Special Edition: April 17, 2020
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Issue SpotlightFive vital lifelines still needed for struggling physician practices
Note: This is an excerpt from a recently published story by AMA President Patrice A. Harris, MD, MA (pictured left). Read the full story here.
As our nation's health care system strains under the weight of COVID-19, independent physician practices have had to make difficult decisions about reducing hours, taking pay cuts and furloughing staff even as the number of cases continue to grow.
Given the magnitude of this crisis and the continued uncertainty about the pandemic's path, it's critical we act now to provide private physician practices with the financial support they so desperately need to weather this storm.
Congress took a crucial step earlier this month when it passed the Coronavirus Aid, Relief and Economic Security (CARES) Act, which allocates up to $100 billion in financial relief for hospitals, physician practices and other health care organizations. The U.S. Department of Health and Human Services began sending out the first $30 billion on Friday in the form of emergency funding support for health care-related expenses or lost revenue attributable to COVID-19.
While physicians are grateful for the actions already taken by Congress and this Administration, in a letter to Congressional leaders, the AMA urges additional steps that must be taken to preserve the viability of independent physician practices. These steps include:
Additional direct financial support. The AMA is calling on Congress to authorize direct financial support, grants and interest-free loans and other mechanisms, such as a 9/11-type COVID fund, for physician practices of all sizes. Reimbursable expenses should include payroll costs and other overhead costs, as well as payments made to outside firms for billing and IT purposes, especially for those practices that are too small to maintain part/full-time staff for these functions.
Loan program. It is clear that the new small business loan program authorized in the CARES Act, the Payroll Protection Program (PPP), is already overwhelmed with applicants seeking assistance. The PPP needs an urgent infusion of additional funding in order to adequately respond to the need for these loans.
Residents and medical students. For residents and early graduated medical students, whose debt averages over $200,000, we urge Congress to provide at least $20,000 of federal student loan forgiveness or $20,000 of tuition relief. These benefits should also be made available to third- and fourth-year medical students who are willing, and deemed competent, to begin providing early direct patient care for patients with COVID-19, or who are making other significant contributions to the pandemic response through research, public health and telemedicine.
Medicare and Medicaid payment. While the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 included modest positive payment updates in prior years, it left a six-year gap from 2020 through 2025 during which there are no annual updates at all. It's vital that Congress implement a positive update similar to those other providers received in 2020, as physicians put their lives on the line to treat patients with COVID-19.
Loan repayment. While the Centers for Medicare & Medicaid Services (CMS) has worked quickly to provide flexibility to physicians who need financial assistance, there are significant concerns about the ability of physician practices to repay this amount of money while patients remain at home and physicians delay non-urgent procedures. The AMA is urging Congress to postpone recoupment until 365 days after the advance payment is issued and to extend the repayment period for physicians to at least two years. We also urge a reduction in the per-claim recoupment from 100% to 25%.
Editor's note: The CARES Act was an essential first step in the COVID-19 fight but as the pandemic grows it is clear that more needs to be done for America's patients and those on the front lines taking care of them. Please contact your member of Congress and Senators today and tell them that any additional COVID-19 relief legislation should include the physician and patient protections outlined above.
Responding to a spike in cyber threats that exploit telework technologies during the COVID-19 pandemic, the AMA and the American Hospital Association (AHA) teamed up to provide physicians and hospitals with guidance on protecting a remote work environment from cyber criminals.
"Working from home during the COVID-19 pandemic" offers actions to strengthen home or hospital -based computers, networks and medical devices from the rise in COVID-19-themed security threats and attacks. The resource includes checklists, sources, tips and advice on strengthening protections to keep pace with deceptive cyberattacks that could disrupt patient care or threaten medical records and other data.
"Amid increased reports of malicious cyber activity, some physicians and care teams are working from their homes and relying on technologies to support physical distancing measures while ensuring availability of care to those who need it," said AMA President Dr. Patrice Harris. "For physicians helping patients from their homes and using personal computers and mobile devices, the AMA and AHA have moved quickly to provide a resource with important steps to help keep a home office as resilient to viruses, malware and hackers as a medical practice or hospital."
On April 1, the Federal Bureau of Investigations (FBI) released a public advisory noting that more than 1,200 complaints related to COVID-19 scams were received at its Internet Crime Complaint Center. According to the FBI, "in recent weeks, cyber actors have engaged in phishing campaigns against first responders…deployed ransomware at medical facilities and created fake COVID-19 websites that quietly download malware to victim devices. Based on recent trends, the FBI assesses these same groups will target businesses and individuals working from home via telework, software vulnerabilities, education technology platforms and new Business Email Compromise schemes."
