• Vol. 60, June 2019 CNS DC E-Newsletter

    Legislative Affairs

    CNS and AANS Release 2019 Legislative and Regulatory Agenda

    On May 28, the CNS and the AANS released their 2019 legislative and regulatory agenda, which includes priorities including prior authorization reform, expanding support for graduate medical education, fixing the broken medical liability system and alleviating the burdens of electronic health records. To read the full legislative and regulatory agenda, click here.

    Legislation on “Surprise” Medical Bills Moves Forward in Congress

    Earlier this year, the CNS and the AANS joined more than 100 state and national medical societies in sending Congress a letter outlining organized medicine’s core principles on so-called “surprise medical bills.” Given the growing concern over the practice of unanticipated medical bills — largely driven by narrow insurance networks, which leaves some patients on the hook with the bill if they receive care from an out-of-network provider — Congress and the Trump Administration are considering legislation and/or regulations to address this problem.

    Recently, there has been a flurry of activity on this topic.

    • Neurosurgery Sends Letter to Congressional Leadership. On May 14, the CNS and the AANS sent a letter to Senate Majority Leader Mitch McConnell (R-Ky.), Senate Minority Leader Charles Schumer (D-N.Y.), House Speaker Nancy Pelosi (D-Calif.) and House Minority Leader Kevin McCarthy (R-Calif.). The letter pointed to legislative solutions for addressing the unanticipated medical bills issue, noting that such legislation must also improve network adequacy, promote transparency, create a fair mechanism to address insurer and physician payment disputes and ensure high-quality care. In our letter, we also cited our significant concerns regarding surprise billing proposals that promote hospital bundled billing and so-call “network matching.”
    • Energy and Commerce Committee Releases “The No Surprises Act.” On May 14, House Energy and Commerce Committee Chairman Frank Pallone (D-N.J.) and Ranking Member Greg Walden (R-Ore.) released discussion draft legislation, “The No Surprises Act,” to tackle unanticipated medical bills. On May 28, in response to a call for comments on this draft legislation, the CNS and the AANS sent a letterto the committee recommending that the bill be amended and modeled more closely on New York’s law, which has proven to protect patients, lower costs and create an incentive for commercial payers to broaden networks and ensure fair and equitable payments to physicians for out-of-network care.  
    • Senator Cassidy Introduces Legislation. On May 15, a bipartisan group of senators, led by Sen. Bill Cassidy, MD, (R-La.), introduced S. 1531, the “Stopping the Outrageous Practice (STOP) Surprise Medical Bills Act.” The goal of this legislation to protect patients from unanticipated medical bills and establish a process for physicians and health plans to resolve billing disputes. In response to the draft legislation, the CNS and the AANS sent the sponsors a letter pointing out areas that we like and dislike about the bill, pledging to continue to work collaboratively with Congress as legislation on this topic is debated.
    • CNS and AANS Sponsor Congressional Briefing. On May 16, the CNS and the AANS joined the American College of Surgeons (ACS) and several other physician organizations in co-hosting a Congressional briefing titled, “How to Protect Patients from Surprise Medical Bills: The Physicians’ Perspective.” Nearly 100 Congressional staff members and others attended the briefing. Panelists highlighted the physician community’s major concerns with recently proposed legislative solutions, as well as potential ideas for a path forward.
    • Ways and Means Committee Hearing. On May 21, the House Ways and Means Committee held a hearing titled, “Protecting Patients from Surprise Medical Bills.” Click here to watch the hearing.
    • House Doctors Release Legislative Framework. On May 23, Reps. Raul Ruiz, MD, (D-Calif.) and Phil Roe, MD, (R-Tenn.), among others, released a detailed outline of legislation, the “Protecting People from Surprise Medical Bills Act.” Based on a preview of the summary, the CNS and the AANS issued a press release supporting this bill.
    • Senate HELP Committee Releases Proposal. On May 23, leaders of the Senate Health, Education, Labor and Pensions (HELP) Committee released draft legislation titled the “Lower Health Care Costs Act.” The bill includes provisions to address unanticipated medical bills, improve transparency and ensure that provider network directories are accurate. The CNS and the AANS will submit comments on this draft legislation.
    • Doc Caucus Sends Letter to Administration. On May 23, the House Doc Caucus sent a letter to the Administration regarding surprise billing. This letter promotes legislation based on the New York law and takes issue with complicated, unproven and unworkable proposals related to a single bundled payment to hospitals for all out-of-network care and network matching.

