In 2022, the AMA launched and made significant progress on our Recovery Plan for America’s Physicians—focused on fixing prior authorization, reforming Medicare payment, fighting scope creep, supporting telehealth and reducing physician burnout—but we’re not done yet. By building consensus, presenting evidence and mobilizing organized medicine, the AMA elevates physician voices to improve our nation’s health.
Get the latest on the AMA’s federal and state advocacy agenda for 2023 in this webinar, and hear about how the AMA is fighting for physicians and their patients.
- Sandra Adamson Fryhofer, MD, chair, AMA Board of Trustees
- Todd Askew, senior vice president, Advocacy, AMA
- Michaela Sternstein, vice president, Advocacy Resource Center, AMA
- Jason Marino, director, Congressional Affairs, AMA
Dr. Fryhofer: Hello, everyone and welcome to this edition of AMA's Advocacy Insight webinar series. I'm Dr. Sandra Fryhofer, AMA Board chair, and I'll be your host for today's session. The topic, AMA's advocacy agenda for 2023, where we are and where we go. But first, here's a recap.
Last fall, we highlighted two urgent issues for physicians and for AMA, looming cuts to physician Medicare payments and fixing the broken prior authorization process. Here's an update. In a year-end hustle, AMA's strong advocacy team spurred Congress to act. We averted the more drastic pay cuts scheduled to kick in, but physicians now still face a 2% cut for 2023.
Yes, physicians continue to bear the brunt of our nation's flawed and unsustainable Medicare payment model. This pay cut represents yet another financial hardship, especially for independent practices already stretched thin by staffing shortages and high inflation. In fact, adjusted for inflation, Medicare physician pay dropped 22% between 2001 and 2021.
This downward trend has already forced some private practices to reduce their hours and lay off support staff while pushing others to the brink of closure. The fact that losses could have been worse this year misses the point. Physicians shouldn't have to face these annual financial cliffhangers year after year. The time is right for real and meaningful Medicare payment reform, a core element of AMA's Recovery Plan for America's Physicians, a plan we introduced just last year.
Other core components of the plan include stopping inappropriate and unsafe scope of practice expansion by non-physicians, fixing prior authorization, supporting telehealth by maintaining its coverage and payment, and reducing physician burnout and addressing the stigma around mental health.
For telehealth, there are positive developments in the omnibus bill. This bill extends telehealth payment and regulatory flexibility for two years. It also extends the 3.5% bonus for APMs, Alternative Payment Models, and delays the scheduled increase in revenue threshold.
As a reminder, for the first few years, in order to receive an APM bonus, physicians had to get 50% of their revenue from patients enrolled in APMs in order to qualify. That revenue threshold was supposed to go up to 75% this year. But since no current APMs would qualify, Congress kept the threshold at 50%.
For physician mental health, there's also some progress. The new law adds an exception to Stark. Hospitals and other entities are now allowed to provide evidence-based programs to boost physician resiliency and mental health and to help prevent suicide among physicians. There's an additional and welcome benefit for pregnant people covered by Medicaid. The new law provides a permanent option for states to extend Medicaid coverage for 12 months postpartum.
The five issues in our recovery plan are AMA's state and federal advocacy priorities for 2023. But as we all know, there are many other issues outside these five that negatively impact patients and physicians and that demand our attention and support. As physicians and as leaders in medicine, we must continue to protect ourselves and our colleagues from laws that seek to criminalize reproductive health care and other health care services.
We must continue to advocate for common sense gun laws to try to reduce the alarming rise in gun-related deaths. We need to protect patients, physicians, and our health system from greater consolidation of the health insurance market and advocate for greater competition by stopping mega mergers by insurance companies.
We also must continue our work urging access to evidence-based care for people with a substance use disorder and spur Congress to remove barriers to care for patients with pain. We have an obligation to fight these battles on behalf of our patients and our profession. And physicians everywhere are looking to organize medicine to lead on these issues and on so many other issues. And that's why we've invited you here today.
In today's discussion, we'll take a deeper dive as we highlight the most pressing advocacy issues ahead of us in the new year. We'll also discuss how you can be a part of the process as we work to influence Congress and state legislatures around the country. With us today are three of AMA's leading advocacy experts. Now, many of you know them already.
First, I'm delighted to introduce Todd Askew, AMA's senior vice president of advocacy. Todd leads AMA's legislative, government affairs, political, health policy and private sector advocacy activities. Todd has extensive Washington experience and a track record of success on our advocacy initiative. So welcome, Todd.
Askew: Thanks, Dr. Fryhofer.
Dr. Fryhofer: Our next guest is Kai Sternstein, vice president of AMA's Advocacy Resource Center, also known as the ARC. The ARC is AMA's state advocacy unit and provides amazing resources to help physicians and state advocacy teams influence legislation and regulations pertaining to the practice of medicine. Hello, Kai, and welcome.
Sternstein: Hi, Dr. Fryhofer. Thank you.
Dr. Fryhofer: Our final guest is Jason Marino, director of congressional affairs at AMA. Jason is a strong and passionate advocate of AMA policy. He's also a great storyteller. Jason's responsible for lobbying Congress on AMA's federal advocacy priorities. Welcome, Jason.
Marino: Thank you, Dr. Fryhofer. Happy to be here.
