March 24, 2023: National Advocacy Update

In a historic move, Congressional advisory body MedPAC (the Medicare Payment Advisory Commission) called for a physician payment update that would be tied to the Medicare Economic Index (MEI) for the first time ever. The AMA has long championed an inflation-based update for physicians, and Medicare physician payment reform is a central component of the AMA’s Recovery Plan for America’s Physicians. In a sign-on letter along with 134 other health care organizations, the AMA signaled appreciation for MedPAC’s move as a critical step towards shoring up the financial viability of medical practices, particularly in a time of high inflation.

At the same time, the letter called MedPAC’s specific recommendation to tie the update to just half of MEI “insufficient” because it would “fail to cover all practice costs” and “be a missed opportunity to meaningfully address this perennial issue of Medicare physician underpayment.” Instead, the groups pushed Congress for an annual inflation-based payment update tied to the full MEI while pointing out that inflation-adjusted Medicare Fee Schedule spending per enrollee has been flat or declining from 2011-2021. Read more in the letter and accompanying press release.

The AMA submitted detailed comments on March 20 in response to a request for information from the Senate Health, Education, Labor and Pensions Committee to understand stakeholder views on the drivers of health care workforce shortages as well as to get stakeholder input on best solutions. The comments, sent to Chairman Bernie Sanders and Ranking Member Bill Cassidy, MD, outline the AMA’s perspectives on what is driving health care workforce shortages and how the committee can help stop the current and impending crisis.

Prior to the COVID-19 pandemic, the U.S. was already facing a rising shortage of physicians, and now, in part due to the increased physician burnout associate with COVID-19, there is a projected shortage of between 54,100 and 139,000 physicians by 2033. This number includes a projected primary care physician shortage of between 21,400 and 55,200, as well as a shortage of non-primary care specialty physicians between 33,700 and 86,700. The AMA is committed to ensuring that there is proper access to physicians for all patients and that physicians are well supported in their role as leader of the health care team. The AMA is working to reduce workforce barriers and ensure that physician burnout is addressed.

The AMA response included comments on a multitude of solutions such as:

• The need for additional GME slots and funding so that more physicians can be trained and in turn access can be improved, including more funding for the THCGME and RRPD programs
• The need for additional funding in support of programs created through the Dr. Lorna Breen Health Care Provider Protection Act
• The need for prior authorization reform, as prior authorization is a driving factor in physician burnout
• The need for more loan repayment and scholarship programs for physicians provided by the Committee, such as through the National Health Service Corps
• The need for MACRA reform, including ensuring that annual Medicare physician payments equal to the full Medicare economic index is enacted

The AMA appreciates the opportunity to submit comments and looks forward to working with the committee on future health care workforce shortage legislation to help fix this important problem. 

In addition to eliminating the X-waiver requirements for physicians to prescribe buprenorphine to treat patients for a substance use disorder (SUD), the Consolidated Appropriations Act of 2023 also included the Medication Access and Training Expansion (MATE) Act. The MATE Act requires physicians to take a one-time eight-hour training in assessing and treating SUDs as a condition of obtaining or renewing their registration with the Drug Enforcement Administration (DEA) to prescribe controlled substances. The DEA is required to implement the MATE Act training conditions in June 2023.

The AMA strongly supports and has long urged education for medical students, residents and physicians in identifying and managing SUDs, but has also been concerned that the MATE Act’s requirements could have unintended consequences and lead to new barriers to care. In a new letter to the heads of the DEA and the Substance Abuse and Mental Health Services Administration (SAMHSA), the AMA is recommending that the agencies broadly interpret the SUD training that will qualify under the MATE Act as they develop implementation policies. The AMA letter urges that courses offered on the AMA Ed Hub^TM qualify as meeting the MATE Act requirements, as well as courses that are required by state and specialty medical boards, those offered by medical schools and residency programs, and training that met the previous X-waiver rules. In addition, to help avoid lapses in physicians’ DEA registrations, the AMA is urging the DEA to provide a one-year grace period for physicians to fulfill the educational requirement while maintaining their DEA registration.

The AMA was also invited to participate in a roundtable convened by DEA Administrator Anne Milgram to discuss expanding patient access to SUD treatment with buprenorphine and methadone. Bobby Mukkamala, MD, chair of the AMA Substance Use and Pain Care Task Force and member of the AMA Board of Trustees, represented the AMA in the roundtable, which also included pharmacy and other stakeholder representatives. Dr. Mukkamala emphasized the need for the government to help eliminate prior authorization as an important factor in improving patient access to comprehensive evidence-based SUD care. 

The AMA submitted two letters to Congress on March 13 in support of three pieces of legislation related to reforming how Pharmacy Benefit Managers (PBMs) conduct business in the U.S. health care system. In one letter, the AMA wrote in support of both S. 127, the “Pharmacy Benefit Manager Transparency Act of 2023” as well as S. 113, the “Prescription Pricing for the People Act of 2023.” S. 127 would prohibit PBMs from engaging in unfair or deceptive reimbursement and payment tactics, incentivize fair and transparent PBM practices, and require PBMs to file an annual report to the Federal Trade Commission (FTC) disclosing certain payments received and fees associated with their operating practices. S. 113 would complement these efforts by directing further investigation on the part of the FTC to study the effects of consolidation in the PBM industry on pricing, and subsequently providing recommendations to Congress on ways to improve competition and protect patients. Both S. 127 and S. 113 have been approved by their committees of jurisdiction in a bipartisan manner and await final consideration by the Senate.

In the second letter, the AMA voiced support for H.R. 830, the “Help Ensure Lower Patient (HELP) Copays Act of 2023.” H.R. 830 would ensure copay assistance counts toward patient cost-sharing requirements in individual, small group and employer-sponsored health plans. The bill would also protect patients from harmful insurance and PBM practices that raise patient out-of-pocket prescription drug costs.

