July 30, 2021: National Advocacy Update

The COVID-19 pandemic has highlighted inequities in our health care system, including maternal health, and as a result, there has been an increased focus on maternal mortality and morbidity at the federal level.

There is higher potential for bills that address maternal mortality introduced during the 117th Congressional session to be passed and signed into law than before. Robust AMA advocacy on maternal health continues and is ongoing. A few highlights include:

• Signed on to a letter (PDF) urging for the highest possible funding for specific federal programs to improve maternal health in fiscal year (FY) 2022 aimed to prevent maternal deaths, eliminate inequities in maternal health outcomes and improve maternal health overall.
• Sent a support letter (PDF) for S. 411 (PDF), the Mothers and Offspring Mortality and Morbidity Awareness “MOMMA” Act. Its six-pronged approach would establish national obstetric emergency protocols through a federal expert committee; ensure dissemination of best shared practices and coordination amongst maternal mortality review committees; standardize data collection and reporting; improve access to culturally competent care throughout the care continuum; provide guidance and options for states to adopt and pay for doula support services; and expand Medicaid coverage to new moms for one year postpartum.
• Joined a sign-on letter (PDF) urging the Centers for Medicare & Medicaid Services (CMS) to act as soon as possible to approve pending Section 1115 demonstration projects aimed at extending the postpartum coverage period for individuals who were enrolled in Medicaid while pregnant to one full year after the end of pregnancy.
  • This advocacy led to CMS approving Illinois Section 1115 waiver to cover postpartum care for Medicaid beneficiaries for up to one year after pregnancy. AMA Chief Health Equity Officer Aletha Maybank, MD, MPH, participated in the congressional call hosted by Senators Durbin (D-IL), Duckworth (D-IL) and Rep. Robin Kelly (D-IL-2) in celebration of the announcement.
• Supported (PDF) the “Connected Maternal Online Monitoring (MOM) Act”, which would require CMS to report to Congress on state Medicaid barriers to coverage of remote physiologic devices in programs to improve maternal and child health outcomes and update state resources.
• Urged (PDF) House Congressional leaders to support the highest possible funding level in FY 2022 for programs at Health Resources and Services Administration (HRSA), Centers for Disease Control and Prevention (CDC) and National Institutes of Health (NIH) that seek to prevent maternal deaths, eliminate inequities in maternal health outcomes and improve maternal health.
• Submitted an extensive statement for the record (PDF) to the U.S. House of Representatives Committee on Oversight and Reform as part of the hearing entitled, “Birthing While Black: Examining America’s Black Maternal Health Crisis.”
• Supported H.R.1218 (PDF) and S. 198 (PDF), “Data Mapping to Save Moms’ Lives Act,” which would instruct the Federal Communications Commission (FCC) to consult with the CDC to determine ways to incorporate data on maternal health outcomes for at least one year postpartum into broadband health mapping tools in an effort to reduce maternal mortality and morbidity in the U.S.
• Supported S. 796 (PDF) and H.R. 958 (PDF), the “Protecting Moms Who Served Act.” This would require the Department of Veterans Affairs to implement the maternity care coordination program with community maternity care providers trained to address unique needs of pregnant and postpartum veterans, and require the U.S. Government Accountability Office to report on pregnant and postpartum veteran maternal mortality and severe maternal morbidity with a focus on veteran racial and ethnic disparities in maternal health outcomes.
• Supported S. 1675 (PDF), “Maternal Health Quality Improvement Act,” to provide grants to identify, develop and disseminate best practices to improve maternal health care quality and outcomes; promote collaboration with state maternal mortality review committees to identify ways to reduce preventable maternal mortality and severe maternal morbidity; promote perinatal collaboration on quality; and implement integrated health care services for pregnant and postpartum women.
• Supported a provision in the American Rescue Plan Act of 2021 that established a temporary, optional provision to assist states in expanding Medicaid and CHIP coverage opportunities to one year postpartum.

In a letter (PDF) to the leaders of a seemingly “indifferent” Congress, the AMA warned of the fiscal uncertainty facing the Medicare physician payment system on Jan. 1, due to the following:

• Expiration of the current reprieve from the repeatedly extended 2% sequester stemming from the Budget Control Act of 2011. Congress originally scheduled this policy to sunset in 2021 but it will now continue until 2030.
• Imposition of a 4% Statutory PAYGO sequester resulting from passage of the American Rescue Plan Act, presumably for at least another 10 years. Should lawmakers fail to act, it will mark the first time that Congress has failed to waive Statutory PAYGO.
• Expiration of the Congressionally enacted 3.75% temporary increase in the Medicare physician fee schedule (PFS) conversion factor to avoid payment cuts associated with budget neutrality adjustments tied to PFS policy changes.
• A statutory freeze in annual Medicare PFS updates under the Medicare Access and CHIP Reauthorization Act (MACRA) that is scheduled to last until 2026, when updates resume at a rate of 0.25% a year indefinitely, a figure well below the rate of medical or consumer price index inflation.

Additionally, potential penalties under the Merit-Based Incentive Payment System (MIPS) which apply to Medicare PFS services, will increase to 9% in 2022.

The AMA highlighted existing policies will lead to a cumulative 9.75% cut to physician practices on Jan. 1. The AMA’s alarm is due to Congress not taking up legislation to prevent these cuts but is considering proposals that aim to wring out more money from Medicare payments to fund an unrelated infrastructure package.

