Vol. 92, March 2023 DC E-Newsletter
Washington Committee Sets 2023 Legislative & Regulatory Agenda
The Congress of Neurological Surgeons (CNS) and the American Association of Neurological Surgeons (AANS) released their 2023 Legislative & Regulatory Agenda, including health policy action items the neurosurgical societies plan to advance with Congress and the Biden Administration. Organized neurosurgery aims to:
- Protect patients’ timely access to care by reforming prior authorization and repealing Medicare’s appropriate use criteria program for advanced diagnostic imaging;
- Support quality resident training and education by increasing the number of Medicare-funded residency positions and preserving the ability of surgeons to maximize education and training opportunities within the profession’s current regulatory structures;
- Champion fair reimbursement by improving the Medicare physician payment system — including providing an annual inflationary payment update and improving the value-based care programs — following the clear language of the No Surprises Act and implementing a fair process for resolving provider and health plan payment disputes, permanently expanding telehealth flexibilities and closing the gap in payments between Medicaid and private insurers to reduce access to care disparities;
- Improve competition in the health care system by increasing scrutiny of hospital and other health care consolidation, removing restrictions on physician ownership of hospitals and other ancillary services, establishing network adequacy standards and broadening health insurance coverage options;
- Fix the broken medical liability system by adopting proven reforms that are in place in California and Texas and other innovative solutions;
- Alleviate the burdens of electronic health records (EHRs) by achieving interoperability, preventing data blocking, reducing unnecessary data entry and improving the functionality of EHR systems to enhance, not hinder, the delivery of medical care; and
- Continue progress with medical innovation by prioritizing funding for the National Institutes of Health, pioneering medical technology and life-saving therapies by streamlining the Food and Drug Administration’s approval processes and expanding Medicare coverage of new technology.
In a press release announcing the advocacy agenda, Russell R. Lonser, MD, FAANS, chair of the CNS/AANS Washington Committee, stated, “The AANS and the CNS will continue to encourage policymakers to work together to find bipartisan solutions for our nation’s top health care issues to ensure that our patients have timely access to high-quality, equitable neurosurgical care. We look forward to working with Congress and the Biden Administration to advance sound health care policy for the betterment of our patients and profession.”
Click here for the policy agenda and here to read the CNS/AANS press release.
HHS to End COVID-19 Public Health Emergency Declaration
On Feb. 9, the U.S. Department of Health and Human Services (HHS) announced its plans to end the COVID-19 public health emergency (PHE) on May 11. The administration will transition away from various pandemic policies and flexibilities over the next few months.
Click here and here for more information and guidance to help neurosurgical practices prepare and plan for the end of the PHE.
Neurosurgery Urges Congress to Hold Hearings on Medicare Physician Payment Reform
On Jan. 23, the CNS and the AANS joined more than 100 national medical associations urging Congress to hold Congressional hearings and work with all stakeholders to explore long-term payment solutions to reform the Medicare physician payment system. The letter points out that Medicare physician payments have declined by 22% over the past 20 years, given that the Medicare fee schedule lacks an annual inflationary update.
The absence of an annual inflationary update, combined with statutory budget neutrality requirements, results in ongoing cuts to neurosurgical payments.
Click here to read the letter.
CNS and AANS Endorse Cerebral Cavernous Malformations Legislation
Once again, the CNS and the AANS endorsed the Cerebral Cavernous Malformations Clinical Awareness, Research and Education (CCM-CARE) Act. Sponsored by Sens. Ben Ray Luján (D-N.M.) and Martin Heinrich (D-N.M.), the bill would expand National Institutes of Health (NIH) research related to cerebral cavernous malformations. The legislation directs the NIH director to:
- Conduct basic, clinical and translational research on CCM;
- Support multi-site clinical drug trials for cavernous angioma; and
- Integrate CCM within existing clinical research networks.
The bill also directs the U.S. Department of Health and Human Services secretary to establish a CCM education and information program to expand training programs for clinicians and scientists.
The sponsors’ press release featured CNS/AANS Washington Committee chair Russell R. Lonser, MD, FAANS, who stated:
Cerebral cavernous malformations can lead to seizures, stroke and death. As neurosurgeons who treat patients with this disease, we appreciate the leadership of Senators Luján and Heinrich in sponsoring the Cerebral Cavernous Malformations Clinical Awareness, Research and Education Act to help expand research and treatment options for patients with this rare but devastating medical condition.
