May 5, 2023: National Advocacy Update

On May 3, AMA President Jack Resneck Jr., MD, testified (PDF) before the Senate Finance Committee on the problem of “ghost” provider networks and potential solutions to improve provider directory accuracy, particularly as it relates to mental health care.

In addition to being a physician who has to deal with inaccurate directories, Dr. Resneck was also able to present to the Committee details of a secret-shopper study he published in 2014 that found that only 26.6% of the individual directory listings for dermatologists in a subset of Medicare Advantage plans were unique, accepting the patient’s insurance, and offering a medical dermatology appointment. Multiple additional studies since have shown similar results, and a study released the morning of the hearing by Chairman Wyden (D-OR) (PDF) found that in phone calls to a sample of 120 provider listings across 12 different plans, 33% were inaccurate, non-working numbers, or unreturned calls. The Chairman’s study found that appointments were available only 18% of the time. 

Dr. Resneck was joined by other panelists in highlighting the real harm that can result when patients are unable to find an in-network physician, including the financial burden and the negative effect on a patient’s health. The impact can be particularly detrimental on patients in need of mental health care. Physicians on the panel generally agreed that physician practices have an important role to play in directory accuracy but ultimately the responsibility lies with the health plans. Several panelists also agreed on the need to standardize the process of data submission so that each practice is not dealing with 20 different submission processes for 20 different plans, especially as they deal with other administrative burdens like prior authorization. Additionally, some panelists called for greater oversight of directories and meaningful penalties on plans when requirements are not met. Finally, Dr. Resneck stressed the need to not only improve regulation of directories but to address important issues such as network adequacy, workforce shortages and violations of mental health parity laws that inaccurate directories may be masking.   

Last year, the House of Representatives passed the Improving Seniors' Access to Timely Care Act. This bipartisan legislation, with over 300 cosponsors, required Medicare Advantage plans to identify and issue real-time decisions for routinely approved services, adopt federally developed standardized electronic prior authorization processes, provide greater transparency surrounding the development and use of utilization management guidelines, and provide rationales for denials. Unfortunately, despite strong bipartisan support in the Senate, the bill failed to receive a floor vote.  

Thankfully, late last year the Centers for Medicare & Medicaid Services (CMS) offered two new proposed rules, one of which has been finalized, that would align with many of the key provisions of the Improving Seniors' Access to Timely Care Act and improve the prior authorization process for physicians and their patients. 

#FixPriorAuth champions in both the House and Senate began circulating a "Dear Colleague" letter urging CMS to promptly finalize the remaining regulation and further expand its provisions to better align with the Improving Seniors' Timely Access to Care Act. In particular, the letter urges CMS to include a mechanism for Medicare Advantage (MA) plans to issue real-time prior authorization decisions for routinely approved services, establish a 24-hour deadline for MA plans to respond to emergent prior authorization decisions and provide detailed transparency metrics. 

Please contact your Representative and Senators and urge them to sign on to this important “Dear Colleague” letter today.  

This flawed system must be fixed, and now it's up to CMS to move electronic prior authorization forward and hold the big insurance companies accountable for the undue burden their policies put on the country's health care system.   

On April 27, the AMA sent a letter (PDF) expressing continued opposition to H.R. 1770, the Equitable Community Access to Pharmacist Services Act. The AMA opposed (PDF) legislation with the same title last Congress and, despite the modifications to the version introduced in the 118th Congress, the bill still expands pharmacists’ scope of practice in a manner that threatens patient safety. 

H.R. 1770 would inappropriately allow pharmacists to furnish services that would otherwise be covered if they had been furnished by a physician, despite pharmacists not having the same extensive education and training as physicians. The bill would allow pharmacists to test and treat patients for COVID-19, respiratory syncytial virus (RSV), the flu and potential future illnesses related to a public health emergency. It would also expand Medicare payment for pharmacists. 

