On Call: The Newsletter of the Alliance of Specialty Medicine

Summer 2021

Specialtydocs Head to the Hill (Virtually)

The Alliance of Specialty Medicine made the most of COVID protocols to hold its 2nd Virtual Advocacy Day.  Over 100 specialists from across the country opened their laptops and tablets to talk healthcare policy with over a dozen Members of the House and Senate.  Dr. M. Anthony Sofia, Assistant Professor of Medicine Division of Gastroenterology and Hepatology at Oregon Health and Science University, attended the advocacy day and offered to share his perspective:

I was happy to be among the 10 AGA members that joined our specialty physician colleagues with the Alliance of Specialty Medicine for a successful virtual congressional fly-in.

Each congressional meeting began with the member of Congress discussing their positions on various policy issues and efforts to advance health care reforms. Following their remarks, each lawmaker heard questions directly from the group. Ten of the 13 we met with are physicians themselves and many of these members of Congress sit on a congressional committee that has jurisdiction over health care issues.

We advocated for:

Furthermore, every legislator heard that the expansion of telehealth during the public health emergency has been an invaluable tool that will remain vitally important long after the public health emergency.

Members of Congress need to hear directly from specialists about the priorities that can best improve our patients’ lives. Like American Gastroenterological Association’s (AGA) Advocacy Day, the Alliance fly-in allows direct exposure to the thoughts of elected officials and offers the ability to personally address each member about matters we all face in practice. The unified voices of the AGA and the Alliance bridge differences in medical specialties to raise congressional awareness of these issues

Alliance Joins the Fight Against Retroactive Denials of E.R. Coverage

The Alliance of Specialty Medicine wrote to Brian Thompson, the CEO of United Healthcare, to protest his proposed (and since withdrawn) policy that would have retroactively denied coverage for emergency care. While this policy may have been an attempt to curb costs by eliminating unnecessary emergency room visits, the majority of the medical community, patients and doctors alike, saw the real danger in an insurance company reserving the right to deny coverage of a trip to the E.R. after the fact.

Patients often head to the hospital emergency department precisely because they don’t have the expertise to determine whether a medical issue needs immediate care.  Accordingly, Congress established the “prudent layperson” standard into federal law.  This standard requires insurers to cover care in situations where a “prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in […] placing the health of the individual (or a pregnant woman or her unborn child) in serious jeopardy,” among other listed outcomes. By definition, any retroactive review that relies on “intensity of diagnostic services performed,” as the new UHC policy would, violates the prudent layperson standard since few laypersons have the benefit of diagnostic services at home to evaluate whether their medical emergency requires immediate attention.

In its letter to Thompson, the Alliance noted, “The UHC policy clearly seeks to look at the final outcome or diagnosis and deny the emergency claim based thereon, which violates the letter and the spirit of the critical patient protections contained in the [prudent layperson] standard.”

The Alliance was proud to be one of several medical societies and healthcare advocacy groups to call out UHC on their shortsighted proposal to place their bottom line over a patient’s access to care especially in an emergency setting. Unfortunately, specialists and other providers are regularly enduring extensive pre-approval requirements to treat their patients due to insurers’prior authorization and step therapy policies.

AUA Continues to Address Specialty Physician Shortages

New GME slots are necessary in the long-term; adding rural specialists are needed in the near-term

COVID-19 has brought to light numerous challenges facing our country’s healthcare delivery system. None more important than the need for additional federal investment in our healthcare infrastructure, and in particular the need for more physicians. As a result, the American Urological Association (AUA) is taking a unique approach to this critical issue by closely examining student loan debt and incentivizing specialty care in certain parts of the country.

In late 2020, Congress finally recognized the physician workforce dilemma by providing 1,000 new Medicare-supported graduate medical education (GME) positions in the end-of-the-year Consolidated Appropriations Act. It was the first increase of its kind in nearly 25 years. Unfortunately, far more needs to be done in expanding the physician workforce to ensure patients have access to the care they need. According to the Association of American Medical Colleges (AAMC), the United States will face an overall shortage of up to 139,000 physicians by 2033 – with rural parts of the country especially impacted. In fact, the Health Resources & Services Administration (HRSA) has stated that 252 rural counties are currently without a single health care provider. This aligns with specific census data from specialties such as urology, in which a practicing urologist can only be found in 38 percent of all U.S. counties.

Overall, the AUA is represented by more than 15,000 domestic members, which totals more than 90 percent of all board certified urologists in the country. Long before the pandemic, the organization placed a high priority on addressing the workforce shortage in all urologic access practice environments mainly due to significant declines in the number of urologists per capita and the average age of a practicing urologist makes the specialty one of the oldest in the medical profession.

