all providers through increased transparency. However, the administration acknowledges some uncertainty about the ultimate result and the possibility for network adequacy issues and possible increases in overall prices.

The second rule released Nov.15 finalized an earlier proposal to require disclosure of similar negotiated rate information at hospitals. Major hospital groups have voiced strong opposition to the final rule and are planning to file suit to block its implementation.

The AMA has strongly supported calls for increased transparency around health care pricing information that is meaningful to consumers, such as out-of-pocket cost information, benefit/coverage information, and patient and physician access to drug benefit and formulary information at the point of care. However, disclosure of negotiated rates raises a number of potential concerns that the AMA is reviewing carefully.

CMS seeks input to improve cost measure field testing

The Centers for Medicare & Medicaid Services (CMS) is user testing reports that provide an opportunity to preview and provide stakeholder input about potential episode-based cost measures for the Merit-based Incentive Payment System (MIPS). Measures currently in development include the first chronic condition cost measures – diabetes and asthma/chronic obstructive pulmonary disease – as well as measures of costs associated with colon resection, melanoma resection and sepsis.

The AMA has heard concerns about prior versions of these reports including that they are overly complex and is encouraging physicians and practice administrators to participate in user testing to improve the field-testing reports and, ultimately, promote transparency and stakeholder input into the development of new episode-based cost measures for MIPS. The user testing will take 60 minutes.

Participants must work for a practice that sees Medicare patients and may sign up to participate at this link.

AMA calls for better data on violence against transgender individuals

The AMA recently wrote to the U.S. Bureau of Justice Statistics, Centers for Disease Control and Prevention, and Federal Bureau of Investigation to ask the agencies to identify and implement strategies to address the epidemic of violence against the transgender community, especially the amplified physical dangers faced by transgender people of color. The AMA has previously addressed the epidemic of transgender violence and notes that the number of victims may be even higher due to underreporting caused by a mistrust of law enforcement and the voluntary nature of many crime statistic reporting programs. Accordingly, the AMA suggested that federal law enforcement agencies should consistently collect and report data on hate crimes, including demographics identifying a victim's birth sex and gender identity.

The AMA strongly opposes any discrimination based on an individual's sex, sexual orientation, gender identity, or race and is deeply committed to improving the health of transgender individuals, including through addressing social risk factors like violence. This letter is the latest in a series of letters to Congress, states, and other federal administrative agencies aimed at addressing the upstream determinants of health to improve outcomes for transgender individuals.

HELP committee advances Dr. Stephen Hahn's nomination for FDA commissioner

On Dec. 3, the Senate Health, Education, Labor and Pensions (HELP) Committee, by a vote of 18 to 5, favorably report the nomination of Stephen Hahn, MD, FASTRO, to serve as the Commissioner of the Food and Drug Administration (FDA). The full Senate may hold a vote confirming his nomination before the end of the year. During the confirmation process, Dr. Hahn insisted that he will examine the data and scientific research when tackling issues such as vaping, opioid addiction, biologics patents, prescription drug pricing, drug shortages and antibiotic resistance. The AMA sent a letter in support of Dr. Hahn's nomination citing his expertise and significant leadership experience in academic medical settings. He has been widely praised for his work at MD Anderson Cancer Center, one of the nation's premier oncology providers, where he assumed the role of Chief Medical Executive after several years leading MD Anderson's radiation oncology unit. Throughout his career, Dr. Hahn has held numerous management positions and has positively navigated a number of challenges.

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State Update

AMA urges Walmart, OptumRx to delay EPCS requirements

Citing patient safety concerns, regulatory barriers and misalignment with state and federal policy, the AMA urged Walmart to delay implementation of its requirement for all controlled substances to be electronically prescribed, set to go into effect Jan. 1. The AMA supports electronic prescribing of controlled substances (EPCS), but currently only 44% of physicians are EPCS-enabled due to a variety of factors. The Walmart policy does not appear to have any exceptions.

"If Walmart does not delay implementation, patients in every state will likely suffer negative consequences from not having their necessary medications dispensed," wrote AMA Executive Vice President and CEO James L. Madara, MD. "This includes patients receiving care for opioid use disorder, anxiety, depression, attention deficit hyperactivity disorder, auto-immune diseases, HIV/AIDS and painful conditions like sickle cell disease. Losing access to medications to help treat chronic disease could have devastating, potentially fatal consequences."

Dr. Madara highlighted several issues, including the lack of updated U.S. Drug Enforcement Administration requirements, misalignment with state and federal laws that do not require EPCS until Jan. 1, 2021, and the Walmart policy stands in direct conflict with state licensing and regulatory authority that has created multiple exceptions to a one-size-fits-all EPCS mandate.

The AMA has heard concerns from multiple medical societies, and Arkansas Medical Society (AMS) further emphasized the need for a delay in implementation. Executive Director David Wroten said that while the AMS was not opposed to EPCS, Arkansas law was designed to go into effect to align with federal law, slated for Jan. 1, 2021. "The failure of Walmart to postpone the implementation of this policy will create a myriad of problems and health consequences for prescribers, patients and even Walmart employees," said Wroten.

