The Alliance Advocates Relief from Regulatory Burden to Improve Patient Care
In July, the House Ways and Means Health Subcommittee announced a new initiative aimed at delivering relief from regulations and mandates under the Medicare program that stand in the way of delivering better care for Medicare beneficiaries. Under the multi-stage Medicare Red Tape Relief Initiative, the Committee is seeking to identify opportunities to reduce legislative and regulatory burdens on Medicare providers.

Under the first stage, the Committee asked for feedback regarding:
  • How Congress can deliver statutory relief from the mandates established in law through legislative authority, and
  • How Congress can work with Health and Human Services (HHS), and Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma to deliver regulatory relief through administrative action.
The Alliance of Specialty Medicine has been active in identifying burden and recommending solutions to provide relief from mandates facing specialists, not only in the Medicare program but also across federal health care programs more broadly. In response to this call for feedback, the Alliance prepared 11 submissions addressing burdens established under both regulatory and statutory mandates. These addressed the following topics, listed in priority order:
  • Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Transition Policies
  • Sunset Quality Programs - Physician Quality Reporting System (PQRS), Electronic Health Record (EHR) Incentive Program, and Value-Based Payment Modifier
  • Drug Compounding
  • Prior Authorization
  • MIPS Adjustments to Part B Drugs
  • Delaying 2015 Edition Certified Electronic Health Record Technology
  • Imaging Appropriate Use Criteria (AUC) Program
  • Narrow Networks
  • Program Integrity Initiatives
  • Two Midnights Rule
  • MIPS Virtual Groups
These submissions are focused on Medicare requirements that have a significant and often disproportionate impact on specialists and subspecialists. For example, several of the submissions address requirements that affect physician payment under the Merit-Based Incentive Payment System (MIPS), which was established under MACRA. In its submissions, the Alliance called on Congress to provide greater flexibility to the Secretary regarding MIPS scoring to ease the transition to MIPS, ensure that MIPS payment adjustments do not apply to Part B drugs, prevent the application of inappropriate standards regarding the use of certified EHR technology, and increase flexibility in determining which clinicians and groups can align to form Virtual Groups for MIPS reporting. These changes would increase CMS’ ability to accurately assess clinicians and adjust payments on the care they deliver.

The Alliance also sought relief from burdensome programs, given the need to focus on preparation for MIPS. For example, the Alliance requested relief from penalties under legacy physician reporting and quality programs, including PQRS, the EHR Incentive Program, and the Value-Based Payment Modifier. The Alliance also requested that Congress terminate the Imaging Appropriate Use Criteria (AUC) Program, which is excessively burdensome and duplicative of MIPS in seeking to promote high quality, efficient care.

Other submissions focused on issues that prevent access to specialty care, including narrow plan networks and restrictions on in-office drug compounding, as well as barriers that prevent clinicians from fully exercising their clinical judgment, including prior authorization and the Medicare Two Midnights rule for inpatient admissions. The Alliance also requested administrative relief from CMS’ duplicative, non-transparent, and overly punitive approach to program integrity through the adoption of concrete steps that would increase certainty and reduce burden for clinicians, while also allowing CMS to continue protecting against fraud, waste, and abuse.

As a whole, these recommended changes will increase access to care, as well as provide clinicians greater ability to apply their clinical judgement and focus on the delivery of high-quality care for patients, rather than worry about paperwork, administrative barriers, and potentially significant payment reductions.

The Committee requested that feedback on this first stage be provided by August 25, 2017. Under Stage 2, the Committee will host roundtables with stakeholders across the country to continue conversations and identify solutions. Finally, Stage 3 will entail Congress taking action based on feedback from stakeholders.

The Alliance of Specialty Medicine looks forward to ongoing engagement with the Committee as this initiative progresses in order to support specialists and their patients.

Alliance Advocacy Fly In. July 16th-18th, 2018. Liaison Hotel, Washington, DC

NOTE: Participation in Alliance events is by invitation-only, with some exceptions. To learn more about how you or your organization can participate, please contact your organization's staff liaison to the Alliance or email us at info@specialtydocs.org.


"Let Physicians Treat the Patient - Not the Potential Lawsuit" The Hill.
- June 14, 2017.

Specialty Docs: Front and Center for Healthcare Debate
Over one hundred specialty physicians from across the country came to Washington this summer as part of the Alliance of Specialty Medicine’s annual Legislative Fly In. For three days, these providers, representing a dozen different medical specialties, heard from and spoke to health policy officials and elected leaders about legislative and regulatory matters affecting their practices and their patients.

Ironically, the timing of the Fly In coincided with the Senate’s back-and-forth debate on repeal and replacement of the Affordable Care Act. On the very day of some key (and at times heated) decision making on this issue, the Alliance’s speaker roster included Rep. Kevin Brady (R-TX), the Chairman of the House Ways and Means Committee, Senator Rand Paul (R-KY) and Tom Price, then Secretary of the Department of Health and Human Services. As leaders in the debate on healthcare, each of them brought very distinctive views on the Affordable Care Act.