Dr. Fryhofer: So many thanks to all of you for being here and here's the plan. I'm going to start with some questions for each of you to set the stage and then we'll move to questions from our audience. Now, many of you in our audience already submitted your questions when you registered and we're going to try to get to as many of those as we can.
But if you didn't submit a question, no worries. You can post your question online in the Q&A section. So that's the plan. Let's jump right in. Todd, I'll start with you. Can you tell us a little more about the political landscape right now and what that means for AMA's work in the year ahead?
Askew: Sure. And thanks again, Dr. Fryhofer, for having us today. So we're obviously coming off a pretty contentious midterm election. We saw the Republicans pick up the majority in the House while actually falling a seat behind in the Senate. And I think we can look at the opening days of the 118th Congress as kind of an indicator that the policy priorities for this new Congress aren't fully established now yet. We do know, however, some things that will take place. There's been a lot of pent up demand for a number of years for the new majority.
So we are going to see, I think, a lot of investigations and some politically focused work that will take a lot of the headlines. But I think the most important driving factor that is going to impact anybody's ability to move priority legislation or issues this year is the debate over spending and the desire to curtail what has been a rapid growth in federal spending during the pandemic, especially. I think it will play out in a couple of places.
One of the first places we're going to see this is in the debate over a budget and the commitment that was made apparently by the Speaker to allow the budget committee to forward a budget that will balance in 10 years. And that's going to mean some serious and significant debate over priorities and cuts and restraining spending, both on the discretionary side and on the mandatory side.
Secondly, we're also going to see this play out in the debate over the debt ceiling, which we know is upon us. The final issue won't be settled or the final date won't come until the late spring or early summer. But that is going to be the catalyst further for these discussions on spending priorities and spending reductions. And then we'll see this also obviously in the appropriations process.
But beyond spending and those important decisions that will be made, there are some things that have to get done, just things that government has to do. And I would argue that one of those things is supporting a Medicare program and supporting the ability of physicians to continue to see patients.
And that means there's going to need to be some attention paid to our issue of Medicare physician payments and the stability of that program and even the Medicare Payment Advisory Commission, which advises Congress and has, for a long time, maintained that payments to physicians are adequate. Even MedPAC just last week voted that the payments need to be increased. So I think that is going to be part of the discussion and I think we'll have to break through at some point. And we will be there to continue to press that issue.
Dr. Fryhofer: Well, things certainly do sound tough right now. So what is feasible for us to accomplish at such a tricky time?
Askew: Well, you never really know. I mean, things do look bleak because a lot of partisan back and forth on both sides. But in reality, everything in the recovery plan and all of AMA's top priorities are really bipartisan issues at their heart. Each of the things that we have prioritized and physicians have prioritized are bipartisan issues. So you never know what's possible until you really jump in there and get to work.
It's important to remember that in the 114th Congress, when the SGR was finally repealed, that was a Republican Congress and a Democratic president. So just because there are divisions in government doesn't mean that it's impossible to get something done.
Dr. Fryhofer: Thanks, Todd. So Jason, I'd love to hear your take. Can you give us a federal update on where we are on some of the key issues of AMA's recovery plan, like telehealth, Medicare payment and prior authorization?
Marino: Sure. Well, if you looked at your retirement account after the ball—after the ball fell on years, you looked at your 401(k), you looked at your account, it's all red. We're in a bear market. The S&P 500 is down more than 20%. There's been 25 bear markets since 1928. Well, it certainly feels like a bear market in the physician world when it comes to the Medicare payment system, when it comes to dealing with prior auth, when it comes to the years of flat payments and cuts that these cliffhangers we talked about.
And it looks like a bear market when you think about a new Congress that's focused on the $31.4 trillion in debt and a $2.4 trillion in annual deficits, and how are they going to deal with that? And it looks like we're heading to an even worse bear market when you look at all of that. And I'll say, well, if you look at history, those 25 bear markets have all been followed by a bull market and reached a new high, all of them. We're in one right now, so we'll find out.
But I like where history is and what history tells us. And what history also tells us is that the best time to invest is when you're in the middle of a bear market and it seems like you're at the worst. That's when you invest. And so same with us here in advocacy. This is the time to invest in prior auth. This is the time to invest in the Medicare payment system to make it better and to really talk to the Hill, make the case, press on, not to despair, not to give up, not to say it's hopeless, we can't figure these things out.
This is when you double down, triple down. And five years down the road, you are happy you did it. And it works in both ways. And I'll say, even when there's a bad market, there's always one silver lining, one good fund in your account that beat the market, that's telehealth. Telehealth's been the silver lining in COVID. It works. It's not perfect. It's not for everything, but it's a great tool. And you know what? We had a good win in that some people in Congress always want to do the least amount. They wanted to just do a little bit, 2023 extension.
But we had momentum to do more and we made the case that physicians need some certainty. Patients need some certainty. If you're worried it's going to go away in three months, five months, you're not going to plan. You're not going to retool. And so we, at the last minute, were able to get it two-year, so 2023, 2024 all of the payment, all of the regulatory flexibilities that we have during COVID and Medicare are all going to continue for two years this entire Congress.
And there were people that wanted to put in red tape. They wanted to put in audits for physicians. They wanted to put in things that would make it a burden to do telehealth. And that all got beaten back. It was clean. So that's a good thing. So in this next two years, it's going to be about finding the evidence that shows how it works best, making sure that we have fraud and abuse under control, make the case that it's not going to lead to increased utilization, that in fact, it might improve the treatment for chronic care patients and other parts of—and mental health.
