April 7, 2023: National Advocacy Update

Earlier this week, Reps. Raul Ruiz, MD (D-CA), Larry Bucshon, MD (R-IN), Ami Bera, MD (D-CA) and Mariannette Miller-Meeks, MD (R-IA), introduced legislation to apply an automatic inflation update to Medicare physician payments. The bill, H.R. 2474, would tie the Medicare physician fee schedule to the Medicare Economic Index (MEI), something the AMA has long supported. Doing so would put physicians on equal footing with almost all other health care providers that receive annual inflation-based updates. Current law requires physician payment rates to be frozen from 2020 through 2025, and most services will receive a minimal 0.25% annual update in 2026 and onward.

Medicare physician payments (when adjusted for inflation) have declined 26% from 2001 to 2023. Increasingly thin operating margins disproportionately affect small, independent and rural physician practices, as well as those treating low-income or other historically minoritized or marginalized patient communities. 

The bill introduction comes on the heels of the Medicare Payment Advisory Commission (MedPAC) recommendation that Congress increase 2024 Medicare physician payments above current law by linking the payment update to the MEI. Also, the Medicare Trustees Report recently said lawmakers should “expect access to Medicare-participating physicians to become a significant issue in the long term” unless Congress takes steps to bolster the payment system.

Please take a moment to contact your legislators and urge them to help fix the flawed Medicare physician payment system by supporting H.R. 2474 today.

In their 2023 report, the Medicare Trustees continue to raise alarms about Medicare physician payment inadequacy and its long-term threat to patient access to care. Specifically, the Trustees note that the expiration of an additional allocation of $500 million per year and annual bonuses under the Medicare Access and CHIP Reauthorization Act (MACRA) in 2025 and 2026, respectively, will result in a pay cut for most physicians. The report adds, “The law specifies the physician payment updates for all years in the future, and these updates do not vary based on underlying economic conditions, nor are they expected to keep pace with the average rate of physician cost increases. The specified rate updates could be an issue in years when levels of inflation are high and would be problematic when the cumulative gap between the price updates and physician costs becomes large. Absent a change in the delivery system or level of update by subsequent legislation, the Trustees expect access to Medicare-participating physicians to become a significant issue in the long term.”  

In a statement, AMA President Jack Resneck Jr., MD, called on Congress to adopt a 2024 Medicare payment update that recognizes the full inflationary growth in health care costs. “We have clearly diagnosed the problem,” said Dr. Resneck. “Now, like doctors do every day, let’s prescribe the remedy.” 

The COVID-19 Public Health Emergency (PHE) is set to end on May 11, 2023. A new resource for physicians (PDF) outlines important information related to the end of the COVID-19 PHE. In this resource, physicians can read about the COVID-19 flexibilities that will end with the PHE, the flexibilities that end prior to the end of the PHE and the flexibilities that will continue past the end of the PHE. In addition, the resource shares relevant AMA policy and a report from the AMA Council on Medical Service on preventing coverage losses after the PHE ends.

The U.S. Drug Enforcement Administration (DEA) recently issued a public safety alert about xylazine, a sedative that is only approved for animal use, but is increasingly showing up in drug-related overdoses and causing other harms. When used by humans, xylazine can lead to significant harm, including “severe, necrotic skin ulcerations; and interfering with the successful treatment of opioid use disorder (OUD),” according to the US Food and Drug Administration (FDA). The DEA said that xylazine has been found in approximately 23% of fentanyl powder and 7% of fentanyl pills. Multiple states and cities have issued safety warnings about human use of xylazine. 

An FDA safety alert said, “xylazine is not safe for use in humans and may result in serious and life-threatening side effects that appear to be similar to those commonly associated with opioid use, making it difficult to distinguish opioid overdoses from xylazine exposure.” The FDA also issued a letter to health care professionals in Nov. 2022 outlining clinical considerations and additional safety warnings.  

The National Institute on Drug Abuse also advises that “in the event of a suspected xylazine overdose, experts recommend giving the opioid overdose reversal medication naloxone because xylazine is frequently combined with opioids. However, because xylazine is not an opioid, naloxone does not address the impact of xylazine on breathing. Because of this, experts are concerned that a growing prevalence of xylazine in the illicit opioid supply may render naloxone less effective for some overdoses. Emergency medical services should always be alerted to a suspected overdose.” 

At least one recent news report indicates that xylazine test strips are now available. The AMA strongly urges states to review their Good Samaritan and drug paraphernalia laws to ensure that possession, distribution and use of new test strips to identify xylazine or other emerging drugs of abuse is not prohibited by law.  

Several leading medical societies have published information about xylazine, including:  

• Opioid Epidemic Updates: “Frankenstein Opioids” and Xylazine-Induced Skin Ulcers. American Family Physician. Feb. 13, 2023.  
• Xylazine Complicating Opioid Ingestions in Young Children. Pediatrics. Jan. 2023.
• Xylazine, an Emerging Adulterant. ACEP Tactical and Law Enforcement Section. Oct. 18, 2021.  
• Xylazine (“Tranq”): The Potential for Loss of Life and Limb. American Academy of Dermatology.

In response to advocacy from the AMA and organized medicine about the ongoing impacts of the COVID-19 Public Health Emergency (PHE), the Centers for Medicare & Medicaid Services (CMS) will continue to allow physicians and group practices to apply for a MIPS Extreme and Uncontrollable Circumstances hardship exception to avoid up to a -9% MIPS penalty in 2025 based on 2023 performance. The exception will not be automatic, and interested physicians and groups must actively request reweighting of one or more MIPS performance categories due to the COVID-19 PHE. Requesting reweighting of all four MIPS performance categories will avoid a MIPS penalty in 2025. CMS expects to release the hardship exception application in spring 2023.  