    Prior Authorization Reform Included in House Appropriations Committee Bill

    On May 8, the House Appropriations Committee approved its Labor, Health and Human Services, Education FY 2020 bill, which would provide the Department of Health and Human Services (HHS) total funding of $99 billion — an increase of $8.5 billion above the FY 2019 enacted level and $20.9 billion above the President’s budget request. At the urging of the CNS and the AANS, the bill addresses prior authorization stating as follows:

    The Committee is aware that Medicare Advantage (MA) plans have increased the use of prior authorization (PA), which requires physicians and other health care providers to obtain advance approval from the plan before services can be delivered to patients. While PA is a valid utilization review tool to ensure appropriate care, health care provider experience and research studies demonstrate that inappropriate use of PA causes significant patient care delays, administrative costs and workflow disruptions. The Committee directs CMS to improve Medicare beneficiary timely access to care, increase transparency, and reduce the burdens on patients and providers by providing guidance to MA plans on their use of PA. Specifically, CMS should require MA plans to selectively apply PA requirements, excluding from PA those services that align with evidence-based guidelines and have historically high PA approval rates. In addition, CMS should increase transparency by requiring MA plans to report annually to the Secretary a list of items and services that are subject to PA, the percentage of PA requests approved, and the average time for approval. Finally, the Committee encourages CMS to work with stakeholders to increase the use of electronic prior authorization.

    The bill also directs the Agency for Healthcare Research and Quality (AHRQ) to spend “no less than $500,000 for research that examines whether and to what extent delays in treatment due to prior authorization negatively impact patient outcomes.”

    A copy of the full report can be found here. The bill now heads to the House floor for a vote.

    Good Samaritan Health Professionals Act Introduced

    On May 7, Sens. Bill Cassidy, MD (R-La.) and Angus King (I-Maine) introduced S. 1350, the Good Samaritan Health Professionals Act of 2019. This legislation will ensure that health professionals who provide voluntary care in response to a federally declared disaster are protected from unwarranted lawsuits. The bill specifically applies to health care providers who cross state lines to aid disaster victims. The CNS and AANS sent a letter to Sens. Cassidy and King supporting this bill. Companion legislation is expected to be introduced in the House soon.

    Neurosurgery Endorses H. Res. 366 Designating May 2019 as Stroke Awareness Month 

    On May 9, Rep. Joyce Beatty (D-Ohio) introduced a resolution, H. Res. 366, designating May 2019 as “Stroke Awareness Month.” The resolution encouraged more support for educational efforts, services, coordination and advocacy that will enhance public awareness of stroke. Since neurosurgeons play a crucial role in the treatment of stroke, the CNS and the AANS endorsed this resolution.

    Senate Passes Pandemic and All-Hazards Preparedness Bill

    On May 16, the Senate cleared S. 1379, the Pandemic and All-Hazards Preparedness and Advancing Innovation Act (PAHPAI). This bill would reauthorize programs addressing various health emergencies. The House companion bill, H.R. 269, passed in January. Due to minor technical corrections to bill language, final passage is expected to occur in early June. Championed by the CNS and the AANS, this legislation clarifies medical liability protections for volunteer physicians and other health professionals who have pre-registered with Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) or the Medical Reserve Corps. Also, the bill contains language included in the MISSION Zero Act, which would assist U.S. military health care providers in maintaining a state of readiness by embedding military trauma teams and providers in civilian trauma centers.

    Neurosurgery Submits Comments on Senate Finance Committee’s Hearing on MACRA

    On May 8, the Senate Finance Committee held a hearing titled “Medicare Physician Payment Reform After Two Years: Examining MACRA Implementation and the Road Ahead.” Before the hearing, neurosurgery joined the Alliance for Specialty Medicine in submitting a statement for the record providing suggestions for improving the Medicare Access and CHIP Reauthorization Act.

    Neurosurgery Urges Congress to Reauthorize PCORI

    On May 13, the CNS and the AANS joined forces with the Friends of PCORI Reauthorization coalition to send letters to House and Senate lawmakers stating our strong support for the reauthorization of the Patient-Centered Outcomes Research Institute (PCORI). In our letter, we highlighted that the reauthorization of PCORI was critical for building the evidence for improved health decisions, empowering patients and driving innovation and value in health care.

    Regulatory Relief

    Neurosurgery Urges CMS to Delay Imaging AUC Program

    The CNS and the AANS have long advocated that Medicare’s appropriate use criteria (AUC) for diagnostic imaging program will place an excessive burden on physicians across a broad range of specialties with little evidence of clinical benefit. In continuing our efforts to eliminate this burdensome program, on April 29, the CNS and the AANS sent a letter urging CMS to delay the Medicare AUC Program educational and operations testing year. In our letter, we stated, “We do not believe the Program’s education and operation year should begin in 2020 given that it marginalizes specialty specific peer-reviewed guidelines from which AUC emanate and, consequently, will inevitably interfere with care delivery.” Efforts to seek legislation to repeal the program are ongoing.

    Coding and Reimbursement

    CMS Updates Professional Liability Relative Value Units for Low Volume Services

    Recently, the Centers for Medicare & Medicaid Services (CMS) announced corrections to professional liability insurance (PLI) relative value units (RVUs) for several hundred procedures that have fewer than 100 Medicare claims reported per year, nearly one-third of which are reported by neurosurgeons. Earlier this year, the CNS, the AANS and the American Medical Association (AMA) voiced concerns about significant unexplained decreases for PLI RVUs for many of these low volume services and asked that CMS make corrections retroactive to Jan. 1, 2019. In its July 2019 Quarterly Update to the 2019 Medicare Physician Fee Schedule, CMS included a list of the updated PLI RVUs. Neurosurgeons who have submitted claims for codes on the list between Jan. and July 2019, may re-submit the claims to receive a refund to reflect the PLI RVU increase. 