It's a great modality. So the next two years are about building the case for permanent. And once physicians and patients get more and more used to telehealth, it's harder and harder for Congress to take it away. So I like where we are in telehealth. It's on a great path. It's not perfect, but it can get better. We got to work some kinks out, but we're on a good trajectory.
On the Medicare payment system, I think last Congress, 117th Congress, was a lot of groundwork was laid with the states and specialties. We all came together and developed some principles to how to reform the payment system. We know what inflationary uptake mechanism, like the hospitals and nursing homes get. We need that, MEI. It's right there. MedPAC said half MEI. We're making progress. Before, they said, freeze it. They said, no update.
So we're making progress. We know we need to do that. We know these budget neutrality cuts that are happening, that they tweak around the different—they increase one physician service and it leads to across the board cuts. And it's a new one every year, it seems like. And it creates all this havoc with these cuts. We can fix that. We can fix how they utilize how much the service is used. We can figure out what triggers it in the first place, make it work better.
And we have solutions out there that we've given to the Congress and the key staff that can solve this. We know alternative payment models offer a lot of promise. We just need more time. We need those APM incentive payments to continue. We know we need to make MIPS work better. The merit-based—that fee for service part, we need to make it so that quality measures are relevant to patient care, and it's not just check the box things. We have ideas on that. We have a template.
Now we got to get Congress first—this 118th have hearings. Have hearings on it. We got to get—we got to keep our champions pushing. In Congress a lot of times, you'll have one part of it, the APM. You'll find a group of senators and House members, bipartisan, that will champion it. They'll find champions on the MIPS side. You'll find champions for MEI. We got to get all our champions to drive different bills and keep building the case to the entire Congress.
I know it's going to cost a lot of money. And as Todd mentioned, we're in a climate where they're going to be cutting back. Doesn't mean they can't fit us in, though. They're still going to—there's going to be a farm bill. There's going to send money to the farmers. So we have a good case to make. We got to play the long game. It may take a while, where you got to one month, one week, one day at a time, just keep making the case, educate everyone why it's important. People do recognize that there's physician burnout. People trust their local physicians. They don't want to see them go away.
So we have good—we have good arguments to make. We have good charts to tell the story. We got to keep pressing on. And on prior auth, we had a great Congress last year. We had a bill that was dropped in the House. Had 308 co-sponsors out of 435. We had 308 bipart. That's killing it. That's the gold standard for a bipart bill. You build support. We had a Senate bill with 40-plus co-sponsors, bipartisan. We got it passed into the key committees, passed in the House.
No one saw or can control the Congressional Budget Office. Gave it a super high score based on assumptions that no one thinks are credible. But they're the referee. They're the referee. They make a bad call. It's the rules of the road. And that prohibited us from passing at the end of the year. But because at the end of the Congress, but because we had so much momentum, boy, the pressure was on the Biden administration to act and they were feeling it.
And no one wants the issues to go away. The issue's not going away. And there's two regs out there that have been released by the administration that were hundreds of pages that we're digesting. But they look very promising. And a lot of what was done could have been done through the bill, can be done through regulation. And so we're hopeful that we keep the pressure on.
And we'll see how that plays out. You got to let that play out before you decide you need to legislate or not. But that helps. It's helpful. And so I think on telehealth, Medicare payment and prior auth, we're moving in the right direction. Hopefully we get into that bull market to a new high.
Dr. Fryhofer: Jason, I love your optimism. And thank you so much for your hard work. Kai, you're next. You lead our state advocacy unit. And here's a question for you. A number of states have supermajorities. So how do you maneuver advancing AMA policy with such differing politics among the states? And what are some of the big issues you're addressing now?
Sternstein: Well, thank you so much. It's such an honor to be here. And I think you can tell and folks here will be able to tell, we lead with our passion and our enthusiasm and our relentlessness every day on behalf of physicians and their patients. We do that at the federal level. We certainly do that at the state level. We look at the 50 states as laboratories of experimentation.
And because of our deep policy database created by our House of Delegates, we are actually able to maneuver quite well working with our colleagues in both the blue states and the red states and then also the purple states. We focus on a collective state health advocacy agenda. My unit is made up of a number of attorneys. There's eight of us total. We divide up our work by issue.
And these folks have become what I would consider to be national experts on the issues that they cover. And we create all sorts of resources—it's why we're called the Resource Center—to help our colleagues at the state level. I think one of the things that's so critical for people to understand is that our model is based on collaboration, consensus and convening when necessary. We do this all year-round.
We work in such close coordination with state medical associations. We will not enter a state without that collaboration, without the approval of the state medical association because there are boots on the ground. We respect that model so much and it's the reason why we have the successes that we do. We hammer away. We chisel away. It's not always big and flashy, but we come back year after year after year on our multifaceted agendas and just relentlessly go after our goal.
I think in terms of the issues that we're planning to see, very aligned with our AMA's recovery plan. So that's not a surprise. We do a survey at the end of every year. We get 100% participation with our friends at the state medical associations to see where their priorities are going to be. And then we align our resources to make sure that we are in lockstep with their priorities. And so again, not surprisingly, we've got to focus on unsafe scope of practice expansion, particularly looking at nurse practitioners, PAs and pharmacists.
