Washington Committee Report

Katie O. Orrico

So far 2016 has been a busy year on the health policy and advocacy front, and the AANS/CNS Washington Committee and Washington Office staff have been working hard to promote policies that benefit neurosurgeons and their patients. Below is a rundown of recent activity.

CMS Proposes Major Overhaul of Medicare Physician Payment System

As previously reported, on April 27, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a proposal to overhaul the way Medicare pays physicians. The proposed rule implements key elements of the Medicare Access and CHIP Reauthorization Act (MACRA). This legislation repealed Medicare’s sustainable growth rate (SGR) formula and replaced it with a new payment system. Through a single framework called the “Quality Payment Program,” the new payment paradigm has two paths—the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs). The new program consolidates components of three existing Medicare penalty programs—Physician Quality Reporting System (PQRS), Electronic Health Record (EHR), and Value-based Payment Modifier (VM)—and creates an opportunity for neurosurgeons to earn quality improvement bonus payments. Initially, most neurosurgeons will likely participate in the Quality Payment Program through MIPS, which will allocate payments based on performance in four categories: quality, advancing care information (formerly EHR meaningful use), clinical practice improvement activities, and cost/resource use. CMS would begin measuring performance for physicians through MIPS in 2017, with payments based on those measures starting in 2019. Neurosurgeons participating to a sufficient extent in risk-based APMs would be exempt from MIPS reporting requirements and qualify for financial bonuses in addition to any shared savings earned through the APMs.

On June 7, 2016, Washington Office staff met with senior staff from CMS, including acting administrator Andy Slavitt, to discuss a number of topics related to the proposed rule. Members of the Neurosurgery Quality Council (NQC) and Washington Office staff developed a detailed comment letter, which was submitted on June 27, 2016. In the letter, organized neurosurgery expressed serious concerns with the new proposed payment rules and urged CMS to make substantial change before finalizing the payment overhaul.

In a release coinciding with the submission of comments, AANS president Frederick A. Boop, chair of the Department of Neurosurgery at the University of Tennessee, remarked, “MACRA presents an unprecedented opportunity to fix the currently broken and burdensome Medicare quality programs, which have little meaningful impact on quality and have been extremely disruptive to physician practices.”

CNS president Russell R. Lonser, chair of the Department of Neurosurgery at Ohio State University, stated, “CMS should seize this moment and make substantial changes to the proposed rule to ensure that the new quality payment program is patient centered, flexible and meaningful for physicians and patients alike.” Dr. Lonser added, “The AANS and CNS recognize the enormity of the task to overhaul the Medicare physician payment system. Nevertheless, it is essential that CMS establish the programmatic building blocks that will ensure the quality payment program’s success into the future.”

Copies of the press release and letters are available at www.cns.org/MACRA. In the coming weeks and months, the CNS will be publishing a variety of educational materials to ensure that neurosurgeons are “MACRA ready” and can thrive under the new quality payment program.

CMS Proposes Onerous Global Surgery Data Collection Mandate

On July 15, 2016, CMS announced a unilateral decision to implement a new sweeping mandate to collect data about global surgery services. According to the proposal, beginning just five months from now on January 1, 2017, neurosurgeons providing 10- and 90-day global surgery services to Medicare patients will be required to report on a whole new set of codes to document the type, level, and number of pre- and postoperative visits furnished during the global period for every global surgery procedure. Under this system, neurosurgeons would be required to use a new set of G-codes to report on each 10-minute increment of services provided. Previously, on November 13, 2014, CMS had finalized a plan to eliminate 10- and 90-day global surgery payments altogether. We prevented the implementation of this ill-conceived plan by successfully advocating for a provision in the Medicare Access and CHIP Reauthorization Act (MACRA) that thwarted the agency’s efforts.

Section 523 of MACRA contained three elements:

  • Prevented CMS from implementing its policy to eliminate 10- and 90-day global surgery payments
  • Required CMS to implement a process for collecting data to evaluate surgical global payments from a representative sample of physicians
  • Allowed CMS to withhold up to 5 percent of the global surgical fee to ensure surgeons required to report additional data to CMS cooperated with this request

Clearly, CMS has disregarded congressional direction, and we have launched an aggressive advocacy campaign to prevent the agency from moving forward with this burdensome data collection proposal.

