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Urology Health Policy and Advocacy 101

Urology Health Policy and Advocacy 101. Mark T. Edney , MD, FACS AUA G. James Gallagher Health Policy Scholar 2012-13 AUA Legislative Affairs Committee AUA Health Policy Council President, Maryland Urologists for Patient Access and Care. Agenda. Vocabulary Federal Infrastructure

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Urology Health Policy and Advocacy 101

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  1. Urology Health Policy and Advocacy 101 Mark T. Edney, MD, FACS AUA G. James Gallagher Health Policy Scholar 2012-13 AUA Legislative Affairs Committee AUA Health Policy Council President, Maryland Urologists for Patient Access and Care

  2. Agenda Vocabulary Federal Infrastructure Current Issues AUA Health Policy Infrastructure UROPAC Ways to Get Involved

  3. Health PolicyVocabulary • CPT—Common procedural terminology—codes for procedures • HCPCS—Healthcare Common Procedure Coding System—codes for procedures • E&M codes—subset of CPT codes for evaluation and management as distinct from procedures, labs, imaging, etc. • ICD-9 (ICD-10)—diagnostic codes (International Classification of Diseases—(new vastly expanded system) • RBRVS—Resource based relative value scale • RVU—relative value units • RUC— relative value unit update committee (AMA) • PC/TC—professional and technical components of code • GPCI—geographic modifier (geographic practice cost index) • PPIS—Practice expense information survey (Physician Practice Information Survey) • SGR—sustainable growth rate • MEI—medical economic index—market basket index of inflation • LCD—local coverage determination policy • NCD—national coverage determination policy • MAC—Medicare Adminstrative Contractor—local Medicare carrier • VBP -- Value based purchasing • VBM – Value based modifier

  4. Health PolicyVocabulary • RAC—Recovery audit contractor (HDI) • CAC—carrier advisory committee • LCA—least cost alternative • MPPR—multiple procedure payment reduction—decrease subsequent studies 50% • UCR—usual and customary rate • HAC—hospital acquired conditions • JAC—Joint Advocacy Conference AUA & AACU • PPACA—Patient Protection and Affordable Care Act 2010 • MedPAC—Medicare Payment Advisory Commission • IPAB—Independent Payment Advisory Board • ACO—Accountable care organization • CER—comparative effectiveness research (measuring outcomes versus cost) • IOAS—In office ancillary services--exempt from Stark prohibitions against self referral • PQRS—Physician Quality Reporting System • P4P—pay for performance • Medicare part A—hospital, SNF, hospice coverage • Medicare part B—physician services, lab, imaging services, in office medications • Medicare part C—privatized Medicare Advantage plans (HMO) • Medicare part D—drug coverage • UROPAC—urology specialty political action committee

  5. Understanding the EnvironmentDebt and Deficit

  6. The Federal Pie

  7. $ 2,300,000,000,000 Medicare Medicare Private Health Insurance

  8. Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database).doi: 10.1787/data-00350-en(Accessed on 14 February 2011). Notes: Data from Australia and Japan are 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. Numbers are PPP adjusted.

  9. World GDP Ranking 2010

  10. Federal Healthcare Regulation

  11. Federal Agency Rule Making • Congress delegates and empowers agencies of jurisdiction (HHS, CMS) to actuate law (PPACA) through the creation of policy/regulation: “rules” • ACO, State Exchanges, Medicaid Rules, Physician Fee Schedule CMS-Center for Medicare and Medicaid Services HHS- Department of Health and Human Services ACO- Accountable Care Organization PPACA- Patient Protection and Affordable Care Act (ACA, “Obamacare”) PFS- Physician Fee Schedule • 1965 Medicare law 137 pages: 132,000 pages of regulation 2010 PPACA 2800 pages: ?