Both Senator Paul and Secretary Price were practicing physicians before they turned to public service. Senator Paul was an ophthalmologist and Secretary Price an orthopedic surgeon. The Alliance also heard from two other doctors-turned-Congressmen in Rep. Raul Ruiz (D-CA), an emergency room physician, and Rep. Phil Roe (R-TN) an OB-GYN. They are two of the fifteen physician members of the United States Congress - a reflection of how the debate around the future of our country’s healthcare system has made the provider community more politically active.

The Alliance was also provided very timely updates from Rep. Gene Green (D-TX) the senior Democrat on the House Subcommittee on Health; Dr. Jonathan Jarow, a senior medical advisor from the US Food and Drug Administration, and Rick Dearborn, the White House’s Deputy Chief of Staff for Legislative and Governmental Affairs. However, it wasn’t all dry policy discussions - as Fox News personality Tucker Carlson entertained everyone with a very colorful and humorous presentation on Washington’s current political climate and culture.

In conjunction with the speaker presentations, each Alliance doctor spent an afternoon on Capitol Hill to meet with their Members of Congress and Senators (or their staffs) to advocate for legislative proposals such as medical liability reform, measures to address physician workforce shortage, repeal of the Independent Payment Advisory Board and reform of the US Preventative Services Task Force. For the providers who couldn't come to Washington, the Alliance held a “Twitter Town Hall” on these issues and both their hashtags #ASMChat and #SpeciatyDocs received a combined ten million impressions on Twitter!

The Alliance Fly In is an annual event and we look forward to the return of our doctors in the summer of 2018 - just months before a very important Congressional election!

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Congressional Committees Approve Increase for NIH Funding
There is strong bipartisan support on Capitol Hill to increase the National Institutes of Health (NIH) budget, despite proposals from the Trump administration to cut funding from the institutes. The current fiscal year expires on Oct. 1, but Congress passed a three-month temporary spending bill to fund the government until Dec. 8. Congress needs to address the funding bill in December along with increasing the debt ceiling, two must-pass items.

The Senate Appropriations Committee approved their fiscal year 2018 Labor, Health and Human Services (HHS), Education bill, which included $36.1 billion for NIH, a $2 billion increase over last year’s levels, amounting to a nearly 20 percent increase. The Labor, HHS, Education appropriations bill is the largest domestic spending bill and funds our nation’s health programs and agencies, such as the Centers for Disease Control (CDC) and the Food and Drug Administration. The House Appropriations Committee also approved their version, which included a $1.1 billion increase to NIH funding.

Earlier this year, President Trump proposed $7.5 billion in cuts to NIH, as well as a cap of 10 percent on the amount of support the government would provide to research institutions for indirect costs, such as utilities, maintenance and other costs to support the facilities. Congress rejected this cap and included specific language in the bills to prevent the administration from capping indirect costs.

The Senate Appropriations Committee bill includes many areas of interest to GI and includes report language that American Gastroenterological Association (AGA) supported for gastrointestinal (GI) research:
  • IBD. Encourages CDC to conduct an epidemiological study of inflammatory bowel disease (IBD) and to focus on increased incidences in minority and underserved communities. Also, encourages the National Institute of Diabetes and Digestive and Kidney Diseases to continue to focus IBD research on environmental triggers and epigenetics, and urges the NIH Director’s office to utilize the Common Fund to study the cause of increased prevalence of IBD.
  • Gastric Cancer. Gastric cancer research is less advanced than many other cancers. The bill encourages the National Cancer Institute (NCI) to develop a scientific framework for advancing stomach cancer research given that the five-year survival rate remains 30 percent.
  • Deadliest Cancers. Many of the deadliest cancers, defined as those whose five-year survival rates are less than 50 percent, are GI cancers, such as pancreas, liver, stomach and esophageal. The bill urges NIH and NCI to continue to support research with an emphasis on developing improved screening and early detection tools and more effective treatments for these cancers.
  • National Commission on Digestive Disease Research. The committee requested an update on the implementation of the National Commission on Digestive Disease Research recommendations that were published in 2009.
AGA members were on Capitol Hill for their Advocacy Day on Friday, Sept. 15, to ask Congress for increased NIH funding and encourage support for the $2 billion increase for NIH that was included in the Senate appropriations bill. They are pleased that Congress recognizes the value in NIH research and how it helps improve patient care, increase our nation’s economic competitiveness and enhance the quality of life for all Americans.

