June 5, 2020
Issue SpotlightCalling for additional relief for physician practices and Medicaid in the COVID-4 bill
As the country continues to grapple with the COVID-19 pandemic, the House has taken the first step by passing its version of "phase four" coronavirus relief legislation. Now it is the Senate's turn and they are expected to introduce their plan in the coming weeks.
As Senators consider how they will approach a coronavirus relief bill package to confront this emergency of extraordinary—and yet, unknown—proportions, the AMA strongly urges they take critical steps to protect patient access to care by preserving the viability of physician practices as part of the nation's essential health care system.
"Physician practices continue to struggle to meet the needs of their patients and staff as they confront revenue shortages from deferred patient visits and procedures as part of the system-wide effort to conserve personal protective equipment (PPE) and support the physical distancing that is necessary to curb community spread of COVID-19," AMA CEO and Executive Vice President James L. Madara, MD, wrote in a letter to Senate leaders. That letter emphasized the need for increased financial support and improved distribution of HHS provider emergency funds for Medicaid-dependent practices, addressing the challenge of access to PPE for community practices, increased federal funding for Medicaid, and targeted COVID-19 related liability relief.
More broadly, the AMA also has been advocating for:
- Continued expansion of and added flexibility for Medicare accelerated and advanced payments to give physicians greater ability to deal with the current crisis
- Addressing Medicare and Medicaid payment policies to account for the lack of positive updates to further assist America's doctors caring for patients during the pandemic
- Continued support for the expansion of telehealth by requiring Employee Retirement Income Security Act of 1974 (ERISA) group health plans to provide the same telehealth services being covered by Medicare
- Increased support for resident physicians and students through federal loan forgiveness and tuition relief, including third- and fourth-year medical students
With respect to liability relief, the AMA has noted that physicians and other clinicians who treat COVID-19 patients are doing so under unprecedented conditions. Lawsuits may come months or even years after the current ordeal is over. These may stem from situations beyond physicians' control such as:
- The suspension of most elective in-person visits
- The need for physicians to provide care outside their general practice areas for which they may not have the most up-to-date knowledge
- Inadequate supplies of safety equipment that could result in the transmission of the virus from patient to physician and then to additional patients, or directly from one patient to another
- Shortages of equipment, such as ventilators, that can force facilities and physicians to ration care
- Inadequate testing
Bipartisan legislation on this issue, the Coronavirus Provider Protection Act (H.R. 7059), has been introduced in the House by California Democrat Lou Correa and Tennessee Republican Phil Roe, MD.
"Physicians and other health care professionals are putting themselves at risk every day while facing shortages of medical supplies and safety equipment, as well as changing directives and guidance from all levels of government," said AMA President Patrice A. Harris, MD, MA. "We commend Reps. Roe and Correa for recognizing that reasonable liability protections are in the best interest of our country as we continue to combat COVID-19 and begin to recover from this pandemic." Much has been done in the battle to curb the pandemic, but the catastrophic damage has taken an undeniable toll. Stimulus relief to date has helped but is far from sufficient.
Please contact your Senators today and tell them that their phase four coronavirus relief legislation must include the critical physician and patient protections outlined above to ensure the health care system stays viable and able to provide high-quality care.
In response to a Centers for Medicare & Medicaid Services (CMS) request for information, the AMA made a number of recommendations to reduce and prevent rising rates of maternal mortality and morbidity and to ensure access to high-quality care for patients in rural communities. Specifically, CMS should apply the increase to standalone office visit codes to office visits included in the surgical and maternal global codes, improve access to treatment in rural areas for pregnant and postpartum women with opioid use disorder, and maintain expanded telehealth access.
While the letter highlighted promising models for addressing workforce shortages in rural and underserved areas, the AMA stressed the need for adequate payments for physician practices that care for patients in rural communities. In addition, the AMA recommended steps to ensure consistent data collection and effective evaluation to improve maternal and infant health outcomes and quality, as well as to address social determinants of health including housing, transportation and food insecurity.
The AMA sent a letter to the U.S. Department of Health and Human Services (HHS) Secretary Alex Azar detailing suggestions for how to close the gap between the number of patients with opioid use disorder (OUD) who would benefit from medication-assisted treatment (MAT) and the number who are currently receiving it.
Many barriers remain to making treatment available to all those who need it, foremost among them is the requirement for physicians to obtain a special registration from the U.S. Drug Enforcement Administration (DEA) and subject themselves to an overly burdensome and stigmatizing regulatory and recordkeeping regime in order to prescribe buprenorphine. The AMA is recommending that the administration enact H.R. 2482, the "Mainstreaming Addiction Treatment Act" or MAT Act. This act would eliminate the need for physicians to obtain a waiver from the DEA to provide MAT in their practices, as well as the need to take an eight-hour training course and get rid of the limits on the number of patients for whom they can prescribe MAT. It would also enable physicians working with their patients to manage other medical conditions to treat them for OUD concurrently without being subjected to separate regulatory procedures.
Eliminating these requirements would go a long way towards making MAT more available to patients who need it and making it easier for physicians to provide it. Additionally, there are high levels of stigma toward individuals with OUD and medications that treat OUD among the public and health professionals. Instead of helping to eliminate stigma, waiver requirements may reinforce and amplify it. There is also fear of inviting the scrutiny of the DEA by pursuing a waiver to treat OUD patients with buprenorphine. The DEA is a law enforcement agency, not a health care agency, and waivered physicians who have experienced DEA audits have expressed concerns that DEA auditors do not understand medical records and do not conduct the audits appropriately. The AMA is recommending the removal of the DEA requirements to help allay physician concerns and hopefully increase the number of physicians treating patients with OUD.