We're looking at burdensome health insurance practices like prior authorization but also network adequacy and balanced billing. We're looking at improving physician wellness, and of course, we're looking at telehealth. But also high up on the list are things like Medicaid, physician workforce, and of course, reproductive health and other public health issues, including addressing health care disparities and social determinants of health.
Dr. Fryhofer: Wow. You're doing so much, Kai, and I want to stay with you for one more question. I know your state advocacy unit works closely with state and specialty medical societies to advance policy. But how do you do it? What's your secret? Can you explain a little bit more about the process and give more detail about how AMA engages at the state level?
Sternstein: Sure. I mean, we have a lot of feedback from physicians, active physicians, from our board, like you, Dr. Fryhofer. We also have our council on legislation that provides us guidance. We develop model legislation. And a lot of our key tools that we create go through a review process, a feedback process, not just from the physicians that are on the board and our councils, but also directly from state medical associations.
We have an executive committee that helps guide our work as well, about 15 state medical associations, CEOs, government affairs staff. We also have a general council in that group to also make sure that we're aligned. We have weekly calls. We developed all sorts of tools. We write letters. We prepare trustees for testimony. We testify sometimes where necessary. We've also carved out a really neat space for the AMA with national policymaking organizations.
And again, in deep collaboration and coordination with state medical associations, but we find these organizations to be particularly impactful and efficient for us. So when we go to the National Association of Insurance Commissioners—and just so folks understand, every regulator at the state level, policymaker, usually has a national policymaking organization, like the insurance commissioners, the governors, the attorneys general. And they too develop policy and guidance for their constituents.
So we try to get there and figure out places where we can work with them, bring the physician voice, bring the patient voice. And that way, if insurance commissioners are looking at guidances on things like prior authorization potentially, reducing the volume of red tape for patients, for physicians, we can go and provide our expertise.
And we work really closely with other units within advocacy. Our health policy group, administrative simplification group, for example, gives us a lot of the evidence we need on these issues. And we bring that. So we're everywhere, basically, doing the good work. Obviously, very passionate about the work that we do. And we whittle our way in wherever we can to be the voice of the physician and to be the voice for patients.
Dr. Fryhofer: Kai, one more question for you. Are there certain situations in which AMA can engage directly at the state level?
Sternstein: Yeah. So I think we touched upon that a little bit. I think these national policymaking organizations, that's really where we feel we can—again, we do go in collaboration. We oftentimes bring state medical associations with us to provide expertise. We bring board members also where appropriate. But these national policymaking organizations, it's a really good space for us.
We oftentimes brought work to the National Governors Association, the attorneys general, on our substance use disorder campaign, for example, our competition campaign, all sorts of things. We are constantly trying to figure out what they're working on, what kind of guidances they're providing, if they're developing model legislation or any sorts of any other types of guidances that they do.
We offer our expertise and provide webinars where appropriate and participate in task forces, however we can get in to affect their policymaking meeting. Because once, for example, the National Association of Insurance Commissioners acts, their guidances go to all insurance commissioners across the country.
So it may be a two, three, four-year process, but it's well worth it because once the guidance goes out, if we've been able to influence it at all, if they've heard our voice and our concerns, that's a huge win for us at the AMA to then have that guidance go out to all 50 insurance commissioners or attorneys general, for example.
Dr. Fryhofer: Well, Kai, thank you so much for all that hard work. And we just had our State Advocacy Summit last weekend that you were in charge of, and it was just a fantastic weekend. We may have time to talk about that a little bit more later. But I want to put Todd on the hot seat now. Todd is AMA's senior vice president of advocacy. You're the big boss, so I want to circle back to you with this one. How can physicians get involved in advocating on these issues alongside the AMA?
Askew: Thanks for that, Dr. Fryhofer. But I would say the physicians are the big boss because that's who we're here for, and that's who we are—that's who we're here to serve and advocate on behalf of but also in partnership with. It's not just alongside the AMA. It's this part of the AMA because advocacy is a team sport and we need everybody's participation.
You just mentioned one key opportunity that was just concluded last week was the AMA State Advocacy Summit, which was just a day and a half of really in-depth really excellent panel discussions on some of these various issues we're talking about, the experiences of advocates and state legislators and others in moving these issues through their state houses. And so that's just a wonderful opportunity for folks to connect and to share experiences and to talk about strategy and efforts and issues at the state level.
And we have a corollary to that at the federal level. It's the AMA's National Advocacy Conference, which is each February. It's coming up here in a few weeks here in Washington, DC, where we have a very similar format, really in-depth expert panels talking about some of these issues. We hear from lawmakers, and we hear from folks from across the federal government about the priorities and the issues that they're working on and their reaction to some of the issues that we're working on.
And then everybody bundles up and heads up to Capitol Hill to meet with senior staff or lawmakers or whoever they can get in to seated to press those issues. And so that is a direct hands-on, on-the-ground advocacy effort. But advocacy doesn't just occur at conferences or when you visit the Capitol or the state capitol. Advocacy really occurs every day. It's a full-time thing, not just for those of us who do it professionally, but for everybody.
A key way to get involved is through the AMA's Grassroots Network. It's simple, physiciansgrassrootsnetwork.org. And you can go there, physiciansgrassrootsnetwork.org. And there's a lot of resources that can help folks learn the ABCs of advocating for issues and also background on that issues.
