Access to Specialty Care

Specialty physicians use their deep knowledge and expertise to reach a precise medical diagnosis, present the full array of available interventions, working with patients to determine which option is most appropriate based on their preferences and values, and coordinate and manage their specialty and related care until treatment is complete and the patient is ready to return to their primary care provider, if one is available. Nevertheless, there is an ongoing effort devalue the role of specialists in delivering comprehensive and effective management of complex health conditions to America’s most vulnerable patients.

The Alliance continues to weigh-in on regulatory proposals and initiatives that undercut the value of specialty medicine, providing recommendations and potential solutions to demonstrate that specialists are an essential and needed component of the healthcare system that can not be replaced by any other clinician, healthcare professional or provider type.


The Alliance appreciates CMS’s efforts to improve the Quality Payment Program (QPP) and reduce the burden of participation, as well as minimize the number of clinicians subject to negative payment adjustments. Nevertheless, specialty physicians continue to face unique challenges as they attempt to engage. For example, CMS’s “Meaningful Measures” initiative aimed at reducing the number of measures in its quality programs have limited the ability of specialists to meaningfully participate in the Merit-based Incentive Payment System (MIPS) as relevant measures have been eliminated.

The viability of the MIPS program is critical, as it is the only track that specialty physicians can engage in the QPP. Most existing Advanced Alternative Payment Models (AAPMs), including Medicare Accountable Care Organizations (ACOs), focus on primary care services and make specialty physician engagement a challenge.

The Alliance continues to work with the agency to improve MIPS and the availability of AAPMs and has made the following recommendations:

  • Provide participation data in MIPS, by specialty, as part of the annual notice and comment rulemaking for the QPP.
  • Remove the “all-or-nothing” aspect of the Promoting Interoperability (PI) category by allowing eligible clinicians to select from a menu of measures that are most appropriate for their practice and patient population.
  • Simplify MIPS scoring so eligible clinicians and practice staff can have a more accurate understanding of how success can be achieved given various levels of participation.
  • Provide participation data in APMs, by specialty, as part of the annual notice and comment rulemaking for the QPP.
  • ACO program:
    Establish pathways for specialists to meaningfully engage in the ACO program.
    Provide ACOs with technical assistance that would allow them to appropriately analyze clinical and administrative data, improving their understanding of the role specialists could play in addressing complex health conditions, such as preventing acute exacerbations of comorbid conditions associated with chronic disease.
    Establish requirements that prohibit ACOs from restricting specialist participation.
    Closely examine the referral patterns of ACOs and establish benchmarks that will foster an appropriate level of access to and care coordination with specialists, in addition to collecting feedback from beneficiaries on access to specialty care.
    Develop an ACO quality measure that would capture the percentage of physicians reporting to specialty-focused clinical data registries.
    Adopt specialty designations for non-physician practitioners to ensure specialty practices are not inadvertently forced into exclusivity.

Medical Liability Reform

The Alliance supports meaningful medical liability reform that reduces growth in health care costs, stabilizes professional liability insurance premiums, preserves access to specialty care, and encourages physician engagement in meaningful quality improvement activities.

Health Information Technology

The Medicare Access and CHIP Reauthorization Act (MACRA) emphasized the use of qualified clinical data registries (QCDRs), an significant health IT tool that is especially important for specialists looking to deepen their understanding of quality and performance for relevant episodes of care. As with quality measure development, specialty societies have invested significant resources to establish QCDRs with the goal of raising the bar in specialty medical care, as well as assist specialists with quality reporting activities. The data collected, and resultant information, has fueled important improvements in quality and resource use across many specialties, not to mention assisted some specialty societies with improving the content of their scientific conferences through the use of aggregate back-end data, benefiting their respective professions at the broadest level.

Despite these efforts, the Alliance remains concerned that QCDRs and other digital health tools are not easily interoperable with electronic health records (EHRs), making bidirectional exchange of key health information about patient care activities a challenge. While some improvements have been made to reduce regulatory burdens associated with other uses of EHRs as part of the new Promoting Interoperabiltiy (PI) category of the MIPS program, these do not address core issues facing specialty physicians.

The Alliance continues to review proposals put forward by the agencies responsible for addressing these issues and intends to make recommendations to resolve core issues.

Regulatory Burden

The Alliance of Specialty Medicine supports the bipartisan effort to improve the discovery, development and delivery that support continued innovation in our health care system. Specialty physicians encourage support for medical innovation that integrates the patient’s perspective into the regulatory process; facilitates responsible communication of scientific and medical developments; modernizes clinical trials; fosters the future of science, including encouraging young scientists; invests in advancing research; incentivizes the development of new drugs and devices for unmet medical needs; promotes interoperability; and supports 21st Century digital medicine by facilitating data sharing and the use of new technologies.

Utilization Management
  • Require transparency in utilization management practices by MAOs.
  • Issue guidance to MA plans consistent with the prior authorization practices endorsed by America’s Health Insurance Plans (AHIP) and Blue Cross/Blue Shield Association (BC/BSA).
  • Standardize MA prior authorization processes to minimize delays in patient care (i.e., finalize Attachment Standard and issue Model prior authorization forms).
  • Collect data on MA utilization management practices (i.e., denial, delay and approval rates) to hold plans accountable, and exercise ongoing oversight over MA plans.
Network Adequacy:
  • Require MA plans to accurately identify physician specialties and subspecialties when calculating network adequacy using the Healthcare Provider Taxonomy code set.
Quality Rating System (QRS):
  • Establish a Star Ratings measure that awards points to MA plans with an adequate network of specialty and subspecialty physicians based on the aforementioned Healthcare Provider Taxonomy code set.
  • Establish a Star Ratings measure that awards points to MA plans with an adequate network of physicians actively participating in the Medicare Quality Payment Program (QPP).
  • Develop a survey of physician’s experiences with MA plans.
    Collaborate with the Alliance to develop a domain of questions focused on specialty physician issues.
    Establish a Star Ratings measure that awards points to MA plans based on physician’s experiences with MA plans.
Regulatory Relief:

Require MA plans to:

  • Follow a standardized process for all medical record requests;
  • Clearly identify the nature of their medical record request (e.g., RADV, other purpose) and provide written documentation when requests are mandated as part of CMS-initiated audits;
  • Provide reasonable deadlines for medical record submissions, as well as a process for extending the submission deadline for extenuating circumstances;
  • Limit the number and volume of medical record requests (e.g., no more than once per year and no more than 20 records per physician);
  • Allow practices to submit medical records through a secure web-portal, on CD/DVD, or by fax, when possible; and
  • Reimburse practices for completing medical record requests at a rate no less than is set under State law.