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July 10, 2020

Issue Spotlight

11 beginning steps to reform policing and tackle racial injustices

In a letter to Democratic and Republican congressional leaders in the U.S. House and Senate, AMA Executive Vice President and CEO James L. Madara, MD, detailed physicians' support for the following changes, among others:

The AMA also opposes "choke and sleeper holds as the use of deadly force with the potential to kill," says Dr. Madara's letter.

"These are but a few of the necessary reforms to address the national disgrace of excessive use of violence against individuals who are part of minoritized and marginalized communities," Dr. Madara wrote. "We are at a critical point in our nation's reckoning with issues of police use of violence, racism and discrimination. The use of excessive police force is a communal violence that significantly drives unnecessary and costly injury, and premature morbidity and death. Police brutality and racism must not be tolerated. We urge Congress to act now on meaningful and effective policing reform legislation."

Read the full story here.

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National Update

Pulling out of the WHO puts the U.S. at grave risk

Statement from American Academy of Pediatrics President Sally Goza, MD, FAAP, American Academy of Family Physicians President Gary L. LeRoy, MD, AMA President Susan R. Bailey, MD, and American College of Physicians President, Jacqueline W. Fincher, MD, FACP, on the dangers of pulling out of the WHO:

"The Trump administration's official withdrawal from the World Health Organization (WHO) puts the health of our country at grave risk. As leading medical organizations, representing hundreds of thousands of physicians, we join in strong opposition to this decision, which is a major setback to science, public health and global coordination efforts needed to defeat COVID-19.

"The WHO plays a leading role in protecting, supporting and promoting public health in the United States and around the world. The agency has been on the frontlines of every global child health challenge over the last seven decades, successfully eradicating smallpox, vaccinating billions against measles and cutting preventable child deaths by more than half since 1990. Withdrawing from the WHO puts these investments at risk and leaves the United States without a seat at the table – at a time when our leadership is most desperately needed.

"As our nation and the rest of the world face a global health pandemic, a worldwide, coordinated response is more vital than ever. This dangerous withdrawal not only impacts the global response against COVID-19, but also undermines efforts to address other major public health threats. The American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians and American Medical Association strongly oppose this short-sighted decision. We call on Congress to reject the Administration's withdrawal from the WHO and make every effort to preserve the United States' relationship with this valued global institution. Now is the time to invest in global health, rather than turn back."

Drafting error could mean 21% tax hit on CARES Act relief funds

The AMA and many other stakeholders in health care are urging Congress to rectify an apparent Coronavirus Aid Relief and Economic Security (CARES) Act drafting error that, if left unaddressed, could mean that entities receiving relief funds under the legislation might have to pay taxes on the money they got from the government.

Organizations representing nurses, dentists, hospitals, optometrists, physical therapists and hospices joined the AMA, the U.S. Chamber of Commerce and others in asking Congress "to clarify and correct" what they "believe are the unintentional tax consequences of policies meant to provide vital funding to health care providers through the Public Health and Social Services Emergency Fund (PHSSEF) and other programs as part of the nation's response to the novel coronavirus (COVID-19) pandemic."

Unless Congress fixes the problem, tax-paying health care organizations would "lose at least 21% of the benefit of these funds," says the letter to congressional leaders in both parties in the U.S. House and Senate. "We do not believe Congress intended such a consequence in enacting the CARES Act and other COVID-19-related legislation."

When the government pays corporations, those payments are taxable, generally speaking. When enacting the CARES Act in March, Congress spotted the issue and specifically exempted Payment Protection Program (PPP) funds from taxation. But drafters failed to have that exemption apply to "entities receiving PPP funds from maintaining their tax deductions for expenditures attributable to PPP funds."

Now there is bipartisan support to fix the problem in upcoming legislation, and the AMA and others are asking to extend the correction to the PHSSEF monies that are vitally needed to help health care organizations adversely affected by the pandemic.

"The congressional response to the COVID-19 pandemic has been swift and decisive. It is critical that the actions taken to support front-line caregivers and hospitals are not diluted by technical issues around the taxability of support funds," says the letter. "Congress should streamline the assistance process and ensure the target entities receive 100% of the assistance Congress intended.

