Vol. 88, August 2022 DC E-Newsletter
Special Announcements
Prior Authorization Bill Clears Critical Legislative Hurdle in Congress
On July 27, the U.S. House of Representatives Ways and Means Committee unanimously approved the Improving Seniors’ Timely Access to Care Act, as amended (H.R. 8487), legislation that would streamline and standardize prior authorization in the Medicare Advantage (MA) program. Among other things, the legislation:
- Establishes an electronic prior authorization process;
- Requires the U.S. Department of Health & Human Services (HHS) to establish a process for real-time decisions for items and services that are routinely approved;
- Improves transparency by requiring MA plans to report to the Centers for Medicare & Medicaid Services (CMS) on the extent of their use of prior authorization and the rate of approvals or denials; and
- Encourages plans to adopt prior authorization programs that adhere to evidence-based medical guidelines in consultation with physicians.
In advance of the committee’s consideration, the Regulatory Relief Coalition (RRC) — which the Congress of Neurological Surgeons (CNS) and the American Association of Neurological Surgeons (AANS) co-lead — sent a letter supporting the amended bill and urging committee members to vote in favor of the legislation. Rep. Suzan DelBene (D-Wash.) singled out the coalition in her statement about the bill. In addition, after the vote, the CNS and the AANS issued a press release, as did the RRC, resulting in a Becker’s Spine Review article titled, “Neurosurgeons urge Congress to pass bill addressing prior authorization by year’s end,” quoting John K. Ratliff, MD, FAANS, chair of the CNS/AANS Washington Committee. The piece notes that the legislation would protect Medicare Advantage patients from prior authorization practices that could limit their timely access to medically necessary care.
Click here to watch the committee markup, here to read the CNS/AANS press release and here to read the RRC press release.
New Prior Authorization Reform Legislation Introduced
On June 15, Rep. Mark Green, MD, (R-Tenn.) introduced additional prior authorization legislation. The Reducing Medically Unnecessary Delays in Care Act (H.R. 8078) would reform prior authorization in Medicare by requiring that all prior authorizations and adverse determinations must be made by a licensed physician who is board certified in the specialty relevant to the health care service in question. It would also direct Medicare plans to comply with requirements that restrictions must be based on medical necessity and written clinical criteria, as well as additional transparency obligations.
Efforts to Fix Broken Medicare Physician Payment System Continue
The CNS and the AANS continue their efforts to fix the broken Medicare physician payment system. On May 25, the CNS and the AANS endorsed principles for reforming the Medicare physician payment system. Developed in collaboration with the American Medical Association and 120 state and national medical societies, the “Characteristics of a Rational Medicare Payment System” document outlines a unified set of shared goals for improving the current system.
Subsequently, the CNS and the AANS issued a press release announcing support for these unified goals. “The current Medicare physician payment system is on life support and needs an overhaul. We are grateful that Congress has stepped in to mitigate steep cuts over the past few years, but comprehensive reform to reflect practice costs and inflation is needed,” stated John K. Ratliff, MD, FAANS, chair of the CNS/AANS Washington Committee.
The CNS and the AANS continue to lead several coalition efforts — including the Surgical Care Coalition (SCC) — to prevent steep Medicare payment cuts and preserve patient access to care. The SCC officially launched year three of its campaign to stop these cuts and implement changes to the physician payment system. After successfully protecting patients’ timely access to quality surgical care in 2020 and 2021 by securing Congressional action to mitigate proposed cuts to Medicare, the SCC has begun to fight against similar cuts proposed for 2023.
Finally, working with a broad coalition of physicians and other health professionals, the CNS and AANS helped spearhead a letter to key congressional committee leaders urging them to take legislative action to avoid an expected 8.5% cut to physician payments in the Medicare program. The recently proposed calendar year 2023 Medicare Physician Fee Schedule (MPFS) rule included a reduction in the Medicare conversion factor of approximately 4.5%. Additionally, a required statutory pay-as-you-go cut of 4% is slated to go into effect on Jan. 1. The letter urged Congress to act, pointing out that the year-over-year cuts demonstrate that the Medicare physician payment system is broken. The groups also welcomed the opportunity to work with Congress to “establish a pathway for identifying policy solutions that will ensure long-term stability for the MPFS.”
The CNS and AANS are working on developing legislation that would prevent these fee schedule cuts, provide physicians with an inflationary update in 2023 and set the stage for long-term reform of the Medicare physician payment system.
COVID-19
Biden Administration Renews COVID-19 Public Health Emergency Declaration
On July 15, HHS Secretary Xavier Becerra renewed the COVID-19 public health emergency (PHE) declaration. The PHE was extended for an additional 90 days. This means that all telehealth and other waivers and flexibilities implemented during the PHE will remain in effect. The department has also stated that it will provide 60 days’ notice when a decision is made to terminate the declaration or let it expire.
