August 2022 AUA Public Policy Council Update For MAS

I am pleased to share updates from the AUA Public Policy Council that may benefit your Section members. Our updates include information on advocacy to mitigate cuts to physician reimbursement as outlined in the 2023 Medicare Physician Fee Schedule Proposed Rule and legislative updates on telehealth, prior authorization, and workforce issues.

2023 AUA Gallagher Health Policy Scholar Application Open

The AUA’s Gallagher Health Policy Scholar Program application opened on August 8. The Gallagher Scholar Program is open to AUA physician members who demonstrate a commitment to or have deep interest in the field of health policy. Scholars receive mentoring from seasoned physician volunteers and participate in key meetings, conferences and public policy activities. The AUA provides a stipend and previous Gallagher Scholars have gone on to become chairs of the Public Policy Council, Science and Quality Council, AUAPAC, and reporting committees.

Learn more about the program and reach out to Juliana Nicolini at jnicolini@AUAnet.org with any questions or for more information. The application window closes on October 14.

AUA Reviews Proposed 2023 Fee Schedule, Urges Congress to Mitigate Cuts to Physician Reimbursement

The AUA joined the Clinical Labor Coalition’s statement to Congress calling attention to the proposed significant cuts in physician reimbursement within the 2023 Medicare Physician Fee Schedule (MPFS) Proposed Rule. The letter points out the disproportionate impact on community-based office settings providing specialty care, such as urology. The reimbursement cuts are further exacerbated by a 4.5% reduction in the Medicare conversion factor, which is the basis for calculating Medicare payments. The second year of Centers for Medicare & Medicaid Services’ (CMS) implementation of the clinical labor pricing update, which was finalized in the CY2022 MPFS rule, impacts reimbursement as well. These cuts will disrupt patient access to care, particularly in community-based settings where critical care is provided to underserved populations.

The AUA met with CMS in August 2021 expressing deep concern that these updates could be potentially dramatic and unpredictable given other cuts occurring to provider payment (e.g., the Medicare conversion factor), as well as the lack of regular updates to the inputs (CMS has not updated clinical labor rates since CY 2002). The AUA urged CMS to consider a four year phase-in period with the first year as a hold-harmless period, as well as more regular and predictable direct PE input updates going forward. The AUA explained that specialties that perform procedures with high supply and equipment input costs, such as urology, would be disproportionally impacted by the current section as written.

The AUA, Clinical Labor Coalition, and other national medical associations recognize the need for increased salary rates for all types of clinical labor. However, the rise in practice expense, as a result of an increase in clinical labor rates, leads to a decrease in reimbursement rates for services with high supply and equipment costs in a community-based setting.

The statement urges Congress to mitigate forthcoming reimbursement cuts, add new funding to the MPFS and provide greater stability within the MPFS. The AUA will continue to identify policies to reform the Medicare physician payment system, specifically to protect the urology community.

In addition, on July 27, the AUA joined 32 other medical and dental organizations, including the Alliance of Specialty Medicine, to send a letter to Senate Finance, House Ways & Means, and House Energy & Commerce Committee leadership urging them to take action to mitigate the scheduled cuts proposed in the 2023 Medicare Physician Fee Schedule. The letter highlights alleviating the 4.5% Medicare conversion factor reduction as the starting point to help reduce the financial instability physicians are still facing.

The letter states, “These year-over-year cuts clearly demonstrate that the Medicare physician payment system is broken. Systemic issues such as the negative impact of the MPFS’s budget neutrality requirements and the lack of an annual inflationary update will continue to generate significant instability for health care professionals moving forward, threatening beneficiaries’ timely access to essential health care services.”

The AUA will continue working independently and with other like-minded physician groups to reduce the impact of payment cuts on the practice of urology and patient access. Please contact the AUA’s Director of Policy & Advocacy Ray Wezik, JD at rwezik@AUAnet.org for a copy of the letters.

AUA Seeks Senate Cosponsor for SPARC Act: Take Action Now!

On July 11-13, the AUA met with staff in the offices of Senators Cindy Hyde-Smith (R-MS) and Shelly Capito (R-WV) to discuss cosponsorship of the Specialty Physicians Advancing Rural Care (SPARC) Act (S. 4330). During the meetings, the senators’ staff were empathetic about the burden student loan debt places on a specialty physician’s decision about where they will practice. This line of thinking led the staff to be receptive to the loan repayment program and show an interest in supporting the legislation. They cited both healthcare and economic benefits to their respective states as reasons for possibly supporting the SPARC Act.