On March 1, the Los Alamos Daily Post posted an article about the bill, including Dr. Lonser’s quote.
CNS and AANS Urge Congress to Address Medical Student Debt
Reps. Brian Babin, DDS, (R-Texas) and Chrissy Houlahan (D-Pa.) in the U.S. House of Representatives and Sens. Jacky Rosen (D-Nev.) and John Boozman, OD, (R-Ark.) in the U.S. Senate, have introduced legislation to address physician student loan debt. The bipartisan Resident Education Deferred Interest (REDI) Act (H.R. 1202/S. 704) would allow borrowers to qualify for interest-free deferment on their student loans while serving in a medical internship or residency program. The CNS and the AANS endorsed the REDI act, joining more than 40 organizations in thanking the bill’s sponsors for introducing this critical legislation.
Click here to read the House letter and here for the Senate letter.
Coding and Reimbursement
Court Rules in Favor of Physicians in Lawsuit Challenging No Surprises Act
In a win for physicians and hospitals, for the second time in less than two years, a federal court in Texas has rejected the Biden Administration’s attempt to rewrite the independent-dispute resolution process that Congress created in the No Surprises Act (NSA). The NSA bans surprise medical bills for out-of-network care and establishes a process for resolving payment disputes between health plans and providers.
Unfortunately, the final rule implementing the law continued to give preference to the qualifying payment amount (QPA) — or median in-network rate — which unfairly favors insurers when settling out-of-network payment disputes. In contrast to the final rule, the NSA requires arbiters to consider several factors equally — not just median in-network rates — including the physician’s training and experience, the severity of the patient’s medical condition, prior contracting history, health plan market share and other relevant information.
According to the court, the final rule “continues to place a thumb on the scale for the QPA by requiring arbitrators to begin with the QPA and then imposing restrictions on the non-QPA factors that appear nowhere in the statute.” In sending parts of the regulations back to the agencies, the court ruled that “rather than instructing arbitrators to consider all the factors pursuant to the Act, the Final Rule requires arbitrators to consider the QPA first and then restricts how they may consider information relating to the non-QPA factors.”
On Oct. 19, the CNS and the AANS spearheaded a physician-led amicus brief, along with the Physician Advocacy Institute, supporting the Texas Medical Association’s (TMA) lawsuit challenging these rules. The Biden Administration has until early April to appeal the decision.
CNS and AANS Comment on Prior Authorization Reform Proposals
On Dec. 6, 2022, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule requiring Medicare Advantage plans and other public health insurers to implement automated prior authorization systems. Subsequently, on Dec. 14, 2022, CMS issued another proposed rule to improve prior authorization in the Medicare Advantage program. Taken together, the proposed rules would:
- Require insurers to adopt electronic prior authorization;
- Reduce care delays and improve patient outcomes by ensuring that health plans respond to prior authorization requests within specific timeframes (72 hours for urgent requests and seven days for standard requests);
- Mandate that prior authorization approvals remain valid for a patient’s entire course of treatment;
- Require coverage determinations to be reviewed by professionals with relevant expertise;
- Support efforts (e.g., gold cards) to waive or modify prior authorization requirements based on provider performance; and
- Compel health plans to publicly report the use of prior authorization, including information on delays and denials.
The CNS and the AANS responded to the proposal by joining several coalition letters.
- Click here and here for the Regulatory Relief Coalition (RRC) letters;
- Click here and here to read the Alliance of Specialty Medicine letters; and
- Click here for the AMA-led letter from nearly 120 organizations.
CNS/AANS Washington Committee chair Russell R. Lonser, MD, FAANS, stated in an RRC press release, “It’s long past the time for CMS to hold health plans accountable for unconscionable delays and denials of care. Clearly, CMS listened to patients and providers when developing this rule, which will help eliminate care delays, patient harms and practice hassles that contribute to physician burnout, and is a huge step in the right direction.”