Pharmacists are well-trained as medication experts within an interprofessional team; however, their training in patient care is limited. Most of the Doctor of Pharmacy (PharmD) curriculum across the country consists of instruction in applied sciences and therapeutics. Residency is not required, and the overwhelming majority of pharmacists working in the community setting have not undergone residency training. Additionally, their limited “practice experiences” training is not focused on providing medical care to patients. Thus, the AMA is especially concerned with new language in H.R. 1770 that would permit pharmacists to evaluate and manage patients for the testing or treatment of COVID-19, influenza, respiratory syncytial virus (RSV) or streptococcal pharyngitis.  

Additionally, pharmacists in the community setting report that they already have so much work to do that everything cannot be done well. Scope expansions like the one proposed in this bill only add further responsibilities to an overburdened pharmacist workforce and threaten patient safety due to their insufficient training in these activities. 

While ensuring access to community-based health care is important, the solution is not having overworked pharmacists offer care that they are not trained to provide. 

On April 25, the AMA submitted comments (PDF) in support of the first application for a switch to non-prescription status by an oral contraceptive manufacturer. If approved, Perrigo Co.’s Opill, a progestin-only oral contraceptive, would become the first daily oral contraceptive to be available over the counter (OTC). The application will be reviewed by FDA advisory committee meetings May 9-10 and then will be returned to the FDA for final decision.

Easy, affordable access to contraception has become increasingly important in the wake of the Dobbs decision and action in several states to restrict access to abortion. At the June 2022 meeting of the AMA House of Delegates, AMA members approved new AMA policy supporting OTC access to oral contraceptives. The AMA has written (PDF) to Department of Health and Human Services (HHS) Secretary Xavier Becerra in support of OTC access to oral contraceptives, asking HHS to ensure that barriers to OTC approval are limited for all oral contraceptive applicants and to ensure that OTC oral contraceptives are affordable to all women. 

The AMA joined more than 30 national medical specialty societies, patient advocacy groups and health care policy think tanks as cosigners of an April 25 letter supporting (PDF) H.R. 2829, the Chronic Care Management Improvement Act. Introduced by Representatives Jeff Duncan (R-SC) and Suzan DelBene (D-WA), this bipartisan legislation is designed to better incentivize the use of Chronic Care Management (CCM) services by eliminating 20% patient cost sharing requirements associated with physician utilization of these services. 

CCM includes behind-the-scenes services that are continuously performed by physicians and billed each month. Examples of work that qualify as CCM include:  

• Recording patient information using certified electronic health record technology 
• Granting continuous, 24/7 access to physicians or other providers 
• Designating a specific team member to schedule future appointments 
• Systematic assessment of the patient’s medical, functional and psychosocial needs 
• Medication review, reconciliation and adherence 
• Creation of comprehensive care plans 
• Transmission of documents to ensure continuity of care during transitions to other providers 
• Coordination with home and community-based providers 

Data demonstrates that seniors receiving CCM services had lower overarching costs in comparison to non-users.

Physicians are mandated to get consent from their patients prior to providing CCM services; however, individuals are often surprised by associated cost-sharing requirements with this disparate work because it is inherently non-patient facing. Although the coinsurance is minimal (approximately $8 per month), patients do not anticipate these charges or the associated Medicare requirements for physicians to attempt to collect the cost-sharing. As a result, the bill seeks to eliminate patient cost-sharing requirements with CCM services. 

Support for H.R. 2829 preceded an April 27 congressional briefing on alternative payment models (APMs) co-hosted by the AMA. The Alliance for Value-based Patient Care, which AMA co-founded along with the American Medical Group Association (AMGA), Health Care Transformation Task Force (HCTTF), the National Association of Accountable Care Organizations (NAACOS), and Premier, Inc, conducted the briefing in conjunction with the co-chairs of the House Health Care Innovation Caucus, specifically Representatives Ami Bera, MD (D-CA), Mike Kelly (R-PA), Suzan DelBene (D-WA) and Neal Dunn, MD (R-FL). In addition to providing key background regarding the origins and scope of APMs, the briefing afforded the speakers an opportunity to urge congressional lawmakers to pass legislation to extend the APM incentive payments and freeze the current revenue thresholds needed to even qualify for the bonuses. Absent congressional intervention before the end of 2023, the current 3.5% APM incentive payments expire, and the 50% revenue requirement jumps to a nearly impossible-to-reach 75% threshold. 

