June 14, 2024: National Advocacy Update

The 2024 Annual Meeting of the AMA House of Delegates covered a wide range of critical issues facing the nation’s health care system.  

Medicare physician payment continues to be a top priority for delegates, especially as Medicare physician payment rates have declined 29% since 2001 (PDF) when adjusted for inflation in practice costs. According to an AMA Council on Medical Service report adopted at the meeting, unsustainable payment rates do not reflect practice costs or the value of care provided. 

Among other things, the AMA HOD directed the AMA to: 

• Increase media awareness around the 2024 AMA Annual Meeting about the need for Medicare payment reform, eliminating budget-neutrality reductions, and instituting annual cost-of-living increases. 
• Step up its public relations campaign to get more buy-in from the general public about the need for Medicare payment reform. 
• Increase awareness to all physicians about the efforts of the AMA on Medicare payment reform. 
• Advocate for abolition of all Merit-based Incentive Payment System (MIPS) penalties in light of the current inadequacies of Medicare payments. 

Other key issues discussed at the meeting include: 

• Prior authorization: Delegates adopted policy to work with payers and interested parties to ensure that prior authorization denial letters include appropriate information. Delegates also modified existing policy related to real-time benefit tools. In addition, delegates adopted policy aiming to increase legal accountability of insurers when delay or denial of prior authorization leads to patient harm. 
• Scope of practice: Delegates adopted policies to address specialty switching among nonphysician providers, counter disinformation about scope of practice expansion, ensure proper physician supervision in the emergency department, and prevent inappropriate scope expansions of dentists and dental hygienists.
• Cybersecurity: Delegates adopted policy calling for a cybersecurity relief fund to protect viability of and patient access to physician practices. The fund would be financed by health insurers and other payers to be used by providers in the event of a cyberattack affecting payment. 
• Substance use disorder and mental health treatment: Delegates adopted policies to support harm reduction, expand access to naloxone and enforce parity laws.   
• Health care coverage: Delegates adopted policy to expand health care coverage for Medicare and Medicaid patients. Specific policies include expanding Medicaid coverage to include hearing and vision, as well as making Medigap policies affordable for Medicare patients. 
• Patient access to care: Delegates adopted several policies to protect patient access to needed health care. This includes making prescriptions affordable for Medicare Advantage patients, expanding health equity through support for medical-legal partnerships, supporting in-vitro fertilization and ethically using de-identified patient data. 
• Public health: Delegates adopted policy aimed at improving health care of minority communities in rural areas, as well as several policies related to tobacco and nicotine. 
• American Indian/Alaska Native health: Delegates adopted several policies intended to improve health outcomes for American Indians and Alaska Natives. 
• Equity in clinical trials and research: Given the long history of medical devices and medications being developed without sufficient data on how they impact women, and sexual and gender minority (SGM) populations, delegates adopted policy to ensure more women and SGM are included in clinical trials and medical research. 

For more information, view the complete day-to-day overview of meeting highlights. In addition, Todd Askew, AMA senior vice president of Advocacy, shared an update on the AMA’s advocacy efforts so far this year on the top priorities for physicians in an episode of ”AMA Update" filmed on-site at the meeting. 

The Department of Health and Human Services (HHS) Office for Civil Rights (OCR) released updated frequently asked questions (FAQs) concerning who is responsible for performing the Health Insurance Portability and Accountability Act (HIPAA) breach notification to HHS, affected individuals, and the media as a result of the Change Healthcare cyberattack. 

The FAQs specify that covered entities can delegate to Change Healthcare the tasks of making the required HIPAA breach notifications on their behalf. In addition, the FAQs maintain that only one party, e.g., Change Healthcare, is responsible for carrying out the breach notifications required by the HIPAA Privacy Rule. According to OCR, if covered entities work with Change Healthcare to perform the required breach notifications, they will not have additional HIPAA breach notification obligations. 

Although the AMA appreciates the additional clarity from OCR, the AMA will be seeking additional clarification on several points to avoid confusion in the physician community. These questions revolve around obligations for physicians that are not in a business associate relationship with Change Healthcare or UnitedHealth Group and are under no breach notification obligation regarding the data breach, as well as specific actions that need to be taken by physicians who are in a business associate relationship with Change Healthcare and wish to delegate breach notification duties.  

OCR’s updated FAQs follow a letter (PDF) from the AMA, several partners and approximately 100 state medical associations and national medical specialty societies that asked the agency about how it intended to enforce HIPAA-related reporting requirements from the cyberattack. 

Early this month, the AMA commented (PDF) on a Request for Information on Consolidation in Health Care Markets (RFI) issued jointly by the Department of Justice (DOJ), the Federal Trade Commission (FTC), and the Department of Health and Human Services (HHS). The RFI (PDF) sought input on deals conducted between alternative asset managers and health care providers, including transactions involving private equity or acquisitions by private payers.  

In short, AMA remarks identify systemic issues in the health care system that may drive physicians toward private equity and shed light on some harms caused by the increase in consolidation across health care markets.  