Legislative Affairs
House Passes Telehealth Legislation
On July 27, by a vote of 416-12, the U.S. House of Representatives passed H.R. 4040, the Advancing Telehealth Beyond COVID-19 Act. Sponsored by Reps. Liz Cheney (R-Wyo.) and Debbie Dingell (D-Mich.), this bipartisan legislation extends through December 2024 key telehealth waivers implemented during the COVID-19 pandemic. These provisions include the removal of geographic restrictions and the expansion of originating sites for telehealth services, as well as flexibility for providers to continue to provide audio-only telehealth services. In addition, the bill would delay the requirement that a Medicare beneficiary attends an in-person visit with their provider before receiving behavioral health services via telehealth.
The Senate must now consider the bill, although it is unclear whether or when the upper chamber will consider this legislation. Without additional congressional action, these telehealth waivers will expire 151 days after the yet-to-be-determined end of the COVID-19 public health emergency.
CNS and AANS Support GME Funding in Budget Reconciliation Legislation
On July 18, the CNS and the AANS joined the Graduate Medical Education (GME) Advocacy Coalition letter urging congressional leadership to include additional Medicare-supported GME training positions in the budget reconciliation package. Based on current estimates, the U.S. faces a shortage of up to 124,000 physicians by 2034. The letter acknowledged that Congress made a critical initial investment in the physician workforce by providing 1,000 new Medicare-supported GME positions in the Consolidated Appropriations Act, 2021 (P.L. 116-260). However, this was the first such increase in nearly 25 years, and more funding is needed.
Click here to read the GME Advocacy Coalition’s letter.
CNS and AANS Urge Congress to Address Medical Student Debt
On July 15, the CNS and the AANS signed a letter calling on Congress to address the high student loan debt facing physicians by adopting the Resident Education Deferred Interest (REDI) Act (S. 3658/H.R. 4122). The bipartisan REDI Act would allow borrowers to qualify for interest-free deferment on their student loans while serving in a medical internship or residency program.
Click here to read the letter.
Neurosurgery Urges Congress to Explore Problem of Long COVID
On July 14, the CNS and the AANS joined a coalition letter to Congressional leaders urging Congress to explore the growing issue of long COVID. Specifically, the groups asked the Senate Health, Education, Labor and Pension Committee and House Energy and Commerce Committee to convene hearings to examine such topics as:
- Definitions and language around long COVID;
- Research, data collection and surveillance opportunities;
- Diversity in research and disparities in care;
- Educating medical professionals and patients about long COVID; and
- Guidance for clinical treatment and care coordination across primary and specialty care providers.
Click here to read the coalition letter.
House Passes Pediatric Medical Research Legislation
On July 27, the U.S. House of Representatives passed the Gabriella Miller Kids First Research Act 2.0 (H.R. 623). This legislation extends funding for this pediatric disease research program within the National Institutes of Health (NIH). Funding is provided by certain penalties assessed by the Securities and Exchange Commission against pharmaceutical companies. In making allocations from the fund, the NIH must prioritize pediatric research that does not duplicate existing research activities.
Senate Releases Health Spending Bill Reflecting Neurosurgery’s Priorities
On July 28, the U.S. Senate Appropriations Committee released its draft fiscal year 2023 appropriations bill for the Departments of Labor, Health and Human Services, Education and Related Agencies. The legislation funds several of neurosurgery’s priorities, including:
- $700 million for the Brain Research through Advancement Innovative Neurotechnologies Initiative;
- $385 million for the Children’s Hospitals Graduate Medical Education Payment Program;
- $15 million for the Pediatric Subspecialty Loan Repayment Program;
- $60 million for firearm injury and mortality prevention research;
- $148 million for heart disease and stroke research and prevention;
- $23 million for traumatic brain injury; and
- $10 million for the Military and Civilian Partnership for Trauma Readiness Grant Program (also known as the MISSION ZERO program).
Click here for the bill, here for an explanatory statement and here for a summary.
Coding and Reimbursement
Appropriate Use Criteria Program Penalty Phase Delayed
On July 7, CMS announced that the agency is indefinitely delaying the penalty phase of the Appropriate Use Criteria (AUC) Program for advanced diagnostic imaging. The program requires physicians ordering advanced diagnostic imaging for Medicare beneficiaries to consult AUC and communicate specific AUC information to the rendering physician, who must then attach the AUC information to the imaging claim to be paid. CMS had previously announced that it would begin penalizing physicians who failed to consult with AUC beginning with the first January after the end of the COVID-19 public health emergency. Given the ongoing challenges CMS is facing with implementation and costs and hassles associated with compliance, this delay is welcome news for neurosurgeons.
