Sept. 20, 2024: National Advocacy Update

The AMA shares the administration’s deep concern about the maternal health crisis, which disproportionality affects Black and Native American/Alaska Native pregnant and postpartum individuals. The AMA is committed to being part of the solution and wants to work collaboratively with the Biden administration toward that end. 

In April, the AMA sent Secretary Xavier Becerra a series of recommendations (PDF) to address the crisis that we hope the administration will pursue. However, the AMA is concerned that the Centers for Medicare & Medicaid Services (CMS) proposal to require data analysis, reporting, and documentation in new Conditions of Participation (CoPs) by all hospitals as outlined in the 2025 Outpatient Prospective Payment System (OPPS) proposed rule would significantly increase the cost and burden of providing labor and delivery services.  

As said in the AMA’s comment letter (PDF), obstetrical services are historically reimbursed at below cost even before considering these additional requirements. If small hospitals and hospitals in rural areas are unable to shoulder the burden and afford the expense of meeting these CoPs while grappling with inadequate payment and workforce shortages, they could close their labor and delivery units. This could worsen access to labor and delivery services, rather than increase the quality of maternity care.  

As a result, the proposal could increase maternal mortality and morbidity rates and exacerbate disparities in maternity care outcomes. Therefore, the AMA urged CMS to discontinue implementation of the CoPs or, at a minimum, to delay implementation to give CMS an opportunity to make modifications based on feedback from interested parties, including physicians and hospitals, and to allow hospitals sufficient time to meet the CoP requirements. If CMS finalizes the CoPs, rural hospitals and critical access hospitals should be exempt, and CMS should explore regional partnerships to accomplish the goals of the CoP requirements. The AMA also urged CMS to phase in the requirements over several years and to provide funding to ensure successful implementation.  

In addition, in the comments on the 2025 OPPS proposed rule, the AMA supported CMS’ continued use of the hospital market basket as the annual update mechanism for ambulatory surgical center (ASC) payments and expressed appreciation for CMS’ thoughtful approach to separate payment of diagnostic radiopharmaceuticals. Specifically, CMS proposes to pay separately for any diagnostic radiopharmaceutical with a per day cost greater than $630. The AMA urged the agency to continue conversations with physicians and other interested parties about the effects of implementation.  

CMS also proposed to change the definition of “custody” so that people with Medicare can access their health benefits when they are in a supervised release program following incarceration. Under current law, when incarcerated individuals over age 65 or disabled have substance use disorders, the period following their release can be an exceptionally high-risk time for drug-related overdose and death. The AMA joined the Legal Action Center and more than 100 other organizations in a comment letter (PDF) calling for CMS to finalize this proposal. 

On Sept. 9, the Department of Health and Human Services, Department of Labor, and Department of Treasury released new final rules to support continued implementation of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA). 

Enacted in 2008, MHPAEA’s final regulations were originally issued in 2013. The law requires group health plans and health insurance issuers offering group and individual health insurance coverage that offer mental health or substance use disorder (MH/SUD) benefits to cover those benefits in parity with medical and surgical (M/S) benefits, without imposing greater restrictions on MH/SUD benefits as compared to M/S benefits. However, compliance with the law has been questioned for more than 15 years as disparities in coverage between MH/SUD benefits and M/S benefits have persisted and grown. The AMA has been advocating for stronger enforcement of the law.   

The AMA issued a statement after the release of this Final Rule that commended the Administration for ensuring that MHPAEA “has the teeth to protect patients from health insurance company actions that unfairly and too-often discriminatorily restrict access to mental health and substance use disorder care.” 

The new rule provides additional protections against more restrictive, nonquantitative treatment limitations for MH/SUD benefits as compared to M/S benefits. Nonquantitative treatment limitations are requirements that limit the scope or duration of benefits, such as prior authorization requirements, step therapy and standards for provider admission to participate in a network. In addition, the rule prohibits plans from using biased or non-objective information and sources that might negatively impact access to MH/SUD care when designing and applying a nonquantitative treatment limitation. 