But it's important that people participate in things like the Grassroots Network and make it part of their ongoing day, not a one-time a year or two time of year thing, but to set aside time whenever they can to reach out to their lawmakers, to express their concerns, to offer their ideas, to pass along ideas that they may find at physiciansgrassrootsnetwork.org or other resources from the AMA because we're here to, yes, press these issues on the Hill, but also to support physicians in their efforts to speak out for their practices and for their patients and to help build those relationships.
That's really the bread and butter. Trust me, they wouldn't want to hear—policymakers want to hear from their constituents more than they want to hear from us. And it really makes an impact when a well-informed advocate physician goes in and tells them what's going on at home, what is impacting the patients that are also the voters for that particular member of Congress. So there's endless opportunities to do it and to be an advocate and to participate in this whole process. And we really encourage physicians to do that.
Dr. Fryhofer: Well, Todd, I'm sure you have everybody all fired up and our National Advocacy Conference will occur around Valentine's Day this year. And as you said, bundle up. Is it pretty cold up there in DC or is it warming up?
Askew: We have had 70 degree Advocacy conferences and we have had ice storms. So you can never tell. Just come prepared.
Dr. Fryhofer: Well, the physicians that come will bring the warmth and get those lawmakers on board with us. I want to thank all the panelists for that overview. And we now have some time for questions from our audience.
Now, many of you submitted questions when you registered, so we'll start with those. But remember, you can still submit your questions online in the Q&A section and we'll try to get to as many of those as we can. And if we can't get them today, we'll try our best to address those during our next webinar. All right. So the first question, Jason, I'm going to hand this one over to you. What affects us most from the latest spending bills passed by Congress?
Marino: I think what affects us most is where we were left off. And that's, I think, in the Medicare space. I mentioned telehealth. We got two-year reprieve. That's great. It's not as front and center. On the Medicare payment, we have a 2% cut that we're facing. We have still no inflationary update. We have new budget neutrality things are coming our way. So we have to—we need to continue on on the Medicare. We got to have a hearing.
We have to keep members understanding the history. We all know it, but the Hill staff come and they turn over a lot. And there's new members and new Congress and you have to start over and educate them and keep pressing over and over and having consistent messaging. And then we have to think bigger picture. We can't just be tied to the current inflation because it could go away. You never know. Inflation could be gone in six months and then we need to be able to have—think beyond that so we are not left behind or tied to one event in time.
And on prior auth, I think it's also a—we have promising rules. And then if we like where we are, it can be law through rulemaking. If not, you can always, later on in the year, have a bill introduced that builds around those rules or fixes things that we didn't like how it was finalized. It's a fluid rule, so there's comments. It's going to change a bit. But you can always legislate around it.
And the thinking is that the CBO may score it less if it's a final rule. It takes away some of that. Helps you in the scoring front. So we have lots of options. But and those stories of issues that we knew issues that crop up between now and two months from now are NAC.
Dr. Fryhofer: So lots of twists and turns as we move our agenda forward. All right. Another question. This next viewer says, there are so many policy issues in health care. What are the AMA's top priorities? I'll ask Todd to review the core elements of our recovery plan but also take this one step further. How does AMA identify and then work to address our top priorities?
Askew: Sure. Good question. So I mean, our top issues are reflected in the recovery plan as has been mentioned here. They are, in a nutshell, Medicare payment reform, prior dealing with prior authorization, dealing with inappropriate scope of practice expansions, telehealth, preserving the ability to do telehealth. And I would say central to all of them is the fifth, which is physician wellness, which really should be the first because physician wellness is impacted by all of these issues and many, many others.
It's not a one thing. It is this culmination of pressures and problems that come to physicians that impact their ability to practice medicine and to really get the joy out of it, quite frankly, that most people went into medicine for in the first place. And those aren't the only priorities. There are other priorities that are reflected in the AMA's commitment to address all sorts of obstacles that interfere with the ability of physicians to practice care.
We also are deeply invested in efforts to increase health care equity across all of health care as well as efforts on improving health care outcomes. And that's scratching the surface. There's certainly many, many more issues that we are all committed to working on. How we identify them, I think first of all, we listen. We listen to physicians through the AMA House of Delegates. We listen to state medical associations and specialties.
And we listen to individual physicians who reach out to the AMA or through their states or specialty associations to express concern about something that is impacting their practice and their ability to provide optimal care for their patients. And we also ask. We look at surveys. Kai mentioned a survey she does of the state medical associations.
We do surveys of physicians when polling to understand, what are those pressures that are most impacting physicians' ability to be the best they can, to provide the best care for their patients, to maintain their practice, and that we can then identify ways to help to provide assistance and support on those issues that we hear—that we hear directly from physicians through those various means.
Dr. Fryhofer: Well, Todd, thank you for listening. Thank you for being there. And that's an impressive body of work that you're talking about. This next question is asking for more details about Medicare payment cuts and APM bonuses for physicians. So Jason, I think this one is for you. It's kind of complicated, so you might want to get your pencil out to take some notes about the numbers.
With the sequestration cut of 2%, we are now 4% below January 2022 with our Medicare pay. Why has the AMA not mentioned this along with the cut of the APM bonus from 5% down to 3 and a half percent? So Jason, explain.
Marino: Sure. Well, I'll start off by saying the last time we had a big debt limit fight more than 10 years ago, it led to a supercommittee. And then that didn't work. And it led to the sequestration cuts across the board 2%. And we were fueling those for several years. And then during COVID, given that the harm and the practices were shut down and we were able to make a case that we cannot afford the 2% sequester and we got some temporary relief for one year, we were able to get it again.
