AACU News & Notes
AACU Participates in Medicare Red Tape Relief Project
posted: August 29, 2017
On August 25, the AACU submitted feedback to the House Ways and Means Health Subcommittee as part of its participation in the Medicare Red Tape Relief Project. Under this new initiative, the Subcommittee is reaching out directly to providers in an effort to reduce the Medicare regulations and mandates that too often stand in the way of their ability to deliver quality patient care.
According to Health Subcommittee Chairman Pat Tiberi (R-OH):
“The Medicare Red Tape Relief Project will help members of our committee work hand-in-hand with doctors, nurses, and other health care professionals to identify areas where we can eliminate red tape and burdensome mandates that are driving up costs in the Medicare program. We will listen to feedback from providers, learn more about the challenges they face, and work to deliver the regulatory relief they need to put patients, not paperwork, first. As the Chairman of the Health Subcommittee, I encourage all stakeholders to participate and I look forward to advancing additional bipartisan solutions that strengthen Medicare for our nation’s seniors.”
The initiative has three stages: after collecting feedback doctors, nurses, clinicians, and other health care professionals, the Subcommittee will then host roundtables with stakeholders across the country to continue the conversations and identify solutions. The final stage will be congressional action based on the recommendations and solutions developed. The AACU believes that this is an important opportunity for urologists and the entire physician community to work directly with lawmakers to reduce the red tape that impedes their ability to care for Medicare patients on a daily basis.
In short, the AACU’s feedback submission to the Subcommittee highlighted problems with EHR, prescribing medications to Medicare patients, prior authorization, and the Stark law. The AACU is pleased that the House is reaching out to physicians directly and is committed to identifying ways to simplify and improve the efficiency of the Medicare program. We will continue to work with the Subcommittee throughout the next stages of the project and will provide updates as they become available.
The AACU’s feedback to the Subcommittee touched on the following points:
Electronic Health Records (EHRs): Meaningful Use and Interoperability
- The AACU commented on the difficulties physicians face with EHRs, especially with respect to the lack of interoperability. Multiple AACU Board Members expressed their frustration with the inability to quickly and easily exchange protected medical information between EHR systems in order to facilitate coordinated care, citing the limits of current EHR technology and the slow progress made towards system compatibility.
- The AACU also pointed out that the underlying data requirements are not only irrelevant or meaningless to actual patient care, but they also do little to enhance and promote interoperability. Exchanging the patient data captured by these requirements is in practice virtually meaningless. The AACU emphasized that interoperability goes far beyond simply being able to exchange patient data between EHR systems. Instead, interoperability means improving patient outcomes by providing physicians timely access to clinically relevant information that enhances their ability to provide high-quality, coordinated care.
- The AACU also pointed out that the Evaluation and Management documentation guidelines were developed when medical records were paper-based and are now severely outdated, creating voluminous medical records that have become a hindrance to care and communication among physicians.
Prescription Medications for Medicare Patients
- The AACU noted that while cost is a major obstacle in providing Medicare patients with the medications they need, that is just the beginning of the struggles faced by physicians. After writing a prescription for their patients based on their medical expertise, physicians are then required to go through multiple dubious steps to ensure that those prescriptions actually get filled and dispensed to the patient, and in some cases, even after going through the process and doing everything required, it still might get denied.
- The AACU pointed out that Medicare Part D coverage is structured in such a way that depending on the coverage phase, patients are responsible for paying a portion or the entire list price of a drug. The problem is that the list price is an inflated, arbitrary amount that does not take into account the discounts and rebates that occur as money flows through the overly complex and opaque prescription drug system.
- Skyrocketing list prices can be attributed in large part to pharmacy benefit managers (PBMs), who act as intermediaries between insurers, manufacturers, and pharmacies and thus play a uniquely central role in the prescription drug market, handling everything from negotiating discounts with drug manufacturers and setting patient copayment amounts to determining which drugs are covered by which health plans.
- A major driving force in increasing list prices is what is known as the rebate system, whereby PBMs negotiate and receive retroactive discounts from drug manufacturers in exchange for preferred placement on the PBM’s tiered formulary. This system puts pressure on the manufacturers to give a rebate amount that is substantial enough to garner favorable placement on the formulary, or in some cases, to get on it at all. In this way, the ability to leverage rebates to ensure formulary placements is a significant market influence that manufacturers must take into account when setting list prices. The end result is higher list prices.
- Cost-sharing obligations under Part D for both the government and patients are based off of the unfairly inflated list price for a drug, which fails to take into account the rebates that are meant to serve as retroactive discounts off the drug price to drive down costs.
- While prior authorization is touted as a mechanism that drives down costs by restricting coverage for costly medications and services, whether or not it actually does so is quite unclear. What is clear, however, is that it puts a huge administrative burden on physicians treating Medicare patients in terms of time and practice costs, which greatly outweighs the likely minimal savings generated.
- Current prior authorization processes are inefficient and non-transparent, making it difficult for physicians to not only navigate but also to understand the rationale for the many requirements and often inconsistent outcomes. In many cases, the lengthy and time-consuming process leads to delayed treatment and puts patients at risk of negative health outcomes. And in those instances where coverage is denied altogether, patients are then forced to pursue another option, assuming one is even available.
Stark Law in the New Era of Coordinated Care
- The AACU noted that Medicare laws and regulations enacted prior to MACRA do not necessarily take into account its new, value-based approach, and in some cases actively work against the goals and aims of both MIPS and APMs.
- One particularly problematic provision, according to the AACU, is the physician self-referral prohibition (commonly known as the “Stark law”), which prohibits payment arrangements that take into account in any manner the volume or value of referrals or other business generated by the parties. By preventing practices from incentivizing their physicians to deliver more effective patient care, Stark law stands in direct contradiction to coordinated care.
- Stark law poses a particular threat to physician participation in Advanced APMs. The AACU expressed its strong support for a urology-specific APM recently submitted for approval by LUGPA and emphasized its concern that without waivers to Stark prohibitions, successfully implementing this APM will be extremely difficult, if not impossible. As such, the AACU urged the Subcommittee to support “The Medicare Care Coordination Improvement Act of 2017,” which will modernize the Stark law by removing barriers to participation and care coordination in APMs.