Advocacy With Congress
The Affordable Care Act (ACA) is a comprehensive health system reform law that will increase health insurance coverage substantially for the uninsured and implement long overdue reforms to the health insurance market. The new law includes many major provisions that are consistent with AMA policy and hold the potential for a stronger, better performing health care system. While the ACA represents a tremendous step forward on the path toward meaningful health system reform, it is not the last step, but rather the beginning.
The AMA is continuing to work with Congress and the Administration to refine certain provisions in the ACA.
Independent Payment Advisory Board (IPAB)
On February 14, 2013, Sen. John Cornyn (R-TX) introduced S. 351, the "Protecting Seniors' Access to Medicare Act of 2013," which would repeal the Independent Payment Advisory Board (IPAB). Rep. Phil Roe, MD (R-TN) introduced this bill as H.R. 351 in the House with bipartisan support on January 25. The IPAB is a panel that puts significant health care payment and policy decisions in the hands of an independent body of individuals with far too little accountability, and could adversely affect access to health care for Medicare patients. Patients and physicians are still struggling with the frequent threat of drastic cuts from the broken SGR Medicare physician payment formula. IPAB would be another arbitrary system that relies solely on payment cuts in an attempt to reduce spending in Medicare. The AMA strongly supports this legislation and looks forward to working with members of the House and Senate to achieve its enactment.
Flexible Spending Accounts (FSAs)
The AMA continues to urge Congress to take action to lift the Affordable Care Act's restrictions on tax-preferred accounts, such as health savings accounts, for over-the-counter medicines.
Section 2706(a), Non-Discrimination
On July 24, 2013, Rep. Andy Harris, (R-MD), introduced H.R. 2817 to repeal Section 2706(a), the “Non-Discrimination in Health Care Providers” provision of the Affordable Care Act. Section 2706(a) states that in making decisions about which providers can participate or will be covered under a health plan, an insurer may not discriminate against health care providers acting within their state scope of practice law. AMA supports repeal of Section 2706(a), as it represents federal intrusion into scope of practice, generally the province of state law and regulations.
The AMA continues to be concerned about increasing health plan consolidation, as well as the regulatory barriers that restrict physicians' ability to work together, and has made improving the antitrust environment for physicians a top priority. The AMA is actively supporting H.R. 1409, the "Quality Health Care Coalition Act of 2011," which was introduced by Representative John Conyers (D - MI). H.R. 1409 would allow health care professionals to jointly negotiate with health plans regarding terms that affect patient care, enabling physicians to advocate for quality care for their patients and reinforcing the patient-physician relationship.
Passage of H.R. 3528, the “National All Schedules Prescription Electronic Reporting Reauthorization Act of 2013” (NASPER 2013) and full appropriations is urgently needed to ensure that physicians across the country have a critical tool at the point-of-care to combat prescription drug abuse while ensuring patients with legitimate need of pain management continue to have access. Unfortunately, the appropriations to fully fund, modernize, and optimize NASPER prescription drug monitoring programs (PDMPs) have not kept pace with the rapid escalation in abuse and diversion of prescription drugs. Fully-funded PDMPs would provide more physicians with access to reliable, real-time information about prescriptions patients have obtained (and filled) from other prescribers, particularly controlled substances.
In a January 7, 2014 letter, Dr. Stack responded to additional questions stemming from the November 2013 House Energy and Commerce Hearing: “Examining Public Health Legislation to Help Local Communities”
AMA urged immediate passage of H.R. 3528 (NASPER 2013) and full appropriations with a strong emphasis on the public health focus of NASPER in a November 2013 statement to the House Energy and Commerce Committee.
Nearly 11 million seniors, or 26.9% of the Medicare population, have diabetes and half of all seniors over age 65 have pre-diabetes. In addition, one in every three Medicare dollars is spent on diabetes and its complications. Interventions targeted at preventing or delaying the onset of serious and debilitating illnesses like diabetes must be a national priority because diabetes is a costly and devastating disease that places people at high risk for severe complications and other chronic diseases. With access to appropriate intervention and information, diabetes can be prevented, even for those at the highest risk.
Sen. Jeanne Shaheen (D-NH) introduced S. 539, the "National Diabetes Clinical Care Commission Act," on March 12, 2013. H.R. 1074, the companion bill, was introduced in the House by Rep. Pete Olson (R-TX). The legislation would create a Commission that will focus on improving diabetes care delivery, patient outcomes and cost effectiveness. AMA supports this legislation.