On July 21, the AUA met with staff in the office of Senator Lisa Murkowski (R-AK) to discuss co-sponsorship of the Specialty Physicians Advancing Rural Care (SPARC) Act (S. 4330). During the meetings, the senator’s staff was empathetic about the lack of access to healthcare a shortage of specialty physicians creates in Alaska. However, they feel that having constituent support would help increase the likelihood that Senator Murkowski will support the legislation. The AUA will work to facilitate a follow-up meeting between the Senator and her constituents on this matter.

On July 27-28, the AUA met with staff in the offices of Senators John Boozman (R-AR) and Joe Manchin (D-WV) to discuss co-sponsorship of the Specialty Physicians Advancing Rural Care (SPARC) Act (S. 4330). During the meeting, Sen. Boozman’s staff acknowledged that the SPARC Act is within the jurisdiction of other issues the senator supported and the legislation would increase access to care and support the physician workforce.

Additionally, Sen. Manchin’s staff was empathetic about the need for a program that helps alleviate specialty physicians’ student loan debt and decisions about where they will practice. The senator’s staff also understood that such a program would help increase access to care in rural areas throughout the country, especially in West Virginia.

As a reminder, this legislation would establish a loan forgiveness program designed for specialty physicians who practice in a rural area for six years—help advocate for the SPARC Act by contacting your U.S. Senators to ask them to cosponsor this legislation. Take Action Now!

ICYMI: Updates from the AUA Policy & Advocacy Brief blog

AUA, ASM Promote Telehealth, Workforce, and Medicare Reimbursement Priorities in RFI to Health and Human Services

The AUA joined the Alliance of Specialty Medicine (ASM) in responding to a Request for Information (RFI) from the U.S. Department of Health and Human Services (HHS) regarding an initiative to strengthen primary health care. The AUA and the Alliance of Specialty Medicine included information on the role of specialists in primary care, making COVID-19 telehealth flexibilities permanent, supporting the physician workforce and improving the Medicare payment system.

The letter urges HHS to support the partnership between primary and specialty care, particularly as it relates to ensuring continuity of care. The AUA and ASM urge HHS to consider requiring federally regulated health plans to expand their networks and establish network adequacy standards to increase access for patients in need of specialty care. Narrow-network provider plans hinder effective coordinated care and limit specialty and subspecialty physicians available for physician referrals.

The letter also

• Urges HHS to work with Congress to establish permanency for many telehealth flexibilities authorized during the COVID-19 public health emergency.
• Urges HHS to work with state Medicaid programs and private payers to adopt policies similar to that of traditional Medicare and reimburse providers at the same rate as face-to-face services.
• Urges support of the Resident Physician Shortage Reduction Act (S. 834/H.R. 2256) to address workforce shortages in specialty care by improving the Graduate Medical Education system and increasing Medicare-supported residency slots.
• Calls for stabilized Medicare physician payments and improvements to the Quality Payment Program (QPP) to offer more clinically relevant participation pathways for specialists.

The Alliance of Specialty Medicine represents more than 100,000 specialty physicians across 15 specialty and subspecialty societies. The AUA is a foundational member of the Alliance and works to align specialty physicians on issue important to urology. For a copy of the letter, please contact the AUA’s Director of Policy & Advocacy Ray Wezik, JD at rwezik@AUAnet.org.

AUA Urges Congress to Support Specialty Physician Workforce via Crucial Legislation

On July 18, the AUA joined 32 other medical and dental organizations in urging the leadership of the Senate Health, Education, Labor, and Pensions Committee and the House Education & Labor Committee to enact a long-term legislative solution to address the high student loan debt many physicians face. The Resident Education Deferred Interest (REDI) Act, S 3658/H.R. 4122 is one of the proposed legislative solutions. In its letter, the organizations highlight that the bill would prevent medical and dental residents from being penalized during residency and save them thousands of dollars in interest. The AUA remains deeply concerned about the impact growing student loan debt has on the shortage of urologists in rural America.

The AUA also joined the Graduate Medical Education (GME) Advocacy Coalition to send a letter to House and Senate leadership urging them to include policies in the forthcoming budget reconciliation legislation to increase Medicare support for GME residency slots.

The AUA and the GME Advocacy Coalition feel Congress must invest in future physicians to replenish the physician workforce. The AUA is committed to advocating for continued investment in the healthcare workforce through, among other things, additional funding for GME.

Addressing the ongoing physician workforce shortages in urology is a legislative priority for the AUA. The AUA will continue promoting bills such as the REDI Act and work with other stakeholders to improve the future of the physician workforce. Please contact the AUA’s Vice President of Legislative & Political Affairs Brad Stine at bstine@AUAnet.org for a copy of the letters.

