Oct. 4, 2024: National Advocacy Update

In response to advocacy from the AMA, the Centers for Medicare & Medicaid Services (CMS) has reopened the 2023 Merit-based Incentive Payment System (MIPS) Extreme and Uncontrollable Circumstances (EUC) hardship exception due to the Change Healthcare cyberattack earlier this year. 

MIPS-eligible clinicians and groups have until Oct. 11 to apply for an EUC and to request reweighting of up to four MIPS performance categories because of the disruptions due to the cyberattack on your practice.  

Note that the EUC application will not override data submission. Therefore, if a physician or group previously submitted data for a category, CMS will continue to score that category. We encourage practices to consider submitting the application for the cost performance category, at a minimum, as there are no data submission requirements for the cost measures, which CMS scores using claims data.  

Due to CMS’ technical limitations, physicians and group practices must request the EUC through the MIPS targeted review process, not through the EUC application form. 

Please review the 2023 MIPS EUC Reweighting Requests Guide (PDF) for more information. 

The AMA urges all physicians and practices to log into the CMS Quality Payment Program (QPP) portal to review their final 2023 MIPS performance year scores. If you believe there is an error in the calculation of your MIPS score or accompanying payment adjustment for the 2025 payment year/2023 performance year, you can request a targeted review until Oct. 11 at 8 p.m. Eastern time. 

For example: 

• Data was submitted under the wrong TIN or National Provider Identifier (NPI) 

• You have Qualifying APM Participant (QP) status and should not receive a MIPS payment adjustment 

• Performance categories were not automatically reweighted even though you qualify for reweighting due to extreme and uncontrollable circumstances 

This is not a comprehensive list of circumstances. If you have questions about whether your circumstances warrant a targeted review, please contact the QPP Service Center by phone at 1-866-288-8292 (TRS: 711) or by email at [email protected].  

How to request a targeted review: 

Physicians can access their MIPS final score and performance feedback and request a targeted review:   

• Sign in using HARP credentials (ACO-MS credentials for Shared Savings Program ACOs); these are the same credentials that allowed submission of 2023 MIPS data.  

• Click “Targeted Review” on the left-hand navigation.  

CMS generally requires documentation to support a targeted review request, which varies by circumstance. A CMS representative will contact you about providing any specific documentation required. If the targeted review request is approved and results in a scoring change, CMS will update the final score and/or associated payment adjustment (if applicable), as soon as technically feasible. Please note that targeted review decisions are final and not eligible for further review.  

Targeted review resources:  

• 2023 Targeted Review User Guide (PDF)—Reviews the process for requesting a targeted review and examples for when you would or wouldn’t request a targeted review.  

• 2025 MIPS Payment Year Payment Adjustment User Guide (PDF)—Reviews information about the calculation and application of MIPS payment adjustments, and answers frequently asked questions. 

As of Sept. 2024, 29 state medical licensing boards and 375 hospitals have taken action to improve their licensing or credentialing applications and ensure that they are free from stigmatizing language and intrusive questions about past mental health care or substance use disorder treatment, the Dr. Lorna Breen Heroes’ Foundation (DLBHF) recently announced. This reflects an increase of four state medical licensing boards and 300 hospitals since last year—removing part of the fear and stigma that physicians, residents and medical students have said prevent them from seeking help. 

“The American Medical Association (AMA) has been proud to work alongside the Dr. Lorna Breen Heroes’ Foundation and so many medical societies and national organizations to take action to remove stigmatizing language on licensing, credentialing and other applications,” said AMA President Bruce A. Scott, MD. “The actions taken now help pave the way for a healthier, safer and more productive physician and healthcare professional workforce. We urge all states, hospitals, health systems, liability carriers and others to join us in this important effort.”  

The AMA, in partnership with the DLBHF, strongly encourages the removal of inappropriate questions that might deter physicians from seeking treatment for mental illness or a substance use disorder from all credentialing, licensing, peer reference forms and other applications.  

Read the AMA’s issue brief (PDF) to learn more about how your state, hospital, health system or credentialing body can review, revise and communicate changes to licensing applications, credentialing and peer reference forms. The issue brief also contains important state legislative best practices from Virginia, Minnesota and other states to remove inappropriate questions as well as provide confidentiality protections for physicians and others seeking care.

The AMA sent feedback (PDF) to CMS in response to a request for information (RFI) on potential consolidation of Medicare Administrative Contractor (MAC) jurisdictions and increasing contract award periods of performance. Specifically, CMS proposes to combine Jurisdictions J5 and J6 into “Jurisdiction G” and Jurisdictions J8 and J15 into “Jurisdiction Q” and increase contract award periods from seven to 10 years. 

In the letter, the AMA emphasized the importance of increased transparency into CMS’ reasoning and supporting data behind the proposed changes and emphasized that no changes should move forward until CMS addresses previous AMA concerns regarding a lack of consistency and transparency across MACs in making payment determinations. The AMA also emphasizes that any future changes should be tied to concrete, transparent criteria about MAC performance and stakeholder engagement. The letter was informed by past AMA recommendations (PDF), as well as feedback from medical state societies and specialties. The AMA is eager to continue to engage with CMS on this issue, and to facilitate conversations with medical state societies and specialties and MACs to develop a workable solution. 

CMS has now issued its report to Congress on the Acute Hospital Care at Home (HaH) initiative, which was required by the Consolidated Appropriations Act, 2023. The new report describes the patient inclusion criteria utilized by participating hospitals, the clinical conditions being treated in patients’ homes instead of in the hospital, and compares quality, cost, utilization and patient experience of care for patients in HaH versus an inpatient hospital setting. The analysis found HaH patients had lower mortality rates and lower post-discharge spending, and patients and caregivers provided positive feedback. With 358 approved hospitals across 137 health systems in 39 states since its start in Nov. 2020 during the COVID-19 Public Health Emergency, this innovation in care delivery has become an important feature of the Medicare program. Under current law, however, the program is slated to end at the end of 2024. The AMA has been supporting legislation (PDF) that would extend the HaH program for an additional five years. 

Physicians who prescribe controlled substances to patients with Medicare Part D prescription drug plans are required to prescribe them electronically unless they qualify for an exemption or waiver. All physicians were exempt from the EPCS requirement for 2023 because the COVID-19 Public Health Emergency was still in effect. Physicians can now access an EPCS portal to learn if they would have complied with the Medicare EPCS requirements for 2023 were this across-the-board exemption not in place. In general, physicians who issue more than 100 controlled substance prescriptions per year for patients with Part D are required to electronically prescribe 70% of them. By accessing the CMS EPCS Prescriber Portal, physicians can determine if they met this standard in 2023. CMS has also developed a user guide to help people access the portal and apply for an EPCS waiver. 

On Sept. 20, the Federal Trade Commission (FTC) announced (PDF) that it is bringing legal actions against three of the country’s largest pharmacy benefit managers (PBMs) and their affiliated group purchasing organizations (GPOs). The complaint alleges that Caremark Rx, Express Scripts and OptumRx engaged in anticompetitive and unfair rebate pricing schemes that artificially inflated the list prices of insulin drugs and made patient access to lower list price drugs more challenging. The FTC claims that even when lower list price drugs were available, the large PBMs “systemically excluded” them in favor of higher list price drugs. 

The price of insulin products has been increasing over the last 15 plus years, with some prices increasing over 1200% since that time. By 2019, one in four patients were unable to afford their monthly insulin. While Congress and the Biden administration have taken important steps to keep insulin products affordable, the FTC acknowledges the ongoing pricing issues and has highlighted the additional serious concerns with the drug manufacturers of these products, noting that further action against these manufacturers directly is a possibility as well.  

The AMA has been pleased to see the FTC’s increased focus on drug pricing and access issues. The announcement of legal action on insulin prices follows an early 2024 announcement of an investigation into the role of GPOs in exacerbating drug shortages. The AMA will continue to support appropriate FTC intervention to anticompetitive and unfair actions that impact drug affordability and access for patients. 

The Food and Drug Administration (FDA) Sept. 26 released a new Digital Health and Artificial Intelligence Glossary. FDA is aiming for the new glossary to serve as “an educational resource to help support consistent use of digital health and artificial intelligence terminology” by both FDA and other interested parties. The glossary is the first federal effort aimed at providing definitions of at least some aspects of digital health and AI, though the agency notes that the glossary has no legal force or effect and does not represent guidance from the agency.  

The AMA has long called for consistent, agreed-upon terminology for use by the federal government when regulating digital health and AI. Terminology currently varies widely across the different departments and agencies, which can lead to significant confusion for interested parties. 

• Oct. 4, 2024: Medicare Payment Reform Advocacy Update
• Oct. 4, 2024: State Advocacy Update
• Oct. 4, 2024: Advocacy Update other news