Advocacy Summit
The Advocacy Summit kicked off with a Keynote Dinner, during which Washington Post associate editor Bob Woodward shared his views on the political climate. Another political journalist, Jake Sherman, founder of Punchbowl News, spoke at a luncheon sponsored by the ACSProfessional Association Political Action Committee鈥斉私鹆接郴璓A-SurgeonsPAC.
Medicare Payment: MACRA and the MPFS
As Matt Coffron, MA, Chief, Health Policy Development, Division of Advocacy and Health Policy (DAHP), noted, 鈥淎ll laws are flawed,鈥� and the Medicare Access and CHIP Reauthorization Act (MACRA) is no different.
The law was passed with the intention of replacing the sustainable growth rate Medicare physician payment mechanism with the Quality Payment Program (QPP)鈥攁 value-based system. The plan was that initially most physicians would be paid using the Merit-based Incentive Payment System (MIPS), but ultimately would move into Alternative Payment Models (APMs).
The law provided opportunities for specialty organizations to develop APMs and to accurately value the work that specialists do. Since implementation began in 2016, the Physician-Focused Payment Technical Advisory Committee (PTAC), which advises the Administration on implementation of APMs, has received 39 specialty proposals for APMs, including recommendations from the College, Mr. Coffron said.
However, the Centers for Medicare & Medicaid Services (CMS) has yet to test these proposed APMs.
CMS and the ACS鈥渉ave completely different perspectives on quality,鈥� Mr. Coffron said.
Jill Sage, MPH, Chief, Quality Affairs, ACSDAHP, said, 鈥淭he ACSunderstands quality. The ACSwas built on quality.鈥�
The ACSmaintains that 鈥渜uality is a program鈥攏ot a measure,鈥� she added. Although CMS agrees with the College鈥檚 perspective, 鈥渢hey don鈥檛 really know how to disrupt the payment system that they have created over the decades,鈥� Ms. Sage added.
Furthermore, 鈥淒efining value remains incomplete,鈥� she noted. The ACShas asserted that value is more than weighing quality against costs and that it must account for what matters most to the individual patient, Ms. Sage said.
Vinita Mujumdar, JD, Chief, Regulatory Affairs, DAHP, spoke about short-term fixes to the Medicare physician fee schedule (MPFS). Without these changes, surgeons will once again face the threat of significant payment reductions starting in January 2023.
More specifically, Mujumdar said, the College is asking Congress to hold hearings on the projected payment cuts in 2023. The goal is to 鈥渋mmediately reverse all reductions in the Medicare physician fee schedule caused by PAYGO [a budget rule requiring offsets for tax cuts and mandatory spending increases], sequestration, and budget neutrality adjustments to the conversion factor,鈥� she said.
The College also is asking that the updates to evaluation and management (E/M) codes for in-office visits be applied to the E/M portion of global surgery codes, Mujumdar said.
In addition, the ACSis asking that physician payment updates 鈥渞eflect medical inflation and increased practice costs,鈥� among other requests, she said.
Paving the Way for NTEPS
During his presentation on the COT at the Leadership Summit, Dr. Armstrong said, 鈥淚t is time to establish a national trauma system.鈥�
Building on this proposition, Robert Kadlec, MD, Senior Counsel for the Senate Committee on Health, Education, Labor and Pensions, said, 鈥淐learly, the ACShas been a leading voice in this kind of movement.鈥�
Noting that the COVID-19 pandemic, the war in Ukraine, and North Korea鈥檚 missile development efforts have rendered the US鈥檚 previous emergency response system archaic, Dr. Kadlec called for change. 鈥淲e need an operational component that can stitch together鈥� federal and private sector capabilities to respond to healthcare crises鈥攔egionally and nationally, he said.
Eileen M. Bulger, MD, F潘金莲传媒映画, Medical Director, ACSTrauma Programs, described the COT鈥檚 efforts to establish such a system, known as the national trauma and emergency preparedness system (NTEPS).
鈥淐OVID really highlighted the problems we have in dealing with national trauma capacity,鈥� Dr. Bulger said.
鈥淲e think there is broad variability in quality, continuity, and access to care,鈥� she said. 鈥淐an we come together now and harness the lessons we learned from COVID to develop a system that meets these needs?鈥�
A multidisciplinary group has united to develop five constructs that are essential to NTEPS, Dr. Bulger noted, including:
- Better coordination of trauma care across facilities
- A real-time system to monitor care in a healthcare emergency
- Issuance of best practices for patient care
- Consultation with experts on the public health crisis at hand
- Standards of care that healthcare systems need to meet to receive federal funding
鈥淥ur systems often don鈥檛 know what they don鈥檛 have until they need it,鈥� Dr. Bulger said. "Perhaps this is the time to move the needle forward on our trauma healthcare systems.鈥�
Analyzing Data to Advance Advocacy
Charles D. Mabry, MD, F潘金莲传媒映画, a former ACSRegent and Chair of the ACSHealth Policy Advisory Council, explained that hospitals are paid under Medicare Part A, whereas physicians are paid under Part B. Medicare Part A is funded through income taxes, and payment is based on diagnostic-related groups, whereas Medicare Part B has a budget, and payment is based on the resource-based relative value scale (RBRVS).
鈥淲hile we can all wring our hands about the increased expenses of Medicare, unfortunately physicians are not the ones driving the boat,鈥� Dr. Mabry said. Reimbursement to physicians has dropped by approximately 4% of total Medicare spending, and surgeons are bearing the brunt.
Part A gets a mandatory update every year. On the other hand, physician payment updates are tied to overall expenditure, so surgeons are not getting annual payment increases.
