urology health policy and advocacy 101

Urology Health Policy and Advocacy 101

Mark T. Edney, MD, FACS

AUA G. James Gallagher Health Policy Scholar 2012-13AUA Legislative Affairs CommitteeAUA Health Policy CouncilPresident, Maryland Urologists for Patient Access and Care

Agenda

VocabularyFederal Infrastructure

Current IssuesAUA Health Policy Infrastructure

UROPACWays to Get Involved

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

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

Understanding the EnvironmentDebt and Deficit

The Federal Pie

Private Health Insurance

Medicare

$ 2,300,000,000,000

Medicare

Japan Italy

Spain U.K.

Austr

alia

Swed

enBe

lgium

Fran

ceGe

rman

y

Austr

iaNe

ther

lands

Cana

daSw

itzer

land

Norw

ay

U.S.A

.

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

$2,729 $2,870 $2,902 $3,129 $3,353 $3,470 $3,677 $3,696 $3,737 $3,970 $4,063 $4,079$4,627

$5,003

$7,538

Total Health Expenditure per Capita, U.S. and Selected Countries, 2008

Per C

apita

Spe

ndin

g - P

PP A

djus

ted

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.

World GDP Ranking 2010

Federal Healthcare Regulation

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 ServicesHHS- Department of Health and Human ServicesACO- Accountable Care OrganizationPPACA- Patient Protection and Affordable Care Act (ACA, “Obamacare”)PFS- Physician Fee Schedule

• 1965 Medicare law 137 pages: 132,000 pages of regulation2010 PPACA 2800 pages: ?


• 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 BINDING on those within their jurisdiction– Congressional, Judicial Oversight


• 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

Anatomy of a Physician Payment (CMS)

RVU x GPCI x Conversion Factor = Payment

RVU- Relative Value UnitGPCI- Geographic Practice Cost Index

Anatomy of a Physician Payment

RVU

ExpenseWork

Liability

Conversion Factor

Enrollment

Volume relative to GDP

Change in input costs

Change in Law/Regulation

X

AMA Relative Value Update Committee (RUC) SGR

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

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

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 optional for 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

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

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

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

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

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

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

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

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

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

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

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

“The Fiscal Cliff”

• “Taxmaggedon” 2012

The lame-duck Congress in December will need to address:

Expiration of Bush tax cutsExpiration of SS payroll tax cutSequester (2% Defense and discretionary spending cut) from

failed super-committeeRise in Alternative Minimum TaxDebt CeilingSGR cut of 27%

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)

AUA Health Policy Reorganization

Legislative Affairs

Coding & Reimbursement

Quality Improvement & Patient Safety

Practice Management

Health Policy CouncilHP Chair, HP Vice Chair, Committee Chairs, Sections and AACU Reps., AMA Delegates

Practice Guidelines

AUA BOARD OF DIRECTORS

AUA Health Policy Division Former Structure


Legislative Affairs



Practice Management

Health Policy CouncilHP Chair, HP Vice Chair, Sections and AACU Reps., AMA Delegates

Practice Guidelines

Data Committee/Panel

Work GroupChair = Treasurer,

Vice Chair = HP Chair,Secretary, Chairs of CRC,

LA, PM, PGC, QIPS

CouncilCommittee

PHASE I- reorganization

Data & Quality Advisory Group

Secretary - Chair,Treas.-Elect- Vice Chair, and PGC Chair, QIPS ChairAACU

UROPAC

LUGPA

External Org.

ABU

Key:

Data Committee


Legislative Affairs



Practice Management

Legislative & Practice Council

HP Chair, HP Vice Chair, Sections and AACU Reps., AMA Delegates

Practice Guidelines

Science & Quality Council

Chair, Chairs of PGC, QIPS , Data and OE, Secretary

Work GroupTreasurer Chair, Secretary, Council Chairs, Respective

AEDs, Others TBD

CouncilCommittee

PHASE II- reorganization

.

Health Policy

External Org.

