June 27, 2019: National Advocacy Update

On June 24, the Senate Committee on Health, Education, Labor and Pensions (HELP) released an updated version of S. 1895, the "Lower Health Care Costs Act," which was considered by the Committee on June 26. Though the bill contains numerous commonsense proposals for lowering the cost of health care, there are significant negative consequences for physicians contained in Title I of the bill, "Ending Surprise Medical Bills."

Earlier versions of the bill had contained several options for addressing the impact on patients of medical bills from out-of-network providers, including an untested concept referred to as an "in-network guarantee" as well as allowing disputes between insurers and providers to be settled in through "baseball-style" arbitration. The final committee bill, however, included a mandate that insurers pay out-of-network physicians at the median in-network rate, with no additional patient cost-sharing allowed. This restriction would apply to all out-of-network physician services at in-network facilities, including freestanding emergency departments, ambulatory surgical centers, critical access hospitals, laboratories, radiology clinics and others when the care was provided in an emergency (or for active labor), or where non-emergency services were provided by physicians not generally selected by patient such as anesthesiologists, pathologists, radiologists, on-call specialists and consultants. It would also apply to out-of-network services furnished after an enrollee has been stabilized but declines to consent to pay out-of-network amounts.

HELP Committee Chairman Lamar Alexander (R-TN) hopes to take the legislation up on the Senate floor before the August congressional recess and use the savings generated by the bill to pay for other federal spending priorities.

While virtually all physician organizations support limiting patient costs to their in-network amount in cases where patients did not have the opportunity to select their physician, there are serious potential implications from a government mandate to pay in-network median rates. Plans will have little incentive to offer fair contacts to physicians when they are guaranteed not to have to pay those physicians more than in-network rates for out-of-network care. Physicians with contracts above a plan's in-network rates will likely see those contracts canceled or face demands for significant rate concessions to remain in-network. Those actions would have the secondary effect of further depressing median in-network amounts and threatening access to care.

Physician organizations, including the AMA, have been calling on Congress to pass legislation based on the successful model in New York that has significantly curtailed surprise billing complaints by instituting a "baseball-style" independent dispute resolution system whereby a neutral arbiter chooses between the amount offered by the plan and the amount billed by the physician. Not only is this proven system efficient, it has encouraged more reasonable plan offers and curtailed outlier billing. Such a proposal was introduced on June 26 as H.R. 3502, the "Protecting People from Surprise Medical Bills Act," by Rep. Raul Ruiz, MD (D-CA), Rep. Phil Roe, MD (R-TN) and over 30 other cosponsors including Rep. Larry Bucshon, MD (R-IN), Rep. Brad Wenstrup, DPM (R-OH), Rep. Ami Bera, MD (D-CA), former U.S. Department of Health and Human Services (HHS) Secretary Rep. Donna Shalala (D-FL), Rep. Joe Morelle (D-NY) who authored the NY law, and Rep. Van Taylor (R-TX).

The AMA has submitted a set of comments and recommendations (PDF) to the Office of the National Coordinator for Health Information Technology (ONC) on the second draft of its Trusted Exchange Framework and Common Agreement (TEFCA). ONC's proposed framework is meant to provide a single "on-ramp" to nationwide interoperability, enable health care teams to better find and use patient medical records and support patients' access to their own information. The AMA expressed its appreciation for ONC's continued involvement of the physician community in developing a nationwide information exchange network. However, the AMA has identified several areas that need more attention before a final version of the TEFCA is released.

While more work needs to be done, the AMA is very supportive of the ongoing efforts by organizations like Carequality and the Sequoia Project to improve information exchange. ONC must take more consideration in minimizing or eliminating proposals that would duplicate and disrupt existing exchanges between participants of health information networks. Fundamentally, the TEFCA should address real, material gaps between currently existing exchanges—with a focus on reducing costs and aiding physicians in finding more complete and accurate medical records.

The AMA urged ONC to take the necessary time for a comprehensive review of its own interoperability policies. This includes recent information blocking and electronic health record (EHR) certification proposals (PDF), as well as ensuring alignment between other federal agencies within HHS. In line with congressional intent, the AMA recommends ONC take a practical approach with the TEFCA, initially establishing a nationwide information exchange for the purposes of treatment and patient access to information. The AMA reiterated its position that any framework must also strengthen patient privacy and be resilient to cyber-attacks.

The AMA also urges ONC to maintain the voluntary nature of the TEFCA, specifically that physicians cannot be deemed "information blockers" if they determine that participation under the TEFCA is not optimally serving their patients or not possible due to technical or cost limitations. ONC should restrict mandatory or de facto mandatory participation requirements imposed by EHR vendors, payers or other federal agencies.