CNS and AANS Join Alliance in Urging CMS to Ensure Network Adequacy Standards
On Dec. 21, 2022, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that includes provisions related to network adequacy standards. The proposal would require all Affordable Care Act exchange plans to comply with existing standards for network adequacy, including those that have not used a provider network. Unfortunately, the CNS and the AANS believe that the existing network adequacy standards fail to ensure robust access to specialty and subspecialty medical care. In commenting on the proposal, the groups urged CMS to take the necessary steps to address the problem of narrow and restrictive provider networks.
Click here to read the Alliance of Specialty Medicine letter.
Neurosurgery Recommends that CMS Expand Carotid Artery Stenting Coverage
On Feb. 7, the CNS, AANS and CNS/AANS Cerebrovascular Section sent a letter to the Centers for Medicare & Medicaid Services (CMS) urging the agency to update its National Coverage Determination for Carotid Artery Stenting (CAS). In 2009, the CNS and the AANS disagreed with proposals to expand coverage for CAS to asymptomatic patients based on the available evidence at that time. However, as noted in the letter, since then, multiple randomized controlled trials have been published, physicians from several different specialties have amassed extensive real-world experience and data have been collected as part of national registries. Therefore, neurosurgery now urges CMS to revisit the coverage for CAS.
Click here to read the letter.
CNS and AANS Urge CMS to Ban Step Therapy in Medicare
On Feb. 13, the CNS and the AANS sent a letter to the Centers for Medicare & Medicaid Services (CMS) asking the agency to reinstate the step therapy prohibition in the Medicare Advantage program. In the letter, the groups requested that the agency prohibit step therapy for Part B drugs as specified in the original Sept. 17, 2012, memo, “Prohibition on Imposing Mandatory Step Therapy for Access to Part B Drugs and Services.” Step therapy, also known as “fail first,” is utilized by health plans to determine coverage and requires that patients fail on an insurer’s preferred medication before the therapy prescribed by their health care provider is covered.
Click here to read the letter.
Drugs and Devices
DEA Issues Proposed Rules on Telehealth Flexibilities
On Feb. 24, the Drug Enforcement Administration (DEA) issued proposals to make permanent limited flexibilities for prescribing controlled substances via telehealth. One proposal covers situations when telehealth is used to prescribe controlled substances when the practitioner and the patient do not have a prior in-person medical evaluation. The DEA is also amending its regulations to expand the circumstances under which individual practitioners are authorized to prescribe schedule III-V narcotic drugs or combinations of such drugs approved for use in continuous medical treatment or withdrawal management treatment via a telehealth encounter.
Click here for the DEA announcement about the rules, which provides links to additional materials and information
Neurosurgery Urges CMS to Improve Quality Payment Program
The CNS and the AANS joined 35 national medical specialty societies in sending a letter to the Centers for Medicare & Medicaid Services (CMS) urging the agency to incorporate changes in the 2024 Quality Payment Program related to the Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs) program. In the letter, the groups requested that CMS reduce burden and create a bridge to alternate payment models. Specifically, the letter recommends that CMS:
- Score the Promoting Interoperability performance category based on physicians attesting that they use certified electronic health record technology (CEHRT) or health information technology that interacts with CEHRT. Alternatively, this would be automatically met by submitting quality data electronically using a Qualified Clinical Data Registry, such as the American Spine Registry.
- Develop MVPs around conditions, episodes of care and clinical priority areas. CMS should work with the national medical specialty societies to develop MVPs with appropriate measures rather than simply repackaging existing, inadequate measures.
- Ensure MVPs remain voluntary and retain traditional MIPS as an option for physicians.
Click here to read the letter.
Washington Office Staff Meets with NINDS Officials
On Jan. 30, as part of the National Coalition for Heart Disease and Stroke, CNS/AANS Washington Office staff participated in a meeting with National Institute of Neurological Disorders and Stroke (NINDS) leaders regarding current research funding programs. NINDS director Walter Koroshetz, MD, informed the group that the institute received $2.8 billion in The Consolidated Appropriations Act, 2023 (P.L. 117–328). Funding continues to target several projects of interest to neurosurgery, including the Brain Research Through Advancing Innovative Neurotechnologies® (BRAIN) Initiative.
