April 24, 2020
Issue SpotlightHighlights of this week's new supplemental COVID-19 bill
Today President Trump signed the "Paycheck Protection Program and Health Care Enhancement Act." This is a supplemental COVID-19 bill.
Highlights of the bill include:
- Provides $75 billion more for hospitals, physicians and health care providers to support COVID-19 related expenses and lost revenue. Language remains the same as in the CARES Act and is in addition to the original $100 billion.
- Increases funding for the Small Business Administration's Paycheck Protection Program by $310 billion.
- Creates $60 billion in set asides for insured depository institutions, credit unions, and community financial institutions to provide the Paycheck Protection Program loans.
- Creates $60 billion in set asides for insured depository institutions, credit unions, and community financial institutions to provide the Paycheck Protection Program loans.
- Increases the authorization level for the Emergency Economic Injury Disaster Grants from $10 billion to $20 billion and appropriates an additional $10 billion.
- Appropriates an additional $50 billion for the Disaster Loans Program account to remain available until expended.
- Provides $25 billion to expand COVID-19 testing capabilities, including $11 billion for states and localities and dedicated funding for FDA, community health centers, and rural health clinics.
- Requires a strategic plan to provide assistance to states for testing and for increasing testing capacity.
Read the full summary of the bill here.
A CARES 2.0/COVID 4.0 bill is already under development as well for consideration in early May and will cover a wider range of issues.
The Department of Health and Human Services (HHS) provided additional information about further allocation of the original $100 billion CARES Act Provider Relief Fund. This updated information is available here.
On April 10 an initial $30 billion was allocated to clinicians and facilities based on their proportion of Medicare Part A and B fee-for-service spending in 2019. HHS is now adding an additional $20 billion to this amount for what it describes as a $50 billion "general allocation." The remaining fund distribution will be based on 2018 net patient revenue, not just Medicare fee-for-service.
Some portion of this distribution is based on cost reports, which are filed with HHS by hospitals and some other facilities. For those without adequate cost reports on file, HHS will open a portal this week for providers to attest to their net 2018 revenue for purposes of determining allocation. We are seeking more information about how the additional funds will be allocated to physicians, including whether or not physicians will need to use this portal process to receive additional funds.
Of the remaining $50 billion, $10 billion will be allocated for a targeted distribution to hospitals in areas that have been particularly impacted by the COVID-19 outbreak based on information they provide on the number of ICU beds and admissions for patients with a COVID-19 diagnosis. An additional $10 billion is being allocated to rural hospitals and rural health clinics based on their operating expenses, and $400 million is being directed to Indian Health Service facilities.
Some portion of the remaining funds is being used to cover the costs of caring for uninsured patients with COVID-19. These funds may be claimed beginning April 27 at hrsa.gov/coviduninsuredclaim and the reimbursement for the uninsured will be based on Medicare payment rates. Physician services provided to uninsured patients, such as office and emergency visits, including those provided via telehealth, may be reimbursed in this manner.
An unspecified portion of the remaining funding will be used for clinicians, such as obstetrician-gynecologists, and facilities that rely more on Medicaid than Medicare revenues.
To encourage physicians to participate in COVID-19 clinical trials and research, clinicians may now earn credit in the 2020 Merit-based Incentive Payment System (MIPS) for participation in a clinical trial and reporting clinical information by attesting to the new COVID-19 Clinical Trials Improvement Activity. The new improvement activity provides flexibility in the type of clinical trial, which could include the traditional double-blind placebo-controlled trial to an adaptive or pragmatic design that flexes to workflow and clinical practice. It also carries a high weight from a scoring perspective. This means that clinicians who report this activity will automatically earn half of the total credit needed to earn a maximum score in the MIPS improvement activities performance category, which counts as 15% of the MIPS final score.
Clinical trials could include those conducted by the National Institutes of Health (NIH) or the Patient Centered Outcomes Research Institute's (PCORI)-sponsored Healthcare Worker Exposure Response and Outcome (HERO) registry.
To view a database of privately and publicly funded clinical studies currently being conducted on coronavirus visit: https://clinicaltrials.gov/. For more information on MIPS visit: https://qpp.cms.gov/ .
The AMA continues to advocate and work with the Centers for Medicare & Medicaid Services (CMS) on solutions to reduce the 2020 MIPS reporting burden and make the program more flexible due to COVID-19.
As a result of the COVID-19 pandemic, Labor Condition Application restrictions have made it difficult for international medical graduates (IMG) to practice in areas where they are most needed. On April 3, the AMA wrote a letter to Vice President Mike Pence and United States Citizenship and Immigration Services (USCIS) urging the administration to permit IMG physicians currently practicing in the U.S.—with an active license and an approved immigrant petition—to apply and quickly receive authorization to work at multiple locations and facilities with a broader range of medical services for the duration of the COVID-19 pandemic. The AMA also urged the administration to expedite work permits and renewal applications for all IMG physicians who are beginning their residency or a fellowship or are currently in training.