Earlier this year, the CNS and the AANS joined more than 40 national medical specialty societies in urging CMS to reassess the program as part of a report the agency is preparing for Congress. In addition, the neurosurgery delegation to the American Medical Association (AMA) collaborated with the radiology associations and others on updated AMA policy related to the program. The new AMA policy states:
Our AMA will advocate to Congress and the Centers for Medicare & Medicaid Services (CMS) to delay implementation of and advance modifications to the Medicare Appropriate Use Criteria (AUC) Program in such a manner that exempts care mandated by EMTALA, adequately addresses technical and workflow challenges that add to clinician’s administrative burden and practice expenses, maximizes alignment with the Quality Payment Program (QPP), and creates provider flexibility for the consultation of physician-developed, evidence-based and transparent AUC or advanced diagnostic imaging guidelines using a mechanism best suited for their practice, specialty and workflow.
The CNS and the AANS will continue advocating for Congress to repeal or modify the program.
Neurosurgery Responds to HHS RFI on Strengthening Primary Care
On June 27, the HHS Office of the Assistant Secretary for Health issued a Request for Information (RFI) seeking input from the public about innovations, models, solutions to barriers and other actions that may strengthen primary care. On Aug. 1, the CNS and the AANS responded to the RFI. The group’s pointed out that policymakers “should be driving towards a well-functioning health care system that meets the needs of all patients,” and while primary care may be a critical foundation of our health care system, patients also need timely access to quality specialty care.” The letter stressed that timely access to neurosurgical and other specialty care saves lives and function. Moreover, focusing on improving primary care in isolation will prevent HHS from achieving its stated goals.
The neurosurgical societies also joined the Alliance of Specialty Medicine in responding to the RFI. Echoing similar themes, this letter recommends that HHS strengthen, rather than weaken, the partnership between primary care and specialty care physicians.
Click here to read the CNS and the AANS letter and here for the Alliance of Specialty Medicine’s letter.
MedPAC 2022 Data Book on Health Care Spending and the Medicare Program Released
On July 19, the Medicare Payment Advisory Commission (MedPAC) released its 2022 data book on health care spending and the Medicare program. The publication provides data on Medicare spending, demographics of the Medicare population, beneficiaries’ access to care and quality of care in the program, among other information.
Click here to access the 2022 MedPAC data book.
Drugs and Devices
2021 Open Payments Data Released
On June 30, CMS published the 2021 Open Payments Program data and newly submitted and updated payment records for previous program years. The Open Payments program collects and publicly reports information annually about payments that biopharmaceutical and medical device companies make to physicians and teaching hospitals for items such as travel, research, gifts, speaking fees and meals.
Click here to access the data.
Guidelines
Review of Cervical Degenerative Disease Treatment Announced
On July 21, the Agency for Healthcare Research and Quality (AHRQ) announced that its Effective Health Care Program is interested in receiving supplemental evidence and data for a systemic review on cervical degenerative disease treatment. This topic was nominated by the CNS, which published guidelines on managing cervical degenerative disease in 2009. According to the announcement, the new systemic review will inform the development of updated guidelines from the CNS. The AHRQ also asks for information on operative versus nonoperative management of cervical degenerative disease.
Click here for more information.
Of Note
President Biden Appoints Neurosurgeon to Cancer Moonshot Panel
On July 13, President Joseph R. Biden, Jr. appointed Mitchel S. Berger, MD, FAANS, to the Cancer Moonshot panel. Dr. Berger — former chair of the Department of Neurosurgery at the University of California San Francisco — will advise the president on opportunities for reducing the burden of cancer. In February, President Biden announced a series of new steps to “reignite” the Cancer Moonshot initiative, with the goal of “ending cancer as we know it” by halving the number of cancer deaths in the United States in the next 25 years.
HHS Physician Burnout Advisory Report Released
On May 23, the U.S. Surgeon General released an advisory report titled “Addressing
Health Worker Burnout: The U.S. Surgeon General’s Advisory on Building a Thriving Health Workforce.” The report notes that the COVID-19 pandemic not only intensified work demands and long working hours but also added new challenges in unprecedented ways. Notably, the report states that if health worker burnout is not addressed, it will be harder for patients to get care when needed, causing health costs to rise and worsening health disparities. The report cited prior authorization as a contributing factor to physician burnout.
Click here to read the full report.
ACP Releases White Paper on Care Coordination
Recently, the American College of Physicians (ACP) released a paper outlining steps that can be taken to improve care coordination. Maya A. Babu, MD, MBA, FAANS, represented the CNS and the AANS in the ACP workgroup that developed the paper. Titled “Beyond the Referral: Principals of Effective, Ongoing Primary and Specialty Care Collaboration,” the document outlines four guiding principles that should underpin primary care and specialty care collaborations:
- Patient and Family Partnering: Clinical care teams should work collaboratively with patients, families and caregivers to empower them to be active partners in all aspects of their care. Their needs, preferences and limitations should be actively predicted, solicited and considered in all care encounters and decisions.