Read more here.

Why IMG physicians are vital to U.S. health security

The AMA is telling the Trump administration that allowing international medical graduates (IMG) and their families into the U.S. on J-1 and H-1B visas is in the country's best interest.

"The U.S. health care workforce relies upon health professionals and scientists from other countries to provide high-quality and accessible patient care," AMA Executive Vice President and CEO James L. Madara wrote in a letter to U.S. Secretary of State Mike Pompeo and Acting Secretary of Homeland Security Chad Wolf.

"During this pandemic, it is more critical than ever to ensure that the U.S. has a fair and efficient immigration system that strengthens the American health care system and advances the nation's health security," Dr. Madara added.

The letter is in response to a June 22 Trump administration executive order suspending the entry of foreign individuals into the U.S. for 60 days.

The executive order does allow entry for persons who "are involved with the provision of medical care to individuals who have contracted COVID-19 and are currently hospitalized; [or] are involved with the provision of medical research at United States facilities to help the United States combat COVID-19."

These exemptions, however, are far too limited—particularly for IMGs who were scheduled to start their medical residency training July 1.

"This carve out is too narrow and fails to exempt a large portion of the IMGs that come to the U.S. to practice in a wide range of medical specialties," Dr. Madara's letter states. Nearly 30% of medical residents in the U.S. in 2017 were IMGs, with about half on nonimmigrant visas, such as J-1 and H-1B.

Additionally, the carve out fails to include spouses and dependent children of J-1 and H-1B physicians by exempting their J-2 and H-4 visa-holding family members from the immigration ban.

"The spouses and children of our physicians, who are entering the U.S. to provide critical health care to patients across the U.S., should not be separated from one another, especially during a global pandemic," Dr. Madara wrote, adding that the immigration ban disproportionately affects IMGs who are parents and whose training may take up to seven years to complete.

"Parent IMGs who are able to enter the U.S. to help treat COVID-19 patients, per the carve out, may be forced to make the impossible decision of leaving behind young children for years or coming to train in the U.S.," the letter says. "To force mothers and fathers to choose whether to be separated from their children and spouses, or take a position treating some of America's sickest patients, in some of our most underserved areas, is unfair."

Read the full story here.

AMA advocates for permanently lifting Medicare restrictions on telehealth

In recent months, the use and coverage of telehealth has expanded tremendously in response to the COVID-19 pandemic. Positive stories about the impact of broader coverage of telemedicine services are being reported from providers and patients around the country. Medicare access in particular has been vastly expanded. Prior to the COVID-19 crisis, the law restricted Medicare coverage of telehealth services furnished via audio-visual technologies to patients in rural areas who received care in a physician's office or clinic. Congress gave the Secretary of Health of Human Services (HHS) the authority to waive the geographic and site restrictions on telehealth services for the duration of the pandemic. However, this expanded access will abruptly end if Congress does not act before the end of the COVID-19 public health emergency declaration.

Congress is beginning to examine what telehealth policies should be made permanent. The Senate Health, Education, Labor and Pensions (HELP) Committee held a hearing on June 17, entitled "Telehealth: Lessons from the COVID-19 Pandemic." The purpose of the hearing was to identify which of the temporary changes in federal policy should be maintained, modified, or reversed—and to determine if any additional federal policies are needed to facilitate patient and physician use of telemedicine. Chairman Alexander, R-TN, began the hearing by acknowledging the tremendous gains in telehealth coverage in recent months. To keep the momentum going post-pandemic, he expressed support for removing site restrictions on telehealth, and allowing Medicare and Medicaid to continue paying physicians for telehealth appointments wherever the patient is located, including the home.

While Congress considers "phase-four" COVID-19 relief legislation, they should ensure that telehealth services are covered and remain available at the end of the COVID-19 public health emergency.

Please contact your Senators and Representative today and tell them that any new COVID-19 relief legislation should include the telehealth provisions outlined above.

Read more here.

