December 2019 - 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 AUAPAC successes, the Annual Urology Advocacy Summit, and our efforts to finalize the 2020 Defense Appropriations Act. Our thanks to Drs. Jonathan Rubenstein and Mark Fallick for their generous individual donations to AUAPAC during the fall Health Policy Weekend meetings that were held at AUA headquarters in Linthicum, MD.
Gallagher Health Policy Scholar: Robert Bass, MD Named 2020 Scholar
Last week, the AUA announced that Dr. Robert Bass had been selected as the 2020 Gallagher Health Policy Scholar. Dr. Bass is the newest participant in this important, year-long program that provides intensive training on a wide range of health policy issues. He joins a long line of program participants who have gone on to be established advocacy leaders for urology, including our current Public Policy Council Chair Dr. Chris Gonzalez and Chair-Elect Dr. Eugene Rhee. Congratulations, Dr. Bass!
AUAPAC Update: AUAPAC Has Successful Inaugural Year
Due to the support of many AUA members, AUAPAC’s first year of existence was a banner one! The AUA was able to support 17 House and Senatorial candidates who champion issues important to the practice of urology. Eight of whom were practicing physicians before coming to Congress, including urologists and AUA members Reps. Neal Dunn and Greg Murphy.
Other supported lawmakers include members of the Appropriations Committee, the House Energy & Commerce and Ways & Means Committees, and the Senate Finance and Health, Education, Labor & Pensions Committees. The full list of AUAPAC-supported candidates in 2019 is as follows:
- Sen. Marsha Blackburn (R-TN)
- Sen. Mike Braun (R-IN)
- Rep. Michael C. Burgess, MD (R-TX-26)
- Sen. Bill Cassidy, MD (R-LA)
- Rep. Neal Dunn, MD (R-FL-02)
- Rep. Andy Harris, MD (R-MD-01)
- Rep. John Joyce, MD (R-PA-13)
- Rep. Robin Kelly (D-IL-02)
- Rep. David McKinley (R-WV-01)
- Greg Murphy, MD (R-NC-03)
- Rep. Phil Roe, MD (R-TN-01)
- Rep. Dutch Ruppersberger (D-MD-02)
- Rep. Markwayne Mullin (R-OK-02)
- Rep. Frank Pallone (D-NJ-06)
- Rep. Raul Ruiz, MD (D-CA-36)
- Rep. Bobby Rush (D-IL-01)
- Rep. Terri Sewell (D-AL-07)
If you would like more information on AUAPAC and its ongoing activities, please visit www.myAUAPAC.org.
2020 Annual Urology Advocacy Summit: Registration Launched; Draft Agenda Online
Registration is now open for the 2020 Annual Urology Advocacy Summit. There are nearly 100 registrants so far. Last year, more than 240 members of the urology community came to Washington, DC and we are anticipating the same number of attendees this year, so secure your spot today! Also, we are proud to say the Mid-Atlantic section has once again agreed to participate in the resident/fellow/young urologist “match” program, which provides stipend opportunities for our younger members to attend the summit – thus encouraging them to get engaged in health policy and advocacy earlier in their careers.
Now in its third year, the 2020 AUA Summit will feature several high profiles, keynote speakers, including Margaret Brennan – Moderator of “Face the Nation” and Senior Foreign Affairs Correspondent for CBS News – as well as a full day of meetings on Capitol Hill and/or at federal agencies in the area. A draft Summit agenda has been posted online and can be viewed here. The Mid-Atlantic Section will be discussing surprise medical billing issues as part of a larger panel discussion on hot-button state advocacy issues. MAAUA also will participating in a joint discussion on infertility with several other urology specialty organizations.
We look forward to welcoming all of AUA’s Mid-Atlantic participants to the Summit to complement our work at the federal and state level!
Local and Regional Updates
The following are updates in your Section. Please contact AUA Executive Vice President Kathleen Z. Shanley at kshanley@AUAnet.org for more information on any of these issues.
