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In today’s AMA Update, AMA Chief Experience Officer Todd Unger discusses the AMA’s recent advocacy efforts in three key areas: telehealth, prior authorization and Medicare payment with Jason Marino—the AMA’s director of congressional affairs in Washington D.C.
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- Jason Marino, director, congressional affairs, AMA
Unger: Hello and welcome to the AMA Update video and podcast. An ongoing series covering a range of topics that are affecting the lives of physicians and patients. Hopefully you have heard at this point about the AMA's Recovery Plan for America's Physicians, and today we're going to talk about the AMA's recent advocacy efforts in three of those key areas, telehealth, prior authorization and Medicare payment reform. I'm joined today by Jason Marino, the AMA's director of Congressional affairs in Washington, D.C. I'm Todd Unger, AMA's chief experience officer in Chicago. Jason, thanks so much for joining us today.
Marino: Oh happy to be here, Todd.
Unger: Well it has been a very busy time for AMA's advocacy team and much of that effort again has been focused on these key recovery plan for America's physician areas. Let's start today's discussion with Medicare payment. New legislation has been introduced. Talk to us about what's in that legislation. And if it passes, what it would mean for physicians.
Marino: Absolutely. So this is a bill that the AMA worked hard to get introduced that our champions, Drs. Bera and Bucshon, introduced and it deals with a 4.42% cut that systems are going to—physicians are going to face on January 1. And as you may recall from past podcasts, that two years ago in 2020 we were facing a 33% across the board cut. This was a physician fee schedule rule that increased payments for evaluation and management codes, and it triggers what's called budget neutrality. And it's an across the board cut for all physician services.
And so we were able that at the end of 2020 to get that stopped, to prevent those cuts. And then it came back 2021 and last year we were able to get those cuts also stopped. And we're back again this year, and this year there's been a second rule that's come out that increased E&M services for non-office based services. That's caused a new 1.42% cut. So you take the 3% existing cut, you add the 1.42 to 4.42% cuts January 1. This bill would stop those cuts and also have a sense of the Congress saying that we need to do some permanent Medicare physician payment reform.
Unger: That's really important. And in fact, I saw a chart that the AMA advocacy team produced that shows most people getting kind of a bigger adjustment. Not so for physicians. So this legislation that you're talking about right now would be a huge help. Talk to us a little bit more about the AMA, how we're supporting that, and how do physicians out there help?
Marino: Yes, so we went back to our champions. I mentioned Dr. Bera from California, Democratic member, and Dr. Bucshon, also a physician from Indiana. And they've paired up and they saw this coming. We saw this coming, this these cuts and they got a bill dropped—H.R. 8800. And we are right now trying to get cosponsors to this bill. We have last—it was dropped last week. We already at 16. We already have people that have committed to us. Another 10. So it's growing.
And we're encouraging physicians to go to our grassroots website and I'm going to look at this real quick. It's the PhysicianGrassrootsNetwork.org. And you go to that site, there's pre-written letters, there's some background materials on what the issue is, what that bill is, what it does and we're just trying to get members of physicians to reach out to their local member of Congress and co-sponsor it.
At the same time, we're trying to get a Senate Bill, a companion bill, a same bill dropped in the Senate. That's still a work in progress. But once we get that we'll have some grassroots messaging to get sponsors for that bill. And the bigger picture is, we're just trying to get show support so at the end of the year, when there's a lame duck session of Congress, this issue gets put in there addressed.
Unger: And huge thanks to representatives Bera and Bucshon the power of having physicians in Congress to support something like this and we've heard from other congressional supporters just how important letters like this from physicians are. You'd be surprised. It doesn't take a million but your voice really matters. So make sure to take a look at PhysiciansGrassrootsNetwork.org. Sign up for that and use those templates, and let your voice be heard.
Jason, while it would obviously be really good news if this legislation passed, you mentioned before, kind of year after year, this temporary fix and the need for a long term solution. Talk to us about what we're doing at the AMA on real and permanent Medicare reform.