  12. Federal Agency Rule Making • Administrative Procedures Act 1946 • Proposed Rule • Comment period • AUA and coalition comment letters • Interim Final Rule • A way around Proposed Rule requirement (in the best public interest/of necessity) • Final Rule • Final rules are BINDINGon those within their jurisdiction • Congressional, Judicial Oversight

  13. Federal Agency Rule Making • CMS • Physician Fee Schedule (PFS) • Proposed Rule published in the Federal Register in early July every year- comments through the end of August • Final Rule published in November each year • HHS • ACO regulations • Significant revisions/improvements in the final rule as a result of comments including AUA’s

  14. Anatomy of a Physician Payment (CMS) RVU x GPCI x Conversion Factor = Payment RVU- Relative Value Unit GPCI- Geographic Practice Cost Index

  15. Anatomy of a Physician Payment SGR AMA Relative Value Update Committee (RUC) X

  16. Current Issues • Sustainable Growth Rate (SGR) • The “doc fix” • Balanced Budget Act 1997 • Formula by which Medicare reimbursement is adjusted year to year • Indexed to GDP • Federal budget baselines predicated on the savings predicted by the formula (as if current law is adhered to)- therefore a “fix” requires an “offset” or it adds to the deficit • Congress has intervened against every prescribed cut since 2003 • Current “fix” expires with 27% cut due Jan 1, 2013

  17. “Health Policy Brief: Medicare Payments to Physicians," Health Affairs, Updated February 28, 2012. http://www.healthaffairs.org/healthpolicybriefs/

  18. Current Issues • Affordable Care Act • SCOTUS upheld the law June 28, 2012 • Individual mandate constitutional under Congress’s taxing authority not by its power to regulate commerce • Medicaid expansion is optionalfor states • 16 states are currently refusing to establish exchanges, 17 have set up exchanges, 5 more are pursuing a state/fed partnership • Expansion is 100% Federally funded for 3 years, then 90% • Current debate over ACA language/IRS authority to allow Federally administered exchanges to grant subsidies • If fully implemented, Medicaid would grow from 53 million beneficiaries to 68 million

  19. Current Issues • Affordable Care Act • Congress has voted 32 times to defund or repeal all or part of the ACA • Election 2012 results make outright repeal all but impossible- many elements (medicare/medicaid reform, IPAB and others) will be on the table during ‘fiscal cliff’ negotiations

  20. Current Issues • ACOs- Accountable Care Organization • Increased interest with final rule; less potential financial risk, fewer quality measures (32) • Medicare Shared Savings Program (MSSP) • 5000 beneficiaries, responsible for cost and quality • Shared savings to shared risk • 27 program enrolled in 2012 • Majority are physician-led (not hospital) • CMMI- Pioneer ACO program (32 programs) • Shared risk to modified capitation

  21. Current Issues • IPAB- Independent Payment Advisory Board • Appointed 15 member panel with broad authority to cut spending with no judicial or administrative review • Hospitals and hospices carved out for first 5 years • Guess who’s left? • HR 452 (Phil Roe R-TN) to repeal passed Energy and Commerce Health Subcommittee 3/12/12 • Dave Penson, MD, Chair, AUA Health Policy Council testified

  22. Current Issues • Protection of In-Office Ancillary Exception to Stark Law (IOAE)- Federal and State Issue • Protection of integrated practice models • CT/MRI (Advanced Imaging) • Radiation Therapy Services • U/S • Pathology • Lab • Medical Liability Reform • Phil Gingrey (R-GA)’s HR 5, combined with IPAB repeal, passed house March 22, 2012 • Unlikely to get a vote in the Senate and President has promised veto • ? Tactical error in combining the Bills • Federal Funding of Research

  23. GME funding • Watershed event • Balanced Budget Act 1997 • Cap on federally funded residency slots • 400 Urology grads/yr in 1970s • 200 by the late 90s- • Now around 250/yr (additional slots funded by clinical revenue) • Current patchwork of funding for GME • CMS • VA • Medicaid and other state funding • Endowments/gifts • Research grants • Clinical revenue • Declining surplus from private payers

  24. GME funding • CMS funds GME at $9.5 Billion/yr • $3B in direct payments • $6.5B as IME (indirect medical education) adjustment • Calculated using (IRB ratio)- intern/resident per bed • Dollars are targeted in current fiscal environment • Perceived ambiguity of true cost • Lack of accountability for the product • Academic mission • Teaching, research, patient care • Ambiguity of actual costs associated with resident education • Increasing costs of surgical education (simulation) • Work hour restrictions • ACGME mandates with respect to core competencies • ACGME’s Next Accreditation System (NAS)- • 5-specialty pilot (including Urology) in 2013

