Fall Finish – Specialty Docs Focus on Efforts to Curb Surprise Billing and Enhance MACRA
The Practice of Care: Neurosurgeons and the NFL Concussion Protocol
Specialty Spotlight: Mohs Surgeon Testifies in Congress on Prior Auth
ASE Foundation Unveils Normal Values Study at Paris Conference
Plastic Surgeons Weigh in on Prescription Drug Pricing Proposal
Fall Finish – Specialty Docs Focus on Efforts to Curb Surprise Billing and Enhance MACRA
Coming out of their successful July Legislative Fly In – where over 150 specialty physicians met and heard from federal health policy leaders – the Alliance of Specialty Medicine has been spending the fall months advocating for reforms related to surprise medical billing and for adjustments to the Medicare Access and CHIP Reauthorization Act or MACRA.
For the issue of surprise medical bills, the Alliance is working with Congress to develop consensus policy to address issues arising from out of network care (which can lead to surprise bills) and avoid unintended and harmful consequences for patients, providers, and the overall health care system. The Alliance urges that any legislation incorporate the following principles:
- Insurer accountability to ensure robust network adequacy standards including specialists and subspecialists;
- Limit patient responsibility to in-network rates and keep patients out of the middle, so payment negotiations are between the health plan and provider;
- Transparency so patients are informed in advance of potential out-of-network charges;
- Avoid setting a benchmark payment rate for out-of-network providers. If adopted, any benchmark payment rate must ensure market-based pricing, such as actual charge data for the same service in the same geographic area from a statistically significant and wholly independent database (e.g., FAIR Health);
- Independent dispute resolution to address payment disputes between health plans and providers; and
- Universality by ensuring that ERISA plans are also covered.
Of the legislative proposals currently under consideration, the Alliance supports HR 3502, the Protecting People from Surprise Medical Bills Act, introduced by Reps. Raul Ruiz (D-Calif.) and Phil Roe (R-Tenn.). You can find out more information about the Alliance’s position on our website.
On MACRA, the Alliance needs Congress to extend positive physician payment updates to the conversion factor, the Merit-based Incentive Payment System (MIPS) exceptional performance bonus and the Advanced Alternative Payment Models (A-APM) incentive payments. Currently, these positive payments are scheduled to expire at the end of 2019, and the MIPS exceptional performance bonus and A-APM incentive payments will expire at the end of 2022. Positive payment updates will help to ensure that Medicare fee-for-service (FFS) and the programs under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) continue to be viable options to ensure access to quality specialty care for all our patients.
The Alliance worked actively with Congress to develop MACRA as a replacement to the old Sustainable Growth Rate (SGR) program and create a more stable system to reimburse physicians who care for Medicare patients. The Alliance was grateful for Congress’ hard work in getting the MACRA law passed in 2015 and for the technical corrections made in 2018. Specialty physicians would like to continue to participate in MACRA, but the Alliance is concerned that recent proposals put forward by the Medicare Payment Advisory Commission (MedPAC), included in the President’s FY 2020 budget proposal, and recent comments by the Secretary and CMS Administrator that fee-for-service is “antiquated” are aimed at eliminating fee- for-service and transitioning physicians into primary care-focused A-APMs or evaluating them in large virtual groups on population-based measures that do not reflect specialty care. Fee-for-service (FFS) remains the most appropriate reimbursement structure for many specialists. Generally, specialists and sub-specialists treat specific diseases and organ systems, providing focused interventions that may include pharmaceutical, procedural, or surgical services. This specialization has led to efficient care delivery, eliminating variations in cost and quality for key conditions and related services. As a result, specialty care may not be well-suited for reimbursement models other than FFS.
To find out more information on the how the Alliance wants to ensure and grow specialist participation in MACRA, visit our website, where you can find our issue briefs, OpEds and Congressional testimony on this issue.
The Practice of Care: Neurosurgeons and the NFL Concussion Protocol
David Okonkwo, MD, PhD, FAANS; Joseph Maroon, MD, FAANS(L); Vincent J. Miele, MD, FAANS; John Norwig
Originally published in AANS Neurosurgeon: Volume 28, Number 3, 2019
American professional football is the epitome of a contact sport. Inherent in participation is the risk of concussion. Neurosurgery has played a central role in improving the safety of the game and fostering player health for more than 30 years. During that span, it has come into focus that sports concussions are not benign, require proper management and can potentially have long-term consequences. The increased awareness of concussion has caused a shift in behavior, leading to immediate removal followed by active treatment, and shortens the length of recovery.[1] To improve the diagnosis and management of concussions in its players, the National Football League (NFL) formed its Head, Neck and Spine Committee in 2010, initially co-chaired by neurosurgeons H. Hunt Batjer, MD, FAANS and Richard G. Ellenbogen, MD, FAANS. The committee developed and introduced a set of concussion assessment guidelines in 2013. The “Concussion Protocol” evolved into the current 2019 system of player management. This protocol guides player management both on and off the field by codifying procedures during games and practices, defining the roles of the medical and training staff and setting specific standards for return-to-play.
