April 24, 2020: National Advocacy Update

The Department of Health and Human Services (HHS) provided additional information about further allocation of the original $100 billion Coronavirus Aid, Relief and Economic Security (CARES) Act Provider Relief Fund. 

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.

View a database of privately and publicly funded clinical studies currently being conducted on coronavirus. For more information on MIPS.

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 Michael 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.

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.

• April 24, 2020: Advocacy spotlight on Highlights of this week's new supplemental COVID-19 bill 
• April 24, 2020: State Advocacy Update