June 16, 2023: National Advocacy Update

The 2023 Annual Meeting of the AMA House of Delegates covered a wide range of critical topics facing the nation’s health care system—including key pillars of the AMA Recovery Plan for America’s Physicians.

The following are some of the major issues that were discussed at the meeting: 

• Medicare physician payment: Adopted policy pushing for a comprehensive campaign to achieve Medicare physician payment reform  
• Physician burnout: Created policy to ensure that only questions about relevant mental health information are asked in licensing and credentialing applications
• Prior authorization: Adopted policy calling for insurers to require human examination of patient records, rather than relying on augmented intelligence, when denying a prior authorization request 
• Administrative burdens: Supported development of tools and education for physicians and insurers on the appropriate reporting of modifiers, including the use of modifier 25 
• Scope of practice: Adopted new policy and strengthened existing policy supporting physician-led care teams and opposing inappropriate scope of practice expansions  
• Telehealth: Adopted policy to support digital literacy and protect continued access to care for underserved populations through the extension of telehealth insurance coverage and payment parity 
• IMG licensure: Developed a strategy to reduce cost barriers for IMGs seeking licensure 
• Substance use: Advocated for access to safe and effective overdose reversal medications in educational settings, as well as increased support and treatment for pregnant people with substance use disorders 
• Physician noncompete provisions: Voted to oppose noncompete contracts for physicians in clinical practice who are employed by for-profit or nonprofit hospitals, hospital systems or staffing company employers  

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 Recovery Plan and top advocacy priorities in an episode of “AMA Update” filmed on-site at the event.  

The AMA submitted a formal statement for the record (PDF) as part of the House Ways and Means Subcommittee on Health’s May 17 hearing entitled, “Why Health Care is Unaffordable: Anticompetitive and Consolidated Markets.” Educating federal lawmakers about and supporting legislation that combats the negative effects of health care consolidation, especially preserving the viability of small, private practice physicians, remains a key tenet of AMA’s advocacy platform. In addition to promoting lower costs, preserving strong health care competition can help ensure all types of physician practices and hospitals remain viable options for patients. As a result, the statement utilizes data to illustrate the harmful effect of health insurance and pharmacy benefit manager (PBM) consolidation, as well as the benefits of lifting the current ban on physician-owned hospitals. 

The results of AMA’s “Competition in Health Insurance: A Comprehensive Study of U.S. Markets,” (PDF) which outlines the growing problem of insufficient competition within this market, served as the backbone for the comments related to insurer consolidation. More specifically, lawmakers on the committee learned that the share of highly concentrated health insurance markets in metropolitan statistical areas rose from 71% to 75% between 2014 and 2021. The statement also prominently features AMA’s ongoing support for removing the restrictions within the Affordable Care Act that largely banned the creation of new or expansion of existing physician-owned hospitals. In fact, the AMA urges Ways and Means Committee members to expeditiously enact H.R. 977/S. 470, the “Patient Access to Higher Quality Health Care Act of 2023,” bipartisan legislation to roll back the existing prohibitions on physician-owned hospitals to spark greater market competition. Finally, the statement features a detailed section on the unscrupulous business practices of PBMs and how these tactics lead to higher pharmaceutical costs and less patient access. To help curb PBM abuses, AMA supports S. 127, the “Pharmacy Benefit Manager Transparency Act of 2023,” S. 113, the “Prescription for the People Act,” and H.R. 830, the “Help Ensure Lower Patient (HELP) Copays Act.” 

An eclectic mix of witnesses testified before the Ways and Means Health Subcommittee including: 

• Dr. Barak Richman, Professor, Duke Law School 
• Glen Mulready, Commissioner of the Oklahoma Insurance Department 
• Joe Moose, owner of Moose Pharmacy, an independent community pharmacy 
• Frederick Isasi, Executive Director, Families USA 
• Benjamin Rome, MD, MPH, Instructor in Medicine, Harvard Medical School 

The AMA appreciates the Ways and Means Committee exploring this topic and looks forward to working with its bipartisan members to promote sound policy solutions that combat anti-competitiveness in the health care market.    

The AMA sent a June 12 letter (PDF) to the Centers for Medicare & Medicaid Services (CMS) expressing its strong concern about the agency’s continued desire to increase the data completeness requirements for satisfying and successfully reporting on a quality measure within the Merit-Based Incentive Payment System (MIPS) program and Medicare Shared Savings Program (MSSP).  