Stay informed and updated on clinical information, guides, advocacy and medical ethics by connecting with the AMA COVID-19 Resource Center.
The U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) is waiving numerous requirements during the COVID-19 emergency to help patients with opioid use disorder (OUD) access treatment to encourage shelter-in-place efforts and minimize travel. In states with declared states of emergency that have requested blanket exceptions from SAMHSA, as the AMA strongly recommends patients may obtain up to 28 days of take-home medication, depending on their level of stability and their treatment program's assessment of the patient's ability to safely handle the medication at home. The AMA is aware of several states that have already requested the blanket waivers. The AMA urges physicians and medical societies to communicate with their state health authorities about the status of their own state's waiver.
Physicians and opioid treatment programs (OTP) may also conduct visits with existing OUD patients via telemedicine, including audio-only telephone visits. Telemedicine visits may replace the required in-person visit for induction for a new patient starting treatment with buprenorphine, but in-person visits are still required for a patient to start treatment with methadone. Patients quarantined at home may have their medications delivered to their home. These are among several new SAMHSA policies for OUD patients.
"During this pandemic, it is critical for patients to be able to access medication without delay. With public transportation limited and social distancing being recommended, physicians know that their patients might not be able to come to an opioid treatment program on a daily basis. Physicians need this flexibility so their patients can keep up with life-saving prescription regimens," said AMA President Dr. Patrice Harris, who also is chair of the AMA Opioid Task Force.
According to Elinore McCance-Katz, MD, PhD, Assistant Secretary for Mental Health and Substance Use, during the first two weeks of treatment with methadone, patients are at the highest risk for overdose and death. Buprenorphine, in her view, is a safer treatment for new patients who cannot obtain care in-person, but a recent study found that many OTPs do not offer treatment with buprenorphine.
The AMA is also urging governors to adopt SAMHSA and U.S. Drug Enforcement Administration (DEA) guidance for OUD care that allows telephone-only initiation of buprenorphine and is recommending that SAMHSA further increase flexibility for OTPs to use telemedicine for new patients receiving treatment with methadone.
As hospitals, clinics and health systems seek to maximize capacity in alternate care sites to deliver supportive care for patients with COVID-19, one stumbling block has been DEA rules governing DEA-registered hospitals, clinics, manufacturers and distributors.
The satellite care locations that may lack the DEA registration usually needed to handle controlled substances are essential to critical care in this moment. The DEA has announced it is making an exception to the registration requirement for the duration of the nationwide COVID-19 public health emergency.
In a letter posted last week, the agency said that "due to the extraordinary circumstances arising from the COVID-19 pandemic," it would allow a health care organization's existing DEA registration to apply to a satellite hospital or clinic if it meets certain conditions, such as:
- It was set up to provide temporary services connected to the public health emergency resulting from the COVID-19 pandemic.
- It is authorized by the state in which it operates to handle controlled substances and is doing so in a manner permitted by the state.
The DEA-registered hospital or clinic must maintain appropriate records and notify the local DEA field office in writing that it is opening a satellite location that will handle controlled substances. Local field offices can be found at the DEA website. The agency also has created a COVID-19 information page.
The DEA also is allowing, for the course of the pandemic, delivery of controlled substances directly to the non-registered satellite hospitals and clinics.
Any physician with reports or examples of drug shortages is encouraged to share that information with the AMA. Please email SMPH@ama-assn.org.
CMS will provide additional relief options for 2019 Merit-based Incentive Payment System (MIPS) reporting due to COVID-19. Practices can submit an Extreme and Uncontrollable Circumstances application until April 30. An application submitted between April 3 and April 30, citing COVID-19, will override any previous data submission. CMS has updated the QPP Participation Status Tool so eligible clinicians can see if the policy has been automatically applied.
Who should submit an application?
- Individual clinicians who started, but are unable to complete, their data submission
- Groups that started, but are unable to complete, their data submission
- Virtual groups that are unable to start or complete their data submission
For more information, please see the Quality Payment Program COVID-19 response fact sheet.
Contact the Quality Payment Program at 1-866-288-8292, Monday through Friday, 8:00 a.m. - 8:00 p.m. Eastern time or by e-mail at: QPP@cms.hhs.gov. Those who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant.