Updated AMA model state legislation regarding needle and syringe services programs (SSP) includes new provisions to help increase access to sterile needles and syringes as well as provide liability protections for SSPs. The AMA updated the model bill to ensure state medical societies had a detailed rationale to support SSPs, including the evidence-base and public health benefits. The model bill also provides for enhanced Good Samaritan protections; formation and operating requirements for SSPs; and urges states to ensure funding is provided for the stability for SSPs' continued operation.
The COVID-19 pandemic has highlighted how SSPs are having challenges in continuing operations. As part of its state recommendations concerning harm reduction, the AMA recommends that states ensure continuity of syringe services programs, including provision of PPE. This includes expanding PPE priority to include harm reduction organizations and other community-based groups that provide services to people who inject drugs to help protect against the spread of infectious disease. The AMA also recommends that states implement, as part of an Executive Order or other initiative, specific policies to increase access to sterile needle and syringe exchange services. The state of Maine provides a good example.
The AMA urges states to consider introducing the model bill when state legislatures come back into session.
For more information or for a copy of the model bill, please email the AMA Advocacy Resource Center.
In a Leadership Viewpoint story, "Police brutality must stop," AMA President Patrice A. Harris, MD, MA, and Board Chair Jesse M. Ehrenfeld, MD, MPH, write:
"Recognizing that many who serve in law enforcement are committed to justice, the violence inflicted by police in news headlines today must be understood in relation to larger social and economic arrangements that put individuals and populations in harm's way leading to premature illness and death. Police violence is a striking reflection of our American legacy of racism…In any season, police violence is an injustice, but its harm is elevated amidst the remarkable stress people are facing amidst the COVID-19 pandemic. Even now, there is evidence of increased police violence in the form of excessive police-initiated force and unwarranted shootings of civilians, some of which have been fatal. This violence not only contributes to the distrust of law enforcement by marginalized communities but distrust in the larger structure of government including for our critically important public health infrastructure. The disparate racial impact of police violence against Black and Brown people and their communities is insidiously viral-like in its frequency, and also deeply demoralizing, irrespective of race/ethnicity, age, LGBTQ or gender."
Read the full statement here.
A new episode in AMA's ReachMD podcast series features a conversation with AMA's Senior Vice President of Advocacy, Todd Askew, on what the AMA has done to address the range of issues physicians are facing in responding to the COVID-19 pandemic. The conversation touches on PPE shortages, lack of testing and financial shortfalls. Listen here, and click here to learn more about advocacy efforts AMA has undertaken to support physicians during this global health crisis.
"The opioid epidemic has been exacerbated by the current pandemic," said AMA President Patrice A. Harris, MD, MA, on a recent AMA podcast. "The key issue here is eliminating treatment barriers," said Dr. Harris, who highlighted increased flexibility for take-home methadone to treat opioid use disorder. "We have to make sure we are supporting our patients with pain that they continue to receive the care they deserve throughout this pandemic."
"It is really critical that as we think about essential services, we recognize that harm reduction services are essential services, and not having access will lead to increased morbidity and mortality for people who are using drugs," said Elizabeth Salisbury-Afshar, MD, Director at the Center for Addiction Research and Effective Solutions at the American Institutes for Research in Chicago. Dr. Salisbury-Afshar also highlighted the challenges and benefits of telemedicine platforms as well as the importance of regulatory changes that have increased accessed to buprenorphine to treat opioid use disorder via telemedicine services.
"We're seeing an increase in alcohol use and cannabis use," said Steven Stanos, MD, Medical Director of Swedish Health System Pain Medicine and Services and the Medical Director of Swedish Pain Services in Seattle, who pointed to the need to be aware of what comes next. "With economic issues and job issues, patients at high risk are at significant risk. We're doing close monitoring of patients, using virtual visits in the right way. Not just to refill medications but to really check in on patients."
The AMA partnered with the RAND Corporation to determine specific factors that influence the implementation of behavioral health integration (BHI) to help inform solutions for this persistent disparity in mental health care. Researchers looked at the motivators, facilitators and barriers to behavioral health integration from the perspectives of 30 physician practices with firsthand experience.
Published in the journal Annals of Internal Medicine, "Factors Influencing Physician Practices' Adoption of Behavioral Health Integration in the United States: a Qualitative Study," found that there are broad motivations for behavioral health integration, including expanding access to behavioral health services, improving other health professionals' abilities to respond to patients' behavioral health needs and enhancing practice reputation. Additionally, the study found that one in five adults in the U.S. has a clinically significant mental health or substance use disorder. Yet, many people do not receive treatment for their problems due to a shortage of mental health providers and lack of access to mental health services. The study identified a potential solution to the low levels of mental health treatment is integrating behavioral health into medical care.
June 1-8: In a time when physical distancing and isolation are necessary responses to COVID 19, health care clinicians are rightfully concerned about their personal mental health as well as that of their colleagues, family members and patients. Join an online discussion and engage with expert panelists, learn and share best practices, and discuss how COVID-19 has affected behavioral health within your practice for you and your patients. The discussion runs June 1 – June 8.