- Defined Clinical Roles and Responsibilities: The roles, responsibilities and mutual expectations of primary care and specialty care team members should be clear and acceptable to all parties, including the patient and family.
- Timely, Productive Communication: All parties should engage in timely, informative and focused communication with one another that highlights critical issues and/or items needing action.
- Effective Data Sharing: Patient data should be shared in a timely, thorough, actionable and well-organized manner.
Communications Updates
CNS/AANS Washington Committee Publishes Op-Ed on Prior Authorization
On June 25, MedPage Today published an op-ed by John K. Ratliff, MD, FAANS, a neurosurgeon and chair of the CNS/AANS Washington Committee. Titled “Prior Authorization Is Hurting Our Patients,” Dr. Ratliff discusses how prior authorization is hurting patients and how bipartisan legislation in Congress, The Improving Seniors’ Timely Access to Care Act (H.R. 3173/S. 3018), can help address these problems in Medicare Advantage. On July 14, Neurosurgery Blog published a cross-post to amplify the message.
Neurosurgeon Recounts Accident Resulting in a Spinal Cord Injury
On June 15, MedPage Today published an op-ed by David J. Langer, MD, FAANS, a neurosurgeon and cast member of the Netflix series Lenox Hill. Dr. Langer recounts a life-changing ski trip accident that resulted in a spinal cord injury and a feeling of powerlessness. His excellent care after the accident now reminds him to keep patients’ humanity front and center. On June 30, Neurosurgery Blog published a cross-post highlighting Dr. Langer’s experience.
Pediatric Neurosurgeon Publishes Op-Ed on Gun Violence
On June 23, Time published an op-ed by pediatric neurosurgeon John “Jay” Wellons, III, MD, FAANS. In “If Our Politicians Could See What We See: A Pediatric Neurosurgeon on Gun Violence,” Dr. Wellons recounts his experience treating a patient hit in the skull by a bullet fired into a crowded playground. He notes, “As surgeons, we find ourselves left trying to fix the ghastly results of so much of this gun violence that seems endemic in our country.” On July 25, Neurosurgery Blog published a cross-post amplifying Dr. Wellons’ message.
Neurosurgery Leadership Featured in Article on Gun Safety Legislation
On June 24, the CNS and the AANS issued a press release praising Congress for passing the Bipartisan Safer Communities Act (S. 2938 (117)). Subsequently, Becker’s Spine Review published an article titled, “Neurosurgeons laud Congress for passing gun safety legislation,” featuring Nicholas C. Bambakidis, MD, FAANS, president of the CNS and Ann R. Stroink, MD, FAANS, AANS president. This legislation will expand background checks, restrict certain individuals from owning guns and provide incentives for states to enact “red-flag” programs.
CNS/AANS Washington Committee Chair Featured in Articles on Medicare Payment Cuts
Following a Surgical Care Coalition press release, on June 8, Becker’s ACS published an article titled, “Physicians balk at ‘devastating’ Medicare proposed pay cuts.” The article featured John K. Ratliff, MD, FAANS, a neurosurgeon and chair of the CNS/AANS Washington Committee. In response to the recently released proposed 2023 Medicare Physician Fee Schedule, Dr. Ratliff stated, “Once again, we are facing another year of devastating cuts to a Medicare system that is already ill-equipped to meet the needs of millions of Americans.”
On July 15, MedPage Today published an article titled, “Medicare’s Proposed Physician Fee Schedule a Mixed Bag, Doc Groups Say.” The piece highlights Dr. Ratliff’s concern that the proposed 2023 Medicare Physician Fee Schedule does not properly value post-operative visits that surgeons provide during the global surgery period. Dr. Ratliff noted that the “non-surgeon is getting more reimbursement for the follow-up visit than a proceduralist would for the same work being done during the global period.”
Neurosurgery Blog Highlights its 500th Post
For the past decade, Neurosurgery Blog: More Than Brain Surgery has investigated and reported on how health care policy affects patients, physicians and medical practices. Posts have discussed the state of neurosurgical sub-specialties and promoted key health care policy and advocacy initiatives that ensure patients’ timely access to care, improve neurosurgical practice and foster continued advancement of neurological surgery. The most popular blogs and focus series showcasing the current state of neurological surgery are included in a post titled “Our 500th Blog Post: Amplifying Neurosurgery’s Voice”.
Neurosurgery Blog Continues Tumor Series
Neurosurgery Blog continued to publish new blogs in its tumor series. Partnering with the CNS/AANS Joint Section on Tumors, the tumor series provides an update on the state of the subspecialty and highlights current issues. Read the latest article in the series, “Neurosurgical Oncologists: Pushing the Field Forward,” by Michael Lim, MD.
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