On June 24, President Trump signed an executive order directing federal agencies to take steps to improve health care price transparency. The order lists five major points:

• HHS will issue regulations requiring hospitals to disclose actual charge and negotiated payment rate information in an easy-to-read format.
• A regulatory framework will be proposed to require health care providers and insurers to disclose cost of care information, including out-of-pocket costs, to patients before services are provided.
• Federal agencies will collaborate on a comprehensive quality roadmap for consolidating consumer-centered quality metrics across all federal health care programs.
• Access to de-identified health care claims data from all taxpayer funded programs will be expanded to enable health care transformation and facilitate research.
• The Department of the Treasury is directed to expand the availability of health savings account options to include services like more preventive care and direct primary care arrangements.

As the various reports and proposals are released by federal agencies, the AMA will prepare detailed comments that reflect the interests of patients and their physicians.

The AMA signed on to a letter (PDF) of support for H.R. 3239, the "Humanitarian Standards for Individuals in Customs and Border Protection Custody Act," along with 13 other health care organizations. H.R. 3239 takes important steps toward ensuring that appropriate medical and mental health screening and care is provided to all individuals, including immigrant children and pregnant women, in U.S. Customs and Border Protection (CBP) custody. The bill was recently introduced by Rep. Raul Ruiz, MD, and currently has 112 cosponsors, including the chairmen of the House Homeland Security and Judiciary Committees.

The Office of Management and Budget (OMB) sought comments on changing the inflation index used to calculate the federal poverty line – a change which may substantially cut eligibility for critical health care assistance programs.

More specifically, the AMA responded (PDF) with a comment letter standing against a switch from the Consumer Price Index (CPI) to the Chained Consumer Price Index (C-CPI) to measure inflation when estimating the federal poverty line (more formally referred to as the Official Poverty Measure or poverty threshold). Making this change would result in the federal poverty line decreasing because inflation estimates based on the C-CPI are consistently lower than those based on the CPI. Because the current poverty guidelines depend on the federal poverty line to determine eligibility and coverage for various health care programs (including Medicaid, CHIP, and Medicare Low-Income Subsidy Program), making this change would, over time, substantially decrease the number of vulnerable patients that qualify for assistance from these critical programs.

Additionally, CPI reflects inflation for the entire U.S. population but studies have shown lower-income households face comparatively higher inflation. Because C-CPI consistently trends lower than CPI, it is likely that C-CPI would understate inflation even more so for these vulnerable groups and generate an even less representative federal poverty line.

Following AMA recommendations, the Centers for Medicare & Medicaid Services (CMS) and its contractor, Acumen LLC, are taking steps to improve transparency throughout the Medicare Access and CHIP Reauthorization Act (MACRA) cost measure development process. This is especially important because the episode-based cost measures under development include chronic condition and disease management measures that will affect physicians across multiple specialties. In addition, CMS and Acumen LLC are developing measures in the following clinical areas: dermatologic disease, general and colorectal surgery, and hospital medicine.

To provide an update and answer questions from specialty societies and other stakeholders about the initial cost measure clinical subcommittee meetings, CMS and Acumen will host office hours on July 2 from 3-4 p.m. Eastern time and July 10 from 5-6 p.m. Eastern time. The clinical subcommittees recently met to provide input on which cost measures to develop and about the composition of workgroups that will give detailed clinical input on specifications for each measure. Register for either office hour session at this link.

Furthering its efforts to transform the way future physicians are trained, the AMA adopted policy at its 2019 Annual Meeting aimed at incorporating augmented intelligence (AI) into medical education. The new policy identifies the steps needed to work toward educating physicians-in-training and physicians on how AI technology works and how to evaluate its applicability, appropriateness and effectiveness in caring for patients.

"To realize the benefits for patient care, physicians must have the skills to work comfortably with augmented intelligence in health care. Just as working effectively with electronic health records is now part of training for medical students and residents, educating physicians to work effectively with AI systems, or more narrowly, the AI algorithms that can inform clinical care decisions, will be critical to the future of AI in health care," said AMA Board Member S. Bobby Mukkamala, MD.

The AMA adopted policies on integrating AI into medical education, which include encouraging the development of AI education modules for physicians and physicians-in-training, addressing disparities in AI education that could impact patient care, and ensuring that physicians are involved in the development and implementation of educational materials on AI.

The new policy builds on the AMA's effort over the past six years to transform medical education to ensure future physicians have the skills they need to practice in modern and future health systems. Launched in 2013, the AMA's Accelerating Change in Medical Education initiative aims to incorporate the newest technologies, health care reforms and scientific discoveries that continue to alter what physicians need to know to practice in the evolving health care landscape.

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