Marino: So I often get as an AMA lobbyist at the end of the year, this time of year, when we bring up these—we're facing cuts, you're back again. Oh, man we just fixed you guys! No, we don't want to be back here either. But this payment formula is broken. And if you could start over and design payment formulas for all providers in Medicare, you wouldn't design it this way, especially for physicians.
And so we don't want to be back here again. We went through the old SGR days where that was eventually repealed and we had all these called the doc fix. And we don't want to be back here. And I know you don't want to deal with it. But here we are. And so we've been working with all of the different physician groups out there and all the state and state medical associations on principles and ideas to what would a permanent reform look like.
And a key part of that is, there would be some sort of payment update. It wouldn't be the only provider group that has no payment update, no increase at all. And that would not be—that's a big part of it. We have ideas how to restructure it to make it more relevant to clinical practice and patient outcomes.
And so we're working on that. We sent a letter to the Congressional leadership, to the House and Senate, that got all 50 state medical associations, all the leading physician specialty groups, to Congress, saying this payment system is broken. It's not working.
And you mentioned a chart, Todd. We have two charts we have one chart that we put in the letter that shows the last 21 years, the physicians have only seen a 10% increase in their payments. That's 22% loss compared to what inflation has been around, practice costs. And so 10% and then CPI, just CPI, is 62% in that 21 year. And the other providers, hospitals, nursing homes are getting 60, 65%.
So it's been a tough 21 years for physicians. And we have a new chart that we've introduced that says, well, what about going forward? What's going to happen in 2023? In January 1? And we all know, we're all living through an inflationary environment we're 8.38—It's 8 plus percent inflation, and our chart says, why is it that physicians are the only provider in Medicare that's not getting an update? Everyone else is and we're not.
And actually we're going to get cut 4.4%? Why is that? How is that fair? And so we're saying, those charts make the case. And then we're saying, so we do want a permanent reform. We recognize that's not going to happen this year. But we hope that the next Congress, 118 Congress, this is one of the top agenda items to fix this so it works better for patients and physicians and for Medicare.
And in the meantime though we have a series of cuts, the 4.42% cuts that are coming down the pike that we need to address before the end of the year. And so we're asking Congress during the lame duck session to address these issues, these cuts.
Unger: And that story you told just at the beginning of that. That is the unified voice in action, and the kind of data and story that you're pulling together is exactly the kind of role that the AMA plays in bringing an issue like this to light. Jason, I'm going to switch gears a little bit and move to something called the Improving Seniors Timely Access to Care Act. This is in the realm of prior authorization. We had Representative DelBene on a month or two ago to talk about how this bill was moving through Congress. Can you tell us where this legislation stands right now?
Marino: Yes, so this is a bill, Congressman DelBene who spoke on a podcast and we've gotten favorable reviews on the Hill that people saw it and they it had an impact. And it helped get us co-sponsors, so with this bill was drawn back in May of 2021, and we did the old fashioned lobbying campaign where you get a bill dropped, you write it the best way you can and it helped address the problem of prior authorization and Medicare Advantage program where the offices are spending time getting claims denied or have to wait arbitrarily only to get it eventually overturned but patients are delaying care while they're waiting for approval.
And this bill would streamline the Medicare Advantage prioritization processes and have some transparency. What are the rules of the road? What are the following guidelines? Things that make sense. Real time decision making.
And we did a co-sponsorship campaign and since May of 2021 we have now hit 326 co-sponsors. Which is pretty amazing. Bipartisan co-sponsors. Republicans, Democrats. You only have 435 members, so you got 327. So it kind of took a life of its own. That podcast that you did help boost those numbers up but it creates such a force momentum that the Ways and Means Committee, which has jurisdiction, had a markup and marked the bill up, and it passed through the committee in a bipartisan way. And then the momentum kept going through the August recess.
A lot of the physicians dialed in their members and this is important priority. And we got the Energy and Commerce Committee, the other committee with jurisdiction, they adopted it. And that same day it went to the House floor. And it passed by a voice vote. I mean, this is—we're not even an election. These are contentious times but here you are, a health care bill that passed by a voice vote. That tells you how strong and how much people care about this issue.