And then we went back again. People started to say, we gave you relief one, two years, not the third time. And 2% means for all Medicare providers. Some hospitals shouldn't get it. But we can't tease it apart and we need to phase it out. And a year ago, the bill had a phase-out where it phased it out. It gave us some relief, but by July 1, it put the cut, the 2% sequestration, back in. And we were told that a bipartisan basis, a member level, staff level, that there's no more right now, that that's not happening.
And sometimes you hit a wall like that. And then we had the burden of all the other cuts too that we were dealing with. So that became a tough one. We still make the point because it's a context that we're getting 2% cut. We haven't gotten inflation in these other cuts. But and then on the APM side, there were that 5% bonus was expiring. And no one really got to use it because you never really had all the models that were hoped that would come on board.
And it's one of those we were pushing for 5%. They came up with 3.5%. There's limited dollars. And there's no magic behind it, but we didn't want it to go to 0 because you don't want it to ever go to 0. You want at least keep it going. Once you go to 0, you're at risk for it never coming back. And so at least we got 3.5%. We'll try and push for more for sure. But it's a toehold. It's something. And they heard us clear on the threshold.
Most people didn't understand that, but you mentioned in your remarks about 75% threshold, no one would meet it. So you can make it 10%. If you can't meet it, if you can't meet the criteria, no one's going to get the bonus. So that's a big one too, and it's a big dollar cost to that. So there's a dollar cost to that threshold change that you don't see, but there is. And so we're hopeful that I think we educate a lot of members on why APMs are important and why they should continue the funding.
Dr. Fryhofer: So Jason, I appreciate your the cup is half full rather than half empty approach. But I know it could have been worse, but there's just four words for this. This is not fair. But we'll now move on to the next question. This is a follow-up question from a different viewer and I'm going to ask Todd to respond to this one. What is AMA doing about physician pay being cut at a time of high inflation?
Askew: Well, I think Jason mentioned some of the actions that we've been taking working across states and specialties to build consensus on the need for reform, real reform, substantial reform because going hat in hand to Congress every year, asking for 2%, 4%, stop that 5% cut, give us this, it's not sustainable, that we can't just keep focusing on the margins here. We've got to talk about the reason that these cuts are happening.
Whether it's at a time of high inflation or not, the system is fundamentally unfair. It treats physicians differently. And that's the entire effort behind what we're talking about and the need to demonstrate also that the access for seniors to care is at risk. The stability of physician practices is at risk here, being chipped away 1% here, 2% there. We are in active discussions all the time with the administration.
We talked to MedPAC. I mentioned MedPAC saw the light and finally recognized the need for physicians to have an actual update and working with Congress in deep collaboration with state medical associations and specialty associations to build that consensus on reform and reminding lawmakers. And this is the message we have to keep taking to them day after day after day. The physicians are doubly impacted by this.
Not only do we have a statutory freeze essentially in our payments and these cuts come about because of budget neutrality requirements which must be addressed, but we are statutorily frozen. And we are the only group of providers, pardon the word, but physicians are the only group of health care providers or institutions in Medicare that don't have an automatic adjustment to address inflation, that if we were going up and keeping up with inflation every year, the rearranging of the deck chairs occasionally because of budget neutrality would not be as painful as it is for everybody.
But because we don't have that automatic inflation adjuster, which would be larger in times of higher inflation, we're doubly impacted. And so that's the focus. That is the entirety of the focus of our effort is to make a more rational application of budget neutrality and to build in an inflationary adjuster for physicians, just like every other sector of Medicare has so that when we have these periods of high inflation, payment rates are adjusted so that practices can keep up with the cost of providing care.
Dr. Fryhofer: And I think about that graph that you have. A picture says a thousand words, that everyone else is going up. They get that inflationary increase and physicians are the only ones going down. It's just not fair.
Askew: No. You're right.
Dr. Fryhofer: The next question is for Jason and Kai. What is being done to support telemedicine? Jason, why don't you start, and then Kai, you take over after Jason on that one.
Marino: I'll just be brief and just say keeping the Medicare coverage is just a big win. And the Congressional law of physics is once you extend something, you tend to keep extending it. And we're on a good path to get permanent and hopefully get permanent in a way that they don't put in a bunch of audit and difficult and burdensome provisions. And you get it covered in Medicare that helps drive other payers too. It sends a signal.
And we've got some more certainty, two years. So physicians can plan. Patients can plan a little more. And this is one of the things that didn't just happen. We spent years, since 2016, working on marker bills that got it all right. And then when COVID happened, it was ready to go. And so a lot of the work has been done and now it's just keep momentum.
Sternstein: Right. And I think at the state level, I was reviewing our survey again in preparation today to look at where the states are since we're at the very start of the legislative sessions. And telehealth, telemedicine really does pop up to one of the top issues that the states expect to work on. I've got some specifics here. 33 states and specialties expect to focus on payment, while 26 states and specialties expect to focus on audio only. 26 states and specialties expect to focus on coverage.
And 22 states and specialties expect to focus on licensure. So those are just the top four subtopics underneath telehealth, telemedicine, that we will be working on. We have model bills and talking points and model letters and testimony ready. We are open for business 24/7 as the states start to gear up for their legislative sessions to help them work on language and make sure that what gets passed or similarly, what gets blocked is right and in alignment with AMA policy.