    Quality Improvement

    Neurosurgery Sends Letter to CMS Supporting CMMI Physician-owned Hospital Demo

    On May 21, neurosurgery sent a letter to CMS urging the agency to approve a demonstration model that will be submitted to the Center for Medicare & Medicaid Innovation (CMMI) allowing physician-owned hospitals (POHs) to expand their facilities by demonstrating the value of POHs in advancing quality and health outcomes for Medicare and Medicaid beneficiaries, while reducing program costs.

    Academic Medical Issues

    Neurosurgery Participates in Graduate Medical Education Day of Action

    On May 6, the Association of American Medical Colleges (AAMC) hosted a Graduate Medical Education (GME) Day of Action in conjunction with the GME Advocacy Coalition — a group of hospital, physician and academic stakeholder organizations, of which neurosurgery is a member. The Day of Action was designed to raise the profile of Medicare-supported GME, which has been effectively frozen since 1997 and to urge members of Congress to co-sponsor the Resident Physician Shortage Reduction Act (S. 348/H.R. 1763). This legislation would provide Medicare funding for an additional 15,000 residency slots (3,000 per year for five years). The CNS, AANS and SNS have joined more than 75 organizations in supporting this legislation.

    The centerpiece of the Day of the Action was a Congressional briefing titled “Medicare’s Role in Addressing the Physician Shortage,” that highlighted AAMC’s recently released 2019 workforce projections report — which predicts a shortage of between 46,900 and 121,900 physicians by 2032 in both primary and specialty care. Additionally, throughout the day, CNS/AANS Washington Office staff, along with the AAMC and other GME Advocacy Coalition members, took to social media using the hashtags #GMEDay. @Neurosurgery was the second most popular. We also had the top impact of all participants.

    Drugs and Devices

    FDA Safety Notice for Wingspan Stent System

    On April 25, the FDA issued a safety notice regarding Wingspan Stent System as a result of incidents reported of stroke or death that have occurred within 72 hours of the procedure when the device was used outside the FDA-approved indications for use. The device is approved through the Humanitarian Device Exemption (HDE) regulatory pathway as a Humanitarian Use Device (HUD) only for the specific group of patients outlined in the FDA-approved indications for use criteria in the device’s labeling. Generally, a patient may be treated with Wingspan only if the treating physician has received Institutional Review Board (IRB) approval to use the Wingspan at the clinical site.

    Neurosurgery Joins the National Academy of Medicine’s Action Collaborative on Countering the U.S. Opioid Epidemic

    The National Academy of Medicine’s Action Collaborative on Countering the U.S. Opioid Epidemic is a one-of-a-kind public-private partnership that comprises government, communities, health systems, provider groups, payers, industry, nonprofits, academia, and more — all committed to sharing knowledge, aligning ongoing initiatives, and advancing collective, multi-sector solutions dedicated to reversing national trends in opioid misuse and overdose. Recently, the CNS and the AANS joined the collaborative by submitting a commitment statement to counter the U.S. opioid epidemic. Ending the opioid crisis is a top priority for neurosurgery.

    Neurosurgery Responds to HHS Interagency Task Force Report on Pain Management

    On April 1, organized neurosurgery sent a letter responding to a draft report issued by the HHS Pain Management Best Practices Inter-Agency Task Force. The letter commended the Task Force for adopting several recommendations supported by neurosurgery, including support for an individualized approach rather than prescribing limits for patients with acute post-operative pain and the recognition of high-quality evidence for neuromodulation to treat pain. On May 6, the final report was released. On May 9-10, the Task Force held a public meeting to discuss the implementation and disseminating of the recommendations in the report.  Jason Schwalb, MD, FAANS, FACS, chair of the CNS/AANS Joint Section on Pain made a presentation at the meeting.

    Of Note

    AMA Releases Updated Data on Physician Practice Arrangements

    For the first time in the United States, employed physicians outnumber self-employed physicians, according to a newly updated study on physician practice arrangements by the AMA. This milestone marks the continuation of a long-term trend that has slowly shifted the distribution of physicians away from ownership of private practices.

    Communications

    Neurosurgery Blog Hosts Vascular Neurosurgery Awareness Campaign

    Throughout May and June Neurosurgery Blog will be hosting a vascular neurosurgery focus awareness campaign. To maximize attention on vascular neurosurgery related issues, we planned our efforts around May, which is National Stroke Awareness Month. Our goal was to shed important light on vascular neurosurgery facts, innovation and the role of vascular neurosurgery interventions. To this end, we have been highlighting these issues through patient storiesinnovationadvocacy and more! We invite all neurosurgeons to continue the conversation using the #vascularneurosurgery hashtag so we can grow awareness through social media. Additionally, we encourage you to visit the blog and subscribe to it, as well as connect with us on our various social media platforms. This will allow you to keep up with the many health-policy activities happening in the nation's capital and beyond the Beltway.

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