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
Current Issues
AUA Health Policy Infrastructure
UROPAC
Ways to Get Involved
Health Policy
Vocabulary
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
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 Policy
Vocabulary
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
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 Environment
Debt and Deficit
The Federal Pie
$ 2,300,000,000,000
Medicare
Medicare
Private Health Insurance
Total Health Expenditure per Capita,
U.S. and Selected Countries, 2008
$8,000
$7,538
Per Capita Spending - PPP Adjusted
$7,000
$6,000
$5,003
$5,000
$4,627
$4,000
$3,000
$2,902
$2,729 $2,870
$3,129
$3,353 $3,470
$3,677 $3,696 $3,737
$3,970 $4,063 $4,079
$2,000
$1,000
$0
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 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
2010 PPACA
137 pages: 132,000 pages of regulation
2800 pages:
?
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 BINDING on those within their jurisdiction
– Congressional, Judicial Oversight
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
Anatomy of a Physician Payment (CMS)
RVU x GPCI x Conversion Factor = Payment
RVU- Relative Value Unit
GPCI- Geographic Practice Cost Index
Anatomy of a Physician Payment
SGR
AMA Relative Value Update Committee (RUC)
Volume relative
Work
Expense
to
Liability
RVU
X
GDP
Change in input
costs
Change in
Law/Regulation
Enrollment
Conversion
Factor
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 90sNow 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 Issues
AUA- 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 valuebased 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 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%
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
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
Legislative
Affairs
Quality
Improvement &
Patient Safety
Practice
Management
PHASE I- reorganization
AUA BOARD OF DIRECTORS
Data & Quality
Advisory Group
Health Policy Council
AACU
UROPAC
Secretary - Chair,
Treas.-Elect- Vice Chair, and
PGC Chair, QIPS Chair
HP Chair, HP Vice Chair,
Sections and AACU Reps.,
AMA Delegates
Coding &
Reimbursement
Legislative
Affairs
Practice
Management
Practice
Guidelines
Work Group
Chair = Treasurer,
Vice Chair = HP Chair,
Secretary, Chairs of CRC,
LA, PM, PGC, QIPS
Quality
Improvement &
Patient Safety
ABU
Data
Committee/Panel
LUGPA
Key:
Council
Committee
External Org.
PHASE II- reorganization
AUA BOARD OF DIRECTORS
Legislative &
Practice Council
AACU
Science & Quality
Council
HP Chair, HP Vice Chair,
Sections and AACU
Reps., AMA Delegates
Coding &
Reimbursement
UROPAC
Legislative
Affairs
Practice
Management
Chair, Chairs of
PGC, QIPS , Data and
OE, Secretary
Health Policy
Practice
Guidelines
Work Group
Treasurer Chair, Secretary,
Council Chairs, Respective
AEDs, Others TBD
Quality
Improvement &
Patient Safety
Data
Committee
ABU
LUGPA
.
Key:
Council
Committee
External Org.
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 year
March 10-13, 2013
Hyatt Regency Washington
Capitol Hill
JAC
Joint meeting
(AUA /AACU)
dedicated to
legislative advocacy
•
Congressional and
White House speakers
•
Advocacy Training
Meetings with your
Members/staff
•
•
•
•
•
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 Income
1992-Present
600000
500000
400000
300000
200000
100000
0
UROPAC- 10th Largest Specialty Physician PAC
Specialty Physician PACS 2010 Election Cycle - Receipts
Specialty Association
American Association for Justice
American Association of Orthopaedic
Surgeons
American Society of Anesthesiologists
American Medical Association
American College of Radiologists
American College of Emergency
Physicians
American College of Ophthalmology
College of American Pathologists
American College of Surgeons
American College of Cardiology
UROPAC
American College of Obstetrics &
Gynecology
American Osteopathic Information
Association
American Academy of Dermatology
American Academy of Family
Physicians
Receipts for 2009-2010 Cycle
$
Percent of Eligible Members
Donating
34,715,804.00
$
3,791,270.00
27.7%
$
$
$
3,145,915.00
2,345,490.00
2,345,140.00
16.5%
--13%
$
$
$
$
$
$
2,245,822.00
1,880,000.00
1,621,634.00
1,345,374.00
1,257,476.00
1,027,662.00
29%
20%
21%
4.2%
10%
18%
$
934,000.00
4.0%
$
$
914,323.00
741,000.00
4.3%
12.0%
$
714,385.00
3.35%
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)
Allergist
Steve Kagan (D- WI 8)
Psychiatry
Jim McDermott (D- WA 7)
CT Surgery
Charles Boustany (R- LA 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)
Radiation Onc
Parker Griffith (R- AL 5)
GI
Bill Cassidy (R- LA 6)
Orthopedics
John Barrasso (R- WY)
Tom Price (R- GA 6)
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)
Physicians in Congress- 113th Congress (20)
Family Medicine/GP
John Flemming (R- LA 4)
Paul Broun (R- GA 10)
Donna Christensen (D-VI)
Amerish Bera (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)
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)
GI
Bill Cassidy (R- LA 6)
Emergency Medicine
Joe Heck (R- NV 3)
Raul Ruiz (D-CA)
Ways to Get Involved
• Leadership Program (sectional program)
–
–
–
–
Northeastern
New England
New York
Mid Atlantic
2
2
2
2
South Central
Western
North Central
Southeastern
3
3
3
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
Ways to Get Involved
• 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”
Ways to Get Involved
Contribute
Contact
mtedney04@hotmail.com
Cell 401-422-9911