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Jan. 30, 2020

Issue Spotlight

Physicians respond to request for feedback on Medicare scope of practice

The AMA, along with 103 state medical societies and national specialty organizations, wrote to Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma to express concerns about the broad scope and far reaching implications of CMS' request for feedback on scope of practice. In reviewing recommendations to weaken or eliminate Medicare regulations requiring physician supervision of nonphysician professionals, the physician organizations strongly urged the administration to consider the vast difference in education and training of physicians and other health care professionals. As the most highly educated and trained health care professionals, physicians should lead the health care team. Patients agree and overwhelmingly want physicians leading their health care teams. In addition, the organizations provided evidence countering common arguments in favor of expanding the scope of practice for nonphysician professionals and urged caution against positioning scope of practice as an administrative burden. Doing so obfuscates the very real administrative burdens facing physicians and other health care professionals every day.

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National Update

Surgeon General issues action call in new report on smoking cessation

On Jan. 23, the nation's doctor, Jerome Adams MD, released Smoking Cessation: A Report of the Surgeon General, to the public. This 700-page report represents a collection of the latest science related to smoking cessation—a new iteration of a similar report issued 30 years ago. Evidence-based recommendations in the report include interventions at three levels: the individual clinician level, the health systems level and the population level. Given the volume of evidence available today, Dr. Adams states there has never been a better time to quit smoking.

However, the report notes that 34 million American continue to smoke, representing the leading cause of preventable death, disease and disability in the United States. Thus, during the release, Dr. Adams called upon stakeholders and invited guests, including the AMA, to use this report as a blueprint for collective, concerted action.

To combat smoking, Dr. Adams enlisted 150 experts to produce this report with a particular focus on the benefits of smoking cessation. For example, smoking cessation benefits people at any age and may add up to 10 years to their life expectancy. More resources and interventions than ever are available online, such as the Center for Disease Control and Prevention's (CDC) Tips from Former Smokers campaign, of which AMA is an official partner organization. The action steps advocated for are routinely counseling patients to quit smoking, eliminating insurer-imposed prior authorization requirements for smoking cessation treatment, and tobacco taxes—all of which are consistent with AMA policy. Unfortunately, disparities remain in the efficacy of smoking reduction efforts to-date in different communities; addressing these gaps will require dedicated efforts moving forward.

Of note, Dr. Adams indicated that the body of research on e-cigarettes does not support their general efficacy as a tool for smoking cessation, especially as compared to, for instance, the therapeutic use of any of seven Federal Drug Administration (FDA)-approved smoking cessation medications in combination with behavioral counseling. AMA continues to advocate for a complete ban on e-cigarette flavors, including mint and menthol, due to their appeal to youth and unclear benefits to patients. The AMA remains committed to improving health outcomes and supporting physicians' work to promote smoking cessation in the United States.

Additional information and the full report are available here.

AMA calls for regulatory changes to facilitate value-based care

The AMA recently responded to federal proposals to modify the physician self-referral and anti-kickback regulations to facilitate the transition to value-based care. The AMA commended the Department of Health and Human Services (HHS) for working to break down barriers to better care coordination and reduce administrative burdens. Traditionally, understanding how to structure practice financial arrangements to comply with self-referral and anti-kickback rules has been extremely burdensome and expensive, often requiring practices to seek help from consultants and attorneys. AMA comments highlight the need to keep the new rules straightforward and avoid unnecessary documentation and other administrative requirements so that physicians in small and rural practices can focus on patient care and avoid extra-legal and consulting costs. The AMA suggests that HHS provide a checklist and model terms for the proposed governing document for value-based enterprises, along with an online portal to provide any information needed to register the arrangement, to make it easier for small and independent practices to participate. Additional information is available in the AMA comment letters on the self-referral proposed rule and the anti-kickback proposed rule.

Physician help needed to improve HPV vaccination rates

In a letter to AMA CEO Jim Madara, MD, Assistant Secretary for Health Brett Giroir, MD, outlines an urgent need to improve human papillomavirus (HPV) vaccination rates. One in four Americans has HPV and it remains the most common sexually transmitted infection in the U.S. The HPV vaccine can prevent many of the cancers linked to HPV, including almost all cases of cervical cancer. Although the vaccine is recommended at age 11 or 12, only 51% of adolescents are fully vaccinated against HPV, leaving many young adults vulnerable to HPV infection and at risk for an HPV-associated cancer.

To help improve HPV vaccination rates, ADM Giroir refers physicians to the HPV toolkit.

AMA submits comments on administration's price transparency proposal

On Jan. 29, the AMA submitted detailed comments in response to the administration's Transparency in Coverage proposed rule, aimed at increasing transparency around health care pricing information. The proposed rule includes two key components. The first calls for private health plans to make available to patients certain price and benefit information specific to that individual, available through internet-based self-service tools that enable patients to estimate their anticipated out-of-pocket health care costs. The second proposal seeks to require private health plans to publicly disclose privately-negotiated payment rates for in-network providers, as well as allowable amounts for out-of-network providers.