AMA testifies before U.S. House on disproportionate impact of COVID-19

As the nation confronts the dual crises of a deadly pandemic that has triggered joblessness unseen since the Great Depression, the starkly disproportionate impact of the virus on minoritized and marginalized communities has become evident. On June 23, Patrice A. Harris, MD, MA, Immediate Past President of the AMA, testified before the U.S. House Budget Committee at a hearing entitled, "Health and Wealth Inequality in America: How COVID-19 Makes Clear the Need for Change." During her testimony, Dr. Harris stated that "the data that have emerged on the racial and ethnic patterns of the COVID-19 pandemic show that the virus has clearly disproportionately affected Black and Latinx, American Indian/Alaska Native—particularly in the Navajo nation—Asian-American and Pacific Islander communities."

Dr. Harris testified that the reasons cited for higher infections, hospitalizations and mortality rates within these communities included:

  • Structural racism
  • Inequities within social determinants of health
  • Higher prevalence of comorbidities including asthma, diabetes, hypertension and obesity
  • A stronger likelihood to be in multigenerational, congregate living arrangements
  • A higher probability of working in essential jobs
  • Historic mistrust of medical institutions and misinformation and disinformation

The coronavirus pandemic has exposed the realities that structural racism and social determinants of health lead to differing health care outcomes for marginalized and minoritized communities. To help alleviate these realities, Dr. Harris urged policymakers to address implicit bias and racism by: fostering a better understanding of social determinants of health; developing a national strategy on testing, vaccine development, and mental health; collecting and releasing more comprehensive data on the virus's impact on communities of color; and expanding access to health insurance. However, the ability to accurately provide equitable public health interventions are dependent on essential changes in data collection at all levels of government, during the current public health crisis and beyond.

To achieve this, AMA sent a letter supporting H.R. 6585, "Equitable Data Collection and Disclosure on COVID-19 Act," which is focused on creating a comprehensive and standardized national set of data collection parameters. Under this legislation HHS will obtain and post data that is disaggregated by race, ethnicity, sex, age, tribal affiliation, socioeconomic status, disability status and country. These data points will also incorporate information on COVID-19 testing, hospital and ICU admissions, and fatalities. An underlying goal of this plan is to provide guidance on how to better collect, develop and analyze racial, tribal and demographic data in responding to future waves of the coronavirus. The provisions in this legislation are an important step forward in helping to improve health outcomes and reduce health inequities.

Read more here.

Physician practices are losing out in the scramble for PPE

As the nation sees single-day record numbers of COVID-19 cases being reported, physician practices continue to report persistent and severe difficulties in obtaining the personal protective equipment (PPE) they need to safely provide patient care and keep their offices open for business.

In letters to Vice President Mike Pence and the Federal Emergency Management Agency (FEMA), the AMA urged immediate action to address ongoing shortages and access issues related to PPE.

"The AMA now believes the situation with PPE in ambulatory settings is so challenging that the only way to address it is for the administration to use the Defense Production Act (DPA) so the much needed N95 masks and gowns are available so patients, physicians and their staffs can safely treat as many patients as possible," AMA Executive Vice President and CEO James L. Madara, MD, wrote in a letter to Pence, who heads the White House coronavirus task force.

The problem is that office-based physicians don't have "existing relationships with vendors or ability to source these critical items. Furthermore, physician offices do not need the same quantity of PPE that large institutions do. As a result, even when physicians find a vendor with available supply, they end up losing to larger institutions with more bargaining power and placing more substantial orders. PPE is needed for all types of health care sites, including ambulatory settings. We need to ensure the safety of patients, physicians and their staff," says the AMA's letter to Pence.

Dr. Madara wrote separately to FEMA Administrator Peter Gaynor noting that the need for PPE, disinfectants and hand sanitizer goes beyond hospitals and nursing homes.

"As non-hospital-based physicians return to work and reopen their practices, the need for these supplies is rapidly expanding to other care sites," the AMA's CEO wrote, urging FEMA to work with the AMA to gather and mine the data to "ascertain whether the central problem is in the availability of raw material, production backlogs, gaps in the distribution systems, or some combination of all three."