Opioid Legislation Signed into Law

On Friday, July 8, 2016, the House of Representatives overwhelmingly approved the conference report to S. 524, the Comprehensive Addition and Recovery Act of 2016 (CARA), by a vote of 407 to 5. On July 13, 2016, the Senate followed suit, passing the conference report by a vote of 92-2, and on July 22, 2016, President Barak Obama signed the bill into law. The new law addresses six pillars of a comprehensive response to addiction: prevention, treatment, recovery support, criminal justice reform, overdose reversal, and law enforcement. Among other things, CARA authorizes grant programs and a task force on pain management; expands prescription drug take-back programs and access to medication-assisted treatments; and includes a provision permitting health insurance plans to limit the number of prescribers and pharmacies available to beneficiaries deemed at risk for opioid addiction.

The CNS joined forces with 76 other organizations in sending a letter to Congress supporting the bipartisan work on CARA. The letter also urged “Congress to continue to build on CARA’s achievements, and to next ensure that appropriate funding is made available in order for providers to have the resources they need to prevent opioid addiction from claiming more lives and causing more devastation to families and communities.”

House Republicans Unveil New Health Care Reform Plan

On June 22, 2016, House Speaker Paul Ryan (R, Wisconsin) revealed a new policy paper titled “A Better Way to Fix Health Care,” which is part of the larger “A Better Way” agenda that the speaker is spearheading. Earlier this year, Speaker Ryan appointed a task force to develop the plan. Members of the task force included:

  • House Budget Committee chair, Rep. Tom Price (R, Georgia)
  • House Education and the Workforce Committee chair, Rep. John Kline (R, Minnesota)
  • House Energy and Commerce Committee chair, Rep. Fred Upton (R, Michigan)
  • House Ways and Means Committee chair, Rep. Kevin Brady (R, Texas)

When unveiling the package, Speaker Ryan stated, “Our plan is about more choices, not more mandates. It’s about putting patients and doctors first. It’s about the freedom and flexibility to choose the care that’s best for you, and the peace of mind that comes with having coverage you can count on and afford.” The final package incorporates several priorities, bills, and concepts endorsed and promoted by neurosurgery, including medical liability reform and repeal of the Independent Payment Advisory Board.

CNS Endorses the EHR Regulatory Relief Act

On July 18, 2016, the CNS and AANS joined the Alliance of Specialty Medicine in endorsing S. 3173, the Electronic Health Record (EHR) Regulatory Relief Act. Sponsored by Sens. John Thune (R, South Dakota), Lamar Alexander (R, Tennessee), Mike Enzi (R, Wyoming), Pat Roberts (R, Kansas), Richard Burr (R, North Carolina) and Bill Cassidy (R, Louisiana), this legislation would provide regulatory flexibility and hardship relief to providers operating under Medicare’s Electronic Health Record (EHR) Incentive Program’s meaningful use (MU) requirements. Importantly, the legislation contains a proposal to move away from the all-or-nothing approach to MU, extends the hardship exemption, and reduces the full-year reporting requirement to 90 days.

In a related development, on July 6, 2016, CMS issued the 2017 Medicare Prospective Payment System (OPPS)/Ambulatory Surgery Center (ASC) proposed rule. In the proposed rule, CMS announced that the agency was streamlining the reporting requirements for hospitals and eligible professionals (EPs) participating in Medicare’s MU program and plans to reduce the 2016 EHR reporting period from a full calendar year to 90 days.

House Advances Sports Medicine Legislation

On July 13, 2016, the House Energy and Commerce Committee passed by voice vote H.R. 921, the Sports Medicine Licensure Clarity Act. Authored by Rep. Brett Guthrie (R, Kentucky), the bill would ensure that sports medicine professionals are covered by their malpractice insurance when providing care to their athletes or teams in states other than where they are licensed. The legislation, endorsed by organized neurosurgery, applies to team physicians who travel as part of their contract to provide services to a team or league.