This is a big relief for physicians and their patients because CMS estimated in the final rule that up to one-third of MIPS eligible clinicians would have received a penalty due to the increasingly stringent requirements to participate in MIPS in 2023. It is also likely that small, rural, and practices serving underserved populations would have been disproportionately impacted by these penalties. The AMA encourage physicians to spread the word about this critical reprieve from up to a -9% penalty due to the COVID-19 PHE. 

On April 3, the AMA submitted comments (PDF) in response to a proposed rule that would seek to expand birth control coverage and access by reversing or revising the expanded moral and religious exemptions. Specifically, the rule would eliminate the moral exemption and establish a new, independent pathway for individual enrollees to access contraceptive services directly from a willing provider or facility at no cost, while leaving the religious exemption for employers or plans intact.  

The AMA largely supported the proposals, reiterating its longstanding position that all clinical decisions should be made by a patient and their physician, and that contraception is evidence-based medicine that is an integral part of women’s comprehensive health care. However, the letter did raise several potential logistical complexities and provided concrete recommendations to reduce potential burden on physicians and help facilitate a smooth implementation.  

The Medication Access and Training Expansion (MATE) Act, included in the Consolidated Appropriations Act of 2023, requires physicians to take a one-time, eight-hour training in assessing and treating substance use disorders (SUD) as a condition of obtaining or renewing their registration with the Drug Enforcement Administration (DEA) to prescribe controlled substances. The DEA is required to implement the MATE Act training conditions in June 2023, and physicians who have not met this requirement will be required to do so by the date of their next scheduled DEA registration submission on or after June 27, 2023.  

A recent letter (PDF) issued by the DEA outlines information on this new requirement. The letter also states that, beginning on June 27, 2023, physicians will be able to simply check a box on their DEA registration application or renewal form confirming that they have satisfied this training requirement.  

A number of continuing medical education (CME) courses offered on the AMA Ed Hub™ related to substance use disorders and addiction qualify as meeting the MATE Act requirement. These courses can be taken in any combination to fulfill the eight-hour requirement. Qualifying courses include: 

• Basics of Safe Opioid Prescribing and Management 
• Basics of Addiction Treatment 
• Management of Addiction in Special Populations 
• Opioids and Fatalities: Prevention and Management 
• Addiction Medicine During the COVID-19 Pandemic  

In a March 13 letter (PDF), the AMA offered a number of recommendations related to the implementation of the MATE Act. This included urging the DEA and SAMHSA to confirm that physicians who have taken SUD-related CME courses on the AMA Ed Hub™ satisfy the requirement.  

For more information on the MATE Act and the AMA Ed Hub™ courses that qualify under the new requirements, visit this page. 

During the COVID-19 pandemic, the Drug Enforcement Administration (DEA) authorized physicians to prescribe controlled substances, including medications to treat opioid use disorder (OUD), based on telehealth patient visits. Because the end of the COVID-19 Public Health Emergency in May 2023 requires the DEA to issue new policies, the DEA recently issued two proposed rules: one for prescribing buprenorphine to treat OUD (PDF) and one for prescribing Schedule III-V controlled substances based on telehealth visits when the patient has not had an in-person visit with the physician. 

In comment letters on the proposals, the AMA agrees with the DEA proposals to continue to allow these practices based on virtual patient visits after the end of the public health emergency as it has helped patients access care. The AMA expressed serious concerns, however, about the very short timeframe – just 30 days – that the DEA proposed for patients to obtain an in-person visit in order to continue receiving their prescriptions. 

The AMA made the following recommendations to improve the DEA proposals:  

1. The proposal requires patients being treated for OUD to have an in-person visit within 30 days of their initial buprenorphine prescription to obtain refills. The AMA recommends that this timeframe be extended to at least six months. The 30-day requirement could cause many patients who were started on buprenorphine to have their prescriptions lapse, leading to more overdose deaths.  
2. New patients prescribed controlled substances in Schedules III-V should be able to fill and renew prescriptions for at least six months before an in-person visit is required. A 30-day rule would result in the lapse of their prescriptions, leading to complications from conditions, emergency department visits, and hospitalizations.  
3. The AMA recommends the DEA extend prescribing based on telemedicine to all Schedule III-V medications. It should also provide a special registration or exceptions process that would extend telemedicine to Schedule II medications.  
4. The AMA is concerned that the recordkeeping requirements of the proposed rules will diminish their effectiveness in increasing access to needed medications. The AMA encourages the DEA to adopt a more flexible approach. 
5. The DEA should target more rigorous enforcement to outlier practices that allow controlled substances to be prescribed based on a form with no meaningful patient-physician relationship. 

Have you ever wondered what it takes to run for political office? Recently, 20 participants from across the country found out at the AMA offices in Washington, D.C., where they learned what it takes to be a successful candidate for public office.   

Attendees of the two-day AMPAC Candidate Workshop were taught the ins and outs of running a winning political campaign. The agenda included a bevy of bipartisan political veterans who spoke from years of experience on topics such as: 

• The secret of effective fundraising 
• The importance of developing a disciplined campaign plan and message 
• How different forms of messaging including direct mail, social media and television can be effectively leveraged to campaign 
• The impact being a candidate can have on one’s family and practice  

The program included a keynote session featuring Congressman Larry Bucshon, MD (R-IN), on his experiences of running, and winning, as a physician and the importance of having physicians in elected office.  

The candidate workshop is just one of the political education programs that AMPAC provides for physicians, spouses and state medical society staff who have ever entertained running for public office. For more information on these programs please visit AMPAConline.org.

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