Dr. Fryhofer: And we had a great session about this at our State Advocacy Summit. For those of you who were there, I know you enjoyed it. And for those of you who were not, you ought to come to the State Advocacy Summit next year because it was fabulous. All right. This next question is about gun violence. How can physicians do more to address the epidemic of gun violence? And as AMA Board chair, I can help respond to this.
At our November 2022 interim meeting, our House of Delegates adopted policy to establish a gun violence task force focusing on preventing and including gun-involved suicide. And I will be chairing this task force. The first step is convening a small number of specialties that are already deeply involved in this issue to reach out, to reach some sort of consensus on the role of organized medicines in these efforts.
And we'll also be talking with some expert groups outside of medicine. AMA's advocacy team has already been working hard in this space. So Todd and Kai, can you share some of our work against gun violence? Todd, why don't we start with you?
Askew: Sure. Thanks, Dr. Fryhofer. No, you're absolutely right. I mean, over the years, we've supported and actively lobbied for really countless pieces of legislation, all different aspects of what might be termed gun control but also violence interruption. A lot of these are multistakeholder efforts across broad range of groups here in DC representing patients, representing victims of gun violence, representing advocacy groups that are solely dedicated to this.
And some of those efforts have been successful. But unfortunately, more than not, they run into roadblocks at the federal level because it's very difficult to legislate. We had one bright moment in the last year, but that's been about it for significant legislation. I think the task force that you mentioned is coming together. We've talked about this, and we really hope to take a different approach here.
I mean, we've said that this is a public health problem. And it definitely is. And maybe it's not something that we can just legislate away because we're unlikely to see significant federal legislative activity on gun control over the next few years. So I think we ask ourselves, what specifically can organized medicine bring to the table that is different and doesn't just replicate what everybody else is doing out there?
And what can doctors do in a clinical setting to help interrupt that cycle of violence? And how can the AMA and other physician organizations support those efforts? So I really am excited about this conversation that you mentioned, talking with, first of all, what is already out there from medicine. And then where are the gaps? What are we—what can we be doing that could do it? But I should defer to Kai as well because there's obviously a lot of efforts at the state—at the state level as well.
Sternstein: Thanks, Todd. Yeah. And it's really complementary. So the model that we use in the Advocacy Resource Center, working with state medical associations, hearing national medical specialty societies, convening them regularly, whether it's calls with the entirety of the federation or regular calls with directly affected specialties that are interested, we have calls all the time on this.
Always probing and trying to figure out what we can bring to the states as legislation pops up or proactive pieces of legislation that the state medical associations can address themselves. So again, based on our surveying of the states, moving into the 2023 legislative sessions—and know that this is early still. This was what was expected as of December of last year. So things change quite radically.
And we're ready. We're ready to work with states that are interested to move on anything related to firearm. But we expect about 20 states to be working on firearm-related issues this year. And of those 20, most expect to focus on safe firearm storage and also prevention of child access to firearms.
I think the other things that are on the radar for state medical association, background checks, extreme risk protection orders, state funding of research and then also gun-free zones, which includes schools, of course. So we are getting all of our resources together. We will be following up with all those states and any more that come onto our radar. Ready to work and row in the right direction on behalf of patients and their physicians on this critical, critical issue.
Dr. Fryhofer: So thank you so much for that work and that update. And your board of trustees is also very excited about this gun violence task force. And you'll be hearing more about that in the future. So we have another question. And Jason, I would like for you to respond to this one. What has AMA done to eliminate long waits for green cards for IMG physicians in underserved areas?
Marino: Sure. We've been championing legislation on the Hill in Congress that deals with the Conrad 30 program. This is a successful program that each state can have 30 physicians, IMG physicians, that can go work in an underserved area of that state. And instead of the requirement that when you get medical training, you have to go back for your home country for two years, you can waive that requirements, waive, and you can stay if you do three years.
And in that bill, this bipartisan bill in the House and Senate that we helped draft, there's also a provision that if a physician, IMG physician, works for five years in an underserved community, at the end of that five years, you could be exempt from the green card cap. This is a big deal, especially a lot of IMG physicians from India. They hit the cap. They're in 40-year wait lists, 40 years-plus. And it's bleak. And their families are aging out of their green card status and they're in limbo.
And their communities want them to stay. They're providing great care. And this bill would allow an exemption. And you serve five years. It's a win-win-win. Doesn't cost anything. It's a win for the patient. It's a win for the physician. And it's one of these issues where like telehealth I mentioned, we have a marker bill. We'll have a ... this new Congress. We've had it in the last three Congresses. When there's an immigration bill that passes, a big one that's biparti—it deals with all of the big stuff that we can't control, this is ready to go.
In fact, this has been held back in prior efforts because it's such a sweetener, bipartisan sweetener, no one wants to give it up because they want to use it to drive a larger immigration bill. But I can assure you, just like with telehealth, just like with medical marijuana research, which is now law, you get these marker bills. It might take three or four Congresses, but when the moment's right, we have it ready to go. And So I'm optimistic on that front.
Dr. Fryhofer: Well, the contributions of IMG physicians is so important, especially at this time of a looming physician shortage. So thank you so much for your work in that area and for that update, Jason. All right. We only have time for one more question. That time has just flown by.
And this next question relates to our work on fixing prior authorization and utilization reform. I'd like to quickly hear from both Todd and Kai. How do we rein in Medicare Advantage plans from arbitrarily and carelessly denying care? So Todd, you start, and then Kai, you pick up.