The NFL Concussion Protocol
Before each season starts, it is now mandatory that both players and team staff are educated on the importance of recognizing and reporting concussions. All players are also given baseline neurological and neuropsychological examinations. This baseline data includes an extensive concussion history for each player and aids in return-to-play decision making. While teams’ medical and coaching staff still play a primary role in identifying players who may have suffered injury, the Concussion Protocol created several new positions specifically designed to identify and refer players for evaluation. The first is the Unaffiliated Neurotrauma Consultant (UNC). As its name implies, this position is held by a physician impartial and independent from the team. At each NFL game, two UNCs monitor players from the sidelines to aid in identifying those who have potentially suffered a concussion and assist in their evaluation, while a third UNC is in the stadium booth to review video. The second position is the Booth Athletic Trainer-Certified (BATC). These ‘spotters’ are placed in stadium booths with access to multiple views of video and replay during all games to identify potentially concussed players and can call a “medical timeout” that temporarily stops play and removes the player for evaluation. The third additional position is the Independent Neurological Consultant (INC). The INC, also impartial and independent from the team, is utilized during the recovery period from a concussion and must confirm that the player has successfully completed the return-to-play protocol before release to full participation. A concussed player-patient is entered into this “Return-To-Participation Protocol,” during which he is monitored at least daily and advances through a stepwise progression of increasing activity. Players are disallowed from returning to participation until they have returned to baseline cognitive function and are asymptomatic at rest and during exertion.
Multi-Disciplinary Care for the Concussed Athlete
A multidisciplinary treatment team offers the most comprehensive approach to actively treating the clinical profiles associated with concussion.[2] In the past, concussions have been treated as a ‘one size fits all’, homogeneous injury, despite often identifying varying symptoms and manifestations across patients. The modern approach to concussion management defines different clinical profiles and recovery trajectories. Thorough, multi-domain assessment is warranted to properly identify concussion subtypes and management is multidisciplinary, involving team physicians (including neurosurgeons), training staff, the independent neurological consultant and neuropsychologists – at a minimum. Additional specialists, such as vestibular and vision therapists, are then added based on the patients’ clinical subtype. This approach allows active and targeted treatments that enhance recovery.[3]
The Integral Role of Neurosurgery
For over a century, neurological surgeons have been involved in the medical management of athletes.[4] This includes the direct treatment of injuries to the brain, spine and spinal column and peripheral nerves. Our specialty, unlike any other, can address pathology in all these areas of neurotrauma. Advancement in the science of brain and spinal cord injury has also been driven in large part by neurosurgical laboratories. Neurosurgeons have been instrumental in the development of treatment paradigms, including return-to-play guidelines and the acute management of severe brain and spinal cord injuries. From the development of modern neuropsychological testing to the first diagnosis of chronic traumatic encephalopathy, our specialty has led the way. The emphasis on player safety over the past decade has and will continue to allow us the opportunity to advance the science of concussion diagnosis and active management.
[1] Elbin, R. J., Sufrinko, A., Schatz, P., French, J., Henry, L., Burkhart, S., . . . Kontos, A. P. (2016). Removal From Play After Concussion and Recovery Time. Pediatrics, 138(3)
[2] Collins MW, Kontos AP, Okonkwo DO, et al. Statements of Agreement From the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015. Neurosurgery. 2016;79(6):912-929.
[3] Kontos AP, Collins MW, Holland CL, et al. Preliminary Evidence for Improvement in Symptoms, Cognitive, Vestibular, and Oculomotor Outcomes Following Targeted Intervention with Chronic mTBI Patients. Mil Med. 2018;183(suppl_1):333-338
[4] Stone JL, Patel V, Bailes JE. The history of neurosurgical treatment of sports concussion. Neurosurgery. 2014;75 Suppl 4:S3-S23
Specialty Spotlight: Mohs Surgeon Testifies in Congress on Prior Auth
Howard Rogers, MD, PhD, FAAD, FACMS, testified on behalf of the American Academy of Dermatology before the US House Committee on Small Business in September at a hearing entitled, “Utilization Management Barriers to Care and Burdens on Small Medical Practices”. Dr. Rogers’s testimony primarily focused on how prior authorization can delay necessary care for patients. American College of Mohs Surgery (ACMS) member, practicing dermatologist and Mohs surgeon for more than 19 years, Dr. Rogers also highlighted that extraordinary administrative and financial burden that prior authorizations create for physicians’ practices. Dr. Rogers explained that when performing Mohs surgery, the skin cancer removal typically does not require prior authorization; however, many insurers are now requiring prior authorization for the reconstruction of the resulting defect. As a result, patients may experience a significant delay in medical care resulting in worse outcomes. Dr. Rogers thanked Congress for permitting the use of the Standardized Electronic Prior Authorization Form, expressed his appreciation for the Patients and Communities Act, passed in October 2018 and urged support for H.R. 3107, the “Improving Seniors’ Timely Access to Care Act”. This bill, which has nearly 100 bipartisan cosponsors would reform prior authorization procedures in Medicare Advantage plans. You can watch the entire hearing here.