Indeed, continuing to add more GME slots is a necessary piece to the puzzle of having enough physicians to meet increasing demand. However, the current existential crisis facing many Americans is the shortage of urologists and other specialists in rural areas of the United States. With 1/5 of Americans living in a non-urban region and only 11 percent of physicians practicing in those same areas, access to preventive measures and lifesaving treatments is severely limited for millions of U.S. citizens. Further exacerbating the workforce shortage particularly for specialties such as urology, nearly 54 percent of urology residents have more than $150,000 in student loan debt, and for approximately 27 percent of them, the figure is $250,000 or more. Not surprisingly, a recent AUA survey showed that 70 percent of those residents will base their decision on where to practice – in part – on programs that can offer some form of student loan forgiveness or repayment. This puts rural hospitals and practices at a disadvantage, as most cannot afford to offer such incentives.

As a result, the AUA has begun to actively work with members of Congress on new legislation that would encourage urologists and other specialty medicine physicians to practice in rural communities by creating a student loan forgiveness program for these important providers. Earlier this year, Representatives David McKinley (R-WV-01) and Peter Welch (D-VT-At Large) introduced H.R. 944 to authorize the U.S. Department of Health and Human Services to provide urologists and other qualified specialty medicine physicians the opportunity to have a portion of their eligible student loans repaid by the federal government in exchange for practicing in a rural community experiencing a shortage of specialty medicine physicians.

The required period of service is six years of full-time employment with no more than one year passing between any two-year period of employment. The loan repayment for each year of service would be 1/6 of the principal and interest on each eligible loan (which is outstanding on the date the service started). The remaining principal and interest on any loans is paid upon completion of the sixth and final year of service. The total amount of repayments cannot be more than $250,000. And, the bill defines a specialty medicine physician as a physician whose specialty has a baseline projected demand that exceeds its projected supply, as identified in HRSA’s report on the physician workforce, “The Physician Workforce: Projections and Research into Current Issues Affecting Supply and Demand”.

Now that legislation has been introduced, building support across the specialty medicine spectrum is vital to successfully advocating for this issue before the U.S. Congress. The AUA recorded a podcast with Rep. McKinley in an effort to educate its own members – particularly residents and fellows – so they can become grassroots champions of the measure. The AUA also was proud and very fortunate to partner with its colleagues in the Alliance of Specialty Medicine to feature workforce/GME during the virtual June fly-in where dozens of specialists were able to meet with members of the House and Senate. Moving forward, the AUA is committed to garnering additional support from provider and patient advocacy organizations alike.

Specialty physicians are faced with unprecedented challenges in providing appropriate medical care to their patients. As member organizations, we must continue to fight on their behalf by promoting policies that allow them to practice to the best of their abilities.

CSRO Helped Stall Most Favored Nation Rule

Biden Administration Waits on Congress to Enact Drug Pricing Reform 

       

In December 2020, the Centers for Medicare and Medicaid Services (CMS) released an interim final rule implementing the “Most Favored Nation” (MFN) pricing scheme for Medicare Part B drugs.

Many in the rheumatology community were deeply concerned with the language that was presented, which left lots of questions unanswered. How would new reimbursement rates be calculated? Which rheumatology drugs would be included? How would biosimilars be treated? Who must participate? What is the bottom line for practices?

Working on behalf of the rheumatology community, the Coalition of State Rheumatology Organizations (CSRO) was successful in sharing these concerns with CMS, joining a lawsuit that effectively secured a court ordered injunction and ultimately delayed the rule from being implemented.

The Biden administration has subsequently announced plans to scrap MFN, but is still eager to address drug pricing.  While laying out his framework this month, he will nonetheless let Congress work through their plans before issuing any new drug pricing demonstrations. Back in April, the House Democrats filed H.R. 3 (The Elijah E. Cummings Lower Drug Costs Now Act) and this summer Senate Finance Chairman Ron Wyden (D-OR) outlined his framework for addressing the cost of prescription drugs.  Wyden’s framework overlaps considerably with H.R. 3.

In response, the CSRO issued a letter to Speaker Pelosi’s office that expressed concerns that providers who administer medications in their offices may be left underwater. Additionally, the Part B Access for Seniors and Physicians (ASP) Coalition, of which CSRO is a member, shared further concerns for unintended access problems that H.R. 3 establishes.

CSRO’s federal government affairs team is actively monitoring this issue and will provide updates to members as they are available.

