March 22, 2024: National Advocacy Update

While the 118th Congress has been characterized by numerous partisan disagreements, a bipartisan collection of members of the House of Representatives joined forces on March 18 to send a letter to the Biden administration related to implementation of the No Surprises Act.

Representatives Greg Murphy, MD (R-NC), Joe Morelle (D-NY), Brad Wenstrup (R-OH) and Bill Pascrell (D-NJ), sent a letter (PDF) to the Departments of Health and Human Services, Treasury and Labor (the Departments) outlining additional policy steps needed to ensure the No Surprises Act is properly implemented and functioning for all affected stakeholders. More specifically, the bill urges these three Departments to:

• Continue their oversight of Qualifying Payment Rate (QPA) calculations, especially eliminating “ghost rates”
• Help reduce shrinking provider networks stemming from insurance companies utilizing the NSA requirements to terminate existing contracts
• Properly enforce compliance with statutory requirements including forcing plans to make payments within 30 days

The letter also urges the Departments to finalize existing policies related to batching, mandating the inclusion of ample information on the claim to determine if it is eligible for the federal open negotiation/independent dispute resolution (IDR) process, creating a process for the government to assist IDR entities to promptly reduce any backlogs in processing disputes, and requiring payers subject to the IDR process to register with HHS, Treasury and Labor and provide general information regarding the applicability of the IDR process to the items and services covered by the plan. More than 40 bipartisan members of Congress joined Reps. Murphy, Morelle, Wenstrup and Pascrell’s surprise medical billing letter.

Meaningful state and federal enforcement of mental health and substance use disorder parity laws is essential if the nation expects to see a decrease in drug-related overdose and death, AMA President Jesse M. Ehrenfeld, MD, MPH, testified to the National Association of Insurance Commissioners (NAIC) last week. Dr. Ehrenfeld emphasized that while health insurers always seem to have reasons why parity compliance is difficult, “failure to comply with parity laws means increased harm, including the possibility of death for patients with a mental illness or substance use disorder.” Dr. Ehrenfeld testified to the NAIC Mental Health Parity and Addiction Equity (MHPAEA) Working Group at the NAIC’s Spring Meeting in Phoenix, Arizona.

Dr. Ehrenfeld acknowledged challenges about workforce for psychiatry and addiction medicine, but said that “We should not confuse or conflate workforce challenges with denials or delays of care for mental illness or substance use disorders.”

Among the recommended action steps, in addition to state enforcement actions, Dr. Ehrenfeld encouraged the U.S. Department of Labor to finalize pending rules (PDF) as well as extend parity laws to Medicaid and CHIP (PDF). He also recommended to the state regulators that all medical necessity criteria used for mental health and substance use disorder should follow the generally accepted standard of care as put forward by professional medical associations such as the American Society of Addiction Medicine, the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry.

“We understand that health plans do not agree with us,” said Dr. Ehrenfeld. “Physicians follow the standard of care as put forward by our peers and professional associations. We believe that should be the same standard followed by every health plan.”

On March 19, the Centers for Medicare & Medicaid Services’ (CMS) Innovation Center announced a new initiative to boost investments for primary care practices in low-revenue Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs). The Primary Care Flex Model (ACO PC Flex Model) will provide a one-time advanced shared savings payment of $250,000 along with monthly prospective primary care payments, which will be based on county-average spending (rather than an ACO’s own historic spending) and the characteristics of the ACO as well as its assigned patient population. In an effort to boost resources for practices serving underserved populations with advanced social and clinical needs, ACO PC Flex is a five-year voluntary model set to begin on Jan. 1, 2025, with CMS planning to accept approximately 130 MSSP ACOs into the model.

More details, including a fact sheet and frequently asked questions, can be found at the new ACO PC Flex Model webpage. CMS will also host a webinar on April 4 at 1:00–2:00 p.m. Central time to provide an overview of the new model. Additional information will be included in the Request for Applications, expected in the second quarter of 2024. ACOs interested in ACO PC Flex must participate in the MSSP for the 2025 performance year, applications for which will be open May 20–June 17.

