April 5, 2018: National Advocacy Update

In a new letter (PDF) to senior diversion control officials at the Drug Enforcement Administration (DEA), the AMA is seeking important updates in the DEA rules that govern electronic prescribing of controlled substances (EPCS). Adoption of EPCS can support high-quality patient care and reduce fraud, tampering and diversion of prescription drugs, such as opioid analgesics.

The current rules, which have been unchanged since 2010, prevent user-friendly devices that are widely available in medical practices from being deployed to meet the multifactor authentication standards DEA now requires. The AMA letter outlines specific changes that are needed in the regulations for biometric devices in order to make it simpler and less expensive for physicians to adopt EPCS and have it integrated into their practice workflows.

These requests are consistent with a recommendation from the President's Commission on Combating Drug Addiction and the Opioid Crisis that the DEA should increase EPCS to prevent diversion and forgery.

At its March 26–27 meeting in Washington, the Physician-Focused Payment Model Technical Advisory Committee (PTAC) reviewed four alternative payment model (APM) proposals and voted to recommend all of them to the Secretary of the U.S. Department of Health and Human Services for testing or implementation.

Two of the proposals aim to improve the availability of palliative care for Medicare patients with advanced illness, including a model (PDF) developed by the American Academy of Hospice and Palliative Medicine that supports interdisciplinary palliative care teams. These teams would be available to patients and caregivers 24/7 to help ensure issues associated with the patient's health conditions and functional limitations are managed in the most efficient way in alignment with the patient's wishes.

In public comments supporting the palliative care model, the AMA reinforced the importance of legislation recently passed by Congress in response to AMA advocacy that clarifies the PTAC's authority to provide feedback to proposal developers to help them refine and improve their proposals. Another model that the PTAC adopted would improve care for nursing home patients by offering around-the-clock intensive care management services from geriatrician-led multidisciplinary teams via telemedicine. The APM would help on-site medical and nursing staff better manage care transitions and prevent patients from cycling back and forth between nursing homes and hospitals.

The AMA wrote (PDF) to the Centers for Medicare & Medicaid Services (CMS) on March 26 to express concerns over unfair business practices with respect to electronic payments to physicians, including the use of virtual credit cards.

The letter urged CMS to republish frequently asked questions issued last summer, since removed from the CMS website, which endorsed honest, fair business in the health care industry by enabling physicians to make informed, independent choices regarding the appropriate payment method for their practice.

In a letter (PDF) to Defense Secretary James N. Mattis sent on April 3, the AMA expressed its concern about recently announced policies that would impose limits on transgender individuals serving in the military. There is a wide body of peer-reviewed research on the effectiveness of transgender medical care, which formed the basis of policy adopted by the AMA's House of Delegates in 2015 that there is no medically valid reason to exclude these individuals from military service.

The AMA further expressed its support for public and private health insurance coverage for treatment of gender dysphoria and its support for a RAND study's conclusion that the financial cost of transgender individuals in the military is negligible.

The AMA submitted testimony for the record for the March 21 House Ways and Means Health Subcommittee hearing that examined implementation of the 2015 Medicare Access and CHIP Reauthorization Act's (MACRA) physician payment policy.

The AMA was supportive of MACRA since it replaced the flawed, target-based sustainable growth rate (SGR) formula with a new payment system and addressed problems found in existing physician reporting programs. Under prior law, possible combined penalties for the legacy pay-for-reporting programs could have been up to negative 11 percent in 2019. Under the Merit-based Incentive Payment System (MIPS), the maximum penalty physicians could receive in 2019 was negative four percent.

AMA testimony included comments on recent changes made to MACRA. Under the Bipartisan Budget Agreement of 2018, Medicare Part B drug costs were excluded from MIPS payment adjustments, flexibility was provided for the Centers for Medicare & Medicaid Services (CMS) to reweight the cost performance category to not less than ten percent for the third, fourth, and fifth years of MIPS. Allowing three additional years for the cost score to be weighted at ten percent will allow additional time for CMS build on its ongoing initiative to use panels of physicians to develop, test and refine resource use measures. The law also allows CMS flexibility in setting the performance threshold for three additional years.

The AMA strongly advocated for Congress to clarify the MACRA statute so that the Physician-focused Payment Model Technical Advisory Committee can provide data and technical assistance to individuals and organizations developing alternative payment model proposals going forward. This will significantly enhance the quality of the submitted proposals and greatly increase the likelihood of their testing and implementation.

The AMA also made suggestions for further improvement. The overarching goals in MACRA regulations should be choice, flexibility, simplicity and feasibility. The MIPS scoring system could be simplified by harmonizing the scoring across the four separate components of MIPS so that physicians can more easily calculate their progress toward achieving success and increasing opportunities for physician reporting to be counted across multiple categories in a more coherent payment system.

The AMA argued that advancing care information (ACI) MIPS performance should require only attestation by reporting physicians and CMS should focus ACI measures on interoperability and patient access. Additionally, MIPS needs to transition from using prescriptive measures to using cases and outcomes.

Nearly $4 billion to support a multifaceted approach to combating the opioid epidemic is included in the $1.3 trillion omnibus budget bill signed into law on March 23. The money will pay for law-enforcement programs directed at opioid trafficking as well as medical programs aimed at preventing and treating opioid-use disorder.

Most of the money will go to Health and Human Services agencies such as the Substance Abuse and Mental Health Services Administration, which will get $1 billion to fund State Opioid Response Grants (this is in addition to the $500 million provided in the 21st Century Cures Act); $84 million for the Medication Assisted Treatment-Prescription Drug and Opioid Addiction state grant program; and $50 million dedicated for health programs for Native Americans.

Read more at AMA Wire®.

• April 5, 2018: Advocacy spotlight on Physicians ask HHS to withdraw proposed rule on conscience rights in health care  
• April 5, 2018: State Advocacy Update