U.S. House Passes Telehealth Expansion Legislation

On July 27, the U.S. House of Representatives voted 416-12 to pass H.R. 4040, the Advancing Telehealth Beyond COVID–19 Act of 2022. The bill would ensure telehealth flexibilities available during the COVID-19 Public Health Emergency continue until at least December 31, 2024. It will continue Medicare flexibility around geographic requirements and originating sites, will allow additional practitioners to provide telehealth services, extend payment for Federally Qualified Health Centers and Rural Health Clinics, allow audio-only telehealth services to continue, and allow recertification of eligibility for hospice care. H.R. 4040 now moves to the Senate for further deliberation. As you know, telehealth expansion was a congressional “ask” during the 2022 Annual Urology Advocacy Summit and remains an important issue as we emerge from the COVID-19 pandemic. The AUA will continue to advocate in support of telehealth expansion, including audio-only services, as the measure progresses through Congress.

AUA Supports Legislation to Reduce Prior Authorization Requirements

On July 28, the AUA joined the Alliance of Specialty Medicine in a letter to the sponsors of H.R. 7995, the Gold Card Act of 2022, formally endorsing the Gold Card Act. The bill expedites the prior authorization process in the case of physicians for whom at least 90% of their requests submitted to a plan in the preceding year were approved. The AUA and its coalition partners remain committed to finding and supporting legislation solutions that reduce the regulatory burden on urologists and help accelerate care that may be delayed because of prior authorization. Please contact the AUA’s Vice President of Legislative & Political Affairs Brad Stine at bstine@AUAnet.org for a copy of the letters.

House Ways & Means Passes Prior Authorization Legislation

On July 27, the House Ways & Means Committee voted unanimously to pass H.R. 8487, the Improving Seniors’ Timely Access to Care Act of 2022. This measure would establish several requirements and standards relating to prior authorization processes under Medicare Advantage (MA) plans, such as real-time decisions for services routinely approved and annual reports detailing prior authorization information including the average response time.
H.R. 8487 now moves to the full House for further deliberation. The AUA will monitor and continue to advocate in support of this important legislation. The AUA remains committed to mitigating prior authorization and other barriers to patient care in an effort to promote practice sustainability during the public health emergency and beyond.

ACES Act Language Included in National Defense Authorization Act

On July 14, the U.S. House of Representatives passed the National Defense Authorization Act (NDAA) for Fiscal Year 2023. This legislation was amended to include the Aviator Cancer Examination Study (ACES) Act. The ACES Act would direct the Secretary of the Veterans Affairs to work with the National Academies of Sciences, Engineering, and Medicine to study the incidence and mortality of cancer among individuals who served as aviators or aircrew members in the Navy, Air Force or Marine Corps.

In May, Legislative Affairs Committee member Eric Biewenga, MD flagged this legislation because prostate cancer was reported at a much higher incidence rate for fighter pilots and their crew.

The House-passed NDAA measure now moves to the U.S. Senate for further deliberation. The AUA will continue to monitor this legislation and advocate in support of this important provision when possible.

Senate Passes Medicare Negotiation Bill

On, August 7, the U.S. Senate passed the Inflation Reduction Act, a keystone piece of legislation meant to fulfill promises by Democrats to address inequities in the healthcare system, climate and taxes. Negotiation by Medicare for the cost of prescription drugs is a centerpiece of the bill. This provision, if signed into law, will allow Medicare to negotiate drug prices starting in 2026 for the top ten high-cost, most-used drugs, and expand to 20 drugs by 2029. Starting in 2025, Medicare beneficiaries will also have their out of pocket costs capped at $2,000 annually. The bill will penalize drug manufacturers if the cost of their treatments for Medicare beneficiaries outpaces inflation.

The AUA continues to express concerns with the development of the top drug costs list as a potentially burdensome provision that could leave urologists in the middle of negotiations between industry and government. The AUA will continue to review the potential side effects of this bill and seek to address those concerns with legislators.

Informational: HHS and DOJ Issue Guidance on Nondiscrimination in Telehealth

The U.S. Department of Health and Human Services (HHS) and Department of Justice (DOJ) issued guidance on the protections in federal nondiscrimination laws requiring that telehealth be accessible to people with disabilities and limited English proficient persons on July 29, 2022.

The guidance will help healthcare providers better understand their nondiscrimination obligations and patients better understand their rights under federal law in this regard. The guidance provides examples of actions that may be discriminatory and describes steps that providers may need to take to ensure that health care offered via telehealth is accessible. The guidance also provides a list of helpful resources for both providers and patients.
The AUA advocates to expand access to telehealth services as an alternative healthcare delivery model in urology to address access to care and healthcare equity.

Below are insurance updates from national insurance carriers. If you have questions about insurer issues, contact Bhavika Patel at bpatel@AUAnet.org.