On April 8, Sen. Amy Klobuchar (D-MN) and Rep. Brad Schneider (D-IL), along with more than 30 members of the House and Senate, sent a letter to U.S. Citizenship and Immigration Services (USCIS) urging the administration to resume premium processing for physicians seeking employment-based visas. Sen. Klobuchar, Rep. Schneider and the other bipartisan, bicameral members of Congress argued that the recently announced suspension of premium processing for employment-based visa petitions by USCIS would exacerbate physician shortages during the COVID-19 pandemic, particularly in rural areas that depend on physicians who participate in the Conrad 30 J-1 visa waiver program.
The original version of the Conrad 30 bill dates back to 1994. Through subsequent reauthorizations, the program has resulted in bringing more than 15,000 physicians to underserved areas. It does so by providing an essential waiver to physicians who come to this country on J-1 work-study visas for residency training. Otherwise, those physicians would be forced to return home for two years before applying for a new visa or green card. In exchange, the physicians give a three-year commitment to practice in an underserved community. The AMA supports the Conrad State 30 and Physician Access Reauthorization Act (H.R.2895/S.948) in accordance with current AMA policy. This bill would reauthorize the J-1 visa waiver program for an additional three years (through Sept. 30, 2021) and make improvements to the program by requiring more transparency in employment contract terms.
"Ensuring that underserved and under-resourced communities have ample access to physicians is a chronic challenge in normal times, and the COVID-19 pandemic is expected to exacerbate this issue. Physicians practicing in underserved communities either via an H-1B visa or as part of the Conrad State 30 program play a key role in providing much needed health care to vulnerable populations. We applaud Senator Klobuchar, Representative Schneider and the other bipartisan, bicameral cosigners for seeking to rectify this problem stemming from the pandemic," said AMA President Dr. Patrice Harris.
Responding to the COVID-19 pandemic, the AMA, in league with the Federation, has been vehemently advocating for policies that would protect patient access to care, the health of physicians and the viability of physician practices. Some recent correspondence activity includes:
Phase four Congressional relief package: As cited above, the AMA, all state medical associations and 89 national medical specialty societies wrote to Congress as members consider a "phase four" coronavirus relief legislative package to further confront the pandemic. In the letter, AMA strongly urges Congress to take additional steps to protect patient access to care by preserving the viability of physician practices as part of the nation's essential health care system.
Addressing the needs of minority populations during COVID-19: The AMA sent a joint letter in conjunction with the American Hospital Association and the American Nurses Association to Secretary Alex Azar at the Department of Health and Human Services (HHS). The letter calls on HHS to mobilize its agencies and use its existing authorities to identify and address disparities in the federal response to COVID-19, including increasing the availability of testing, ensuring access to equitable treatment and disseminating timely, relevant, culturally appropriate and culturally sensitive public health information.
ERISA plan guidance: The AMA sent a letter to Eugene Scalia, Secretary U.S. Department of Labor, urging the department to issue guidance to Employee Retirement Income Security Act of 1974 (ERISA) health plans to expand the use of telemedicine during this pandemic. It is critical that telemedicine, as a means to allowing patients to safely access covered care during this emergency, is available to all. Medicare and many states have taken action to expand access and the AMA is urging the DOL to help push ERISA plans to catch up.
Addressing PPE shortages: The AMA sent a letter to the Federal Emergency Management Agency (FEMA) urging the creation of a national system for acquisition of personal protective equipment (PPE) as well as a system of distribution managed by the federal government so that a healthy physician workforce can be maintained in both hospital and laboratory settings.
Telehealth payment parity: In a sign-on letter to CMS Administrator Seema Verma, the AMA and 41 national medical specialty societies urge CMS to provide payment parity between telehealth visits and regular office visits and provide guidance to Medicare Administrative Contractors (MAC) to ensure that recent CMS guidance and rules are followed appropriately to enable the payment of telephone E/M claims.
The AMA Advocacy Resource Center has compiled a robust list of policy options for states to address COVID-19, with information on telemedicine, liability protections, reducing administrative barriers, elective procedures and expanding coverage. Some new resources include:
- Updated state telemedicine chart + COVID-19 state policy guidance on telemedicine: Provides guidance or a checklist for states on key provisions they should consider in expanding the reach of telemedicine in responding to COVID-19. These policies, some temporary, include expanding coverage of telemedicine services, ensuring services provided via telemedicine are paid for at the same rate as in-person services, expanding the types of telemedicine modalities covered to include audio-only, allowing any in-network contracted provider to provide telemedicine services without requiring they contract with a specific telemedicine provider, and ensuring telemedicine coverage and payment for new and established patients. This document also provides links to best practices which can be used as a model for other states.