The following Highmark insurance updates cover Delaware, Pennsylvania, and West Virginia.
Highmark has revised the Treatment of the Prostate medical policy with the following changes to criteria and coding:
- Added transurethral incision of the prostate (TUIP) to the list of procedures that may be considered medically necessary when criteria are met.
- Added the following CPT code:
- 52450- Transurethral Incision of prostate.
Highmark Blue Cross Blue Shield has revised the Diagnosis and Treatment of Male Sexual Dysfunction medical policy with the following changes to criteria, & coding:
- Added the following as medically necessary:
- Vasodilator injection (e.g., papaverine, phentolamine, alprostadil)
- Vasodilator suppository (e.g., alprostadil)
- Collagenase clostridium histolyticum injection (e.g., Peyronie’s disease).
- Revised criteria for treatment of male sexual dysfunction with an internal penile prosthesis or an external device to no longer require consideration of a vacuum constriction device.
- Revised statement for nocturnal penile tumescence (NPT) testing to no longer state that NPT testing using the postage stamp test or the snap gauge test is rarely medically necessary.
SB 857 – Telemedicine
On October 30, Senator Elder Vogel (R) introduced SB 857. This bill defines and lays out requirements for telemedicine. This measure defines telemedicine as: “The delivery of health care services provided through telemedicine technologies to a patient by a health care provider who is at a different location. The term does not include a provider-to-provider consultation.” This measure also requires health insurance policies to cover telemedicine services.
On November 21, this measure passed the House Appropriations Committee. This measure is eligible to be sent to Governor Tom Wolf to be signed into law. This bill is available here: 11/18/2019 Version
HB 2110 – Medical Licensure
On December 9, Representative Morgan Cephas (D) pre-filed HB 2110. The measure stipulates that each person, upon applying for a license or certification issued by a health-related State board, shall submit documentation certifying that they have completed training regarding implicit bias and cultural competence in accordance with the continuing education requirements of the health-related State board in order to receive a license. At a minimum, the training shall include the understanding of implicit bias, including, but not limited to, practical techniques to mitigate implicit bias and improve cultural competence.
On December 9, this measure was pre-filed and referred to the House Professional Licensure Committee. This measure is eligible for a hearing at the discretion of the Chair. The bill is available here: 12/9/2019 Version
Capital Blue Cross has updated the Treatments of the Prostate medical policy with the following changes:
- Revised the following criteria for prostatic urethral lift procedure (Urolift):
- Removed requirement that the individual has a prostate-specific antigen (PSA) blood test that was performed within 12 months of the procedure; and resulted in a value of 2.5 ng/mL or less for individuals who are up to and including 60 years of age and 4.0 ng/mL or less for individuals who are over 60 years of age.
- Added criterion stating that if the individual has a diagnosis or history of prostate cancer, either the individual is not a candidate for surgical resection of the prostate but will be treated by radiation therapy and has symptoms that are so severe that immediate relief is required; or the individual is clinically in remission as evidenced by a PSA < 1.0 ng/mL.
- Removed the following CPT code:
- C9748- Transurethral destruction of prostate tissue; by radiofrequency water vapor (steam) thermal therapy
Read the complete policy here.
SB 4249 – Balance Billing
On November 18, Senator Vin Gopal (D) introduced SB 4249. This bill requires the Department of Banking and Insurance to post on its website a list of any self-funded health benefits plans that have not elected to be subject to the “Out-of-network Consumer Protection, Transparency, Cost Containment and Accountability Act.” The law also requires self-funded plans to provide covered persons with health insurance identification cards that indicate that the plan has elected to be subject to the out-of-network law.