On March 5, 2013, Senator Al Franken (D-MN) and Rep. Susan Davis (D-CA) introduced the “Medicare Diabetes Prevention Act of 2013” (S. 452/H.R. 962), a bipartisan bill which would provide coverage for the National Diabetes Prevention Program under the Medicare program. The National Diabetes Prevention Program at the Centers for Disease Control and Prevention is a public-private partnership that provides low-cost, evidence-based community programs to prevent diabetes. Providing Medicare coverage for the National Diabetes Prevention Program will help seniors avoid diabetes and other chronic illnesses. The AMA joined the American Diabetes Association and others from the medical community in expressing its support for this legislation.
On February 14, 2013, Senator Barbara Boxer introduced S. 330, the "HIV Organ Policy Equity (HOPE) Act." This bipartisan legislation would serve to establish safeguards and standards of quality for research and transplantation of HIV-infected organs to HIV-positive recipients. It would also make important, common-sense reforms to current organ transplant law by repealing the current ban on organ donations from HIV-positive donors to HIV-positive recipients.
On March 14, Representative Joe Courtney (D-CT) introduced H.R. 1179, the "Improving Access to Medicare Coverage Act of 2013." The companion bill, S. 569, was introduced in the Senate by Senator Sherrod Brown (D-OH) on March 14, 2013. This legislation would require the time period of outpatient "observation" care in a hospital to be counted toward satisfying the three-day inpatient hospital requirements for coverage of skilled nursing facility services under Medicare. The AMA strongly supports this legislation.
Letter to Sen. Sherrod Brown supporting S. 569, the “Improving Access to Medicare Coverage Act of 2013,” June 13, 2013
Letter to Reps. Courtney and Latham in support of H.R. 1179, the "Improving Access to Medicare Coverage Act of 2013."
In a January 17, 2012, letter to the Congressional Leadership, AMA called on Congress to stop the required implementation of the International Classification of Diseases, 10th Revision (ICD-10) originally scheduled for October 1, 2013. In response to AMA advocacy, the Department of Health and Human Services (HHS) announced a one year delay of ICD-10 implementation – now scheduled for October 1, 2014. AMA had recommended that ICD-10 implementation be delayed by a minimum two years.
The transition from ICD-9 to ICD-10 will create substantial administrative and financial burdens for physician practices, with no direct benefit to patient care, by increasing the number of diagnosis codes from 13,000 to 68,000. This transition will also compete with other costly physician practice transitions underway today associated with quality and health IT programs. The ICD-10 transition costs will range from $83,290 to $2.7 million depending on the size of the medical practice.
As Health Insurance Portability and Accountability Act (HIPAA) covered entities, physicians must comply with the ICD-10 mandate and will bear the entire costs of the transition. Additionally, under ICD-10 if physicians submit the wrong seven digit diagnosis code they risk non-payment altogether.
On April 24, 2013, Rep. Ted Poe (R-TX) introduced H.R. 1701, the "Cutting Costly Codes Act of 2013," which would prohibit the Secretary of HHS from replacing the current ICD-9 with ICD-10 diagnostic code set. Senator Tom Coburn introduced S. 972, the Senate companion bill, on May 16, 2013. These bills would also require the Government Accountability Office to conduct a study on ways to mitigate the disruption of health care providers resulting from the replacement of ICD-9 with new coding standards required by HIPAA.
In a May 17, 2013 letter, the AMA provided feedback on a health information technology (HIT) white paper entitled, “REBOOT: Re-Examining the Strategies Needed to Successfully Adopt Health IT,” which was authored by Senators John Thune (R-SD), Lamar Alexander (R-TN), Pat Roberts (R-KA), Richard Burr (R-NC), Tom Coburn, MD (R-OK), and Mike Enzi (R-WY).
The white paper outlines several concerns with the Meaningful Use (MU) of Electronic Health Records (EHRs) program, focusing extensively on the lack of interoperability of EHRs. The AMA response expresses its continued support for financial incentives to support physician adoption of HIT. However, it also outlines several serious concerns with the way the MU program has been structured, and makes multiple recommendations for improving the program, including modifying the rulemaking for Stage 2 of the MU program to provide physicians with greater flexibility.