Cybersecurity is a patient safety issue. The Healthcare Sector Coordinating Council (HSCC) has just released a new one-hour (total) cybersecurity video series that physicians and other health care providers can use to better understand the ins and outs of cyber hygiene. The HSCC is a national public-private partnership dedicated to strengthening the nation’s health care critical infrastructure. This “Cybersecurity for the Clinician” video training series includes eight videos explaining in easy, non-technical language what clinicians and medical students need to understand about how cyber attacks can affect clinical operations and patient safety, and what you can do to help keep health care data, systems and patients safe from cyber threats. 

On April 17, HHS published a report (PDF) focused on trying to better understand the state of cybersecurity within U.S. hospitals. The Landscape Analysis highlights how cyber-attacks are growing both in numbers and severity, and these intrusions have been responsible for the disruption and delay of care delivery at health care facilities across the country, resulting in an increased risk to patient care and safety. The report was authored by several partners, including the HHS 405(d) Program, Health Sector Coordinating Council Cybersecurity Working Group and the Centers for Medicare & Medicaid Services. 

This study was focused on developing a clear understanding of the current cybersecurity capabilities and preparedness across participating U.S. hospitals, as well as their ability to combat cyber threats, and sharing these findings for informing prioritized cybersecurity practices for U.S. hospitals. Key observations from the Report included:  

• Directly targeted ransomware attacks aimed to disrupt clinical operations are an outsized and growing cyber threat to hospitals. Since 2021, primary intrusions used to cause disruption and damage increased across all sectors and industries by 50%. 
• Variable adoption of critical security features and processes, coupled with a continually evolving threat landscape can expose hospitals to more cyber-attacks. For example, adoption of multi-factor authentication (MFA) is taking place in over 90% of surveyed hospitals; however, data suggests that MFA may not be utilized consistently across key systems and critical entry points, creating additional risk of exploitation. 
• Hospitals report measurable success in implementing email protections, which is a key attack vector. Over 99% of hospitals surveyed reported having basic spam and phishing protection capabilities in place. 
• Supply chain risk is pervasive for hospitals. 

Look to the AMA’s physician cybersecurity webpage for educational resources to help protect your practice.  

Since 2015, CMS has released an Open Payments Report to the public on items of value that reporting entities (pharmaceutical companies and group purchasing organizations) give to covered recipients (physicians and teaching hospitals). More recently, in 2022, CMS expanded the definition of covered recipients to also include physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists and anesthesiologist assistants, and certified nurse-midwives. Preceding the Report’s release on June 30, physicians and other covered recipients are given 45 days to review their data and dispute errors. The review and dispute period ends May 15. 

Physicians planning to review their 2022 Open Payments Data should test their CMS Enterprise Portal (EIDM) logon credentials beforehand. Logon issues can be fixed by visiting Open Payments Registration Page. For answers to additional questions, please email Medicare’s Open Payment Help Desk at [email protected] or call (855) 326-8366. 

U.S. Surgeon General Vivek H. Murthy, MD, recently released “Our Epidemic of Loneliness and Isolation: The U.S. Surgeon General’s Advisory on the Healing Effects of Social Connection and Community” (PDF), an advisory focused on the alarming impacts of loneliness and isolation on the nation’s collective health, as well as the healing power of social connection. According to a letter from Surgeon General Murthy introducing the advisory, “The mortality impact of being socially disconnected is similar to that caused by smoking up to 15 cigarettes a day, and even greater than that associated with obesity and physical inactivity.” Along with the advisory, Surgeon General Murthy also released a “Framework for a National Strategy to Advance Social Connection,” providing actionable efforts that can be taken by individuals, organizations and others to cultivate sustainable social connection and combat the public health problem of loneliness and isolation. 

• May 5, 2023: Advocacy Update spotlight on MIPS hardship exception
• May 5, 2023: State Advocacy Update