Aetna

Aetna reviewed its Tumor Markers (Commercial) Policy removing detailed criteria for prostate-specific antigen (PSA) for prostate cancer screening. Read the update.

Aetna reviewed its Benign Prostatic Hyperplasia (PA Medicaid) Policy updating CPT code descriptors and references. Read the update.

Cigna

Cigna reviewed its Xtandi Dispensing Limit (CA Commercial) Quantity Limit (QL) Criteria updating override criteria for co-administration of Xtandi 80 mg tablets with strong CYP3A4 inducers. Read the update.

Humana

Humana reviewed its Benign Prostatic Hyperplasia (BPH) Treatments Policy adding transperineal laser ablation to coverage limitations section as experimental/investigational and non-covered code 0714T. Read the update.

Palmetto

Palmetto released its draft Prognostic and Predictive Molecular Classifiers for Bladder Cancer (MolDX) (JJ, JM) (DL38576) Local Coverage Determination. An open teleconference is scheduled for August 1. The comment period is currently open, and ends August 6. Read the update.

Palmetto retired its ConfirmMDx Epigenetic Molecular Assay (MolDX) (JJ, JM) (A56955) Local Coverage Article (LCA), effective July 3. This article is being retired because the information in this article has been incorporated within “Billing and Coding: MolDX Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer” (A58700) (L38985).
Read the update. (JJ, JM) (A56955)
Read the update. (JJ, JM) (L35632)

Palmetto issued a new version of its Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer (MolDX) (JJ, JM) (A58652) Local Coverage Article (LCA) with the following changes:

• Under CPT/HCPCS Codes group 1: codes added 81322, 81403, 81404, 81405, and 81406, and deleted 81321.
• Under CPT/HCPCS Codes group 2: codes added 81162, 81163, 81164, 81165, 81166, 81167, 81201, 81203, 81212, 81216, 81292, 81294, 81295, 81297, 81298, 81300, 81307, 81317, 81319, 81321, 81323, and 81351.
• Under CPT/HCPCS Codes group 2: paragraph added verbiage “These code(s) are non-covered”.

Read the update.

Palmetto retired its Progensa PCA3 Assay (A53107) Local Coverage Article (LCA), effective July 3. This article is being retired because the information in this article has been incorporated within “Billing and Coding: MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer” (A58700).
Read the update.

Noridian

Noridian released its draft Prognostic and Predictive Molecular Classifiers for Bladder Cancer (MolDX) Local Coverage Determination (LCD). The comment period is open, and ends August 27.

Read the update. (JE) (DL38647)
Read the update. (JE) (DL38647)

Local and Regional Updates

The following are updates in your Section. The AUA routinely monitors state legislative, regulatory, and insurance policy trends. Please contact AUA State Advocacy Manager Catherine Hendricks at chendricks@AUAnet.org for more information on any of these issues.

Delaware

Highmark BCBS Delaware

Highmark BCBS Delaware reviewed its Prostate Disease: Diagnosis, Staging, and Treatment Policy adding CPT code 0714T. Read the update.

District of Columbia

D.C. B 24-0917 – Medical Business
Introduced by Councilmember Elissa Silverman (I), D.C. B 24-0917 outlines the limitations of a non-compete agreement between an employer and physician. The agreement must specify the functional scope, including what services, roles, industry, or competing entities the employee is restricted from performing; the geographical limitations of the work restriction; and, if the employee is a medical specialist, the non-compete must not exceed 730 calendar days from the termination of employment. The agreement must be provided by the employer, in writing, 14 days prior to the individual beginning employment. The bill is before the Council for consideration.

Pennsylvania

Independence Blue Cross

Independence Blue Cross reviewed its Surgical and Minimally Invasive Treatments for Urinary Outlet Obstruction due to Benign Prostatic Hyperplasia (Commercial) Policy adding CPT code 0714T as experimental/investigational.
Read the update.

S.B. 818 – Medical Business ENACTED
Introduced by Senator Judy Ward (R), S.B. 818 seeks to allow certain ambulatory surgical facilities to seek an exception or waiver from the Department of Health (DOH) for surgical procedures not specified on the CMS Ambulatory Surgical Center Covered Procedures List (ASC-CPL) or otherwise as provided by law. The DOH will maintain the complete ASC-CPL on the department’s website. Governor Tom Wolfe (D) signed the bill into law on July 12.

New Jersey

Horizon BCBS New Jersey

Horizon BCBS New Jersey reviewed its ClaimsXten Editing Rules Reimbursement & Billing Document adding Evaluation & Management Edits subsection.
Read the update.

Best regards,
Kathy and the AUA Public Policy & Advocacy Team