And so we do have some momentum in the Senate. And we have Senator Dr. Marshall from Kansas and we have Senator Sinema from Arizona. They've teamed up and they have the Senate Companion Bill. And the Senate with 43 co-sponsors over there. And we're hoping that the Senate can take this and pass it at the end of the year in their lame duck session. And we think it will make a big difference on making priorities work better Medicare Advantage and then also in private insurance outside of Medicare Advantage, is the hope.
Unger: That is really great news. And the thing that we learned when Representative DelBene was on just how personal an issue like prior authorization—a prior authorization can be. We've all experienced it. And it really hits home. So it's great news to see that kind of bipartisan support in both the House and the Senate, and we'll look forward to further updates on that. As you kind of look at the larger context of prior authorization, kind of what's the prognosis for additional work from the AMA?
Marino: I think the first step is to get this deal finalized. And the one thing that—the one thing going against us was the Congressional Budget Office. They score how much legislation costs, and they said we thought it would be a low score and they said it was going to be $16 billion over 10 years. So that's too high. That's a high number in that may be too high to pass the Senate. So we're working behind the scenes with the Congressional Budget Office to see if we can get that score in a better place. So it can be a little—so it can pass the Senate.
But our real hope and our strategy here is that you reform Medicare Advantage, and it has—and it will have an influence on the private health plans. And spread because once you retool it, the Medicare Advantage processes for Medicare Advantage, it makes sense to do it for your other plans as well. And that's the hope that drives some change in a good way, where it's a win-win for the patients, physicians, health care costs. No one's saying get rid or prior authorization, we're just saying let's make it work better.
Unger: And we want your stories out there. So if you've got one and you want to show your voice out there, make sure to visit fixpriorauth.org. Share your stories, let your voice be heard. Jason, speaking of temporary fixes and working to address those. I want to talk now about telemedicine. This has been a really important way, of course, through the pandemic, as a way for physicians to connect with their patients. Really important from an access and a continuation of this kind of integrated practice. What's the latest there?
Marino: I would say continued momentum. I think the one positive thing to come out of COVID has been telehealth coverage and Medicare. Before COVID, less than 1% of seniors were using telemedicine and it was because it wasn't covered. And the laws are outdated. And they really moved on, except the coverage hadn't moved on. And then the waivers during COVID have allowed broad coverage of telehealth and it's been a game changer.
One of the number one used services has been mental health care. One hour psychotherapy visits. And there have been near—are access problems for mental health care. Then even cancer care. A significant percentage are cancer—second opinion on oncology result. You can do through telemedicine. It's addressed rural areas that didn't—had to drive hours to see a physician in-person, they can do it through telehealth. Telestroke, literally saving lives with the physician on the screen saying, should we take that medicine or not. Decisions can be made and lives saved and costs saved, and there's been a lot of innovation in the last two years in telehealth.
And I think members of Congress on both sides of the aisle have seen it. They've heard it from their constituents back home. This works. We want to keep this. So earlier this spring, we had a bill passed that said, once the public health emergency ends, all this coverage goes away. And they said, well, we don't want that to happen. So we have enough money to give five months and once the public health emergency ends we'll do a five month extension of coverage, which is a good way and that was a good progress. And I spoke on this forum before on that.
And now the momentum is, well, this is working so well, but physicians and patients need a little more certainty. We don't want to think it's just—we don't know when the public health emergencies going to be declared over. And we don't want all the coverage to just end. And how do you plan a practice or retool your practice to have more of a telehealth program or if you're a patient you get used to a provider to telehealth, you don't want to worry that it's going to go away. And you want to be able to plan it out.
And so we've got a lot of momentum for at least a short term—a two year. The hope is that—so this came to a vote that they had in the House of Representatives a month ago or so, and they didn't expect the vote that they got. But they got 416 to 12 in support. We call it a jailbreak vote. It was everyone wanted to be part of this. It showed momentum and clear will, and now we're the Senate we're trying to get some momentum in the Senate to say this House has spoken on this one. It makes a lot of sense. Before you leave in a lame duck session, two year extension. We think it makes sense.
Unger: Jason, what kind of provisions are we looking for in a—let's call it a permanent extension?