“All this financial uncertainty comes at a time when physician practices are still recovering from the financial impact of the COVID-19 public health emergency, including continued infection control protocols that, while necessary, have increased the costs of providing care,” the AMA wrote in its letter. “The combination of all these policies would be challenging to endure in normal times. Yet, physician practices continue to be stretched to their limits clinically, emotionally, and financially as the pandemic persists well beyond 15 months. The enactment of further Medicare payment cuts will undoubtedly threaten patient access to care, especially considering the stark reality that, adjusted for inflation in practice costs, Medicare physician payment actually declined 22% from 2001 to 2020, or by 1.3% per year on average.”

The letter urged Congress to pass legislation to prevent the fiscal cliff awaiting on Jan. 1 and to hold hearings on how to permanently improve the Medicare physician payment system, asserting, “The state of the program is increasingly dysfunctional and, ultimately, it will be patients who suffer.”

The AMA joined more than 400 prominent (PDF) physician, health care and technology stakeholder groups on a letter urging Congressional leadership in the U.S. House and Senate to pass legislation that would permanently continue many of the current telehealth flexibilities enacted at beginning of the COVID-19 public health emergency (PHE). The Alliance for Connected Care, American Telemedicine Association, Consumer Technology Association, Connected Health Initiative, American Academy of Family Physicians, American College of Physicians, Federation of American Hospitals and Zoom video conferencing were among the diverse collection of cosigners pushing federal lawmakers to address the impending “telehealth cliff.”

Expanded telehealth flexibilities have proven to be a lifeline for countless patients trying to retain access to their physician during the pandemic. The temporary suspension of the Medicare geographic and originating site restrictions that largely preclude beneficiaries from accessing telehealth services other than at qualifying health care facilities located in rural areas has been especially important for patients dealing with chronic conditions and looking to limit community spread of COVID-19.

Yet, absent Congressional intervention, these flexibilities that have permitted virtual services to proliferate will expire and numerous antiquated statutory restrictions related to telehealth will snap back into effect. As a result, the sign-on letter urges Congress to, among other things, remove arbitrary restrictions governing where patients can access telehealth services, as well as eliminate recently enacted in-person requirements for patients seeking telemental health services upon the conclusion of the current PHE.

Many of the concepts touted in the sign-on letter to Congressional leadership are included in three bills that form the primary pillars of AMA’s advocacy agenda related to telehealth, specifically:

• H.R. 1332/S. 368, the Telehealth Modernization Act
• H.R. 2903/S. 1512, the CONNECT for Health Act
• H.R. 4058/S. 2061, the Telemental Health Care Access Act

AMA continues to work with federal lawmakers to enact legislation to retain existing telehealth flexibilities beyond the COVID-19 PHE.

The CDC has an opportunity to support individualized treatment decisions for patients with pain by removing arbitrary thresholds in its 2016 opioid prescribing guideline, said AMA Board of Trustees Chair Bobby Mukkamala, MD, in a recent letter (PDF) to the CDC. Dr. Mukkamala’s letter followed the most recent CDC public hearing on the CDC’s 2016 "Guideline for Prescribing Opioids for Chronic Pain," where dozens of patients with pain highlighted how misapplication of the guideline caused health insurers, pharmacy chains and pharmacy benefit management companies to restrict or deny opioid therapy to patients with chronic pain, sickle cell disease, cancer and those in palliative care.

“A revised CDC guideline that continues to focus only on opioid prescribing will perpetuate the fallacy that, by restricting access to opioid analgesics, the nation’s overdose and death epidemic will end,” said Dr. Mukkamala, who pointed to data showing opioid prescriptions have decreased by more than 44% since 2011 as well as the fact that the nation’s drug overdose epidemic is worsening and being fueled by illicit fentanyl, methamphetamine and cocaine.

At the hearing, the CDC was presented with recommendations from its opioid work group (PDF), which also called for removing the arbitrary thresholds from the recommendations. With minor amendments, the CDC Board of Scientific Counselors voted to adopt the opioid work group report.

“While the patient harm from the 2016 guideline was unintended, it was not unforeseeable,” said Dr. Mukkamala. “The AMA urges CDC to make all of the changes to the guideline that the AMA recommended in our June 2020 letter (PDF), much of which is also supported by [the CDC] Opioid Workgroup report and has been endorsed by the CDC Board of Scientific Counselors.”

In response to the recent COVID-19 surge driven by the delta variant, the AMA, American Hospital Association (AHA) and American Nurses Association (ANA) issued a joint statement (PDF) in support of vaccine mandates for all workers in health care and long-term care. With hospitalizations and deaths once again rising throughout the United States due to COVID-19, vaccination is the only way to put the pandemic behind us and avoid a return to stringent public health measures. However, many health care and long-term care personnel remain unvaccinated. To protect those who are vulnerable like children and the immunocompromised, along with their families and the patients they care for, all health care workers should be required to be vaccinated against COVID-19.

Earlier this year, United Healthcare (UHC) announced the launch of its Designated Diagnostic Provider (DDP) program for laboratory services. To qualify as a DDP, a laboratory must meet certain quality and efficiency (i.e., cost) requirements. UHC initially presented the DDP as a strict covered/not covered benefit design, under which patients receiving services from a non-DDP laboratory would be responsible for the full cost of the test(s)—even if the lab was in network.

The AMA, along with many state medical associations and national medical specialty societies, expressed strong concerns about this program’s impact on both physician practices and patients. In response to this advocacy, UHC changed the DDP program benefit design to a tier-based system and UHC patients will pay lower cost shares for labs performed by DDPs. UHC also launched extensive educational outreach to both physicians and patients about the DDP program after numerous complaints regarding the poorly communicated rollout.

The AMA will continue to monitor the DDP program, which went “live” in certain states effective July 1, and advocate for changes that will minimize practice administrative burdens and ensure patient access to laboratory services. Find more information about UHC’s DDP program.

• July 30, 2021: State Advocacy Update