UROPAC

AACU

LUGPA

ABU

Key:

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

AUA/AACU Joint Advocacy Conference

The “JAC”

March of every yearMarch 10-13, 2013

Hyatt Regency WashingtonCapitol Hill

JAC Joint meeting

(AUA /AACU) dedicated to legislative advocacy

• Congressional and White House speakers

• Advocacy Training

Meetings with your Members/staff

http://teachpol.tcnj.edu/amer_pol_hist/fi/000001ff.htm

• 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

UROPAC Income1992-Present

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

0

100000

200000

300000

400000

500000

600000

Specialty Physician PACS 2010 Election Cycle - ReceiptsSpecialty Association Receipts for 2009-2010

CyclePercent of Eligible Members Donating

American Association for Justice $ 34,715,804.00American Association of Orthopaedic Surgeons $ 3,791,270.00 27.7%American Society of Anesthesiologists $ 3,145,915.00 16.5%American Medical Association $ 2,345,490.00 ---American College of Radiologists $ 2,345,140.00 13%American College of Emergency Physicians $ 2,245,822.00 29%American College of Ophthalmology $ 1,880,000.00 20%College of American Pathologists $ 1,621,634.00 21%American College of Surgeons $ 1,345,374.00 4.2%American College of Cardiology $ 1,257,476.00 10%UROPAC $ 1,027,662.00 18%American College of Obstetrics & Gynecology $ 934,000.00 4.0%American Osteopathic Information Association $ 914,323.00 4.3%American Academy of Dermatology $ 741,000.00 12.0%American Academy of Family Physicians $ 714,385.00 3.35%

UROPAC- 10th Largest Specialty Physician PAC

Physicians in Congress- 111th Congress (16)

Family MedicineVic Snyder (D- AR 2)John Flemming (R- LA 4)Paul Broun (R- GA 10)Donna Christensen (D-VI)

PsychiatryJim McDermott (D- WA 7)

OB/GYNTom Coburn (R-OK)Michael Burgess (R –TX 26)Ron Paul (R- TX 14)Phil Roe (R- TN 1)Phil Gingrey (R- GA 11)

AllergistSteve Kagan (D- WI 8)

GIBill Cassidy (R- LA 6)

CT SurgeryCharles Boustany (R- LA 7)

Radiation OncParker Griffith (R- AL 5)

OrthopedicsJohn Barrasso (R- WY)Tom Price (R- GA 6)


Family MedicineJohn Flemming (R- LA 4)Paul Broun (R- GA 10)Donna Christensen (D-VI)


OB/GYNTom Coburn (R-OK)Michael Burgess (R –TX 26)Ron Paul (R- TX 14)Phil Roe (R- TN 1)Phil Gingrey (R- GA 11)


CT SurgeryCharles Boustany (R- LA 7)Larry Bucshon (R- IN 8)


General SurgeryDan Benishek (R-MI 1)

AnesthesiaAndy Harris (R- MD 1)

OphthalmologyNan Hayworth (R- NY 19Rand Paul (R-KY)

Emergency MedicineJoe Heck (R- NV 3)


Family Medicine/GPJohn Flemming (R- LA 4)Paul Broun (R- GA 10)Donna Christensen (D-VI)Amerish Bera (D-CA)Scott DesJarlais (R-TN)


OB/GYNTom Coburn (R-OK)Michael Burgess (R –TX 26)Phil Roe (R- TN 1)Phil Gingrey (R- GA 11)


CT SurgeryCharles Boustany (R- LA 7)Larry Bucshon (R- IN 8)


General SurgeryDan Benishek (R-MI 1)

AnesthesiaAndy Harris (R- MD 1)

OphthalmologyRand Paul (R-KY)

Emergency MedicineJoe Heck (R- NV 3)Raul Ruiz (D-CA)

Ways to Get Involved• Leadership Program (sectional program)

– Northeastern 2 South Central 3– New England 2 Western 3– New York 2 North Central 3– Mid Atlantic 2 Southeastern 3

• AACU States Society Network Annual Meeting– Every September in Chicago

• Joint Advocacy Conference – AUA/AACU, annually in March in Washington DC– The MAAUA, beginning with the 2013 JAC, will support the travel of 1

MAAUA resident to the JAC- see website for details and to apply

Ways to Get Involved• Gallagher Health Policy Scholarship– Annual award in its 7th year

• Biannual HP meetings• Brandeis (ACS) Health Policy/Leadership course (1 week)• AMA RUC • AMA CPT • MedPAC • JAC

• American College of Surgeons– Health Policy Fellowship

• Open to all surgical residents• James Dupree, MD, MPH inaugural fellow

Ways to Get Involved

• Section Level Participation

– Section representatives to • AUA Board• Practice Management Committee• Young Urologists Committee• Health Policy Council


• State-level advocacy development

– Critical unmet need– State law can supercede federal law/protections– Opportunity for the motivated to immediately assume a

leadership role• Make calls/generate interest

– Critical mass of practices• Retain counsel• Retain a lobbyist• Incorporate

Staying in the loop

“IF YOU ARE NOT AT THE TABLE YOU WILL SURELY BE ON THE MENU”


Contribute

Contact

[email protected]

Cell 401-422-9911

urology health policy and advocacy 101

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