On March 21, 2013, Rep. Diane Black (R-TN) introduced H.R. 1331, the “Electronic Health Records Improvement Act,” in an effort to improve the MU program. The AMA expressed its support in a May 30 letter for the “hardship exemptions” from meaningful use financial penalties for solo practitioners and physicians near retirement contained in this legislation. AMA also expressed its belief that the legislation will help make improvements to the program by imposing a one-year limit on the back-dating of program requirements, expanding the options for participation in the incentive program, providing scope of practice exemptions, and establishing a formal penalties appeal process.
The AMA strongly supports comprehensive medical liability reform (MLR), including reasonable limits on non-economic damages similar to successful reforms in California and Texas.
The "Patient Protection and Affordable Care Act" (ACA) included multiple provisions concerning the establishment and implementation of national care and practice standards and guidelines for health care providers, with potential for new causes of legal action against physicians. The AMA believes physicians should not have to worry about potential new causes of action or liability exposure in their attempts to develop new ways to improve the quality and efficiencies of care.
On April 10, 2013 Rep. Phil Gingrey (R-GA), who has long been a proponent for MLR, introduced H.R. 1473, the "Standard of Care Protection Act of 2013." The companion bill, S. 1769 was introduced in the Senate by Sen. Pat Toomey (R-PA) on November 21, 2013. This bi-partisan legislation would clarify that the care standards and guidelines specified in the ACA cannot be used to create new causes of legal action against physicians providing care to patients. In addition, it would preserve state medical liability laws. AMA supports this legislation.
In the 113th Congress, the "Medicare Patient Empowerment Act" has been introduced by Senator Lisa Murkowski (S.236), and by Representative Tom Price (H.R. 1310). This legislation would establish a Medicare payment option for patients and physicians (and practitioners) to freely contract, without penalty, for Medicare fee-for-service physician and practitioner services, while allowing patients to use their Medicare benefits and physicians to bill the patient for all amounts not covered by Medicare. The AMA strongly supports this legislation. More information on this issue as well as a petition that physicians are encouraged to sign can be found at www.mymedicare-mychoice.org
As the leading force in Washington for Medicare reform, the AMA continues to advocate for replacement of the flawed Medicare physician payment formula. In this effort, the AMA is aggressively working with Congress and federal agencies to improve the Medicare program by repealing the sustainable growth rate (SGR), enacting stable, adequate annual Medicare physician payment updates, and ensuring beneficiaries’ continued access to care. The AMA has recommended to Congress a three-pronged approach to reforming the physician payment system:
- repeal the SGR;
- implement a five-year period of stable Medicare physician payments; and
- transition to an array of new payment models designed to enhance care coordination, quality, appropriateness and costs.
Recent Congressional testimony and correspondence
In a September 30, 2013 letter to Senators Baucus and Hatch, the AMA provided input on how to improve the mental health system under the Medicare and Medicaid programs.
Key to improving the mental health system is the better integration of psychiatric and medical care. Not only would better integration improve quality of care and population health and reduce morbidity and mortality among patients with psychiatric and substance abuse disorders, but it would also reduce overall health care costs. Primary care physicians are often the initial point of contact for screening, assessing, and treating mental health issues, whether during annual physicals or other scheduled appointments. However, Medicare’s traditional fee-for-service (FFS) system is a barrier to allowing psychiatrists to assist primary care physicians manage patients with depression and other mental health issues. Current Medicare policy that will not pay for consultations or team meetings imposes a barrier to the communication that is necessary among treating clinicians for effective integrated care. One way to begin to address these problems would be to start paying for non-face-to-face and care coordination services. The adoption of such a policy is one way that Medicare could begin to promote care improvements and reduce spending that physicians can achieve through participation in alternative payment models (APMs).
The AMA continues with efforts to address physician workforce shortages, including strongly supporting stable, adequate funding for graduate medical education (GME) training positions.
Initiatives to fight health care fraud, or to identify areas of waste, have a tangible impact on physician practices. To comply with anti-fraud rules and regulations, physicians proactively conduct internal audits and adopt compliance programs at their own cost. Broad-brush regulations that impose burdens on all providers, rather than focusing on those providers who have demonstrated a propensity to commit fraud or abuse, inequitably affect physicians who are good actors, and result in unnecessary costs to the health care system.
On June 29, 2012, the AMA responded to a request from the Senate Committee on Finance for input on waste, fraud, and abuse (or "program integrity") reforms. The AMA submitted a white paper that outlined the recommendations of the AMA for greater value and efficiency in program integrity efforts.