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Ensuring Adequate Pediatric Trauma Care
Pediatric trauma — a severe and potentially life-threatening or disabling injury to a child resulting from an event such as a motor vehicle crash or a fall — is the leading cause of death and disability for children in the U.S. More children die of traumatic injury each year in the U.S. than from all other causes combined, with brain injuries being the most common specific cause of death and disability.

Access to timely care is critical in the prevention of death and disability after injury. Only 57 percent of the 73.7 million children in the U.S. during the period 2011-2015 lived within 30 miles of a pediatric trauma center capable of treating all injuries regardless of severity across the spectrum of care; additionally, there is a significant variability between states in this statistic, ranging from above 75 percent to less than 25 percent. In areas without pediatric trauma centers, injured children may have to rely on adult trauma centers or less specialized hospital emergency departments for initial trauma care. Having well-developed trauma systems is therefore critical to provide access to timely neurosurgical and other surgical care, transfer to next-level centers after stabilization and treatment of immediately life-threatening injuries, and provision of specialized services such as rehabilitation after injury.

It is important to note the difference between an organized trauma system and the identification and maintenance of trauma centers. A trauma system is an integrated system involving multiple components of care, which may be organized on a state, regional, or county level, depending on demography, geography, epidemiology, and governmental or regulatory demands. The mature trauma system includes: pre-hospital management and transport; acute care in hospitals; aftercare in rehabilitation hospitals, physician offices and clinics, and the like; community reintegration programs at home, school, and work; quality improvement mechanisms across this continuum; education and research; and epidemiologically-driven prevention programs based upon regional injury patterns. The maturity of trauma systems and the ways in which they are organized is highly variable across the U.S., and rural areas face particular challenges across the spectrum of care. Caring for injured children is incredibly complex, requires specialized knowledge and equipment, and access to specialty physicians. Because most children die or have permanent disability after trauma from injuries to the brain, involvement of neurosurgeons in not only medical and surgical care, but also in the thoughtful development of systems of care, is crucial.

Children are not just “little adults.” Due to several differences that exist between the developing immature brain and the mature adult brain, the impact of injury is different for infants and children. Mechanisms of injury are also different, owing to age-related activities. Therefore, considerations related to acute care and recovery also vary.

Because of these differences, special attention at all levels of care is essential — particularly in neurotrauma — and systems must address the uniqueness of children and their injuries. Furthermore, since injuries are occurring in a developing brain, and most research is done in mature adults, there is a great deal of research to be done on the impact of various forms of therapeutics in children. These research advancements may also help to establish mechanisms for treatment and restoration of function after common adult brain injuries not only from trauma but other processes such as stroke, Alzheimer’s, Parkinson’s, and others.

There are many challenges to be faced and opportunities for improvement in organization and delivery of pediatric trauma care. These include:
  • ensuring adequate and appropriate pre-hospital care for all infants and children;
  • providing access to specialty physicians and pediatric trauma centers;
  • offering continuing medical education and training for providers at all levels;
  • funding research for pediatric traumatic injuries;
  • implementing epidemiologically targeted prevention programs;
  • evolving appropriate age- and development-related outcomes measures; and
  • identifying patient-specific rehabilitation plans and executing them in home environments over the long-term.
As an example of challenges faced in pre-hospital care, one unique challenge is that many emergency medical service vehicles are not fully equipped for pediatric transport. Space for equipment is restricted on both air and ground ambulances, which results in limited availability of all sizes of pediatric airways, cervical spine immobilization devices, and other vital equipment. Furthermore, many emergency responders have limited experience with managing pediatric airways, requiring more frequent education, simulation training, and practice in non-clinical settings. Since airway compromise is a leading cause of preventable death, this is particularly important.

Neurosurgical care is often lifesaving for children suffering from head trauma and brain injuries, and all neurosurgeons are trained to care for injured children, especially in the surgical removal of blood clots that may compress the brain and the prevention and stabilization of brain swelling. Pediatric neurosurgeons have additional training in many aspects of care as relates to infants and children and may assume care from non-specialized neurosurgeons after initial stabilization. Likewise, some neurosurgeons specialize in neurotrauma and neurocritical care and are trained to care for brain injury at all ages. The key is to provide neurosurgical access to all of our population for those time-dependent interventions that save lives, and subsequent sophisticated neurocritical care and neurorehabilitative care to minimize secondary injury and maximize the potential for recovery. This can occur in a variety of configurations and neurosurgeons are actively engaged in designing and implementing trauma systems.

However, there is work to be done to provide universal timely and high-quality access to pediatric trauma care through ongoing systems development and support.