All three pieces of legislation are in line with AMA policy, as well as with recommendations that AMA made in a 2022 Policy Research Perspective entitled “Competition in Commercial PBM Markets and Vertical Integration of Health Insurers with PBMs.” This analysis is the first to shed light on variations in market shares and competition among PBMs at the state and metropolitan levels. The AMA is committed to working with Congress to see positive reforms made to a currently flawed PBM industry.

On March 20, the AMA submitted comments in response to an Interim Final Rule from the Department of Veterans Affairs (VA) that will establish a new benefit for the provision of emergent suicide care. The benefit goes farther than the VA’s traditional medical benefit by allowing any veteran who is in acute suicidal crisis—defined as an individual who is determined to be at imminent risk of self-harm by a trained crisis responder or health care provider—to receive 30 days of inpatient care or 90 days of outpatient care from virtually any provider regardless of whether they are affiliated with the VA. Either timeframe can be extended by the VA if a veteran remains in acute suicidal crisis. When care is delivered by non-VA providers that are not part of the Community Care Network, the VA will pay the facility directly or reimburse the veteran for the cost of care received. Veterans with dishonorable discharges are not eligible for the emergent suicide care benefit.

On March 17, the Centers for Medicare & Medicaid Services (CMS) instructed certified Independent Dispute Resolution (IDR) entities to resume all payment determinations under the Federal IDR Process. Processing of claims with dates of service on/after Oct. 25, 2022, was temporarily suspended after a federal judge ruled in February that the most recent regulation implementing the No Surprises Act (released in Aug. 2022) defied the original statute by instructing arbiters to weigh the Qualified Payment Amount (QPA) more heavily than other factors or circumstances included in the law, despite “nothing in the Act” directing them to do so, vacating certain sections of the rule in the process. 

CMS has released updated guidance in response to the ruling detailing how claims dated on/after Oct. 25, 2022, will be processed. Specifically, the updated guidance states that Certified IDR Entities must consider all information submitted to determine the appropriate out of network rate (that is otherwise not prohibited), removes references directing IDR entities to consider the QPA first, instructs IDR entities to include “the weight given to the QPA” in their written decisions, and removes prior requirements that “other information” aside from the QPA must first be deemed “credible.” Earlier guidance for claims with dates of service prior to Oct. 25, 2022, can be found here. In a separate update, disputing parties will begin receiving payment determination notices from [email protected] and are encouraged to save this email address as an allowed sender.

On March 2, the AMA submitted comments to the U.S. Department of Health and Human Services (HHS) in response to the agency’s proposed rule on “Safeguarding the Rights of Conscience as Protected by Federal Statutes.” HHS proposed partially rescinding and partially retaining the provisions from a May 2019 Final Rule promulgated by the Trump Administration that sought to greatly expand the scope and enforcement of federal conscience protection statutes, which prohibit recipients of certain federal funds from coercing physicians and other health care providers into participating in actions they find religiously or morally objectionable.

In its comments, the AMA noted that pursuant to the AMA Code of Medical Ethics, the AMA supports conscience protections for physicians and other health care professional personnel and believes that no physician or other professional personnel should be required to perform an act that violates good medical judgment, and no physician, hospital or hospital personnel should be required to perform any act that violates personally held moral principles. However, the exercise of these rights must be balanced against the fundamental obligations of the medical profession and physicians’ paramount responsibility and commitment to serving the needs of their patients. As advocates for patients, the AMA strongly supports patients’ access to comprehensive reproductive health care and freedom of communication between physicians and their patients, and opposes government interference in the practice of medicine or the use of health care funding mechanisms to deny established and accepted medical care to any segment of the population.

The comments also note that physicians’ freedom to act according to conscience is not unlimited: i.e., physicians are expected to provide care in emergencies, honor patients’ informed decisions to refuse life sustaining treatment, and respect basic civil liberties and not discriminate against individuals in deciding whether to enter into a professional relationship with a new patient. Physicians have stronger obligations to patients with whom they have a patient-physician relationship, especially one of long standing, when there is imminent risk of foreseeable harm to the patient or delay in access to treatment would significantly adversely affect the patient’s physical or emotional well-being, and when the patient is not reasonably able to access needed treatment from another qualified physician.

While the letter supports the partial rescission of the Trump conscience rule, the AMA argued that the proposed rule does not go far enough, and that HHS should fully rescind the 2019 Final Rule. As acknowledged by HHS in the preamble to the 2023 proposed rule, no statutory provision requires the promulgation of rules to interpret or implement various conscience laws that have been in existence for years. The AMA believes physicians are aware of their legal obligations under these requirements and does not think that the promulgation of this rule is necessary to enforce the conscience provisions under existing law. The AMA argued that there was a lack of data to justify the 2019 Final Rule, and HHS had failed to provide any updated data about more recent conscience complaints or allegations of conscience statute violations.

A new AMA Policy Research Perspective provides a detailed examination of the 2021 U.S. National Health Expenditures (NHE) data released by the Centers for Medicare & Medicaid Services (CMS). In 2021, health spending increased by 2.7% to $4.3 trillion or $12,914 per capita. This spending growth rate is substantially lower than that of 2020 (10.3%) and the result of a substantial decline in pandemic-related government spending offsetting increased utilization of medical goods and services that rebounded due to delayed care and pent-up demand from the pandemic. Health spending as a share of GDP was 18.3% in 2021, down from 19.7% in 2020.

Read more.

• March 24, 2023: Advocacy Update spotlight on prior authorization
• March 24, 2023: State Advocacy Update