Physician practice revenue fell by half during the early months of the pandemic, from March to May, surveys and claims analyses show. That means a $70.6 billion drop in revenue for physician practices.

"This is a challenge for any small business to absorb," Dr. Madara wrote to the vice president. "For the sake of our patients' health and to ensure we do not drastically reduce the number of site available to provide health care services, we need to make sure practices remain open and able to provide care."

"Physician practices should be the first line of defense in caring for patients," he added. "Delayed care often means sicker patients. We do not want patients to unnecessarily end up in a hospital when they could have been effectively cared for by their personal physician. Furthermore, closure of practices would have a long-term negative impact on access to care, especially for those patients in underserved areas that do not have ready access to a choice of physician practices."

Read more here.

COVID-19 exposed systemic weak points. How to get it right next time.

In formulating a response to future pandemics based on lessons learned from COVID-19, the AMA stresses the need for having coordinated national strategies in place for supplies and testing, and to consider the needs of nonhospital practices in the response.

In addition, there must be policy solutions with an acute focus on protecting underserved areas and populations as emerging racial and ethnic data reveals that the COVID-19 pandemic has had a disproportionate effect on minoritized and marginalized communities, as detailed in a 20-page letter to Sen. Lamar Alexander, R-TN.

Alexander recently released a white paper, "Preparing for the Next Pandemic," and requested feedback and further recommendations to be addressed by the Senate Health, Education, Labor and Pensions Committee, which he chairs.

"In this internet age attention spans are short—even with an event as significant as COVID-19, memories fade and attention moves quickly to the next crisis," Alexander wrote. "That makes it imperative that Congress act on needed changes this year in order to better prepare for the next pandemic."

Specifically, the AMA recommended:

  • Creating better coordination across federal and state governments and streamlining pandemic response logistics.
  • Improving diagnostic testing infrastructure, organization and regulation.
  • Ensuring accelerated vaccine and therapeutic development is guided by evidence and protects health of subjects and patients.
  • Enhancing state and federal stockpiles and improving systems for acquisition and distribution of medically necessary supplies.
  • Creating and maintaining a comprehensive, well-coordinated and culturally sensitive data collection strategy.
  • Ensuring digital contact tracing efforts are built around privacy and transparency to promote trust.
  • Expanding access and coverage to telehealth services.
  • Protecting physicians and other front-line health professionals from increased liability arising from situations outside their control.

Having a national strategy to coordinate a pandemic response with clearly defined roles for federal and state governments is a key to better preparedness.

Read more here.

Cutting Medicare pay during COVID-19 pandemic doesn't make sense

Physicians practicing in certain medical specialties—already facing severe economic strain and uncertainty while continuing to meet the needs of patients during the pandemic—may be subject to significant Medicare payment reductions in 2021.

That is why the AMA and more than 100 other health care organizations are strongly urging HHS to provide regulatory relief to hard-hit medical specialties whose practices suspended procedures during the COVID-19 public health emergency.

In addition to financial hardships and instability related to the pandemic, these specialists now face deep cuts in Medicare payment due to statutory budget-neutrality rules that require the Centers for Medicare & Medicaid Services' (CMS) to offset the upward payment adjustments created by widely supported revisions to CMS policy that better describe and recognize the resources involved in office visits.

"We strongly urge HHS to utilize its authority under the public health emergency declaration to preserve patient access to care and mitigate financial distress due to the pandemic by implementing the office visit increases as planned while waiving budget neutrality requirements for the new Medicare office visit payment policy," says a letter to HHS Secretary Alex Azar from the AMA and the other organizations.

Physicians who rely primarily on office visits for their practice revenue, including primary care physicians, will experience much needed revenue increases and reduced documentation burdens when the new coding and payment rules take effect.

However, physicians and health professionals who report relatively few office visit codes, including radiologists, pathologists and physical therapists, face an estimated 8% payment cut for 2021.

Specialties including general surgery, critical care medicine, anesthesiology, emergency medicine and hospital medicine face estimated cuts ranging from 5% to 7.8%.

These budget-neutrality driven cuts will also serve to reduce the positive impacts of the office visit changes for primary care physicians, oncologists, pediatricians and other specialties for whom office visits are a high proportion of their services, the letter says.