In addition, on April 14, the AMA sent a letter urging USCIS to recognize COVID-19 as an extraordinary circumstance beyond the control of the non-U.S. citizen IMG applicant or their employer and thus expedite approvals of extensions and changes of status for non-U.S. citizen IMGs practicing, or otherwise lawfully present, in the U.S. In addition, the AMA urged the administration to extend the current 60-day maximum grace period to a 180-day grace period to allow any non-U.S. citizen IMG who has been furloughed or laid off as a result of the pandemic to remain in the U.S. and find new employment. Moreover, the AMA asked USCIS to protect the spouses and dependent children of H-1B physicians by automatically granting a one-year extension of their H-4 visas so that the families of practitioners are not separated during the pandemic.
For pressing questions on this issue please consult the newly created AMA resource, "FAQs: Guidance for international medical graduates during COVID-19."
This $200 million program supports health care providers responding to the COVID-19 pandemic by providing eligible health care providers support to purchase telecommunications services, information services, and devices necessary to enable the provision of telemedicine services during this emergency period. It will provide selected applicants with full funding for these eligible telehealth services and devices. In order to receive funding, eligible health care providers must submit an application to the Federal Communications Commission for this program, and the Commission would award funds to selected applicants on a rolling basis until the funds are exhausted or until the current pandemic has ended.
It should be noted that only select "health care providers" are eligible for funding. In this context, the applicable statute defines a health care provider to mean:
- post-secondary educational institutions offering health care instruction, teaching hospitals and medical schools
- community health centers or health centers providing health care to migrants
- local health departments or agencies
- community mental health centers
- not-for-profit hospitals
- rural health clinics
- skilled nursing facilities (as defined in section 395i–3(a) of title 42)
- consortia of health care providers consisting of one or more entities described in clauses (i) through (vii)
More information on the FCC's fund can be found here.
To help physicians and patients get started with telehealth services, HHS launched the telehealth.hhs.gov website with resources and best practices for accessing care virtually. For physicians, there are tips for getting starting, preparing patients for telehealth visits, billing and payment, and legal considerations. AMA resources, including the Telehealth Quick Guide, are featured. Hear from Surgeon General Jerome Adams, MD, MPH, on the importance of integrating telehealth into your practice and "Join the Telehealth Revolution."
On April 6, the AMA submitted comments to CMS in response to its proposed rule updating Medicare Advantage (MA or Part C) and the Medicare prescription drug benefit (Part D) program. In the proposed rule, CMS sought input on a new specialty tier, drug management programs, a beneficiary real-time benefit tool, administrative burden, refinements to the Medicare Advantage and Part D Quality Star Rating system and network adequacy provisions.
If allowed to go into effect, the proposed rule would allow a second "preferred" specialty tier in Part D. In its comments, the AMA raised concerns that a second specialty tier may lead to increased cost-sharing and co-payments for patients currently stabilized on a specialty drug and urged CMS to exempt such patients from unfavorable coverage changes resulting from a secondary specialty tier. The AMA also reiterated its commitment to ensuring that prescribing decisions should be made between the physician and patient. Additionally, the AMA recommended that Medicare Advantage plans consider covering the provision of validated devices, including self-measured blood pressure devices, particularly as hypertension is an underlying risk factor for adverse COVID-19 outcomes.
Included below is a non-exhaustive list of additional comments:
- CMS should encourage MA plans to facilitate enrollees' access to medical treatment with buprenorphine or other appropriate medications to manage opioid use disorder.
- Part D sponsors should be required to increase coverage, availability and affordability of non-opioid treatment options, including placing non-opioid pharmacologic and non-pharmacologic options on the lowest cost-sharing tiers with minimal co-pays and benefit limitations.
- The AMA shares CMS' goal of improving patients' access to useful information regarding drug benefits and costs, however, when considering implementation of real-time benefit technology, is urging CMS to consider the ability of such tools to support patient-physician discussions regarding treatment selection and the utility of the data for the majority of Medicare patients.
- The AMA generally supports CMS' proposal to increase the weight of the patient experience and access measures in Medicare Advantage and Part D Star Ratings programs but encourages CMS to work with AHRQ to update the Health Plan CAHPS survey.
- Improving the prior authorization process for patients and physicians is a priority for the AMA and as such, CMS should consider the inclusion of processing time, approval/denial rates and denials overturned on appeal in prior authorization metrics in Medicare Advantage plan Star Ratings.