Dr. Madara sent a similar letter to OptumRx, which will require EPCS for all home delivery prescriptions beginning Jan. 1, 2020.

Read the full AMA letter here.

Colorado legislative package focuses on evidence-based approaches to end opioid epidemic

The Colorado Legislature's Opioid and Other Substance Use Disorders Study Committee has drafted a five-bill legislative package that demonstrates the leading edge of policymaking for Colorado's patients. Among the evidence-based approaches put forward:

  • Removing step therapy and prior authorization barriers for non-opioid pain care
  • Placing non-opioid pain care options on the lowest cost-sharing tier of a health insurance company formulary
  • Increasing access to naloxone by requiring the carrier to reimburse hospitals that provide naloxone to covered patients upon discharge
  • Removing certain restrictions on establishing needle and syringe programs
  • Requiring correctional facilities to provide at least one opioid agonist and one opioid antagonist as well as improved continuity of care provisions upon release

The package also has provisions to support medical, evidence-based criteria for the treatment of opioid use disorder; funds for loan repayment for service in underserved areas; and provisions for housing assistance, behavioral health coverage and other services.

Many of the elements in the legislative package also are part of the recommendations in the recently released AMA-Manatt Health national opioid roadmap, which contains policy provisions that the AMA recommends for all states to pursue. The national roadmap was created after an in-depth review of the work being done in four states, including Colorado.

Please contact the AMA Advocacy Resource Center with any questions about the Colorado legislation or national roadmap.

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Other News

New advocacy dashboard now available

The 2019 update to the AMA advocacy dashboard highlights wins and ongoing work in addressing surprise medical bill proposals, improving Medicare physician payment, regulatory relief, fighting prior authorization and insurer practices that hinder patient care, ending the opioid epidemic, fighting for drug price transparency, preventing gun violence, addressing health equity and protecting immigrant health.

Read more here.

New podcast series on reaching the potential of value-based care

Efforts to address the unsustainable trajectory of the current U.S. health care system continue to accelerate. But physicians still want—and need—to know how the promises of these "value" initiatives compare to the reality for their practices and, ultimately, their patients. Reaching the Potential of Value-Based Care podcast series provides real-world insights from experts in advancing value in health care. Hear the latest episode on behavioral health integration and how two physician experts helped implement a more integrative approach to behavioral health services within their organizations.

New resources that help physicians engage in direct-to-employer arrangements

To help physicians navigate direct-to-employer arrangements, the AMA created resources including case studiesa model checklist and a snapshot to inform physicians of the benefits and potential pitfalls of engaging in direct-to-employer arrangements.

Culmination of the transforming clinical practice initiative grant

The Transforming Clinical Practice Initiative (TCPI) was designed to help clinicians achieve large-scale health transformation. During the four-year lifespan of the grant which was completed at the end of September, more than 140,000 clinician practices were supported in sharing, adapting and further developing their comprehensive quality improvement strategies. The initiative was one part of a strategy advanced by the Affordable Care Act (ACA) designed to strengthen the quality of patient care and spend health care dollars more wisely.

As one of the initiative's 39 support and alignment networks, read more about how the AMA helped physician practices achieve large-scale transformation efforts.

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Upcoming Events

Register now for the State Advocacy Summit in Bonita Springs, FL

Day one of the State Advocacy Summit will kick off with a strategy session that will provide the big sky view on the future of health policy, looking at broad themes of affordability, consolidation and innovation. As the day moves on, the focus will shift to the local level to meet with current and former state policymakers to talk about upcoming health care efforts coming to the floor in a statehouse near you. The day will come full circle with a discussion of Medicine's role in health care reform, diving into all the ways medical societies can weave localized advocacy issues into the broader health care debate.

Register now for both the State Advocacy Summit in Bonita Springs, FL Jan. 9-11 and the National Advocacy Conference Feb. 10-12 using the code "SASNAC20" to save 20% on dual registration until Dec. 20.

Ready to jump in the race? Start with the 2020 AMPAC Candidate Workshop

Thinking about running for public office? The 2020 AMPAC Candidate Workshop is designed to help physicians take the leap from the exam room to the campaign trail. The workshop will take place February 28 – March 1 at the AMA Office in Washington, DC.

The curriculum is targeted to AMA members, their spouses, residents, medical students and medical society staff who want to learn more about what it takes to be an effective candidate. You will learn:

  • How and when to make the decision to run
  • The importance of a disciplined campaign plan and message
  • The secrets of effective fundraising
  • What kinds of media advertising are right for your campaign
  • How to handle the inevitable crises that emerge for every campaign
  • The role of your spouse and your family
  • How to become a better public speaker

Registration fee is $250 for AMA members and $1000 for non-members. Airfare and hotel accommodation not included, but a discounted room block at the Hyatt Regency Capitol Hill is available.

Space is limited so register by Feb 3.

Register today for the Rx Drug Abuse and Heroin Summit

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. This year's summit will take place in Nashville, TN, April 13-16.

Register today and save an additional $50 with code ALUM.

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