  25. GME Funding • What’s at stake for Urology? • Severe workforce shortage predicted in next 10 years at current graduation rates • We gain 300/year from training and lose 500/year to retirement • Severe current academic workforce shortage • 85% of programs are recruiting faculty • Need 390 new academicians in the next 5 years • Keeping salaries competitive is a problem • Further impediments to training expansion will exacerbate an already bleak workforce picture

  26. GME funding • Policy options being discussed • Establish an all-payer premium for GME • Currently private payers, pharma, and medical device companies do not contribute directly to GME • Tie GME funding to core competency performance measures • NAS • Create built-in GME premium for state insurance exchanges • Studies ongoing: • IOM ( Macy Institute ): funding and governance of GME • RAND Corporation (MedPAC): GME funding allocation

  27. Current Issues • USPSTF final categorization of PSA screening as “D” (not recommended) • Under ACA, “A” and “B” must be covered “C” and “D” are at the discretion of local contractors • LCD- local coverage decision • No current indication of defunding but it remains a risk • Public confusion, primary care behavior • AUA response • State-level responses • NJ • PA • MD

  28. Current IssuesAUA- led initiatives • HR 5998 • USPSTF Transparency and Accountability Act of 2012 • Sponsored by Rep. Marsha Blackburn (R-TN) and 9 cosponsors in the House • HR 1162- AUA Urotrauma Bill • Sunset Commission to study prevention/treatment/public-private resources to support GU injured soldiers • Congressman Brett Guthrie and 26 co-sponsors • I’m leading a renewed collaborative effort to push this in the 113th Congress

  29. What’s Next • From fee-for-service (pay for volume) to value-based purchasing (pay for quality) • Comparative Effectiveness Research • Physician Resource Use Reports • 2012 pilot in the midwest • Value Based Modifier (INDIVIDUAL PAYMENT ADJUSTER) • Groups of ≥ 100, applied in 2015 based on 2013 performance • HCAHPS (Consumer Assessment of Healthcare and Systems) • ACOs, medical homes • Bundled payments/episodes of care

  30. “The Fiscal Cliff” • “Taxmaggedon” 2012 The lame-duck Congress in December will need to address: Expiration of Bush tax cuts Expiration of SS payroll tax cut Sequester (2% Defense and discretionary spending cut) from failed super-committee Rise in Alternative Minimum Tax Debt Ceiling SGR cut of 27%

  31. AUA Health Policy Council • Health Policy Council • The Council oversees and investigates the governmental, private, professional and socioeconomic issues affecting the delivery of urologic care as requested by the Board of Directors • Voting members • 1 Representative per section (HP chair or equivalent) • AUA Delegates to AMA House of Delegates • 3 members of AACU • Chairs of Component Committees • Legislative Affairs • Practice Management • Coding and Reimbursement • Practice Guidelines • Quality Improvement and Patient Safety (QIPS)

  32. AUA Health Policy Reorganization

  33. AUA Health Policy Division Former Structure AUA BOARD OF DIRECTORS Health Policy Council HP Chair, HP Vice Chair, Committee Chairs, Sections and AACU Reps., AMA Delegates Coding & Reimbursement Practice Guidelines Quality Improvement & Patient Safety Legislative Affairs Practice Management

  34. PHASE I- reorganization AUA BOARD OF DIRECTORS Data & Quality Advisory Group Secretary - Chair, Treas.-Elect- Vice Chair, and PGC Chair, QIPS Chair Health Policy Council HP Chair, HP Vice Chair, Sections and AACU Reps., AMA Delegates AACU Practice Guidelines Coding & Reimbursement UROPAC Work Group Chair = Treasurer, Vice Chair = HP Chair, Secretary, Chairs of CRC, LA, PM, PGC, QIPS Quality Improvement & Patient Safety Legislative Affairs ABU Practice Management Data Committee/Panel LUGPA Key: Council Committee External Org.