AMA comments expressed support for the first proposal, urging the administration to finalize requirements that plans provide patients with information about expected out-of-pocket costs and other benefit information. However, AMA expressed serious concerns regarding the proposal to require disclosure of negotiated rate information, citing concerns about potential for serious adverse impacts on competition and patient access to care. A similar rule was recently finalized for hospitals, which was strongly opposed by hospital groups and health plans. Those groups have filed suit to block implementation of that rule. The AMA will be closely monitoring further administration actions and the outcome of any judicial action on this issue.

Health subcommittee holds hearing on pressing need for cannabis research

The House Energy and Commerce Health Subcommittee held its first-ever medical marijuana hearing on Jan. 15. During the hearing, lawmakers from both parties pressed officials from the FDA, Drug Enforcement Administration (DEA) and National Institute on Drug Abuse to explain why the federal government continues to block research on medical marijuana, given the widespread availability of cannabis products at the state level. Cannabis is currently listed as a Schedule I substance with no medical value and high potential for abuse, severely restricting legitimate research into the safety and efficacy of cannabis products. The committee discussed six bills that propose various policy changes such as rescheduling or de-scheduling marijuana, providing a safe harbor for patients and veterans who use medical marijuana and streamlining cannabis research processes. 

The AMA strongly support S. 2032, the "Cannabidiol and Marihuana Research Expansion Act," sponsored by Senators Feinstein, Grassley and Schatz. This legislation would improve the process for conducting scientific and clinical research on cannabidiol (CBD) and marijuana and streamline the development of safe and effective cannabinoid-based drugs approved by the FDA.

Energy and Commerce Committee examines state efforts to curb opioid crisis

On Jan. 14, the House Energy and Commerce Subcommittee on Oversight and Investigations held a hearing to examine state efforts to curb the opioid crisis. The hearing was a continuation of the committee's ongoing, bipartisan efforts to address the opioid epidemic, and is expected to be the first in a series of hearings to identify additional opportunities for federal legislation to support state efforts. 

The AMA shared the AMA Opioid Taskforce's 2019 report, "National Roadmap on State-Level Efforts to End the Opioid Epidemic: Leading-edge Practices and Next Steps," for committee consideration. Among other recommendations, the AMA believes policymakers should focus on removing barriers to treatment for opioid use disorder (OUD)/ substance use disorder (SUD) and pain, along with other policies that limit patients' ability to receive care. These include prior authorization, step therapy and other administrative burdens, as well as inadequate enforcement of state and federal laws that require insurance parity for mental health and substance use disorders.

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State Update

Former AMA president appointed Kentucky health commissioner

Steven J. Stack, MD, was appointed this week as the Commissioner of Kentucky's Department for Public Health by Gov. Andy Beshear. Dr. Stack, an emergency medicine physician, was AMA President from 2015-2016.

The Kentucky Medical Association congratulated Dr. Stack, saying, "Dr. Stack is an experienced leader and advocate, and we look forward to working with him to continue moving the health of Kentuckians forward."

"Kentucky will be well-served by the leadership and commitment Steve has demonstrated to his patients throughout his career," said AMA President Patrice A. Harris, MD, MA.

"I am proud to be a part of health programming that is innovative, accountable and focused on making Kentuckians' lives better," Dr. Stack said. "Our state health officials are here to support and enhance local health departments. We can't forget that health care is local, and we have to balance a practice of targeting the right care with the approach of maximizing our state and federal resources."

State legislatures across the country tackle scope of practice

Scope of practice legislation has been introduced in states across the country and the AMA's state advocacy team is working to keep patient safety at the center of the debate, emphasizing the importance of education and training to protect patient safety. The AMA expects hundreds of individual bills this year, and currently opposes legislation in Idaho (H.B. 317) and Nebraska (L.B. 828) that would allow optometrists to perform surgery, legislation that would allow psychologist prescribing controlled substances in Nebraska (L.B. 817) and legislation in South Dakota (S.B. 50) that would allow CRNAs to practice outside of a physician-led health care team.

The AMA also is concerned that the Idaho Board of Nursing is considering whether to allow nurse anesthetists to use the term 'nurse anesthesiologists'. The AMA urged the board to "put patients first and not authorize CRNAs to refer to themselves as 'nurse anesthesiologists'" which is "both misleading and confusing to patients and does not further the IBN's mission to protect the health, safety and public welfare of the people of Idaho."

South Dakota physicians should oppose the scope expansion of CRNAs in S.B. 50

The AMA is urging physicians to make their voices heard to protect patient safety. South Dakota S.B. 50 passed the Senate last week and will be heard in the House Health and Human Services Committee likely next week. In its current form, the legislation allows CRNAs to provide anesthesia care and pain management without any physician supervision or collaboration. The bill also grants CRNAs broad prescriptive authority for controlled substances. South Dakota has a short legislative session, so action is needed immediately.

The AMA and South Dakota State Medical Association encourage all South Dakota physicians to contact members of the House Health and Human Services Committee and urge them to oppose S.B. 50.