Marino: So we're looking for that you can do telehealth—we call it—it's called originating site, where do you do telehealth. That the current law before COVID was you had to go—you had to be in a rural area and being some old satellite campus when the technology was different. We're saying, get rid of this originating site. You can do telehealth from your car, from your home, from the library, from your work. Anywhere the patient is where they can reach the physician.
Let's lift that and geographic site. Anywhere in the country. You don't have to just be in a super rural area, the current law says. You can do it from anywhere. Those are core things.
And we also don't want a bunch of arbitrary restrictions on what's covered that's not—that don't exist for in-person visits. And for instance, there's some proposals that say, well, there'll be certain audits triggered if a certain services hit a certain spending threshold and the physician would be audited. That can have a chilling effect, and be arbitrary and create different standard for the same service, whether it's in-person or two way audio visual. And I'm happy to say that, what passed the House and it has a lot of momentum is clean. Clean coverage. And that's what we're hoping to keep it clean.
I will say that one of the barriers to permanent coverage, why can't we just do permanent right now? If it's so bipartisan. So much will. The reason is there's concern that there could be increased utilization. Where there would be a lot more usage of in-person and telehealth visits, and it'll increase the cost of Medicare. And I will say, so far we have not seen that spike. The levels have normalized, we haven't seen that.
The other concern is that there will be rampant fraud and abuse. And so far the Inspector General of HHS has issued a report recently that hasn't shown signs of that. There will always be abuse. Anything with Medicare, it's always bad actors. But that's existed since the beginning of the program. And we argue that the administration, HHS, Health Human Services has the tools to go after that. To go after abuse.
And we haven't seen any big spike in that. But also the Congressional Budget Office, I mentioned earlier in there, and the prior authorization bill, they scored how much bill is going to cost. And that's what Congress has to follow. It's like the referee in a football game makes the call, you have to stick with that. And they want to see some time go by and see is there a spike in utilization, is there a spike in front of use or not. And they're going to score it that way.
And so it might take a little more time. I just like where we stand as far as the patients like it, physicians like it, it's working. I would predict we're going to get to the permanent doubt in the future.
Unger: And I think, Jason, you can kind of clarify this but part of that long term vision is about telehealth being used by physicians as an integrated part of patient care. You know, it quickly ballooned in the pandemic and the perspective here is to keep that as a valuable part of integrated patient care. Tell us more about how that particular vision drives the AMA's advocacy work.
Marino: Yes, just think about it. Patients that have a chronic condition or two chronic conditions, and they have issues with mobility, there's things you can do with remote patient monitoring and telehealth combined where that patient doesn't have to leave or drive or get transportation to a physician practice or not. And then real time monitoring, "Oh, I notice that you're this level has spiked, and let's find out why." And you can do that through two-way audio without having to come in.
And also you can prevent unnecessary ER admissions. If you're someone who's borderline condition and their condition could worsen but if you can monitor it through telehealth, you can prevent an expensive and costly ER visit. And you can also potentially get patients out of the hospital sooner because you can do things through telehealth. And that's a way to save money. Works for it's convenient for patients but is not just about convenience. It's about good clinical improvements and innovation.
And you can even do—I was mentioning telestroke. You can do some emergent care. You can triage things. Makes a difference. Really works well for psycho—for psychiatric care, because I think some patients like the—it is more confidential. You're not going to an office. It's some people are very comfortable with that modality of it. You can build trust through that and that's a positive.
So there's been lots of positives. And I think if there was a certainty of permanent coverage for Medicare, I think there might be more investment, and even more innovation.
Unger: Jason, thanks so much for being here today. There's a lot of news from the AMA advocacy team. A lot of work that's being done on the Hill. Thanks out there to all our supporters for helping drive these really important patient-based initiatives out there. I encourage you to find out more about what the AMA is doing and all of these key areas that make up the AMA Recovery Plan for America's Physicians. You can visit our website ama-assn.org and find out all about that. Again, make sure your voice is heard. It's really important.
We'll be back soon with another AMA Update. In the meantime, you can check out all our videos and podcasts at ama-assn.org/podcasts. Thanks for being with us here today and please take care.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.