  35. PHASE II- reorganization AUA BOARD OF DIRECTORS Legislative & Practice Council HP Chair, HP Vice Chair, Sections and AACU Reps., AMA Delegates Science & Quality Council Chair, Chairs of PGC, QIPS , Data and OE, Secretary AACU Health Policy Coding & Reimbursement Practice Guidelines UROPAC Work Group Treasurer Chair, Secretary, Council Chairs, Respective AEDs, Others TBD Legislative Affairs Quality Improvement & Patient Safety ABU Practice Management Data Committee LUGPA . Key: Council Committee External Org.

  36. American Association of Clinical Urologists (AACU)A brief History • Est. 1968 • Charles A. Hoffman, MD (AUA President 1968) and Russell B. Carson, MD • Increased government involvement in medicine (Medicare/Medicaid); need for physician voice in policy making • AUA - 501 c.3 (prohibition of political activity) • AACU - 501 c.6 socioeconomic/political activity and relationships

  37. AUA/AACU Joint Advocacy Conference The “JAC” March of every year March 10-13, 2013 Hyatt Regency Washington Capitol Hill

  38. JAC Joint meeting (AUA /AACU) dedicated to legislative advocacy • Congressional and White House speakers • Advocacy Training Meetings with your Members/staff

  39. Urology’s only political action committee • Founded 1992 (AACU), joint AUA/AACU PAC since 2003 • Contributions for 2010 election cycle $1,000,000+ • Support urology-friendly candidates and other key lawmakers • The only fuel source for national urological advocacy

  40. UROPAC Income1992-Present

  41. UROPAC- 10th Largest Specialty Physician PAC

  42. Physicians in Congress- 111th Congress (16) Family Medicine Vic Snyder (D- AR 2) John Flemming (R- LA 4) Paul Broun (R- GA 10) Donna Christensen (D-VI) Psychiatry Jim McDermott (D- WA 7) OB/GYN Tom Coburn (R-OK) Michael Burgess (R –TX 26) Ron Paul (R- TX 14) Phil Roe (R- TN 1) Phil Gingrey (R- GA 11) Allergist Steve Kagan (D- WI 8) GI Bill Cassidy (R- LA 6) CT Surgery Charles Boustany (R- LA 7) Radiation Onc Parker Griffith (R- AL 5) Orthopedics John Barrasso (R- WY) Tom Price (R- GA 6)

  43. Physicians in Congress- 112th Congress (20) Family Medicine John Flemming (R- LA 4) Paul Broun (R- GA 10) Donna Christensen (D-VI) Psychiatry Jim McDermott (D- WA 7) OB/GYN Tom Coburn (R-OK) Michael Burgess (R –TX 26) Ron Paul (R- TX 14) Phil Roe (R- TN 1) Phil Gingrey (R- GA 11) GI Bill Cassidy (R- LA 6) CT Surgery Charles Boustany (R- LA 7) Larry Bucshon (R- IN 8) Orthopedics John Barrasso (R- WY) Tom Price (R- GA 6) General Surgery Dan Benishek (R-MI 1) Anesthesia Andy Harris (R- MD 1) Ophthalmology Nan Hayworth (R- NY 19 Rand Paul (R-KY) Emergency Medicine Joe Heck (R- NV 3)

  44. Physicians in Congress- 113thCongress (20) Family Medicine/GP John Flemming (R- LA 4) Paul Broun (R- GA 10) Donna Christensen (D-VI) AmerishBera (D-CA) Scott DesJarlais (R-TN) Psychiatry Jim McDermott (D- WA 7) OB/GYN Tom Coburn (R-OK) Michael Burgess (R –TX 26) Phil Roe (R- TN 1) Phil Gingrey (R- GA 11) GI Bill Cassidy (R- LA 6) CT Surgery Charles Boustany (R- LA 7) Larry Bucshon (R- IN 8) Orthopedics John Barrasso (R- WY) Tom Price (R- GA 6) General Surgery Dan Benishek (R-MI 1) Anesthesia Andy Harris (R- MD 1) Ophthalmology Rand Paul (R-KY) Emergency Medicine Joe Heck (R- NV 3) Raul Ruiz (D-CA)

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