Alliance of Specialty Medicine Holds Annual Legislative Conference

On July 11-13, 2016, the Alliance of Specialty Medicine, held its annual 2016 Legislative Conference in Washington, DC. Approximately 150 specialty physicians from 33 states attended and took their message to their elected officials. Specialties represented included neurosurgery, cardiology, cataract surgery, dermatology, facial plastic surgery, gastroenterology, plastic surgery, rheumatology, and spine specialists. Neurosurgeons in attendance included Shelly D. Timmons, Moustapha Abou-Samra, and Clemens M. Schirmer.

Conference attendees heard from a variety of key speakers, including elected officials, Congressional staff, Obama administration officials, and political experts:

  • Rep. Marsha Blackburn (R, Tennessee), vice-chair, House Energy and Commerce Committee
  • Sen. Rand Paul (R, Kentucky), member, Senate Health, Education, Labor and Pensions Committee
  • Sen. Chris Murphy (D, Connecticut), member, Senate Health, Education, Labor and Pensions Committee
  • Sen. Roy Blunt (R, Missouri), chairman, Appropriations Subcommittee on Labor, Health and Human Services (HHS), and vice chair, Senate Republican Conference
  • Rep. G. K. Butterfield (D, North Carolina), chief deputy Whip and House Democratic Caucus chair
  • Rep. Larry Bucshon, MD (R, Indiana), member, House Energy and Commerce Committee
  • Kate Goodrich, director of the Center for Clinical Standards and Quality at the Centers for Medicare & Medicaid Services (CMS)
  • Political commentator, Charles E. Cook Jr., editor and publisher of The Cook Political Report and a columnist for the National Journal

Washington Committee chair Shelly D. Timmons and CNS Executive Committee member Clemens M. Schirmer with Sen. Roy Blunt (R, Missouri) at the Alliance of Specialty Medicine’s 2016 legislative conference in Washington, DC.

Organized Neurosurgery Issues Position Statement on Concurrent and Overlapping Surgery

The topic of concurrent and overlapping surgery has been the focus of significant attention in the media and by state and federal policymakers— in particular, the Boston Globe Spotlight Team and Senate Finance Committee. To help provide clarity about the many facets of this issue, the CNS, AANS, American Board of Neurological Surgery (ABNS), Society of Neurological Surgeons (SNS), and Washington Committee collaborated to produce a position statement addressing the intraoperative responsibility of the primary neurosurgeon. The statement builds on the American College of Surgeons’ “Statements on Principles.”

These guidelines recognize that the primary attending neurosurgeon is personally responsible for the patient’s welfare throughout the operation. In general, the patient’s primary attending neurosurgeon should be in the operating suite or be immediately available for the entire surgical procedure. There are instances consistent with good patient care that are valid exceptions. However, when the primary attending neurosurgeon is not present or immediately available, another attending neurosurgeon should be assigned to be immediately available. Specifically:

  • A primary attending neurosurgeon’s involvement in concurrent or simultaneous surgeries on two different patients in two different rooms is not appropriate.
  • A primary attending neurosurgeon may be involved in two overlapping surgeries provided that the key or critical elements of the first operation have been completed, and there is no reasonable expectation that there will be a need for the primary attending neurosurgeon to return to that operation.
  • The neurosurgeon may delegate part of the operation to qualified practitioners under his or her personal direction, including residents and fellows. However, the primary neurosurgeon must be an active participant throughout the key or critical components of the operation.
  • Neurosurgeons must fully inform every patient about his or her illness and the proposed treatment. As part of the pre-operative discussion, patients should be informed of the different types of qualified medical providers that will participate in their surgery (assistant attending neurosurgeon, fellows, resident and interns, physician assistants, nurse practitioners, etc.) and their respective roles explained.

Organized neurosurgery believes these principles strike the appropriate balance of optimizing surgical care and neurosurgical training with informed and safe patient care.

Neurosurgeon Announces Candidacy for AMA Council on Medical Education

Former CNS Executive Committee member Krystal L. Tomei has launched a campaign for a position on the American Medical Association’s (AMA) Council on Medical Education (CME). The CME formulates policy on medical education—including graduate medical education financing, medical student debt, and physician workforce—and is also responsible for recommending the appointments of representatives to medical education organizations, accrediting bodies and certification boards. The election will be held in June 2017.

For more information on these or other health policy issues, please contact Katie O. Orrico, director of the Washington Office, at korrico@neurosurgery.org.