ASE Foundation Unveils Normal Values Study at Paris Conference
Alliance Newsletter copy October 2019
ASE Foundation Funded WASE Normal Values Study Presented as Late-Breaking Science at European Society of Cardiology Congress in Paris
Final data from the World Alliance Societies of Echocardiography (WASE) Normal Values Study was presented in September as a part of the late-breaking science at the European Society of Cardiology (ESC) Congress in Paris, France. The data presented focused specifically on 2D left ventricular dimensions, volumes, and function. The WASE Normal Values Study, which was launched in 2016, is unique in that it provides normal reference values of echocardiographic parameters in adults across a wide range of age, race, and ethnicity from 15 different countries. In contrast to previous studies, WASE included head-to-head inter-country and inter-race comparisons, in which all technical differences in data acquisition between regions were minimized and standardized by using state-of-the-art equipment and strictly following the 2015 ASE and European Association of Cardiovascular Imaging (EACVI) updated recommendations for chamber quantification. In addition, data analysis and interpretation were conducted uniformly by a core-laboratory at MedStar Health Research Institute and the University of Chicago.
Federico M. Asch, MD, FASE, MedStar Health Research Institute, Washington, DC, and Roberto M. Lang, MD, FASE, University of Chicago, Chicago, IL, served as co-Principal Investigators on this study. Dr. Asch, who presented the data at ESC, said, “The clinical usefulness of echocardiography is based on the detection of abnormalities, which relies on the accurate definition of “normality” across different countries or races. Currently, available echocardiographic ‘reference values’ that define ‘normality’ are mostly based on cross-sectional observations of Caucasians from the United States and Europe. The WASE study evaluated individuals from multiple countries and races with the aim of describing normative values that could be applied to the global community world-wide, and to determine differences and similarities among people from different countries and races. The current report focuses specifically on 2D left ventricular dimensions, volumes, and function.”
In total, 2008 subjects were enrolled in the study. The average age was 45, where 42.8% were of White race, 41.8% Asian, and 9.7% Black. Results indicated that left ventricular (LV) dimensions and volumes are larger in males, while left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) are higher in females. Global WASE normal ranges for LV dimensions were similar to those in the ASE/EACVI guidelines, but the upper limits of normal for LV volumes and the lower limits of normal for LVEF were higher in WASE study participants in all countries. Significant inter-country variation was identified for all left ventricular parameters reflecting LV size (dimensions, mass, and volumes) even after indexing to body surface area (BSA), with left ventricular end-diastolic volume and left ventricular global systolic function having the highest variation. The largest volumes were noted in Australia, while the smallest were measured in India for both genders. While there were no differences in LV size between individuals of White and Black race, the LV of Asians and Mixed (mostly Mexicans mix of White and native American) were smaller. However, within each race group, there were significant inter-country variations. This finding suggests that in addition to gender and BSA, specific country should be considered when evaluating LV volumes. Inter-country variation for LVEF and GLS was smaller, but still statistically significant. In conclusion, this study points out that current guideline-recommended normal ranges for LV volumes and EF should be adjusted. Inter-country variability is significant for LV volumes and therefore nationality should be considered for defining ranges of normality. A manuscript reporting these findings has been accepted for publication in the Journal of the American Society of Echocardiography will be published in November.
The WASE Normal Values Study was funded by the American Society of Echocardiography Foundation and its donors, and with generous in-kind support from MedStar Health, University of Chicago, TOMTEC Imaging Systems, and Medidata.
Plastic Surgeons Weigh in on Prescription Drug Pricing Proposal
The House Ways & Means Committee unanimously passed the Prescription Drug Sunshine, Transparency, Accountability, and Reporting (“STAR”) Act, a bipartisan effort to increase transparency and public reporting of information in the “opaque” prescription drug market. If enacted, the STAR Act is intended to address the high cost of prescription drugs and provide insight across the health care supply chain to ultimately reduce costs for families.
The American Society of Plastic Surgery (ASPS) recognizes that the rising cost of pharmaceuticals is an issue for both patients and providers. However, the Society joined with the Alliance of Specialty Medicine (Alliance) in taking exception to a section within the legislation that will require drug manufacturers to annually report the value and quantity of sample medications provided to physicians via the Open Payments database. This website and downloadable database displays payments and other transfers of value (historically defined as honoraria, royalties, consulting services, gifts, entertainment and travel or lodging) made from manufacturers to physicians.
The Alliance highlighted the flawed premise that drug samples are “transfers of value” to physicians in a letter sent to Congress. The member societies emphasized the benefits of free samples, including the temporary help they can provide while insurance coverage is being authorized, or when determining if a new treatment is effective or may have side-effects. The letter also urges Congress not to advance the STAR Act until reform is implemented to address insurers’ delay of treatment through step therapy, prior authorization, and other utilization management tools.
Following the submission of the Alliance’s letter, the coalition was invited by the House Energy and Commerce Committee to testify on the bill during a drug pricing transparency hearing on May 21, 2019. ASPS worked with the members of the Alliance in finalizing Madelaine Feldman, MD’s testimony to the Committee that praised the policies under consideration that would increase transparency in the drug supply chain, but suggested changes to the bill to avoid unintended consequences such as limiting patients’ access to free drug samples. (I will include a link to her testimony).