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State Update

AMA urges all states to follow Michigan effort to increase access to naloxone

The AMA and Michigan State Medical Society (MSMS) are applauding a new state effort to provide free naloxone to community groups and others, a move that will decrease fatal opioid-related overdoses. The program was announced June 29 by Joneigh Khaldun, MD, chief medical officer and chief deputy for health at the Michigan Department of Health and Human Services (MDHHS).

"During the COVID pandemic, when states are facing budgetary challenges, this is a remarkable effort to help save lives," said AMA Immediate Past President Patrice A. Harris, MD, MA. "We are greatly concerned that the COVID-19 pandemic has made the drug overdose and death epidemic worse because of increased isolation and reduced access to treatment and harm reduction services such as naloxone. We urge all states to follow Michigan's lead and make a similar commitment to expand access to naloxone."

"MSMS appreciates the state's proactive leadership to ensure Michiganders have readily available access to naloxone, a safe, effective antidote for reversal of an opioid overdose," said MSMS President S. Bobby Mukkamala, MD, who also is chair-elect of the AMA Board of Trustees. "In 2018, Michigan experienced 2,036 deaths from opioid-related overdoses leaving families and friends heartbroken. Community-based naloxone distribution has been shown to save lives."

The MDHHS announcement said naloxone distribution is available to "any community organization statewide, including substance use treatment providers, non-profits, harm reduction organizations, jails, first responders, local governments and small businesses." After reviewing distribution plans, approved organizations will receive as many as 12 naloxone kits by mail.

"While this type of community-based program will save lives, physicians must also continue to do our part," Dr. Harris said. "As the nation's opioid epidemic now is being fueled by more deadly and illicitly manufactured fentanyl and heroin, it is more important than ever for physicians to prescribe naloxone to patients at risk of overdose."

Learn more about the AMA's recommendations for physicians to prescribe naloxone.

Oklahoma voters approve Medicaid expansion

On June 30, voters in Oklahoma narrowly approved a state ballot measure to expand Medicaid under the Affordable Care Act (ACA) to childless adults with incomes up to 133% of the federal poverty level. An estimated 200,000 people will become eligible for Medicaid beginning on July 1, 2021.

Oklahoma is the 37th state to expand Medicaid and joins Idaho, Maine, Nebraska and Utah as the fifth state to adopt Medicaid expansion via ballot measure. Voters will also decide whether to expand Medicaid in Missouri via a ballot measure in August.

Earlier this year, Oklahoma Governor Kevin Stitt withdrew a plan that would have expanded Medicaid effective July 2020 but retained a Section 1115 demonstration waiver proposal to implement work requirements and other restrictions on Medicaid expansion beneficiaries. Stitt has also requested federal Medicaid funding via a block grant. The AMA submitted comments on the waiver proposal opposing block grant funding, work requirements and other restrictions.

Georgia extends Medicaid coverage for six months postpartum

Georgia lawmakers have approved extending Medicaid coverage for postpartum care for six months following birth. The state previously covered postpartum care for two months after birth. The initiative is fully funded in the 2021 state budget.

More than half of the births in Georgia are covered by Medicaid, and Georgia has one of the highest maternal mortality rates in the country. The AMA believes access to care during the postpartum period is critical to preventing pregnancy-related deaths and supports Medicaid coverage for 12 months postpartum. The AMA and the Medical Association of Georgia supported the bill.

Issue brief highlights state action on SUD treatment

The National Governors Association released a new issue brief highlighting policy and other options for states to take to increase access to care for those with a substance use disorder (SUD). The brief, "State Strategies to Support Access to Substance Use Disorder Treatment Services through the COVID-19 Pandemic," provides examples of promising state efforts and challenges in several areas, including:

  • The need to better understand and gather data on SUD provider access
  • Funding opportunities for states
  • How Medicaid can better support providers
  • Reducing barriers to care for those with a substance use disorder

The brief emphasized, "As it becomes increasingly apparent that the medical, economic and fiscal fallout from the pandemic may be felt for an extended period of time, the question arises as to how states will support continued access in the longer term."