The ongoing, long-term effort to reform the way the Congressional Budget Office (CBO) analyzes the potential cost or savings associated with preventive health care services took a major step forward on March 19 following the House’s passage of H.R. 766, the Dr. Michael C. Burgess Preventive Health Savings Act. This House passed the legislation under “suspension of the rules,” or a fast-track parliamentary procedure, by a voice vote. Introduced by Representatives Burgess, MD (R-TX) and Diana DeGette (D-CO), the legislation currently has 29 bipartisan house cosponsors.

This important bipartisan legislation grants the authority to the chair and ranking members of the budget and health-related committees in the House or Senate to jointly request a cost/savings analysis of the two 10-year periods beyond the existing initial 10-year window. This new, 30-year budget window should permit the non-partisan CBO to capture savings associated with patients receiving crucial preventive health care. The CBO is often criticized for utilizing cost methodologies that are not able to identify preventive care as a net savings to the federal government due to their rigid requirements to analyze the costs of a particular piece of legislation only within the decade that follows the date of enactment. In addition, the provisions requiring these long-term cost assessments to come jointly from the chair and ranking member of the budget and health-related committees in the House or Senate will ensure the CBO is not diverted to frivolous or overly partisan analyses.

The AMA has been a long-standing supporter (PDF) of the Preventive Health Savings Act, which was renamed after its principal author, Dr. Michael Burgess, following its passage out of the House Budget Committee, over many Congresses. The AMA submitted another formal letter (PDF) of support on March 18 in advance of the bill’s consideration on the House floor. The likelihood of passage of H.R. 766 or the identical Senate companion bill, S. 1685 (PDF), is still uncertain at this time. The AMA appreciates the House of Representatives passing this important bill and will continue to work with bipartisan leaders in the Senate to ensure it clears the upper chamber before the end of 118th Congress.

With the U.S. having the highest maternal mortality and morbidity rates among developed countries, the AMA continues to sound the alarm to policymakers that a multi-faceted approach is needed, one which includes addressing the leading causes of preventable maternal deaths and investing in the physician workforce to improve access to maternity care. During Black Maternal Health Week, April 11-17, it is particularly important to raise not only awareness of this issue, as it disproportionately affects Black and Native American/Alaska Native pregnant and postpartum individuals, but also to advocate for solutions.

Register for this Advocacy Insights webinar on April 15 at 11:00 a.m. Central time to learn about the AMA’s newly released recommendations on maternal health and what approaches are needed. Moderated by Willie Underwood III, MD, MSc, MPH, chair of the AMA Board of Trustees, speakers will include:

• Maryanne C. Bombaugh, MD, MBA, MSc, member, Council on Legislation, American Medical Association
• Michael Rakotz, MD, vice president, Health Outcomes, American Medical Association
• Jennifer Brown, JD, health equity director, Advocacy, American Medical Association

The AMA Physician Practice Information (PPI) Survey is nearing completion, and the AMA urgently needs all selected physicians to actively engage in this effort. The intent of the survey, which has been endorsed by over 170 medical societies and other health care associations (see full list), is to collect updated and accurate data on practice costs which are a key element of physician payment. These data have not been updated since last collected over 15 years ago, and it is critically important to update these data to ensure accurate payment.

Find more information about this survey.

Mathematica, a well-regarded consulting firm, is helping the AMA run this survey. Your practice may have received an email (from [email protected]) and a USPS mail packet from Mathematica that contained a link to the survey as well as supporting information. We urge you to speak with your practice management colleagues to determine if they have received these communications and ask them to complete this important survey. In the coming weeks or months, you may be asked to complete a brief survey on the number of weekly hours spent on direct patient care. We urge you to complete this two-minute survey.

• March 22, 2024: Advocacy Update spotlight on Change Healthcare
• March 22, 2024: Medicare Payment Reform Advocacy Update
• March 22, 2024: State Advocacy Update