To this end, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) have been founding partners in efforts to establish and promote the efforts of the Congressional Pediatric Trauma Caucus. Representatives from organized neurosurgery, including P. David Adelson, MD, FAANS, and AANS president-elect, Shelly D. Timmons, MD, PhD, FAANS, have participated in several Congressional briefings convened by caucus co-chairs Reps. Richard Hudson (R-N.C.) and G.K. Butterfield (D-N.C.). These events have highlighted the challenges facing pediatric trauma patients and the need to find bipartisan solutions to ensure adequate trauma care for children. As part of this overall effort, the Government Accountability Office (GAO) was tasked with examining various issues related to pediatric trauma. Leaders from the pediatric neurosurgery community provided input to the GAO, including a white paper on pediatric neurotrauma. The resulting GAO report, titled “Availability, Outcomes,and Federal Support Related to Pediatric Trauma Care,” will serve as the basis for future efforts to improve pediatric trauma systems.

Our nation’s children deserve the best we have to offer so that they can have every chance of surviving and recovering when they get hurt. America’s neurosurgeons stand at the ready to provide care and to help make vital improvements in our delivery systems.

This post originally appeared on Neurosurgery Blog which is a publication of The American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS). It was authored by Clemens M. Schirmer, MD, a neurosurgeon from Wilkes Barre, Pennsylvania and Shelly D. Timmons, MD, a neurosurgeon from Hershey, Pennsylvania.

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ASDSA Kicks Off New Skin Cancer Screening Initiative
The American Society for Dermatologic Surgery Association (ASDSA) took advantage of the summer recess in Washington to kick off its Congressional In-District Skin Cancer Screening program. During a Health and Wellness Fair being held by Rep. Brad Schneider (D-IL), ASDSA members provided free skin cancer screenings to constituents, along with sunscreen samples and helpful information about sun-safe behavior. Feedback from Rep. Schneider’s office was overwhelmingly positive, with 80% of attendees finding the fair helpful. Deputy Director Greg Claus stated that ASDSA had one of the best booths and that if skin cancer was caught in one attendee "then this was a major success."

Many thanks to ASDSA members Amy L. Brodsky, MD (pictured, with Rep. Schneider), and Cynthia Abban, MD, PhD, for volunteering their time to provide screenings. If you know a Member of Congress who would be interested in hosting a skin cancer screening, email advocacy@asds.net.

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Mohs Surgeon Underscores Value of Specialty Physicians in Aftermath of Hurricane Harvey
Even though Hurricane Harvey did immeasurable damage to the Metro Houston area, the collective efforts of first responders and members of national and local specialty medical societies displayed compassion for community and hope for recovery.

Dr. Tri Nguyen is a dermatologist and Mohs surgeon with Texas Surgical Dermatology. He visited shelters and conducted primary care triage of displaced residents approximately a week after Hurricane Harvey hit. It soon became evident that his expertise would be best utilized assisting those first responders affected by exposure to flood waters.

Nguyen scheduled three-hour visits at five central fire stations in the metro Houston area. First responders from satellite stations were invited to make appointments during these scheduled visits, and those with rashes and other common ailments were diagnosed and treated. Those without immediate medical conditions were provided free skin cancer examinations. Equipped with an assortment of medical samples and two teenage daughters for support and assistance, Nguyen was able to effectively triage, diagnose and treat almost 50 first responders.

Specialty doctors are encouraged to form a relationship with their local medical society; it is often through these groups that physicians are best able to navigate local infrastructure and provide the most meaningful support in times of crisis. Similarly, the American College of Mohs Surgery reached out to members within 100 miles of Houston to offer support.

First responders are vital to efficient and effective disaster response, however, they too may require medical attention. While early intervention is critical to treatment in the aftermath of natural disasters and other crises, any help is deeply appreciated. Their individual ailments aside, the displaced residents and firefighters Nguyen met were grateful that someone was looking out for their well-being as they grappled with devastation, loss, and uncertainty, he said.

"Mohs surgeons are not impotent in moments of crisis" said Nguyen. "We aren’t primary care physicians, but there is a need for specialists in times of crisis. We can do good after disasters."

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Join the most powerful group of specialty physicians!
Joining forces with specialty doctors from across the country helps amplify the concerns specialty doctors share. By working together, specialty medical organizations can work more effectively to influence health care policy and ensure our primary goal: to continue to provide our patients the optimal care they need. As a part of the non-partisan umbrella organization representing all of specialty medicine, your organization will:

  • Promote specialty specific issues as part of a larger coalition, increasing visibility and understanding of issues.
  • Help increase exposure for specialty medical care.
  • Gain access to insider information, background materials and research on health policy initiatives and the political landscape.
  • Receive expert analysis on proposed legislation.
  • Caucus with other specialty organizations at the AMA House of Delegates and other forums to promote key issues that are important to specialty physicians.
  • Coordinate physician and patient grassroots efforts through a large and robust network.
  • Participate in future Alliance Fly-In events in Washington, D.C. Past events have included Capitol Hill visits and presentations by health policy experts.
For information on joining the Alliance of Specialty Medicine, visit our website at www.specialtydocs.org or contact Vicki Hart at vhart@hhs.com

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