SB 4249 has been referred to the Senate Commerce Committee. The bill is available here: 11/18/2019 Version
Horizon Blue Cross Blue Shield New Jersey has revised the Radiation Therapy for Prostate Cancer medical policy with the following changes to criteria:
- Removed criterion stating that for monotherapy with three-dimensional conformal radiation therapy (3DCRT) or intensity-modulated radiation therapy (IMRT) with either conventional or hypofractionation, radioactive seed implant, or high dose rate brachytherapy to be considered medically necessary in the treatment of low, intermediate, or high-risk prostate cancer, the member must have had a negative bone scan within the last 6 months, where applicable;
- Revised criteria applicable to radiation therapy for high-risk prostate cancer from stating that 3DCRT or IMRT with conventional or hypofractionation alone or conventional hypofractionation combined with brachytherapy (high dose rate [HDR] or radioactive seed implant) may be considered medically necessary, given that all other criteria are met, to now state that conventional fractionation with delivering 1.8 to 2.0 Gy/fraction, 36 to 45 fractions of 3DCRT or IMRT, hypofractionation of up to 28 fractions of 3DCRT or IMRT, low dose rate (LDR) brachytherapy, i.e. seed implant, in combination with 25 to 28 fractions of 3DCRT or IMRT, and HDR brachytherapy in combination with 25 to 28 fractions of 3DCRT or IMRT may be considered medically necessary in the treatment of high-risk prostate cancer;
- Revised criterion stating that radioactive seed implant may be considered medically necessary for intermediate-risk prostate cancer, given that all other applicable criteria are met, to now specify that LDR brachytherapy, i.e. seed implant, may be considered medically necessary either alone for the treatment of prostate cancer with favorable intermediate risk disease, or in combination with 25 to 28 fractions of 3DCRT or IMRT for prostate cancer with unfavorable risk disease;
- Revised criterion stating that HDR brachytherapy may be considered medically necessary for intermediate-risk prostate cancer, given that all other applicable criteria are met, to now specify that HDR brachytherapy may be considered medically necessary either alone for the treatment of prostate cancer with favorable intermediate risk disease, or in combination with 25 to 28 fractions of 3DCRT or IMRT for prostate cancer with unfavorable intermediate risk disease;
- Revised criterion stating that 3DCRT or IMRT in the postoperative setting may be considered medically necessary for one of the listed indications, to now state that adjuvant (postoperative) or salvage radiation therapy may be considered medically necessary in one of the listed settings, with a dose of 32 to 40 fractions of 3DCRT or IMRT being considered medically necessary;
- Specified that conventional fractionation is delivering 1.8 to 2.0 Gy/fraction, 36 to 45 fractions, in criterion stating that conventional fractionation when delivering 1.8 to 2.0 Gy/fraction, 36 to 45 fractions of 3DCRT or IMRT may be considered medically necessary in the treatment of low- and intermediate-risk prostate cancer;
- Specified that hypofractionation is delivering up to 28 fractions, in criterion stating that hypofractionation when delivering up to 28 fractions of 3DCRT or IMRT may be considered medically necessary in the treatment of low- and intermediate-risk prostate cancer;
- Replaced specified therapy radioactive seed implant with LDR brachytherapy, i.e. seed implant, alone, in criterion stating that LDR brachytherapy alone may be considered medically necessary in the treatment of low-risk prostate cancer, given that all other criteria are met;
- Clarified that other forms of radiation delivery are applicable and that bulking/spacer material may refer to SpaceOAR Hydrogel, in policy statement indicating that injection or implantation of bulking/spacing material (SpaceOAR Hydrogel) in conjunction with IMRT and other forms of radiation delivery for prostate cancer is considered investigational.
Read the complete policy here.
Horizon New Jersey Health Medicaid plan has revised the GnRH Agonists and Antagonists medical policy with the following changes to criteria and administrative information:
- Added criterion applicable to Eligard, Lupron, Supprelin LA, Synarel, Trelstar, Vantas, Viadur, or Zoladex in the treatment of gender identity disorder/gender incongruence or gender dysphoria for adolescents stating that for medical necessity to be indicated, in addition to all other applicable criteria being met, mental health disorders, if present, must be reasonably well-controlled;
- Removed criteria applicable to Eligard, Lupron, Supprelin LA, Synarel, Trelstar, Vantas, Viadur, or Zoladex in the treatment of gender identity disorder/gender incongruence or gender dysphoria for adolescents stating that for medical necessity to be indicated the member must fulfill the DSM V criteria for gender dysphoria, not suffer from a psychiatric comorbidity that interferes with the diagnostic work-up or treatment, and receive psychological support during treatment;
- Removed criteria applicable to Eligard, Lupron, Supprelin LA, Synarel, Trelstar, Vantas, Viadur, or Zoladex in the treatment of gender identity disorder/gender incongruence or gender dysphoria for adults stating that for medical necessity to be indicated the member must be receiving gender-affirming hormone therapy together with GnRH and fulfill the DSM V criteria for gender dysphoria;
- Removed age restrictions for Eligard, Lupron, Supprelin LA, Synarel, Trelstar, Vantas, Viadur, or Zoladex in the treatment of gender identity disorder/gender incongruence or gender dysphoria stating that adolescents must be 10-19 years of age and adults must be 20 years or older.
Read the complete policy here, and then click on the Gonadotropin Releasing Hormones (GnRH) Agonists and Antagonists link.
Horizon Blue Cross Blue Shield New Jersey has reviewed and revised the Radiation Treatment of Urethral Cancer and Upper Genitourinary Tract Tumors with the following changes to criteria:
- Revised policy position for external beam photon radiation therapy (EBRT) in the definitive treatment of cancers of the ureter or renal pelvis from being considered not medically necessary, to now state that medical necessity may be indicated for postoperative radiation therapy in the definitive treatment of cancers of the ureter or renal pelvis for advanced T3-T4 disease, positive lymph nodes, or positive surgical margins;
- Added policy statements for fractionation in the treatment of upper genitourinary tract stating that preoperative or neoadjuvant treatment may be considered medically necessary when combined with chemotherapy in an effort to improve resectability, that in the postoperative adjuvant setting up to 30 fractions may be considered medically necessary, and that in the palliative setting up to 20 fractions may be considered medically necessary;
- Specified that for EBRT to be considered medically necessary for palliative treatment, the treatment must be for urethral and upper genitourinary tract disease;
- Clarified that existing policy statements for fractionation apply to fractionation in the treatment of urethral cancer.
Read the complete policy here.
HB 58 – Balance Billing
On December 3, Delegate R Lee Ware (R) pre-filed surprise billing legislation for the 2020 legislative session. HB 58 prohibits balance billing for emergency services and establishes standards for health carriers’ required payments to out-of-network providers.
The session is expected to convene on January 8, 2020. The measure awaits committee referral. The bill is available here: 12/3/2019 Version
ICYMI: Updates from the AUA Policy & Advocacy Brief blog
Congressional Outreach: AUA Meets with Legislator on Priority Issues; Attends Meet & Greet with Men’s Health Caucus Co-Chair
On December 5, the AUA met with the office of Rep. Jimmy Panetta (D-CA-20) to discuss H.R. 3534, the USPSTF Transparency and Accountability Act, as well as veterans’ issues. Rep. Panetta introduced legislation to direct research into the correlation between radiation exposure and prostate cancer in veterans. The study would help determine if prostate cancer should be included as a presumptive disability for certain compensation offered to veterans who may have been exposed to ionizing radiation or radiation during their military service. The AUA Veterans Health Workgroup reviewed the bill and unanimously agreed that the AUA should endorse the measure. As a result, the AUA plans to issue a formal support letter and hopes to work closely with his office further on veteran and prostate cancer issues moving forward.
In addition, on December 4, the AUA attended a meet and greet with Rep. Markwayne Mullin (R-OK-02) hosted by the Alliance of Specialty Medicine. Rep. Mullin serves on the House Energy & Commerce Committee and co-chairs the Congressional Men’s Health Caucus. Rep. Mullin discussed his concerns with the current surprise billing legislation and accepted the Alliance’s point on having an independent dispute resolution process that is fair to both providers and payors.