The AMA recently testified before the Advisory Council on Employee Welfare and Pension Benefit Plans, known as the ERISA Advisory Council, on the topic of claims and appeals procedures. In both its oral testimony and written statement (PDF), the AMA detailed health plans’ burdensome and opaque claims and appeals procedures and the use of inappropriate utilization management programs—all of which harm patients, intrude in the patient-physician decision-making process, and undercut the stability of physician practices. Citing data from both the AMA prior authorization physician survey (PDF) and other studies finding pervasive issues with inappropriate denials and challenging appeal processes, the AMA built a strong case on the need for regulatory reform and improved enforcement. The AMA urged the Council to consider extending the numerous recent reforms implemented at both the federal (e.g., Medicare Advantage) and state levels related to prior authorization, denials, and appeals to ERISA plans. Based on the testimony provided by the AMA and other stakeholders, the ERISA Advisory Council will prepare a report with recommendations for the Department of Labor on future rulemaking for ERISA plans. 

The AMA joined a coalition (PDF) of 86 organizations representing physicians and patients in support of the Physician Led and Rural Access to Quality Care Act (H.R. 9001), which would improve access to care in rural and underserved communities by creating physician hospital ownership exemptions. The legislation would also allow grandfathered physician-led hospitals to expand to meet community needs.  

“Rural communities deserve every tool possible to save hospitals that are on the cusp of closure. Unfortunately, the law prevents physicians from owning hospitals, which limits one of the most logical class of potential owners, physicians, from saving a rural hospital. Lifting the physician ownership ban would give underserved rural areas a potential tool to provide hospital services in the form of a physician-led hospital,” says the letter. With more than 130 rural hospitals having closed since 2010, this legislation is crucial to ensure access to hospital services in rural communities. 

The AMA signed on to a letter (PDF) from the American Indian/Alaska Native Health Partners coalition in support of Sections 12 and 13 of H.R. 8318, the Tribal Tax and Investment Reform Act of 2024, which would provide health care professionals who receive student loan repayments and scholarships from the Indian Health Service (IHS) with the same tax-free status as those who receive loan repayments from the National Health Service Corps. 

“Recruitment and retention tools like loan repayment and scholarship funding are vital for providing needed health care to Native Americans. The taxation of these benefits limits the Service’s reach to health professionals who are interested in doing this critical work, especially in remote locations,” reads the letter.  

In the 2023 fiscal year, the IHS was unable to hire 455 applicants who applied for a loan repayment due to a lack of funds—this is especially alarming when considering the 36% vacancy rate for physicians in the IHS as of Feb. 2024. The IHS uses over $9,000,000 of its resources to pay the taxes that are assessed on its loan and scholarship recipients. By removing the taxation of these benefits, Sections 12 and 13 of H.R. 8318 would greatly support the IHS’ efforts to provide needed health care to Native Americans, especially in remote locations. 

After the Change Healthcare cyberattack earlier this year, cybersecurity has become a central concern for physicians and patients alike. Join us for this AMA Advocacy Insights webinar on Oct. 18 at 12:30 p.m. Central, to learn about how to implement appropriate cybersecurity measures to protect your practice as well as your patients against the cybersecurity challenges of today. Also, hear about advocacy that is underway to strengthen cybersecurity systems and provide support to physician practices for enhancing their cyber hygiene. 

Moderator: 

• Michael Suk, MD, JD, MPH, MBA, chair, AMA Board of Trustees   

Speakers: 

• Christian Dameff, MD, Department of Emergency Medicine, School of Medicine, University of California, San Diego  

• Greg Garcia, executive director for cybersecurity, Health Sector Coordinating Council 

If you are unable to attend live, a recording of the presentation will be emailed out to all registrants—so register now. 

• Sept. 20, 2024: Medicare Payment Reform Advocacy Update
• Sept. 20, 2024: State Advocacy Update
• Sept. 20, 2024: Advocacy Update other news