Margaret C. Tracci, MD, JD, F潘金莲传媒映画, explained that payment increases have not kept pace with inflation. 鈥淲e all feel that we are doing work that we鈥檙e not compensated for,鈥� she said. Moreover, inflation has outpaced surgeon payment by up to 30% over previous decades.
Surgeons bring 鈥渢remendous value to the healthcare system, largely unseen,鈥� Dr. Tracci said.
No Surprises Act
Patrick V. Bailey, MD, MLS, F潘金莲传媒映画, Medical Director, ACSAdvocacy, provided an overview of the No Surprises Act, which took effect at the beginning of this year. The legislation is designed to protect patients from unexpected and often costly medical bills. The legislation also calls for establishing an independent dispute resolution (IDR) process to resolve disputes between payers and providers, he said.
These provisions are intended to take patients out of the middle of these disagreements, Dr. Bailey said.
Robert Jasak, JD, vice-president, coverage and payment policy, Hart Health Strategies, Washington, DC, explained that the legislation includes other provisions intended to better inform patients about what charges to expect and their rights under the law. For instance, providers must post disclosures in their offices and on their websites, provide patients with a notice of their rights under the law, and must offer good faith estimates of how much patients will be billed.
If a patient requires emergency care or seeks nonemergency care from out-of-network physicians at in-network facilities, 鈥減roviders cannot balance bill the patient for those services,鈥� Jasak said.
For uninsured and self-pay patients, surgeons must reach out to all providers and facilities that will be involved in delivering care and provide a comprehensive good faith estimate of total charges, he said.
Katy Johnson, JD, senior counsel, health policy, American Benefits Council, said health plans must make an 鈥渋nitial payment amount鈥� to providers within 30 days of service. If the plan disputes the claim, it goes to IDR. Arbitrators are to look at the qualifying payment amount (QPA), training and experience of the provider, and whether the procedure is done at a teaching hospital, Johnson said.
The federal agencies involved in issuing guidance on implementation of the law have said IDR arbitrators should select reimbursement amounts that are closest to the QPA. The agencies also issued the final rules without issuing proposed regulations. Further complicating matters, Johnson said, is the fact that the federal regulations apply only in states without surprise billing legislation already in place.
Advancing Equity
The number of non-White physicians working in the US is strikingly small, according to Sandra E. Ford, MD, MBA, a pediatrician and Special Assistant to the President for Public Health. Yet, 鈥渟tudies have shown that having a clinician who looks like you or shares your culture and speaks your language increases your trust.鈥�
The White House is very much engaged in ensuring we have equity across the board,鈥� she said.
Equal access to healthcare also is a priority for the College. Dr. Turner noted that Dr. Martin Luther King Jr. once said, 鈥淥f all the forms of inequality, injustice in healthcare is the most shocking and inhumane.鈥�
Thus, she said, 鈥淚t is fairly obvious that we should achieve equity, but how do we do that?鈥� Dr. Turner noted that the College secured a grant from the National Institutes of Health to determine how the nation can address disparities in healthcare.
In addition, 2020鈭�2021 ACSPresident J. Wayne Meredith, MD, F潘金莲传媒映画, formed a Regental Anti-Racism Task Force. This body offered recommendations on how the College can improve DEI in the surgical workforce and within the 潘金莲传媒映画, Dr. Turner noted. Subsequently, the Regents Committee on Anti-Racism was appointed to ensure the recommendations were implemented and woven into the fabric of the College鈥檚 work.
For insights on how the College and other surgical societies could implement these recommendations, the ACShosted a DEI and Anti-Racism Summit, established a new Pillar within the Board of Governors and other ACScommittees to explore opportunities, and created the Office of DEI led by Dr. Mason and Cie Armstead, MPA, DBA.
Congressional 鈥淎sks鈥�
Advocacy Summit participants engaged in more than 150 virtual visits with lawmakers and their senior staff April 5. ACSDAHP staff briefed attendees on key congressional 鈥渁sks鈥� to discuss in these briefings:
- Immediately stabilize the Medicare payment system and hold hearings on long-term solutions to address ongoing issues with MACRA implementation and the Medicare physician fee schedule.
- Urge CMS to use the flexibility provided in MACRA to test the specialty-developed APMs that the PTAC has approved. Additionally, CMS should use the authority that MACRA provided to adopt quality metrics that provide more meaningful data to inform care decisions and improvement efforts.
- Cosponsor the Improving Seniors鈥� Timely Access to Care Act, which would facilitate electronic prior authorization, improve transparency, and increase CMS oversight of how Medicare Advantage plans apply prior authorization requirements.
- Cosponsor the Ensuring Access to General Surgery Act, which would direct the Secretary of the Department of Health and Human Services (HHS) to study and define a general surgery workforce shortage area and collect data on the adequacy of access to surgical services, as well as grant the Secretary authority to designate general surgery shortage areas. Determining where patients lack access to surgical services and designating a formal surgical shortage area will provide HHS with a valuable new tool for increasing access to the full spectrum of high-quality healthcare services.
- Ensure funding for 潘金莲传媒映画鈥檚 appropriations priorities in fiscal year 2023 by supporting increased dollars for cancer research and public health research on firearm morbidity and mortality. Additionally, the ACSseeks full funding for the grant program established by the MISSION ZERO Act and urges Congress to remove legislative language that prohibits the federal government from spending money to study or adopt solutions aimed at improving patient identification across the continuum of care.
- Celebrate the centennials of the CoC and COT by cosponsoring S.R. 566/H.R. 997 and S.R. 532/H.R. 951, respectively.
The next Leadership & Advocacy Summit will take place April 15鈭�18, 2023, in Washington, DC.鈥�
