November 2021 - AUA Public Policy Council Update for MAS
From the Chair
I am pleased to share updates from the AUA Public Policy Council that may benefit your Section members. Our updates include information on the CY 2022 Medicare Physician Fee Schedule Rules and the recent American Medical Association House of Delegates Annual Meeting.
A special thank you to Mid Atlantic Section members Ruchika Talwar, MD; Thomas Guzzo, MD; Ariana Smith, MD; Trinity Bivalaqua, MD; Esther Nivasch-Turner, MD; Marjorie (Margaux) Johnson, MD; R. Caleb Kovell, MD; and Daniel Roberson, MD for hosting Representative Dwight Evans (D-PA-03) during his site visit to Penn Urology.
Registration for the 5th Annual Urology Advocacy Summit in Washington, DC from March 14-16, 2022 opened on November 1. To register, visit www.AUAsummit.org and sign in with your AUA member credentials. We look forward to seeing everyone in Washington, DC come March.
The AUA Summit is an event designed to expand, strengthen and unify the voice of urology on policy matters impacting your practices, and patients. As always, we will be engaging Sections, urologic specialty organizations and patient advocacy organizations alike – and we hope you will be among them! Please share the AUAsummit.org link with your students, residents/fellows, and colleagues.
Register Now: AUA to Host State Advocacy Webinar for Students, Residents, and Fellows
On December 2 from 7:00-8:00 p.m. EST, the AUA State Advocacy Committee chair Mark Edney, MD, MBA, and the Policy & Advocacy Resident Work Group will host an educational advocacy event tailored for medical students, residents, fellows, and young urologists. Dr. Edney will detail the importance and steps for getting involved in state advocacy. Please share news of this event with your students, residents, fellows, and colleagues. Interested attendees can register for the webinar here.
American Medical Association (AMA) House of Delegates (HoD): AUA Delegation Discusses Medicare Payment, Telehealth Confidentiality, and More
On November 12-16, sequestration/impending Medicare payment cuts and allowing Medicare to negotiate drug prices, headlined the many clinical practice, payment, medical education, and public health topics discussed at the AMA’s virtual House of Delegates Interim Meeting.
AUA Delegates Terry Grimm, MD and Hans Arora, MD; Alternate AUA Delegates Jason Jameson, MD and James Gilbaugh, MD; Young Physician Section Delegate Clint Cary, MD; and Resident/Fellow Section Delegate Ruchika Talwar, MD represented the AUA during the meeting. The AUA delegation agreed to cosponsor one specific resolution, Resolution 236, for the Interim Meeting. Resolution 236, “Repeal or Modification of the Medicare Appropriate Use Criteria (AUC) Program” would amend existing AMA policy to advocate Congress for either the full repeal of AUC or legislative modifications to the program to adequately address technical and workflow challenges, ensure alignment with the Quality Payment Program, and create provider flexibility for the consultation of AUC or advanced diagnostic imaging guidelines using a mechanism best suited for their practice, specialty, and workflow. Unfortunately, this measure was never considered on the House floor.
Throughout the meeting, the AUA’s delegates participated in various virtual caucus meetings, including the Surgical Caucus (organized by the American College of Surgeons), the Cancer Caucus (organized by the American Society of Clinical Oncology), and the Specialty and Service Society Caucus. They also participated in eight reference committee hearings and then two full days of full House deliberations.
Numerous measures and their impacts on specialty care were considered during the interim meeting – including the following:
- Resolution 101 – Standardized Coding for Telehealth Services (Virginia)
- This resolution would urge the AMA to advocate by regulation and/or legislation that telehealth services are uniformly identified by using place of service (02) without any additional requirements, such as modifiers imposed by third party payors, for claim submission and reimbursement. While consistency in reporting and coding rules to identify telehealth services in claims is important, some in the House felt that being overly prescriptive could undermine ongoing advocacy in this space. As a result, the measure was referred for a decision at later HoD meeting. AUA delegate Dr. Terry Grimm spoke in favor of this recommendation.
- Resolution 113 – Supporting Medicare Drug Price Negotiation (California)
- Resolve clauses one and three of this measure were ultimately adopted, which 1) reaffirmed existing AMA policy supporting federal legislation that gives the Secretary of the Department of Health and Human Services the authority to negotiate contracts with manufacturers of covered Part D drugs; working toward eliminating Medicare prohibition on drug price negotiation; and prioritizing its support for the Centers for Medicare & Medicaid Services (CMS) to negotiate pharmaceutical pricing for all applicable medications covered by CMS, and 2) that AMA support legislation that limits Medicare annual drug price increases to the rate of inflation.
- Resolve clause two – dealing with foreign pricing indices – was referred for further consideration. Testimony cited that if international price averages were applied in Medicare Part B, it is unclear where limitations on pricing would occur. Physicians could be reimbursed at a lower amount than the purchase price of the drug, which would raise significant access concerns for patients.
- Four separate Medicare payment resolutions (212, 221, 224, 225) were combined and considered as Resolution 212
- Looming payment cuts facing physician practices at the end of this year, including sequester and budget neutrality, must be addressed to ensure that practices can remain fiscally viable – particularly as physician practices have not yet recovered from the financial strain of the COVID-19 pandemic. The upcoming cuts place an unreasonable burden on physician practices and severely impact patient access to care as many practices will struggle to keep their doors open. These sentiments were echoed by AUA delegate Dr. Hans Arora, who submitted written testimony in support of these measures over the weekend. Res. 212 was subsequently adopted by the House.
- Resolution 226 – Address Adolescent Telehealth Confidentiality Concerns (Michigan)
- This resolution amends existing AMA policy on Confidential Health Services to encourage physicians in a telehealth setting to offer a separate examination and counseling apart from others and to ensure that the adolescent is in a private space. Dr. Arora, who is a practicing pediatric urologist, spoke in favor of this measure during reference committee hearings. Res. 226 was ultimately adopted by the House.
- Resolution 411 – Addressing Public Health Disinformation (Young Physicians Section)
- This measure was amended and ultimately adopted to urge the AMA to collaborate with relevant stakeholders on efforts to combat public health disinformation on all forms of media and work with health professional societies to address disinformation that undermines public health initiatives.
As a reminder, the AMA HoD is the principal policy-making body of the AMA. It represents the views and interests of a diverse group of member physicians from more than 170 societies. These delegates meet twice a year to establish policy on health, medical, professional, and governance matters.
For a more comprehensive recap of the meeting, check out the daily blogs on the AUA Policy & Advocacy Brief:
Day 1 Overview: https://community.auanet.org/blogs/policy-brief/2021/11/13/2021-special-meeting-of-the-ama-house-of-delegates
Day 2 Overview: https://community.auanet.org/blogs/policy-brief/2021/11/14/2021-special-meeting-of-the-ama-house-of-delegates
Day 3 Overview: https://community.auanet.org/blogs/policy-brief/2021/11/15/2021-special-meeting-of-the-ama-house-of-delegates
Day 4 Overview: https://community.auanet.org/blogs/policy-brief/2021/11/16/2021-special-meeting-of-the-ama-house-of-delegates
Centers for Medicare & Medicaid Services (CMS) 2022 Medicare Physician Fee Schedule Final Rule Phases in Clinical Labor Rate Update, Finalizes Telehealth Services Provisions
On November 2, the Centers for Medicare and Medicaid Services (CMS) published the CY 2022 Medicare Physician Fee Schedule Final Rule. On January 1, 2022, the Final Rule will implement a number of policies that impact urology. These policies include a reduction in the Medicare conversion factor from $34.8931 (2021) to $33.5983 (2022) and an update to direct practice expense clinical labor rates that CMS significantly modified based on AUA input.
AUA staff have completed a deep-dive analysis of the CY 2022 MFS Final Rule that can be found here.
In addition to the Medicare conversion factor and the clinical labor rate update, the CY 2022 PFS Final Rule also finalizes policies related to the provision of telehealth services, split (or shared) Evaluation & Management (E/M) visits in the facility setting, Stark law regulations, other urologic payment policies for specific urologic codes, and the Medicare Quality Payment Program (QPP) and MIPS Value Pathways (MVPs)
For the Final Rule’s impacts on urology-specific procedures compared with CY 2021 rates, please click here. For the Final Rule’s impacts on Evaluation & Management visits compared with CY 2021 rates, please click here. For a list of services on the CY 2022 Medicare telehealth list, please click here.
Additional GME Slots Under Consideration in Latest Version of Build Back Better Act
The AUA continues to advocate for increased funding for Graduate Medical Education (GME) slots to ease the urology workforce shortage. We were pleased to learn that Congress is considering additional steps to assist in these efforts. In the recently released Build Back Better Act draft text, Congress is looking to appropriate funding for 2,000 new GME slots in 2025 and 2026. The Build Back Better Act was created to enact the Biden administration’s framework that provides funding, establishes programs, and modifies existing government programs to help the United States’ economic recovery. The legislation touches many areas of life, including education, healthcare, and the environment. Some of the major healthcare funding provisions included in the draft measure, aside from GME, are public health infrastructure and supply chain resiliency.
If enacted, this would be the second increase to GME slots in the last twelve months. The fiscal year (FY) 2021 omnibus appropriations measure enacted late last year contained a provision for adding 1,000 GME slots. While rulemaking has not been finalized, it is important to note the aggregate number of positions may not exceed 200 for each fiscal year. In addition, the program will take effect beginning in fiscal year 2023 (October 1, 2022).
As the Build Back Better Act works its way through the legislative process, the AUA will continue to closely monitor these plans to expand federal GME training positions and will work to ensure urology is eligible to apply when available.
Surprise Medical Billing Interim Final Rule Reviewed
On September 30, the Departments of Health and Human Services (HHS), Labor, and Treasury, in conjunction with the Office of Personnel Management (OPM), issued an interim final rule (IFR) with comment period, titled “Requirements Related to Surprise Billing; Part II,” implementing provisions of the No Surprises Act to protect patients from surprise medical bills.
Specifically, this IFR implements provisions of the No Surprises Act related to the independent dispute resolution (IDR) process, good faith estimates for uninsured (or self-pay) individuals, the patient-provider dispute resolution process, and external review. Additionally, in this IFR HHS has announced the establishment of an online Federal IDR Portal that will serve as the hub of the IDR process. The provisions outlined in this IFR are set to be effective January 1, 2022, and HHS will release more information prior to the implementation date. The AUA has complied an analysis of the IFR, viewable here.
AUA Participates in Call with Office of Management and Budget on Proposed Medicare Part B Clinical Labor Rate Update
On October 25, the AUA and the Clinical Labor Coalition met with the Office of Management and Budget (OMB) to discuss the Center for Medicare & Medicaid Services (CMS) proposal to update direct practice expense clinical labor rates for the first time in 20 years. As written, this proposal would negatively impact the ability of urologists to perform a number of procedures in the non-facility office setting by significantly reducing reimbursement for those procedures.
During the call, the AUA’s Thomas Turk, MD spoke about urologic procedures performed in the non-facility office setting that require expensive devices. According to Dr. Turk, the result of this proposal would not only make the cost of these procedures prohibitive, relative to reimbursement, but would also drive care to more expensive facility settings, and would ultimately impact the ability for patients to receive care.
AUA Action Alert: Urge Your Senator and Congressperson to Support the Veterans’ Prostate Cancer Treatment and Research Act
On October 11, the AUA met with staff on the Senate Veterans’ Affairs Committee to discuss the Veterans’ Prostate Cancer Treatment and Research Act. The professional staff noted that the bill is a top priority for the committee, particularly as both the Chairman, Senator Jon Tester (D-MT), and the Ranking Member, Senator Jerry Moran (R-KS), are the two main sponsors of the measure.
On October 13, the AUA also met with the staff in the office of Senator Sherrod Brown (D-OH), who is a member of the Senate Veterans’ Affairs Committee and has a clear interest in legislation impacting healthcare within our Veterans Administration.
On October 20-21, the AUA met with Republican staff on the Senate Veterans’ Affairs Committee (SVAC), which immediately preceded the committee’s legislative hearing where numerous bills were deliberated – including S. 2720.
On October 25 and 28, the AUA met with staff in the office of Senators Tommy Tuberville (R-AL) and Kyrsten Sinema (D-AZ) regarding S. 2720. Both are members of the Senate Veterans’ Affairs Committee (SVAC).
On November 1, the AUA met with staff in the office of Senator Joe Manchin (D-WV) regarding S. 2720. Sen. Manchin serves on the Senate Veterans’ Affairs Committee. Additionally, on November 3, the AUA met with Democratic staff on the House Veterans’ Affairs Committee to have further dialogue and gauge the committee’s interest in taking up H.R. 4880 through a legislative markup hearing.
H.R. 4880/S.2720 would establish a viable clinical pathway for prostate cancer within the Department of Veterans Affairs for those men who selflessly served this nation in uniform. The AUA will continue to promote and advance H.R. 4880/S.2720 in numerous ways moving forward. You also can help this key initiative move forward in both chambers by logging onto the AUA’s grassroots alert system and urging your federally elected officials to support these measures by clicking here.
Current House cosponsors include the following:
- Allred, Colin Z. (D-TX-32)*
- Axne, Cynthia (D-IA-03)
- Bishop, Sanford D., Jr. (D-GA-02)
- Delgado, Antonio (D-NY-19)
- Dunn, Neal (R-FL-02)**
- Lee, Susie (D-NV-03)
- Lieu, Ted (D-CA-33)
- McKinley, David B. (R-WV-01)
- Miller-Meeks, Mariannette (R-IA-02)
- Murphy, Gregory (R-NC-03)
- Neguse, Joe (D-CO-02)
- Ross, Deborah K. (D-NC-02)
- Slotkin, Elissa (D-MI-08)*
- Soto, Darren (D-FL-09)
- Van Drew, Jefferson (R-NJ-2)
Current Senate cosponsors include the following:
- Jerry Moran (R-KS)**
- John Tester (D-MT)*
**Original sponsor
*Original cosponsor
ICYMI: Updates from the AUA Policy & Advocacy Brief blog
From Congress to the Clinic: Congressman Dwight Evans Visits Penn Urology
Recently, Representative Dwight Evans (D-PA-03), who serves on the House Ways & Means Subcommittee on Health, toured Penn Urology in Philadelphia, Pennsylvania. The tour began with chief resident Ruchika Talwar, MD and professor and Chief of Urology at the University of Pennsylvania Perelman Center for Advanced Medicine Thomas Guzzo, MD, highlighting key clinic elements and facilities. Then, they were joined in a round table conversation with Ariana Smith, MD; Trinity Bivalaqua, MD; Esther Nivasch-Turner, MD; Marjorie (Margaux) Johnson, MD; R. Caleb Kovell, MD and Daniel Roberson, MD. The conversation mainly centered on bladder cancer research, benign urology and bladder health research, community outreach for urologic health, and Penn Urology’s opioid reduction initiative. Read more information here.
If you are interested in hosting a similar congressional site visit or setting up an in-person district meeting, please do not hesitate to contact the AUA’s Legislative & Political Affairs Department at LegislativeAffairs@AUAnet.org.
AUA Supports Continuing Telehealth Benefits for HDHP-HSAs
The AUA convened on a letter to Senate Finance Committee and House Ways and Means Committee leadership concerning the continuation of telehealth benefits for high-deductible health plans with Health Savings Accounts (HDH-HSAs). Americans with HDHP-HSAs must meet minimum deductibles defined in statute before the cost of telehealth can be defrayed by their employer or insurer. Congress took swift action as part of the CARES Act to ensure employees could receive covered telehealth services before their deductible is met by allowing employers to provide pre-deductible coverage for such services. The safe harbor is not part of the flexibilities provided by the Public Health Emergency (PHE), and will expire on December 31, 2021 regardless of how long the PHE lasts.
The letter urged Congress to “extend the virtual care provisions in the CARES Act for individuals with HDHP-HSAs beyond the current deadline of December 31, 2021”. For a copy of the letter, please reach out to Ray Wezik, AUA Director of Policy & Advocacy, at rwezik@auanet.org.
AUAPAC Supports Three Energy & Commerce Committee Members
On October 21, AUAPAC participated in a fundraiser for Representative Anna Eshoo (D-CA-18). Rep. Eshoo serves as the Chair of the House Energy & Commerce Subcommittee on Health, which has jurisdiction on critical healthcare workforce issues, including H.R. 944 and H.R. 2256, the Resident Physician Shortage Reduction Act. H.R 2256 expands graduate medical education (GME) training and funding over a five-year period and is a bill the AUA has endorsed for the past several Congresses.
On October 26, AUAPAC hosted a fundraiser for Representative David McKinley (R-WV-01). He also serves on the House Energy & Commerce Subcommittee on Health and is a champion for addressing physician workforce shortages. 15 other physician groups participated in this event.
On October 28, AUAPAC participated in a fundraiser for Representative Neal Dunn, MD (R-FL-02), hosted by the coalition of Medical and Dental Political Action Committees (MaDPAC). He is a urologist and also a member of the GOP Doctors Caucus. Rep. Dunn serves on the House Energy & Commerce Subcommittee on Health and is a proponent of diagnosing and treating prostate cancer through championing legislation such as H.R. 4880, the Veterans’ Prostate Cancer Treatment and Research Act.
Bladder Health: 8th Annual Bladder Health Alliance Roundtable Convenes More than 60 Participants; Features Plenary Session Highlighting Women’s Bladder Health, the Patient Voice in Bladder Health Research, and More
On October 12 and 14, the AUA and Urology Care Foundation hosted the 8th Annual Bladder Health Alliance roundtable meeting. The program convened more than 60 participants representing 30 patient, physician, and research advocacy organizations. The event included an extraordinary panel of presenters, including Lisa Finkelstein, DO, Urology Telehealth Task Force member and Toby Chai, MD, immediate past Research Advocacy Committee Chair. Panelists highlighted key issues facing bladder health; including women’s bladder health, the patient voice in bladder health research, COVID-19 and bladder health, and stigma associated with the treatment and management of bladder health symptoms.
Additional discussion topics included informed decision-making, marketing for the November 2021 Bladder Health Month campaign, and effective marketing and communications approaches to raise awareness about bladder health conditions. As a reminder, promoting appropriate care for bladder health and bladder-related conditions is an AUA legislative priority. For more information on the Bladder Health Alliance, please contact Kim Nelson, AUA Policy & Advocacy Manager, at knelson@auanet.org.
Action Alert: AUA Continues to Meet with Incumbent Lawmakers to Discuss Workforce Bill (H.R. 944)
Throughout October, the AUA met with staff in the office of Representatives Gus Bilirakis (R-FL-12), Brett Guthrie (R-KY-02), Markwayne Mullin (R-OK-02), Anna Eshoo (D-CA-18), Billy Long (R-MO-07), Nanette Diaz Barragàn (D-CA-44), and G.K. Butterfield (D-NC-01) to discuss co-sponsoring H.R. 944.
In addition, the AUA met with staff in the office of Senators Richard Burr (R-NC) and Tommy Tuberville (R-AL) to garner support and sponsorship for a Senate companion of H.R. 944.
On November 2-3, the AUA met with staff in the office of Representatives John Rutherford (R-FL-04) and Lori Trahan (D-MA-03) to discuss co-sponsorship of H.R. 944. Both offices seem to have a vested interest in the issue as Rep. Rutherford has supported other loan repayment initiatives for health care providers in the past, and Rep. Trahan is a new member of the House Energy & Commerce Committee, which has jurisdiction on this particular bill.
As a reminder, Representatives David McKinley (R-WV-01) and Peter Welch (D-VT-AL) introduced this legislation in February 2021. It establishes a loan repayment program to encourage specialty medicine physicians to serve in rural communities experiencing a shortage of specialty medicine physicians. Offices remain receptive to the idea of incentivizing specialists to practice in rural areas while helping patients gain much-needed access to care.
The AUA also has created a grassroots alert that allows any domestic AUA member to easily contact their federally elected officials to ask them to cosponsor this legislation. To access this action center, click here or simply text AUA to 52886 to get started.
Below are insurance updates from national insurance carriers. If you have questions about insurer issues, contact Gregory Craig at cgraig@auanet.org.
Aetna
Aetna reviewed its Botulinum Toxins (PA Medicaid) Prior Authorization Criteria with the following changes:
- Added prior authorization criteria for neurogenic bladder for Botox, diagnosis of urinary incontinence due to detrusor overactivity associated with neurologic condition
- Revising prior authorization criteria:
- For neurogenic bladder and overactive bladder for Botox to indicate trial of behavioral therapy must be for at least 8-12 weeks
- For overactive bladder for Botox to decrease number of formulary urinary anticholinergics tried and failed from three to two
Aetna reviewed its Prostate Biopsy (Commercial) Policy adding an investigational statement for ultrasound superb microvascular imaging for guiding targeted biopsy of the prostate.
Aetna reviewed its Nocturnal Enuresis Treatments (PA Medicaid) Policy with the following changes:
- Added Tuina (massage) therapy as experimental/investigational for nocturnal enuresis
- Removed code 0029T – Treatments for incontinence, pulsed magnetic Neuromodulation, per day
Cigna
Cigna reviewed its Infertility Services Policy adding a sperm capitation assay assessment definition.
Cigna reviewed its Sacral Nerve and Tibial Nerve Stimulation for Urinary Voiding Dysfunction, Fecal Incontinence and Constipation Policy with the following changes:
- Added codes for screening trial of SNS
- C1778 – Lead, neurostimulator (implantable)
- C1897 – Lead, neurostimulator test kit (implantable)
- Removed code for permanent SNS implantation
- C1897 – Lead, neurostimulator test kit (implantable)
CMS
CMS reviewed its Prostate Specific Antigen (190.31) National Coverage Determination (NCD) adding links to April, July and October ICD-10 covered code lists and October Lab NCD edit software.
Palmetto
Palmetto reviewed its Prognostic and Predictive Molecular Classifiers for Bladder Cancer (MolDX) (JJ, JM) (A58028) Local Coverage Article (LCA) removing coverage information for Decipher Bladder and tests for FGFR2 and FGFR3, as that information is located in the associated Local Coverage Determination.
United Healthcare
United Healthcare revised its Prostate Services and Procedures (Medicare Advantage) Policy referencing revised applicable coverage guidelines for UroLift system from InterQual criteria to UHC Commercial policy.
United Healthcare published its Prostate Surgery Policy stating:
- High-energy water vapor thermotherapy for the treatment of malignant prostate tissue is unproven and not medically necessary due to insufficient evidence of safety and/or efficacy.
- The transperineal placement of biodegradable material, peri-prostatic (via needle) is unproven and not medically necessary for all other indications due to insufficient evidence of safety and/or efficacy.
- The following procedures are unproven and not medically necessary due to insufficient evidence of safety and/or efficacy:
- Transurethral waterjet ablation of the prostate (aquablation)
- Focal laser ablation
- Insertion of a temporary prostatic urethral stent
- Vascular embolization
United Healthcare reviewed its Prostate Surgeries and Interventions (Commercial West) Policy adding a list of required clinical information.
WPS Government Health Administrators
WPS Government Health Administrators reviewed its Prognostic and Predictive Molecular Classifiers for Bladder Cancer (MolDX) (JJ, JM) (A58211) Local Coverage Article (LCA) removing coverage information for Decipher Bladder and tests for FGFR2 and FGFR3, as that information is located in the associated Local Coverage Determination.
WPS Government Health Administrators published its Response to Comments: Botulinum Toxin Type A & Type B (J05, J08) (A58907) Local Coverage Article (LCA) Comment/response article published for DL34635 Botulinum Toxin Type A & Type B.
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.
Virginia
The Virginia legislature is in special session from August 2 to November 30.
Best regards,
Kathy and the AUA Public Policy & Advocacy Team