The AMA believes there is a lack of understanding with the maturity of health IT standards to seamlessly aggregate data from electronic health records (EHRs) or registries from physicians who practice at multiple sites or as a part of an Accountable Care Organization (ACO) to meet this reporting requirement. The AMA urged CMS to work with the physician, ACOs, and the EHR vendor communities to find solutions to these data aggregation problems. Until the technology standards are more mature, CMS should reduce the quality measure data completeness requirement within MIPS and delay mandatory electronic clinical quality measure (eCQM) adoption for ACOs.  

Since 2020 within the MIPS Program, CMS has required physicians to successfully report on a quality measure for 70% of all eligible patients—not just Medicare patients. Starting in 2024, CMS will increase this data completeness requirement to 75% of all eligible patients. Another 2024 change is that ACOs participating in the MSSP must report their quality measures through eCQMs and MIPS Clinical Quality Measures (CQMs). 

In response (PDF) to the Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) proposed rules, the AMA strongly opposed proposals to: 

• Revoke flexibilities for physician-owned hospitals that serve greater numbers of Medicaid patients 
• Increase the agency’s regulatory authority to grant or deny exceptions to expansion 
• Expand the scope of community input 

The AMA stressed that these proposals limit the capacity of physician-owned hospitals to increase competition and choice in communities throughout the country and, more significantly, limit patients’ access to high-quality care. The AMA’s comments highlight the benefits of physician-owned hospitals, including their high performance on quality and efficiency, value to the community, promising role in value-based care delivery and payment models, and increased competition. 

In addition, the AMA supported the proposed changes to Graduate Medical Education (GME) payments for rural emergency hospitals and urged CMS to implement safeguards to ensure accurate updates to GME funding in the future. The AMA also supported the concept of adding a Health Equity Adjustment (HEA) to the Hospital Value-Based Purchasing (HVBP) Program scoring methodology but recommended improvements to the methodology considering the size of the hospital’s budget relative to uncompensated care, creating separate calculations for distinct types of safety net hospitals, and incorporating socioeconomic indices and racial segregation in the formula. 

On Monday, the U.S. Department of Health and Human Services (HHS) announced new flexibilities intended to help mitigate mass disenrollments as states resume Medicaid and Children’s Health Insurance Program (CHIP) eligibility checks and renewals following the end of the COVID-19 Public Health Emergency. Among other changes, the departments will: 

• Allow managed care plans to assist with completing renewal forms 
• Allow states to delay termination for one month while additional targeted outreach is performed 
• Allow certain frontline entities such as pharmacies and community-based organizations to facilitate reinstatement of coverage based on presumptive eligibility criteria 

In an accompanying letter to governors, the department explains what it is calling its “all hands on deck” approach, which includes calling on state Medicaid agencies to take the full 12 months to perform renewals, take full advantage of available flexibilities and waivers, and get creative in partnering with schools, grocery stores, faith-based organizations, and other community-based groups to perform targeted outreach. The department created a list (PDF) of all available waivers and flexibilities plus a separate list of waivers and flexibilities that individual states have taken up so far. Visit Medicaid.gov/unwinding for more information and physician-focused resources, including printable signs for waiting rooms. 

On June 8, CMS announced a new voluntary payment model designed to strengthen primary care. The Making Care Primary (MCP) Model, slated to begin July 1, 2024, will operate across the Medicare and Medicaid programs in eight states and aims to engage practices with limited or zero experience in value-based payment, including small, independent, rural and safety net organizations. Advancing health equity is a central focus of the MCP Model, which CMS aims to accomplish by including health-related social needs interventions, risk-adjusting for clinical and social risk factors, reducing cost sharing for low-income patients, and requiring a tailored health equity strategic plan from each applicant, among other strategies.  

The AMA released a statement saying it was encouraged to see many of the AMA’s longstanding recommendations featured in the model, including the stability of a 10.5-year model test period, financial incentives for increased coordination between primary care physicians and other specialists, on-ramps to increased financial risk, and upfront investment payments to help build out the necessary infrastructure. 

More information can be found at this CMS webpage and blog. Many payment and quality measurement details are still outstanding and are expected to be released with the Request for Applications later this summer. Certain practices, including rural health clinics, concierge practices, Primary Care First practices and Medicare Shared Savings Program participants will be ineligible to participate in the model. The AMA will closely monitor and release additional information and educational opportunities as more details emerge.

• June 16, 2023: Advocacy Update spotlight on new Fix Medicare Now website