On February 25, 2013, Rep. Tom Price re-introduced H.R. 805, the "Quality Improvement Organization Program Restoration Act." This bill would restore and maintain local physician involvement in Quality Improvement Organizations (QIOs) and keep the program state-based. The bill would also support local physician involvement in peer review.
The AMA strongly supports H.R. 1427, the "Truth in Healthcare Marketing Act of 2013." This legislation was introduced by Rep. Larry Bucshon (R-IN) and Rep. David Scott (D-GA) on April 9, 2013, and would help patients make informed decisions about their health care by ensuring that they have accurate information regarding the education, training, and qualifications of individuals providing their health care services. In addition, H.R. 1427 would require disclosure of health care providers' licensure in advertisements for health care services, and provide vital resources to address patient confusion in the health care marketplace.
Form 1099 Information Reporting
After House and Senate passage, H.R. 4 was signed into law April 14, 2011. The law repealed an IRS 1099 reporting requirement for businesses that was included in the Affordable Care Act. The provision required businesses, including physician offices, to file a 1099 form with the IRS if the total amount of payments made to another business in exchange for goods and services was $600 or more in a year. The AMA strongly advocated for the repeal of this requirement since the stricter requirements in the provision would have created an expensive reporting burden which would have negatively impacted the operation of businesses, including physician practices.
On April 20, 2011, AMA sent a letter to Chairman Rehberg of the House Approps. Subcommittee on Labor-HHS, Education and Related Agencies sharing its views on funding priorities for various health programs under the subcommittee's jurisdiction, including those that are crucial to ensuring an adequate supply and distribution of physicians.
PDUFA/Drug Shortages/Generic Antibiotic Incentives
On June 20, the House passed S. 3187, the "Food & Drug Administration Safety and Innovation Act," by voice vote. The Senate adopted the measure on June 26 by a vote of 92-4, and the President is expected to sign it into law shortly.
The final version of S. 3187, which is the result of a bipartisan compromise between the House and the Senate, would reauthorize the Prescription Drug User Fee Act and the Medical Device User Fee Act, and newly authorize user fees for generic drugs and biosimilars. It includes several provisions that the AMA supports and worked to improve throughout the legislative process. These provisions would address the drug shortage crisis, incentivize the development of new antibiotics, place various chemical substances known as "bath salts" in schedule I of the Controlled Substances Act, and require the Comptroller General to prepare a report on issues posed by rogue online pharmacies. Additionally, the bill omits a provision that was of significant concern to the AMA, which would have reclassified combination products containing hydrocodone from Schedule III to Schedule II of the Controlled Substances Act. While the AMA supports efforts to prevent the abuse of such products, this approach could have unintentionally limited patient access to legitimately needed pain treatment. The final bill requires the Secretary of Health and Human Services to hold a public meeting to solicit recommendations regarding drugs containing hydrocodone.
The AMA believes that conditioning physician licensure on participation in any public or private insurance plans unduly restricts a physician's freedom to practice. The AMA is actively supporting H.R. 969, the "Medical Practice Freedom Act of 2011," introduced by Representative Tom Price (R - GA), which would ensure that physicians are not required to participate in any health plan as a condition of licensure in any state.
The AMA is a strong opponent of section 511 of the Tax Prevention and Reconciliation Act of 2005 (TIPRA). Under this provision, federal, state and local government entities are required to withhold 3 percent of all payments made for services or property after December 31, 2011, including payments under the Medicare program. The AMA strongly opposes section 511 and we support repeal of this provision.
On October 27, 2011, the U.S. House of Representatives passed H.R. 674, AMA-supported legislation that prevents a planned 3% tax-withhold for many Medicare payments, by a vote of 405-16. The Senate passed this legislation on November 10 by a vote of 95 to 0.
The legislation was signed into law by President Obama on November 21, 2011 and completely repeals this provision of law and eliminates the planned withholding. The cost of this repeal was offset by a change in the definition of Medicare Adjusted Gross Income for the calculation of eligibility for Medicaid or insurance subsidies under the Affordable Care Act. This modification was supported by a majority in Congress and the White House.
This represents a significant victory for physicians and a step forward in stabilizing the Medicare system. The additional burden of a 3% tax-withhold would have been untenable in the current Medicare payment environment.