- State recommendations for liability protections: Helps states interested in seeking additional medical liability protections for physicians in response to COVID-19. This resource offers sample language and points to several state actions thus far as good examples. This document was created in partnership with the Medical Professional Liability Association.
The AMA sent letters to the National Governors Association (NGA), the National Association of Insurance Commissioners (NAIC) and the National Council of Insurance Legislators (NCOIL) asking their members to adopt state policies that promote patient access to their physician during this pandemic and after the emergency. The letters identify three specific policy areas that governors, insurance commissioners and state legislators could address, including broader access and flexibility in the provision of telemedicine; continuity of coverage provisions (e.g., grace periods for premium nonpayment) that do not shift risk or costs onto patients and physicians; and suspension of administrative requirements, such as prior authorization, that delay care and waste practice resources.
States have options when it comes to helping patients with opioid use disorder, pain and further supporting harm-reduction efforts. The AMA's COVID-19 policy recommendations for OUD, pain, harm reduction emphasize three main areas:
- Ensuring access to care for patients with an opioid use disorder. This includes designating medications to treat addiction (buprenorphine, methadone, naltrexone) and medications to reverse opioid-related overdose (naloxone) as "essential services" to reduce barriers to access during shelter-in-place orders. It also includes prohibiting cost-sharing and prior authorization for medications used to treat addiction, including buprenorphine, methadone and naltrexone; allowing for a 90-day prescription for patients receiving buprenorphine; and removing any restrictions on the Medicaid preferred drug lists to help avoid medication shortages. This includes ensuring coverage for methadone for patients receiving care in an OTP.
- Protecting patients with pain. The AMA recommends that states waive limits and restrictions on prescriptions for controlled substances, as well as dose and/or quantity as well as refills for the duration of the state and national emergency declaration.
- For patients with chronic pain, states and payers should waive testing requirements and in-person counseling requirements for refills and allow for telephonic counseling to fulfill state prescribing and treatment requirements.
- Harm reduction to help prevent overdose and spread of infectious disease. This includes designating supplies provided by harm reduction organizations as "essential services" to reduce barriers to access during shelter-in-place orders; and ensuring continuity of syringe services programs, including provision of PPE and expanding PPE priority to include harm-reduction organizations and other community-based organizations that provide services to people who inject drugs to help protect against the spread of infectious disease.
The AMA has identified many new ways in which states are taking action to help patients with opioid use disorder and pain and how states are further supporting harm reduction efforts. This includes a new Minnesota law that protects patients with chronic disease. The law, enacted as part of the response to the COVID-19 global pandemic, allows Schedule II-V controlled substances to be dispensed for more than 30 days and removes existing refill limitations.
The AMA also is urging states to adopt a new Maine needle, syringe exchange policy. A recent Executive Order issued by Maine Governor Janet Mills removed restrictions in the state on sterile needle and exchange services to help reduce harm among people who inject drugs and protect against the spread of infectious disease. Under Executive Order 27, the state will no longer require a 1:1 exchange during the national COVID-19 emergency—allowing individuals to receive multiple sterile needles and exchanges.
Additional areas where states are taking action include recommendations from state governments in Washington, New Jersey and Ohio, where clinics are providing options for patients like curb-side and "doorstep" deliveries of methadone and buprenorphine for patients who are quarantined or isolated because of COVID-19 or are older with severe health issues.
In New Hampshire, drug courts have adopted telehealth options that are reducing transportation barriers and helping enrollees in the program avoid unnecessary contact with others.
The Colorado Consortium for Prescription Drug Abuse reports that small and large treatment centers (and individual providers) have transitioned intensive outpatient programs and regular outpatient program services to virtual delivery, and most residential services have developed protocols for accommodating new admissions while assessing and/or mitigating risk associated with potential COVID-19 infection. OTPs have arranged for curbside delivery of methadone with increased security and telephone check-ins/scheduling; and there is greater use of online/free recovery support services being offered across the state, in English and Spanish.
Additional harm-reduction efforts include the Indiana Division of Mental Health and Addiction, which has announced it will provide opioid treatment programs with lockboxes and naloxone kits. The lockboxes will enable Hoosiers who are stable in their treatment of opioid use disorder to reduce the number of trips and time spent at an OTP to receive their daily dose of methadone. Naloxone will be issued with the lockboxes as a precautionary method.