SPECIALTY SPOTLIGHT:   Stronger Together – Surgery and Osteopathic Manipulative Treatment

by Gerard. A. Baltazar, D.O., FACOS, FACS

 

In a country starkly divided on issues ranging from politics to public health, providing osteopathic manipulative treatment (OMT) to surgical patients can build cultural bridges among the medical community and the public.  At first glance, surgery and OMT may seem antithetical to each other. Surgeons use ever-advancing technologies to disrupt the body, taking something out, putting something in, or repairing tissues. In contrast, OMT aims to optimize the body’s functions as an intact whole by adjusting its structure through the art of touch. However, when applied together, these treatment approaches yield benefits that demonstrate the value of unity and may help push our culture towards diversity and progress.

A growing body of scientific evidence suggests that OMT in the perioperative period may effect positive changes in outcomes. Trials following patients after gynecologic1 and orthopedic2 surgery found that adding preoperative OMT improves postoperative pain. Goldstein et al1 demonstrated that the combination of preoperative morphine and OMT results in the least postoperative morphine required after total abdominal hysterectomy. Barral et al2 showed that preoperative OMT decreased visual analog pain scores (VAS) and decreased use of both morphine derivatives and non-opioid analgesics after total knee arthroplasty. In addition, Mills et al3 published a case series describing how OMT may assist with post-cholecystectomy pain.

Evidence also suggests that OMT may improve postoperative return of function. Jarski et al4 added OMT after lower extremity arthroplasty and noted significantly faster negotiation of stairs and further ambulatory distance. Slezsynski and Kelso5 compared OMT lymphatic pump to incentive spirometry after cholecystectomy, concluding both are “effective in preventing postoperative atelectasis,” providing a potential alternative for patients unable to perform incentive spirometry. Multiple studies report that the use of OMT after gastrointestinal operations is associated with earlier return of bowel function and decreased length of stay.6-8 Early reports from an OMT rib-raising and postoperative ileus randomized controlled trial (RCT) are encouraging,9 despite pending final results.10

Further, application of OMT after cardiothoracic surgery is associated with improved hemodynamics and return of bowel function and mobility.11-13 O-Yurvati et al11 measured distinct benefits in thoracic impendence and mixed venous oxygen saturation by providing OMT after coronary artery bypass graft. In a RCT, Racca et al13 compared 40 post-sternotomy patients who received postoperative OMT to a control group who did not. The cohorts were similar across all pre-enrollment comparators, and investigators noted significant improvements in the OMT cohort: VAS at discharge was lower, inspiratory volume higher, and hospital length of stay shortened.

Trauma is another realm of surgical care for which OMT has demonstrated value. A series of recent studies suggest OMT may play a unique role in brain and spinal cord injury management.14-18 Yao et al15performed a RCT showing improvement in concussion symptoms with OMT compared to concussion education. Kashyap et al17 found intriguing evidence that OMT may help optimize glial lymphatic clearance of cerebrospinal fluid. The combination of OMT and pharmacologic management improved long-term pain among spinal cord injury patients better than either pharmacy or OMT alone18—this study thus reinforces how integration of osteopathic principles and practice (OP&P) into standard trauma care may be most advantageous.

Some authors have explored trauma’s effects on the body and mind and the impact of manual treatments on both,19-21 proposing a fascinating avenue for translational trauma surgery research. In their book, Trauma: An Osteopathic Approach,19 Drs. Barral and Croibier examine the physiologic underpinnings of trauma from a perspective based on palpation. In The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma,20 Dr. van der Kolk offers insight from a psychiatric perspective into the interconnectedness of physical and psychoemotional trauma, noting that he “encourage[s] all [his] patients to engage in some sort of bodywork.” Translating the concept of mind-body connection into clinical OMT, Schwerla et al21 found that patients who suffered whiplash injury, after starting an OMT program, experienced decreased pain as well as improvements in quality of life measures and lowered incidence of patients meeting criteria for post-traumatic stress disorder.

In light of these positive data and noting a deficit of well-designed research on OMT and surgery, Drs. Sposato and Bjersa, in their qualitative review, identified “an urgent need to evaluate OMT in [the surgical] context of care and with a proper research approach.”22 In fact, some allopathic residencies have already successfully integrated OP&P into their programs,23-25 and the recently-established, single-accreditation system for residency training is an opportunity to increase exposure of trainees to OP&P. This opportunity combined with funding availability for OP&P research26-27 could help meet the need for studies of OMT in the surgical field.

Among medical colleagues and the public at large, there is a tendency to dichotomize ideas as good or bad, and the M.D./D.O. dichotomy is not immune to this. During the summer of 2020, the media erupted with criticisms of osteopathic physicians after former President Trump’s personal physician was noted to be a Doctor of Osteopathic Medicine (D.O.). High-profile celebrities opined on social media, making comments that the President’s physician not being an M.D. was “way beyond negligence” and that an osteopath is “1/2 step above Doogie Howser.” Some medical colleagues also joined the bandwagon and criticized D.O.s as inferior doctors. A noted cancer researcher so far as to comment that all D.O.s should be added to a list of doctors “one should never ever consult.” Such caricatures of D.O.s create public discord and feed into misinformation as well as stymie medical cultural progress and research. In fact, President Biden named, Kevin O’Connor, DO, as the White House Physician earlier this year.