- Given the strain the COVID-19 pandemic is placing on the health care system, the AMA urges CMS to suspend weighing the Effectiveness of Care Measures based on 2020 data given the amount of clinical information required of plans to collect from practices, and immediately send out an advisory notice to plans informing them of this suspension, as well as recommend in the guidance that they suspend collecting the information from physicians.
- To improve network adequacy, CMS should require plans to report the percentage of physicians in the network who actually provided services to plan members during the prior year and publish the research supporting the ratio and distance requirements CMS uses.
- MA plans should be encouraged to cover all visits and other services that are on the Medicare telehealth list when provided through telehealth by patients' physicians.
- CMS should consider allowing patient conditions and symptoms documented during telehealth visits to be incorporated into Medicare Advantage plan risk scores.
In a recent comment letter, the AMA urged the Senate Finance Committee to implement several policies to reduce and prevent rising rates of maternal mortality and serious or near-fatal maternal morbidity. The AMA urged Congress to work in a bipartisan manner to ensure Medicaid and CHIP (Children's Health Insurance Program) coverage for women for one-year postpartum. The AMA also urged Congress to address the issue of poor network adequacy and low Medicaid reimbursement for physicians, which the AMA believes poses a substantial barrier to improving maternal mortality and morbidity in this country. In addition, the AMA urged the committee to help improve the health and safety of pregnant women and save families from devastating losses by investing in local Maternal Mortality Review Committees.Back to Top
In a letter to the CEO of the National Governors Association (NGA), the AMA called on governors to adopt civil immunity for physicians providing COVID-19-related care and those adhering to federal, state or local directives. The AMA urged that such measures are necessary to preserve and expand the COVID-19 workforce, alleviate the strain on front-line physicians, remove obstacles for physicians seeking to fill workforce gaps, and safeguard physicians adhering to federal, state or local directives necessary to protect valuable health care resources and mitigate the spread of COVID-19.
The AMA provided clear guidance for governors moving forward, including recent Executive Orders in Connecticut and New York which provided immunity for care provided in support of the state's COVID-19 response, as well as recent legislation in New York which provided additional protections for care provided pursuant to state or federal directives.
Important liability protections were adopted this past week by state legislatures in Massachusetts and Wisconsin. On April 15, Wisconsin enacted A.B. 1038, which provides civil immunity to health care professionals for care provided in good faith pursuant to a governmental directive, guidance or order related to the public health emergency. The legislation notes the civil immunity extends to services provided 60 days after the expiration of the public health emergency.
On April 17, Massachusetts Governor Charlie Baker signed S. 2630 into law. S.2630 grants civil immunity to physicians and health care facilities for care provided during the COVID-19 emergency. The language is quite broad, extending immunity for any damages alleged to have been sustained by care provided in good faith pursuant to a COVID-19 emergency rule or where the care was impacted by the health care facility or health care professional's decisions or activities in response to or as a result of the COVID-19 outbreak or emergency rules.
The AMA joined the Indiana State Medical Association in seeking clarification from the state medical licensing board as to whether existing patients with chronic pain can be evaluated via telephone-only communication to satisfy state-specific controlled substances prescribing rules.
The new flexibility "may have been satisfied by Executive Orders (EO) 20-12 and 20-13, but we seek clarification – along with the Indiana State Medical Association – as to whether those EOs specifically supersede 844 Indiana Administrative Code 5-6-6," wrote AMA Executive Vice President and CEO James L. Madara, MD, in a letter to the Indiana Medical Licensing Board (MLB).
Dr. Madara also encouraged the Indiana MLB to "adopt, in full, guidance provided by the U.S. Drug Enforcement Administration (DEA) to help ensure patients with pain receive the medications they need while simultaneously helping support public health measures to protect patient safety, reduce unnecessary travel and potential exposure to the COVID-19 virus." This includes urging the MLB to allow for "multiple prescriptions authorizing the patient to receive a total of up to a 90-day supply of a Schedule II controlled substance, subject to specific conditions being met."
If you have any specific examples of states/institutions taking action to help patients with chronic pain, please consider sharing them with the AMA. Information can be sent to Daniel.Blaney-Koen@ama-assn.org.
Language always matters to addiction medicine physician Yngvild Olsen, MD, MPH: "Whether we are talking to our patients about medical concerns—or to policymakers about terminology—we must be clear, honest and accurate." Dr. Olsen explained that the emphasis on using correct terminology is one of the prime reasons why the American Society of Addiction Medicine (ASAM) updated its definition of "addiction" as well as clarifying how people use the term "MAT."
Dr. Olsen commended the work of a special ASAM Task Force, which recommended that "addiction" should be viewed as a treatable medical disease that has many interrelated parts. The updated definition, she said, reflects that complexity:
"Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment and an individual's life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences. Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases."
Dr. Olsen also explained that while ASAM recognizes the widespread use of "MAT" to be defined as "medication-assisted treatment," it is important to update the term to be defined as "medications for addiction treatment."