Read more about AMA recommendations to help patients with pain, those with an opioid use disorder and recommendations in support of harm reduction efforts. There are more than 35 states that have reports of increases in overdose and other concerns relating to the drug overdose epidemic.

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Judicial Update

U.S. Supreme Court strikes down admitting-privilege restrictions

In June Medical v. Russo, the court agreed with plaintiff physicians who said the law linking their ability to perform abortions with having admitting privilege to a hospital not further than 30 miles away placed an "undue burden" on their patients' rights. The court issued the same ruling in Whole Woman's Health v. Hellerstedt, a case decided in June 2016.

"Today's decision is a victory for patients and a strike against government interference in the patient-physician relationship," said AMA President Susan R. Bailey, MD. "There is no evidence that Louisiana's admitting privileges requirement improves patients' safety, and we are pleased by the U.S. Supreme Court's finding that such regulations are constitutionally invalid."

Dr. Bailey added that the Louisiana law "interferes with clinical judgment and obstructs women's access to abortion services in the state."

The court ruled in the Whole Woman's Health case that there was a "virtual absence of any health benefit" to such admitting-privilege laws. This point was noted in an amicus brief filed by the AMA and the American College of Obstetricians and Gynecologists regarding June Medical v. Russo. The brief was joined by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians and nine other health care professional societies.

Read the full story here.

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Other News

Comparison of COVID-19 telehealth payment policies

As telehealth grew exponentially during the first phase of the COVID-19 public health emergency, physicians encountered varied payment policies to address the urgent need for flexibility to best care for their patients. A variety of state executive orders, CMS interim final rules, federal legislation and individual private health plan policies quickly led to inconsistent approaches in coding and payment policy. The AMA urged the Blue Cross Blue Shield Association and America's Health Insurance Plans to work with their member plans to bring greater consistency to these policies.

Today, it appears that the market has evolved to greater uniformity. The AMA has published a grid comparing Medicare and health plan COVID-19 telehealth coding and payment policies that illustrates most plans have implemented payment parity, cost-sharing waivers and expanded the services that may be provided via telehealth.

New podcast on behavioral health integration

The integration of behavioral and physical health care has long been identified as one of the more effective solutions to increasing access to treatment for many mental health conditions. But despite its proven effectiveness, sustained behavioral health integration (BHI), is still not present in a majority of practices.

Listen to a new podcast episode on this topic here.  

Five steps health systems can take to support physicians amid COVID-19

The AMA STEPS Forward™ open-access modules offer innovative strategies that allow physicians and their staff to thrive in the health care environment. Physicians and care teams looking to refocus their practice can turn to STEPS Forward for proven, physician-developed strategies for confronting common challenges in busy medical practices and devoting more time to caring for patients. The following modules are specifically tailored to help health systems and organizations support physicians and clinical teams amid COVID-19.

Establishing a chief wellness officer position
Create the organizational groundwork for professional well-being

Chief wellness officer roadmap
Implement a leadership strategy for professional well-being

Peer support programs for physicians
Mitigate the effects of emotional stressors through peer support

Patient portal optimization
Empower patients as partners in health care

LISTEN-SORT-EMPOWER
Find and act on local opportunities for improvement

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Upcoming Events

Lessons from the Front Lines: COVID-19 CMS calls

July 17: "Lessons from the Front Lines" calls are a joint effort between CMS Administrator Seema Verma, FDA Commissioner Stephen Hahn, MD, and the White House Coronavirus Task Force. Physicians and other clinicians are invited to share their experience, ideas, strategies and insights with one another related to their COVID-19 response. There is an opportunity to ask questions of presenters. The call will be held on July 17 12:30 – 2 p.m. Eastern time. The toll free dial-in is 833-614-0820, access code 30964343, or join the webcast.

Conference lines are limited. Participants are encouraged to join via audio webcast, either on their computer or smartphone web browser. These calls are not intended for the press.

For more information please visit Coronavirus.gov, the CMS Current Emergencies website and the Podcast and Transcripts webpage: Audio recordings and transcripts.

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