Oct. 20, 2023: National Advocacy Update

National Addiction Treatment Week (Oct. 16-22), which was organized by the American Society of Addiction Medicine and is co-sponsored by the AMA, serves as a powerful reminder of the work needed to address the overdose and death epidemic.   

“Addiction is a treatable, chronic disease. Not a moral failing,” said Bobby Mukkamala, MD, chair of the AMA Substance Use and Pain Care Task Force, in a recent AMA Update episode.  

Dr. Mukkamala emphasized how physicians and others can reduce the stigma around addiction, how to address common barriers to substance use disorder treatment, and how all physicians can play a role in addiction treatment and recovery.  

Visit treataddictionsavelives.org to learn more about how you can get involved in National Addiction Treatment Week. To get year-round information on the AMA’s work to end the nation’s the overdose and death epidemic, visit end-overdose-epidemic.org. 

The AMA submitted detailed comments (PDF) to the House Ways and Means Committee on Oct. 5 in response to Chairman Jason Smith’s (R-MO) request for information (RFI) from outside stakeholders entitled, “Improving Access to Health Care in Rural and Underserved Areas.” Although responses were capped at 10 pages, the RFI sought greater feedback within the broad categories of “geographic payment differences,” “sustainable provider and facility financing,” “aligning sites of service,” “health care workforce,” and “innovative models and technology.” 

“Patients across America are facing increasing health care facility closures, travel distances and wait times, driven by a shrinking health care workforce, health care consolidation, and patchwork financing models,” wrote Chairman Smith in the Sept. 7 letter to interested stakeholders. “The Committee will identify how geographic barriers, misaligned Medicare payment incentives, and consolidation may be driving facility closure and workforce shortages—hurting overall access to health care—while innovative care models and technology are improving such care.” 

AMA’s comments pertaining to “sustainable provider and facility financing” focused on the multitude of ways Congress needs to improve the Medicare payment system. AMA outlined a comprehensive list of ways to reform the Merit-based Incentive Payment System (MIPS) within the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 including: 

• Freezing the MIPS performance threshold for three years to prevent steep payment penalties while simultaneously allowing practices ample time to transition back into the program after COVID-19
• Eliminating the “tournament-style” nature of the program so penalties assessed to poor performing participants no longer fund the bonuses for high performing physicians
• Exempting any eligible participant from associated payment penalties if they do not receive at least three quarters of feedback and claims data report during a performance year
• Allowing participants to receive credit across multiple MIPS categories (e.g., “Cost,” “Quality,” Promoting Interoperability” and “Improvement Activities”); 
• Permitting participants to utilize clinical data registries to meet the “Promoting Interoperability” category requirements
• Enhancing the overarching accuracy of measures within the “Cost” category
• Harmonizing measures within the “Cost” and “Quality” categories to be applicable to the same patient for the same condition
• Improving quality measurement accuracy by awarding credit for testing new or significantly revised measures, including Qualified Clinical Data Registry (QCDR) measures, for up to three years. 

The letter also touts AMA’s strong support for H.R. 2474, the “Strengthening Medicare for Patients and Providers Act,” which requires physicians to receive an annual, permanent inflationary payment update in Medicare tied to the Medicare Economic Index. Furthermore, the AMA outlines the need to make improvements to the system of budget neutrality within the Medicare Physician Fee Schedule. These concepts, which are the byproduct of a months-long AMA-led working group, were ultimately included in a legislative discussion draft (PDF) unveiled by the GOP Doctors Caucus during the week of Oct. 9. The budget neutrality legislation, entitled the “Provider Reimbursement Stability Act,” was reviewed by the House Energy and Commerce Committee as part of an Oct. 19 legislative hearing. Finally, the letter outlines weaknesses with policies that would pay physicians based solely on the site of service where patients receive care, as well as how any savings generated from this type of legislation need to be reinvested back into Medicare to help improve physician payment. 

The remainder of the letter provides detailed comments on the need to enhance the physician workforce via more Medicare-supported graduate medical education slots (e.g., H.R. 2389/S. 1302, the “Resident Physician Shortage Reduction Act”) and targeted immigration reforms (e.g., H.R. 4942/S. 665, the “Conrad State 30 and Physician Access Reauthorization Act”), protecting patient safety by preserving physicians’ scope of practice, promoting greater access to telehealth in Medicare, and ensuring crucial incentive payments for alternative payment models do not lapse (e.g., H.R. 5013, the “Value in Health Care Act”).   

In public comments (PDF) on Requirements Related to the Mental Health Parity and Addiction Equity Act Proposed Rule, the AMA asked for enhanced enforcement of all existing as well as new provisions regulating the “Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008” (MHPAEA). The AMA supported the proposed rule’s efforts to clarify how nonquantitative treatment limitations (NQTLs) must be evaluated for parity compliance and reported to regulators. With MHPAEA in effect since 2008, the AMA applauded efforts to issue new guidance and make multiple improvements to clarify the law’s requirements over the past 15 years. Overall, the AMA commended the Internal Revenue Service, the Employee Benefits Security Administration, and the Department of Health and Human Services for taking a more assertive approach in this proposed rule to enforce the law’s patient protections.  

The AMA agreed with the proposed requirement that plans analyze the impact of an NQTL on access to mental health and substance use disorder services as part of a comparative analysis. The AMA further supported the data collection and reporting requirements of the rule, especially with respect to the comparative analyses of NQTLs and network composition. When a plan fails to meet the existing requirement to evaluate coverage of mental health and substance use disorder services relative to medical/surgical services, the AMA recommended that plan be held accountable through the imposition of fines and prohibition against using the NQTL until the plan can demonstrate compliance with the law. 

In addition, the AMA supported the Departments’ proposal that plans and issuers evaluate outcomes data for NQTLs as part of a reasonable parity audit to ensure that NQTLs imposed by plans are not more restrictive or have disparate impacts on mental health and substance use disorder services.  

The comments also urged changes to the proposed exceptions relating to “independent professional medical or clinical standards” as the language proposed was too general and could be exploited by health plans to patients’ detriment. The AMA did highlight that several states have acted on this issue by adopting a strong definition of “generally accepted standards of care” for mental health and substance use disorder services. Moreover, the AMA did not support the proposed exception relating to fraud, waste, and abuse in the proposed rule. The AMA endorsed meaningful efforts to address fraud, waste and abuse, but also conveyed how plans often cite fraud, waste and abuse as reasons for their inappropriate and often dangerous prior authorization and other harmful utilization management policies and practices. 

A new Policy Research Perspective (PDF) uses AMA’s nationally representative Physician Practice Benchmark Survey to provide a detailed look at practice involvement in medical homes and ACOs as well as the extent to which APMs are involved in practice revenue. In 2022, 58% of physicians reported participation in at least one type of ACO (up 14 percentage points from 2016) and 64% of physicians were in practices that received at least some payment through APMs (up 7 percentage points from 2012). Nonetheless, since 2014, roughly 70% of practice revenue has been coming from FFS, although, there was a shift away from complete reliance on FFS. 

• Oct. 20, 2023: Medicare Payment Reform Advocacy Update
• Oct. 20, 2023: State Advocacy Update
• Oct. 20, 2023: Advocacy Update other news