The evolving literature of OMT for surgical patients suggests that the best outcomes for our patients may be achieved, not by exclusion of ideas and practices, but by desegregating the knowledge and skills of the M.D. and D.O. professions. Most consider a surgeon’s hands to be the most sensitive and talented among medical specialists: surgeons palpate and diagnose subtle physical examination findings to guide major clinical decisions and employ fine dexterity to manipulate tissues in the operating room. Thus, training such skilled hands to treat with OMT may lead to the best outcomes for surgical patients. Even if surgeons are not the primary providers of OMT, research suggests that integration of OP&P into the surgical standard of care may support well-being. Perhaps, most importantly, the integration of surgery and OMT, seemingly opposed medical practices, may bring the medical community and the public one step further away from a culture of division and one step closer to an inclusive modern America.

Dr. Baltazar is a Trauma and Critical Care Surgeon based in New York. 

REFERENCES

  1. Goldstein FJ, Jeck S, Nicholas AS, Berman MJ, Lerario M. Preoperative Intravenous Morphine Sulfate With Postoperative Osteopathic Manipulative Treatment Reduces Patient Analgesic Use After Total Abdominal Hysterectomy. J Am Osteopath Assoc. 2005;105(6):273-9.
  2. Barral P, Klouche S, Barral N, Lemoulec Y-P, Thes A, Bauer T. Preoperative Osteopathic Manipulative Therapy Improves Postoperative Pain and Reduces Opioid Consumption After Total Knee Arthroplasty: A Prospective Comparative Study. J Am Osteopath Assoc. 2020;120(7):436-445.
  3. Mills M, Sevensma K, Serrano J. Osteopathic Manipulative Treatment for a Recognizable Pattern of Somatic Dysfunction Following Laparoscopic Cholecystectomy. J Am Osteopath Assoc. 2020 Oct 1;120(10):685-690. doi: 10.7556/jaoa.2020.111.
  4. Jarski RW, Loniewski EG, Williams J, Bahu A, Shafinia S, Gibbs K, Muller M. The effectiveness of osteopathic manipulative treatment as complementary therapy following surgery: a prospective, match-controlled outcome study. Altern Ther Health Med. 2000;6(5):77-81.
  5. Sleszynski SL, Kelso AF. Comparison of thoracic manipulation with incentive spirometry in preventing postoperative atelectasis. J Am Osteopath Assoc. 1993;93(8):834-838.
  6. Baltazar GA, Betler MP, Akella K, Khatri R, Asaro R, Chendrasekhar A. Effect of osteopathic manipulative treatment on incidence of postoperative ileus and hospital length of stay in general surgical patients. J Am Osteopath Assoc. 2013 Mar;113(3):204-9. Erratum in: J Am Osteopath Assoc. 2013 Apr;113(4):271.
  7. Crow WT, Gorodinsky L. Does osteopathic manipulative treatment (OMT) improves outcomes in patients who develop postoperative ileus: A retrospective chart review. Int J Osteopath Med. 2009;12(1):32-7.
  8. Herrmann EP. Postoperative adynamic ileus: its prevention and treatment by osteopathic manipulation. The DO. 1965;6(2):163-4.
  9. Polman J. “The Efficacy of Rib Raising for the Treatment of Post-Operative Ileus.” https://www.academia.edu/32452310/The_Efficacy_of_Rib_Raising_for_the_Treatment_of_Post-Operative_Ileus. Accessed July 6, 2021.
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  17. Kashyap S, Brazdzionis J, Savla P, Berry JA, Farr S, Patchana T, Majeed G, Ghanchi H, Bowen I, Wacker MR, Miulli DE. Osteopathic Manipulative Treatment to Optimize the Glymphatic Environment in Severe Traumatic Brain Injury Measured With Optic Nerve Sheath Diameter, Intracranial Pressure Monitoring, and Neurological Pupil Index. Cureus. 2021 Mar 11;13(3):e13823. doi: 10.7759/cureus.13823.
  18. Arienti C, Dacco S, Piccolo I, Redaelli T. Osteopathic manipulative treatment is effective on pain control associated to spinal cord injury. Spinal Cord. 2011;49:515-519.
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  26. “AOA Research Grants.” https://osteopathic.org/life-career/osteopathic-research/research-grants/grant-opportunities/ Accessed July 7, 2021.
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