The outset of the letter (PDF) stresses that independent physician practices are made vulnerable by consolidation in health care market—for example, they may face a lack of bargaining power against consolidated market power health insurers, and therefore struggle to effectively negotiate rates sufficient to keep their practices viable. The letter notes that the trend toward consolidation in the health care industry has directly led to the closure of independently operated physician practices, and the AMA acknowledges that private equity is well-positioned to capitalize on the vulnerability of independent physician practices. 

Note that the AMA does not oppose transactions between physician practices and private equity groups or other corporate investors. AMA has long-standing policy supporting a physician’s right to choose their mode of practice and type of employment. The AMA recognizes that private equity deals—which, among other benefits, typically provide an influx of capital for physician practices and may promise to reduce administrative burdens on physicians—can be successful where they preserve high-quality, physician-led, patient-centered care. Ultimately, AMA remarks to the DOJ stress that if a physician elects to pursue an investor partnership, that choice should be freely made.  

At the same time, the AMA expresses deep concern that market forces emerging from increasing consolidation across the health care system drive physicians toward private equity agreements that may not be favorable, causing them to sell to private equity when perhaps they otherwise would not. One such factor is the broken Medicare payment system, which threatens the viability of independent physician practices. Excessive administrative burdens such as prior authorization, which drain practice resources, take time away from patient care and threaten access to needed care, is another. The letter also touches on the strain of inefficient quality reporting processes arising from the shift to value-based payment arrangements. 

Examining the consequences of consolidation in health care more broadly, the AMA also describes some harms of consolidation to physician practices. The letter points to the degradation of physician working conditions by monopsonist health insurers and the lack of employment opportunities for physicians in highly concentrated hospital markets. Using the Change Healthcare cyberattack as example, the AMA also calls out the highly variable and context-specific consequences of vertical acquisition and encourage the DOJ and FTC to consider the impact of vertical integration on physician practices when examining proposed vertical mergers and serial acquisitions. 

Ultimately, AMA remarks highlight that systemic issues in the health care system may drive physicians away from private practice and toward private equity, despite the fact that private equity acquisitions are not always preferred by physicians and may interfere with the physicians’ ability to autonomously provide patient-centered care. The AMA stresses that, to neutralize the environment for independent physicians competing in consolidated markets, underlying key challenges that threaten physician practices must be addressed. Finally, the AMA emphasizes that consolidation in the U.S. health care system causes certain harms to physicians and patients, that AMA supports competition in all health care markets, and that markets should be sufficiently competitive to allow physicians to have adequate practice options. 

On May 21, the Senate Committee on Health, Education, Labor and Pensions, Subcommittee on Primary Health and Retirement Security, held a hearing entitled “Feeding a Healthier America: Current Efforts and Potential Opportunities for Food is Medicine.”  

The AMA submitted a detailed statement for the record (PDF), highlighting the AMA’s comprehensive correspondence with the federal government over the last few years, including detailed recommendations for improving federal nutrition policy as well as legislative changes that can be made to positively impact health outcomes. Specifically, the statement focused on the AMA’s policy and recommendations regarding the following topics: patient education and research, food labeling, food substitutes, reducing processed meats, added sugars and sodium, medical nutrition therapy services, medically necessary foods and supplements, food assistance programs, and home blood pressure monitors. Additionally, in the statement, the AMA noted the critical role that structural and societal barriers continue to play in inequitable access to healthy foods, and diet- and chronic disease-related medical treatments, as well as the importance of solutions aimed at addressing social determinants of health and other access-related issues. 

The AMA signaled its appreciation for the Committee’s interest in continuing this important work on nutrition and food, which is critically linked to health and chronic disease in this country, and expressed an interest in working with the Committee and Congress to help ensure that every American has access to high-quality, nutritious food. 

The AMA provided comments (PDF) to the Office of the National Coordinator for Health Information Technology (ONC) on its Health Equity by Design (HEBD) Concept Paper (PDF). The AMA fully supported ONC’s HEBD approach and committed to collaborating with ONC and other contributors to advance health equity through innovative health IT solutions. In addition, the AMA wants to contribute to ongoing discussions on how best to integrate health equity into IT design, implementation and policy. 

To further strengthen the HEBD approach, the AMA recommended enhanced collaboration that commits resources to convenings that foster collaborations among federal agencies, health care providers and community organizations. In addition, the AMA championed implementation support that provides detailed guidance, dedicated technical assistance and infrastructure investment to support implementation of HEBD principles in various health care settings, particularly small physician practices and institutions operating in rural areas and other communities that have historically experienced marginalization and disinvestment. The AMA also supported data integrity and ongoing evaluation initiatives that remain adaptable and responsive to emerging health equity challenges.  

Given the highly sensitive nature of an individual’s personal information, the letter also noted that it is critical that ONC’s equity initiatives support safeguards around patients’ and other individuals’ privacy interests and preserve the security and integrity of one’s personal information. 

• June 14, 2024: Advocacy Update spotlight on reintroduced prior authorization bill
• June 14, 2024: Medicare Payment Reform Advocacy Update
• June 14, 2024: State Advocacy Update