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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.

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Presentation on theme: "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."— Presentation transcript:

1 Urology Health Policy and Advocacy 101 Mark T. Edney, MD, FACS AUA G. James Gallagher Health Policy Scholar 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 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

4 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

5 Understanding the Environment Debt and Deficit

6 The Federal Pie

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

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

10 World GDP Ranking 2010

11 Federal Healthcare Regulation

12 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: ?

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14 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

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16 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

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

18 Anatomy of a Physician Payment RVU ExpenseWorkLiability Conversion Factor Enrollment Volume relative to GDP Change in input costs Change in Law/Regulation X AMA Relative Value Update Committee (RUC) SGR

19 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

20 “Health Policy Brief: Medicare Payments to Physicians," Health Affairs, Updated February 28,

21 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

22 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

23 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

24 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

25 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

26 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

27 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

28 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

29 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

30 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

31 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 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 113 th Congress

32 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

33 “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%

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35 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)

36 AUA Health Policy Reorganization

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

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

39 Data Committee AUA BOARD OF DIRECTORS Legislative Affairs Coding & Reimbursement Quality Improvement & Patient Safety 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 Group Treasurer Chair, Secretary, Council Chairs, Respective AEDs, Others TBD Council Committee PHASE II- reorganization. Health Policy External Org. UROPAC AACU LUGPA ABU Key:

40 American Association of Clinical Urologists (AACU) A brief History Est – 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 c.3 (prohibition of political activity) – AACU c.6 socioeconomic/political activity and relationships

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

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

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45 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

46 UROPAC Income 1992-Present

47 Specialty Physician PACS 2010 Election Cycle - Receipts Specialty AssociationReceipts for Cycle Percent of Eligible Members Donating American Association for Justice$ 34,715, American Association of Orthopaedic Surgeons $ 3,791, % American Society of Anesthesiologists $ 3,145, % American Medical Association $ 2,345, American College of Radiologists $ 2,345, % American College of Emergency Physicians $ 2,245, % American College of Ophthalmology $ 1,880, % College of American Pathologists $ 1,621, % American College of Surgeons $ 1,345, % American College of Cardiology $ 1,257, % UROPAC $ 1,027, % American College of Obstetrics & Gynecology $ 934, % American Osteopathic Information Association $ 914, % American Academy of Dermatology $ 741, % American Academy of Family Physicians $ 714, % UROPAC- 10 th Largest Specialty Physician PAC

48 Physicians in Congress- 111 th 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)

49 Physicians in Congress- 112 th 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)

50 Physicians in Congress- 113 th 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) 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)

51 Ways to Get Involved Leadership Program (sectional program) – Northeastern 2South Central 3 – New England 2Western 3 – New York 2North Central 3 – Mid Atlantic 2Southeastern 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

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

53 Ways to Get Involved Section Level Participation – Section representatives to AUA Board Practice Management Committee Young Urologists Committee Health Policy Council

54 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

55 Staying in the loop

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

58 Ways to Get Involved Contribute

59 Contact Cell


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