Askew: Thanks, Dr. Fryhofer. Well, obviously, I mean, prior authorization is the leading administrative burden for physician practices. And we hear about it all the time, rightly so. We talked about it some today already. We've really been a leader in this conversation for a number of years. Back in 2017, we released some principles with a coalition of health professional groups and patient groups.
And that led to this consensus statement in 2018, where the insurers came on board and said, we will agree to these basic things like better timelines and the opportunity to streamline some of these processes. And we've been monitoring this with surveys over the years. And I don't think anybody would be shocked to say that progress has been limited, that there has not been a lot of efforts put forward unfortunately by the payer community to implement some of these things that we had pretty much agreed to.
And then just recently, we saw this OIG report regarding Medicare Advantage, the Office of Inspector General at HHS, which really raised very serious questions about the clinical validity of some of the prior auth criteria that the organizations were using. So while we were very strong supporters of the Seniors' Timely Access to Care Act, which Jason mentioned, which we came so close to getting into law this year but really have very good momentum on, we're also really pleased as we look at some of the details in the rules on prior authorization that have just come out of the administration, partially in reaction to what the Office of the Inspector General showed.
A lot of these things really align with some of our longstanding advocacy ask on the prior authorization principles. And so it's an important first step. It doesn't get to prescription drugs in Part D, which is a major, major problem. I think probably the overwhelming volume of prior auth is with Part D problems. But it is so critically important, some of the things they put forward.
And we hope that this will, as Jason mentioned earlier, lower the cost of the legislation that can wrap all these issues up together. But it's not just the federal level. I think a lot of the action here on prior authorization beyond Medicare Advantage really recurs at the state level. And really great things are happening there too. So let me, if I could, just ask Kai to jump in on that.
Sternstein: Sure. Thanks, Todd. And yeah, we're really proud of this campaign. I wish we could make this issue disappear, but we've had this campaign on our books for a really long time related to prior authorization and the burdens that it creates for physician offices and for patients. This year, we expect at least 38 states to focus their work on varying facets of prior authorization.
And just to show you the relentlessness of this and the multifaceted and multi-year process, we worked with about seven states, I believe, last year on introducing gold carding legislation that's based off of the Texas bill. But once Texas passed that, we took best practices from Texas and surveyed our states and created our own model legislation and are working with state medical associations. Laid the groundwork with seven. We'll see what kind of process and progress we can make this year.
But this is a really, really important issue. And talk about a way that physicians can get involved. Your stories matter so much here. The stories of your patients, what this does—at the State Advocacy Summit, I was talking to a physician who was telling me about a study that had just come out that said primary care physicians spend, on average, 28% of their time on patient care, 28%. The rest on red tape.
Imagine what we could do with the workforce issues that we hear are looming if we could release some of that time and get to primary care physicians caring for their patients 50% of the time. And maybe go crazy and try to get to 80%. I mean, and again, the real-time impact of that conversation is that we've already had talks on my team about that. We're digging into that study. And we're going to add some of that material to our talking points, to our campaign. Real-time action right there. Real-time impact on the work that we do.
Dr. Fryhofer: Yes. So physicians want more time with our patients, that's for sure. And I've just been impressed at how many advertisements on TV this Medicare Advantage companies have. I've also heard some people say instead of calling them Medicare Advantage, maybe they should be called Medicare Disadvantage.
So I'm going to try to sneak one more question in. And Todd, this one is for you. What issues can other societies support along with you? Now, of course, all. But if we had—what if we had to align on one or two? What do you say, Todd?
Askew: Well, I think we are doing it because so much of what we do at the federal and at the state level is in coalition with the Federation of Medicine through workgroups and meetings and other efforts where all of the specialties of the states and the AMA all work together on these issues. I think it's most prominent in the work—in the Medicare reform payment space.
I think in the scope of practice space, especially at the state level, that is all coalition work. It is all AMA partnering with specialty societies and state medical associations to advance those issues of common interest. The one most important valuable thing that we—the most valuable thing I think we can bring is agreement among medicine.
And when you go to Capitol Hill, when you go to a state capitol and it's not 20 or 30 or 40 different groups with similar asks, but it is a powerful voice with the AMA convening people and coming to consensus and presenting a unified front, that gets people's attention. And it makes people understand that the debate on what the policy should be is over.
Now it's just about the building the will to get it done. And so I think on Medicare payment reform, on scope, but really on any of the issues that we have talked about today, it is that unifying role that the AMA can play that really has value to our advocacy.
Dr. Fryhofer: Yes. And AMA's convening power is so powerful. And I think on the Hill, AMA is looked to as the voice of America's physician. So as much as we can work together to get that voice more meaningful, the better. Unfortunately, we're out of time. And if we didn't get to your question today, we'll try our best to answer it during our next webinar. Many thanks to our panel of experts and many thanks to you for joining us for this insider's look at AMA's advocacy priorities for 2023.
And be sure to join us at noon Eastern time, February 7, for our next AMA Advocacy Insights webinar, and find out more about how AMA is fighting for physicians and patients in Washington and how you can join us. Be sure to check your inbox for an email with a link to register and we will continue to do our best to keep you abreast of opportunities to engage around topics that impact America's physicians. Thank you and have a great rest of your day. I'm Dr. Sandra Fryhofer.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.