"This is not about semantics," said Dr. Olsen. "This is about highlighting the fact that treatment is not just medication, and that addiction is a highly complex medical disease. As physicians, we want to ensure that complexity is understood. This is important for the current epidemic, but also for future generations of physicians. The updated definition captures the known factors that enter into the development of a diagnosable substance use disorder in any given individual. It highlights and concisely explains the underlying brain disease of addiction and acknowledges the symptoms that form the basis for the accompanying substance use disorder diagnoses that clinicians make."
Any change in health care-related terminology can disrupt care or policy as providers, policymakers and the public work to understand new or revised definitions. However, Dr. Olsen emphasized that ASAM's update only underscores already needed policy change.
"Like the AMA and the AMA Opioid Task Force, ASAM is focused on promoting evidence-based care and removing all barriers to that care," said Dr. Olsen. "This new definition doesn't change the fact that health insurance companies and state policy need to change to support physicians and patients. It doesn't change the fact that mental health and substance use disorder parity laws need to be enforced. It's simply an important advancement to help us all speak and work together for our patients."
The AMA has released a GME resource guide that addresses some of the benefits that are currently available for residents and medical students, ranging from loan relief to additional grants to new policies that help make it easier to practice as a resident during this challenging time. The information in the resource guide also highlights some of the helpful provisions that the AMA successfully advocated for in the Coronavirus Aid, Relief, and Economic Security (CARES) Act, including the deferment of student loan payments and interest, increased volunteer liability protections, and federal work study flexibility.
On March 5, Executive Order 13861 established the President's Roadmap to Empower Veterans and End a National Tragedy of Suicide (PREVENTS) Initiative. In light of current events, the PREVENTS interagency taskforce has created a messaging campaign specifically in response to the COVID-19 crisis called More Than Ever Before. This campaign is designed to help people deal with the stress and anxiety caused by the pandemic by encouraging them to care for their mental health – and support those they love – every day. Tips, resources and other information about More than Ever Before can be found here.
The PREVENTS roadmap and suicide prevention campaign will be officially launched once the pandemic has abated.
Physician employees of hospitals, health systems and other entities are likely to confront unique challenges during the COVID-19 pandemic. Factors such as the financial distress of their employer, changes in clinical service demand and growing anxiety related to caring for COVID-19-diagnosed patients may complicate the employer-employee relationship.
The AMA developed a new resource for physicians in response to the unique financial and employment challenges posed by the COVID-19 pandemic. The "Know Your Rights: Navigating Physician Employment During COVID-19 Guide" build on the AMA's continued efforts to equip physicians and their practices with the latest information and resources necessary to navigate the changing landscape of COVID-19.
Action steps taken by an organization before, during and after a crisis will reduce psychosocial trauma and increase the likelihood its workforce will cope or even thrive. A new resource from the AMA provides 17 steps that health care organizations can take in order to effectively care for health care workers during times of crises. Successful organizations will take a systems approach and focus on becoming a resilient organization prior to times of crises, rather than limiting their efforts to a focus on individual resilience. Resilient organizations will need to rapidly reconfigure their well-being priorities to meet the biggest new drivers of stress in a crisis setting.
As the nation's opioid epidemic has now become a deadlier drug overdose epidemic, the AMA Opioid Task Force urges individualized and evidence-based patient care for those with a substance use disorder. Offering a frontline perspective on how to help patients, physician members of the AMA Opioid Task Force shared their experiences helping patients with substance use disorders. Over the span of two episodes Drs. Patrice Harris, Frank Dowling, Elizabeth Salisbury-Afshar, Sharon Levy, John Renner, David Ring, Ameet Nagpal and Steven Stanos provide insight on how the 2019 AMA Opioid Task Force is working to support individualized care for patients with pain. Listen here.
The AMA developed two new resources to provide regulatory clarifications on extended prescription duration to improve practice workflows and where physicians and health care workers can safely store and consume food and beverages at their workplace. Visit the overview page for information on additional regulatory clarifications.
May 20: Given the ongoing stress that COVID-19 has placed on individuals seeking care for opioid use disorder (OUD), Get Waivered, ACEP and ED-Bridge are partnering to provide the first Zoom DEA X waiver training class on May 20 from 10 a.m. to 6 p.m. Eastern time. Elevated levels of anxiety and depression caused by isolation measures are having a particularly severe impact on patients with opioid addiction. Given the realities of isolation and the increased difficulties of accessing care during the COVID-19 pandemic, many patients who struggle with addiction are having a harder time finding the treatment they need. Combined with new guidelines on telemedicine, remote waiver training will allow physicians to manage OUD in an outpatient setting while maintaining required social distancing.
Please register at getwaivered.com/remote.