As a reminder, throughout the year, the AUA has had numerous conversations with Rep. Mullin on top health policy issues both in congressional and political settings. He remains a champion of the many issues that impact a urologist’s ability to provide quality care to patients around the country.
Urologic Workforce: AUA Sends Comment Letter to House Ways & Means Committee
On November 29, the AUA submitted a comment letter in response to the House Ways & Means Committee’s request for information soliciting input on priority topics that affect health status and outcomes in underserved communities. The information collected will be used to inform the bipartisan Rural and Underserved Communities Health Task Force as it works to draft legislation to identify the causes of health care disparities, develop strategies to close gaps in care, and ultimately improve health care outcomes in both urban and rural underserved areas.
The AUA’s comments focused mainly on the specialty workforce shortage and how it plays a significant role in health care disparities in rural parts of the country. “It is also important for the Task Force to consider that rural areas account for 50 million Americans; however, according to the AUA Census, which is a systematically designed, specialty-representative survey of urology, reports that 62 percent of counties in the United States have no urologist and, as a result, the mortality rate for kidney, prostate, and bladder cancer are all higher in these counties”, the letter states.
Top Takeaways: First Friday Clinician Outreach Meeting, December 6, 2019
The top takeaway from the Centers for Medicare & Medicaid Services (CMS) December Clinician Outreach Meeting focused on lessons learned from the Transforming Clinical Practices Initiative (TCPI), a practice transformation and quality improvement initiative of the Center for Medicare & Medicaid Innovation (CMMI). Read more.
Medicare Physician Fee Schedule: Alliance of Specialty Medicine, AUA Voice Concerns
The AUA has joined 11 other organizations, as part of the Alliance of Specialty Medicine, to voice our concerns regarding the provisions of the Centers for Medicare & Medicaid Services’ (CMS) Final Rule for the Medicare Physician Fee Schedule. Comments include the following:
Payment for Evaluation and Management (E/M) visits: Recommend, that regardless of the number and level of E/M services that are delivered, when post-operative E/M services are furnished, they should be valued based on the updated E/M values. We also urge CMS to reverse its decision to exclude the updated E/M values in codes with global periods.
Principal Care Management (PCM) Services: CMS finalized separate coding and payment for these services, and requires management by another, more specialized, practitioner. We urge CMS to work with the Alliance to establish educational materials that clearly describe the differences in and appropriate scenarios for coding and billing PCM services.
Fiscal Year (FY) 2020 Appropriations: Appropriations Package Includes Research Funding Increase
On December 16, Congress released two comprehensive appropriations packages that are favorable to the urologic research community. Highlights of the Consolidated Domestic and International Assistance Bill (H.R. 1865) include a $2.6 billion funding increase for the National Institutes of Health (NIH) and an 8 percent funding boost for the National Cancer Institute over Fiscal Year (FY) 2019. , The Consolidated National Security Bill (H.R. 1158) included allocations for Department of Defense research funding for prostate cancer ($110 million), kidney cancer ($40 million), which is a $20 million increase from the previous year, and bladder cancer, which remained eligible for research grants from a pool of funding totaling $110 million. Congress plans to consider the legislation this week before the Friday, December 20 funding deadline.
As a reminder, promoting urologic/cancer research funding remains an important legislative priority at the AUA. In particular the AUA continually makes a concerted effort to partner with other provider associations and patient advocacy groups to educate lawmakers into the tremendous value that research funding brings to clinical care around the country. Through initiatives such as coalition support letters sent to congressional leadership and House/Senate appropriators, and face-to-face meetings with members of Congress and their staff, progress is being made towards increasing the overall research funding levels at key agencies such as the NIH and the DoD. The AUA will continue to build on this momentum throughout 2020, particularly during the 3rd Annual Urology Advocacy Summit in March.