South Dakota bill would criminalize transgender care

Legislation that would criminalize gender-affirming care of transgender minors is advancing in the South Dakota legislature. On Jan. 22, a House committee voted to move the bill to the House floor. The bill, as approved by the committee, would make it a misdemeanor for medical professionals to provide certain services, including hormone therapy and surgeries, to minors for the purpose of gender transition regardless of whether the services are medically necessary. The original version of the bill would have made the provision of such services a felony.

In coordination with the South Dakota State Medical Association, the AMA is opposing this legislation as a dangerous legislative intrusion into the practice of medicine.

New Jersey passes first vaping bill of 2020

On Jan. 21, Governor Phil Bryant signed legislation to prohibit the sale and distribution of flavored e-cigarettes and other vaping products in New Jersey. The prohibition applies to all flavors except tobacco and includes mint and menthol. The law will take effect in April.  

In 2019, eight states (MA, MI, MT, NY, OR, RI, UT, WA) banned the sale of flavored e-cigarettes via executive action. Massachusetts subsequently enacted legislation to make its flavor ban permanent. The AMA supports prohibitions on the sale of all flavored tobacco and e-cigarette products.  

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Judicial Update

High court ruling must avoid encouraging involuntary commitment

Giving mental health patients access to outpatient care and reserving involuntary commitments for situations that warrant them is crucial to patient safety because studies show that involuntarily commitments result in patients refusing help for fear their civil rights will be taken away.

State laws over decades have evolved to support physicians in striking that balance. Now a plaintiff is asking Pennsylvania's highest court to interpret a commonwealth law in a way that would ultimately force physicians who feared being sued to err on the side of providing involuntarily treatments for patients to whom they otherwise would have provided voluntarily outpatient care.

The Litigation Center of the American Medical Association and State Medical Societies in December joined the Pennsylvania Medical Society and the Pennsylvania Psychiatric Society in filing an amicus brief in the matter. The brief asks the Supreme Court of Pennsylvania to uphold an appellate court decision that does not open physicians up to a new liability when they are making treatment decisions involving mental health patients.

"Overall, studies have shown that 77% of previously admitted patients will not risk being institutionalized again, even if they know they pose a danger to themselves or others. Creating a liability system that would incentivize involuntary commitment, which a liability ruling here would do, would have larger repercussions," the brief tells the court in the case, Leight v. University of Pittsburgh Physicians, et al.

A ruling opening up doctors to new liability would result in physicians involuntarily committing more patients out of fear of lawsuits. That would not improve mental health care, the brief states, and would raise costs while creating greater risks for patients and the public as a whole. One in five adults experiences a mental illness at some point, and one in 25 is living with a serious mental illness.

Read more here.

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Other News

Electronic standards group takes steps to increase clinician input and data protections

Health Level Seven (HL7) International, a standards development organization that creates and maintains electronic standards for clinical data exchange, and leaders of the Da Vinci Project, a private sector initiative focused on accelerating adoption of HL7 Fast Healthcare Interoperability Resources (FHIR) technology, recently announced formation of a Clinical Advisory Council. This council, which includes physicians representing the AMA, the American College of Surgeons, and the American Academy of Family Physicians, will ensure that practicing clinicians contribute insights, expertise and input to the development of FHIR technology for various use cases, including prior authorization automation. While the Da Vinci Project holds promise in reducing practice burdens associated with prior authorization, the AMA and over 100 other state medical associations and national medical specialty societies raised concerns in a September 2019 letter to CMS regarding payers' unprecedented access to electronic health records that will be enabled by Da Vinci. The Da Vinci Clinical Advisory Council recently released a set of Guiding Principles that will protect both physician practices and patients from inappropriate access and use of clinical data by payers. These principles represent a major win for organized medicine and illustrate the critical importance of physician input in the development of electronic standards.

Claim alternative payment model incentive payments

CMS has published a list of nearly 3,000 physicians who are eligible to receive alternative payment model (APM) incentive payments based on their APM participation in 2017, but whom CMS has been unable to find in order to make the payments to them. Physicians whose practices participated in APMs during 2017 but who have not yet received their lump sum incentive payment should review the list and follow the instructions for providing contact and banking information to CMS to claim these payments. Even physicians who are no longer with the practice or whose group no longer participates in the APM may be entitled to payments based on their 2017 participation.

The deadline to respond with the needed information is Feb. 28. Additional information on the incentive payments is available in this brief CMS fact sheet.

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Upcoming Events

Register for the 2020 AMPAC Candidate Workshop by Feb. 3

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 be taking place Feb. 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 now for the 2020 National Advocacy Conference

The National Advocacy Conference gives you the opportunity to connect with industry experts, political insiders and members of Congress about current federal efforts to improve health care in addition to visiting Capitol Hill to advocate on crucial health care issues affecting you and your patients. Featured speakers will include CMS Administrator Seema Verma, and HHS Secretary Alex M. Azar.

Register today and click here for more info on the speakers and agenda.

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.

International Conference on Physician Health – Sept 14-16

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, at the IET London: Savoy Place in London, England.

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

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