Accountable-Safe-Confidential: Moving Toward an Effective State PHP

By Robert J. Summerer, DO
SDSMA President

SDSMA leadership participated in the annual National Advocacy Convention of the American Medical Association (AMA) in February. This was my second opportunity to participate in this event, and once again it didn’t disappoint. The conference is designed to update attendees on issues at the forefront of concern for the AMA that have relevancy among rule makers in Washington. Speakers include the AMA lobbyist contingency, media correspondents, and members of Congress. The house of medicine also gets updates from the Department of Health and Human Services and the Centers for Medicare & Medicaid Services via top officials from those organizations. The conference also provides for and encourages the state participants to meet with their congressional representatives while in D.C.

It came as no surprise that we heard over and again that the political climate in Washington is hyper partisan. Despite this, we were encouraged that many of the issues that are important to doctors are issues that both parties can agree upon. In fact, many of the congressional speakers, some of them physicians themselves, spoke of the work they are doing to introduce or encourage bills that address important health issues. During our visit with Sen. John Thune, we were able to briefly discuss his work regarding telemedicine.

The following are some of the more important topics on the national forefront.

Reduce Prior Authorization Burdens

Delays in care for patients awaiting prior authorization can lead to serious negative consequences – to include hospitalization, disability, and even death. While H.R. 3701, the “Improving Seniors’ Timely Access to Care Act,” is aimed at addressing care for patients enrolled in the Medicare Advantage program, hopefully it can set a precedent for other health care plans. As proposed, it calls for the implementation an electronic prior authorization program intended to mesh with existing EHRs. Further proposed, it will mandate reporting of approval/denial rates including rationales for denials, and calculate and report adherence rates to evidence-based guidelines. It would promote continuity of care for patients changing policies and prohibit additional prior authorization for medically necessary services for procedures already authorized.

“Surprise” Medical Bills

Work in both houses and by both parties has been in play for several months. It is important that patients are shielded from disputes between health plans and providers. Legislation needs to address network inadequacies and provide for a fair arbitration system such as an independent dispute resolution process; provide a method to establish rates that are fair to all stakeholders; and  include actual commercial payer data as determined through an independent claims database.

Improve the Medicare Access and CHIP Reauthorization Act (MACRA)

Medicare payments for physicians have not kept pace with payments for hospital and skilled nursing care. Physician payment rates have stagnated the last two decades while practice costs and the consumer price index have continued to rise. Adjusted for inflation, Medicare physician pay has declined 20 percent from 2001-2019. As a result, the rates have become insufficient to pay for the cost of delivering health care to Medicare patients. The Medicare payment shortfall will continue to compound as  MACRA left a six-year gap from 2020 through 2025 during which there are to be no updates in the Medicare Physician Fee Schedule.

MACRA is responsible for the Merit-Based Incentive Payment System (MIPS) and alternative payment models (APMs). MIPS and APMs intend to improve the delivery of care and to create a margin for investing in care delivery improvements, respectively. Both are hampered by the lack of technical improvements. APMs simply haven’t had time for adequate development and are not widely available for participation. Technical improvements would reduce the burden of MIPS and make reporting more clinically meaningful.

Our senators and representative were encouraged to continue to focus on improvements to MACRA. While continuous improvement is well established in the medical community, the same cannot be said for federal regulation. The need for implementation of positive payment adjustments for physicians to replace the six-year payment freeze, extending the advanced APM bonus payments another six years, and promoting technical improvements to MACRA were impressed upon the legislators.

In addition to the above we also discussed medical marijuana, health care technology and the Conrad 30 program. In hopes of advancing research into medical marijuana, Senators Rounds and Thune were asked to cosponsor S. 2032, the “Cannabidiol and Marijuana Research Expansion Act.” We also asked them to support CONNECT, the “Creating Opportunities Now for Necessary and Effective Care Technologies for Health Act,” which would remove restrictions for Medicare beneficiaries to obtain their care through telemedical technologies. Finally, we asked for their support of the Conrad 30 program, which would address physician shortages by making improvements to and extending the Conrad 30 waiver program, creating an avenue for international medical graduates to practice in underserved areas. Both the AMA and the SDSMA will continue to take action on affairs germane to physicians and the patients we treat.