Dr. Koroshetz indicated that there is also a strong focus on vascular health and disease. For example, StrokeNet began in 2013 and has 27 recognized regional coordinating centers nationwide, with more than 500 participating hospitals conducting clinical trials to address stroke prevention, treatment and recovery. Additionally, several vascular contributions to cognitive impairment and dementia (VCID) programs launched last year — including the Determinants of Incident Stroke Cognitive Outcomes and Vascular Effects on RecoverY (DISCOVERY) program — which seek to understand different kinds of stroke.
Finally, the NINDS continues to implement its strategic plan. Four task forces are developing a roadmap of goals for the next four to five years.
Neurosurgeon Publishes Op-Ed on Prior Authorization
On Jan. 3, The American Spectator published an op-ed by CNS/AANS Communications and Public Relations Committee member Richard Menger, MD, MPA, FAANS; Jessica Murfee, RN, BSN and Erin Roberts, RN, BSN. Titled “Insurance Companies Use Stalling Tactics to Save Themselves Money,” the authors discuss health care provider burnout from the cumbersome prior authorization process required by insurance companies.
On Jan. 18, Neurosurgery Blog published a cross-post to amplify this message.
Neurosurgery Blog Highlights StacheStrong’s Support of Neurosurgeon-Scientist Training Program
Neurosurgery Blog: More than Just Brain Surgery recently published a blog post highlighting the brain tumor nonprofit StacheStrong’s $110,000 donation supporting the Society of Neurological Surgeons (SNS) Neurosurgeon-Scientist Training Program (NSTP). The primary goal of this new SNS program is to improve health by providing participants with the skills, mentorship, education and experience needed to successfully compete for individual research funding. With this donation, the NSTP now has crucial funding for brain tumor-related grants.
Click here to read the blog post.
CNS and AANS Featured in Article on Scientific Statement on Rapid Evaluation for Suspected TIA
On Jan. 20, Medscape published an article highlighting a scientific statement from the American Heart Association (AHA) endorsed by the CNS and the AANS. The “AHA Scientific Statement on Rapid Evaluation for Suspected TIA” statement offers a standardized approach to rapidly evaluate patients with a suspected transient ischemic attack (TIA). Nearly one in five people who suffer a TIA will have a full-blown stroke within three months, and almost one-half of these strokes will happen within two days.
Click here to read the article.
Neurosurgeons Pen Op-Ed on the Burden of Electronic Health Records
On Jan. 21, MedPage Today published an op-ed titled “Death by 10,000 Clicks: The Electronic Health Record.” In the op-ed, neurosurgeons Anthony M. DiGiorgio, DO, MHA, FAANS, and Praveen V. Mummaneni, MD, MBA, FAANS, discuss the burden of electronic health records (EHR) at their institution, the University of California San Francisco. Drs. DiGiorgio and Mummaneni audited EHR logs to examine their neurosurgery residents’ work and better understand the benefits and burdens. The results found that on-call residents spent 20 hours logged into the EHR over a single shift. They are detracting from trainees’ educational experience, and health care costs are increasing because of the inefficiencies that come with EHRs.
On Jan. 26, Neurosurgery Blog published a cross-post to amplify the message. The Alliance of Specialty Medicine also included the article in its winter newsletter, which is broadly distributed to all members of Congress and other policymakers.
Neurosurgery Blog Highlights a Night in the Life of a Busy Neurosurgical Resident
The Winter 2023 issue of Medicine@Brown magazine featured an article by neurosurgery resident Abdul-Kareem Ahmed, MD. Titled “An Improbable Life,” Dr. Ahmed provides a poignant depiction of one night as a neurosurgical resident at the University of Maryland. Every patient’s worst moment is Dr. Ahmed’s every day.
“Tragedy is not rare. We diagnose a child with a life-changing brain tumor; a mother suffers a brain aneurysm rupture, stealing her wit; a husband’s cancer metastasizes to his spinal cord, strangling his strength and independence. Death and disability precede me,” states Dr. Ahmed. He continues, “Triumph is common, and I’ve reflected on it. There are many saves. We open the skull or the spine, pressure is relieved, and life or livelihood is restored. Most of our patients get better, rehabilitate, and move on.”
On Feb. 24, Neurosurgery Blog published a cross-post to highlight Dr. Ahmed’s article.
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