Letter/Comment

Letter/Comment / en Fri, 25 Apr 2025 14:53:01 -0500 Tue, 15 Apr 25 13:22:45 -0500 AHA Supports House Securing Access to Care for Seniors in Critical Condition Act /lettercomment/2025-04-15-aha-supports-house-securing-access-care-seniors-critical-condition-act April 15, 2025The Honorable Kevin Hern U.S. House of Representatives 171 Cannon House Office Building Washington, DC 20515The Honorable Brendan Boyle U.S. House of Representatives 1502 Longworth House Office Building Washington, DC 20515Dear Representatives Hern and Boyle:On behalf of our nearly 5,000 member hospitals and health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and our 2,425 post-acute care members, the �� Association (AHA) is pleased to support the Securing Access to Care for Seniors in Critical Condition Act (H.R. 1924).Long-term care hospitals (LTCHs) play a unique role for Medicare and other beneficiaries by caring for the most severely ill and medically complex patients, who often require extended hospitalization and highly specialized care. LTCHs are critical partners for acute-care hospitals, alleviating capacity for overburdened intensive care units and other parts of the care continuum that would otherwise be further strained without access to LTCHs for these patients.Since implementing the dual-rate payment system in 2016, the volume of LTCH standard-rate cases has fallen by approximately 70% from its peak under the prior system, and the number of LTCH providers has decreased by 20%. At the same time, the average acuity of LTCH patients has risen by 20% or more in that same period, and these patients are increasingly consolidated into a limited number of Diagnosis-Related Groups (DRGs).1 The smaller yet sicker patient population and dwindling reimbursement have created many challenges for LTCHs, as evidenced by the closure of so many of these facilities. The remaining patient pool is notably more acute and costly to treat, resulting in cases increasingly qualifying for high-cost outlier (HCO) payments to compensate for the lack of precision in the DRGs, as so many cases are consolidated into a limited number of DRGs. However, the fixed-loss amount for HCO cases has risen by more than 300% since 2016, forcing LTCHs to take on significant financial losses when caring for these particularly ill patients.For these reasons, the AHA supports legislation that would provide more adequate reimbursement to LTCH providers caring for some of Medicare’s sickest beneficiaries. Thank you for your leadership on these important issues to ensure patients have continued access to this vital care.Sincerely,/s/Lisa Kidder Hrobsky Senior Vice President Advocacy and Political Affairs __________1<a href=/white-papers/2023-12-29-white-paper-medicares-ltch-outlier-policy-needs-reforms-protect-extremely-ill-beneficiaries" target="_blank"> /white-papers/2023-12-29-white-paper-medicares-ltch-outlier-policy-needs-reforms-protect-extremely-ill-beneficiaries</a> Tue, 15 Apr 2025 13:22:45 -0500 Letter/Comment AHA Comments on CMS Marketplace Integrity and Affordability Rule /lettercomment/2025-04-11-aha-comments-cms-marketplace-integrity-and-affordability-rule April 11, 2025Mehmet Oz, M.D. Administrator Centers for Medicare &amp; Medicaid Services Hubert H. Humphrey Building 200 Independence Avenue, S.W., Room 445-G Washington, DC 20201RE: Patient Protection and Affordable Care Act; Marketplace Integrity and Affordability (CMS-9884-P)Dear Administrator Oz:On behalf of the �� Association’s (AHA) nearly 5,000 member hospitals, health systems and other health care organizations, including approximately 90 that offer health plans, and our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, we thank you for the opportunity to respond to the Centers for Medicare &amp; Medicaid Services (CMS) rule on marketplace integrity and affordability.We appreciate CMS’ attention to concerns regarding the inappropriate enrollment of large numbers of low-income individuals into Health Insurance Marketplace coverage by certain brokers.&nbsp;As detailed in the proposed rule, it appears that in several states, some brokers have enrolled cohorts of low-income individuals (including, at times, Medicaid enrollees) into marketplace plans without the individuals’ knowledge. This has led to patient confusion, barriers to care and financial pressure on hospitals.These impacts have been confirmed by AHA member hospitals. In these instances, hospitals scheduled services for patients when their coverage indicated Medicaid. In one example, the hospital only learned that the patient’s coverage had changed upon submitting the bills for care to the appropriate Medicaid agency, which then denied the claims due to the patient having marketplace coverage. The patients were completely unaware of this change in their coverage, and, unfortunately, in many instances, the hospital was not in-network with the marketplace plan, leaving the care uncovered. This change in coverage without the patients’ consent is&nbsp;interfering with&nbsp;patients' access to care,&nbsp;including&nbsp;services being postponed or canceled. One health system shared that they have found 2,500 unique patients with this issue, resulting in over $45 million in outstanding claims going unpaid as a result. A separate health care system estimates the financial impact on their hospitals is much greater.The agency has proposed several policy changes to address this issue. While we appreciate the agency taking action to stop these inappropriate enrollments, we are concerned that the proposed changes will create barriers for truly eligible marketplace consumers without sufficient focus on the agents and brokers instigating these enrollments. Taken with other policies in the rule, CMS estimates that between 750,000 to 2 million consumers could lose their coverage. We are deeply concerned by these estimates of coverage loss, particularly as we have seen no credible evidence to support that such a high number of individuals have been impacted by inappropriate broker enrollments.Coverage loss of this magnitude would have substantial consequences for patient access to care, as well as the financial stability of hospitals, health systems, and other providers. As CMS notes in the rule, “some enrollees, particularly those facing financial constraints, might need to adjust their household budgeting to maintain coverage or, if they are not able to, become uninsured. Depending on the circumstances, these enrollees, if they become uninsured, could face higher costs for care and medical debt if care is needed. These costs could in turn be incurred by hospitals and municipalities in the form of uncompensated care” (emphasis added). These new costs to hospitals would come at a time when many hospitals and health systems, particularly critical access hospitals and those in rural areas, are operating with little to no margin. They cannot absorb further losses without consequences on access to care that will be felt by everyone in a community, not just those enrolled in marketplace coverage.1For these reasons, we encourage the agency to pause finalizing many of these policies to give it and stakeholders additional time to consider the impacts while simultaneously investigating and taking appropriate action to stop the specific agents and brokers responsible for these inappropriate enrollments. In addition, we urge the agency to address reimbursement for services rendered to those impacted patients.Thank you for your consideration, and we look forward to working with the administration to ensure efficient and affordable marketplaces.&nbsp;Please contact me if you have questions, or feel free to have a member of your team contact Ariel Levin, AHA’s director of coverage policy, at 202-626-2335 or&nbsp;<a href="mailto:alevin@aha.org">alevin@aha.org</a>.Sincerely,/s/Ashley Thompson Senior Vice President Public Policy Analysis and Development<div><hr><div id="ftn1">1 <a href="/costsofcaring">/costsofcaring</a></div></div> Fri, 11 Apr 2025 12:10:58 -0500 Letter/Comment AHA Comments on MedPAC Physician Fee Schedule Payment Recommendations /lettercomment/2025-04-04-aha-comments-medpac-physician-fee-schedule-payment-recommendations April 4, 2025Michael Chernew, Ph.D. Chairman Medicare Payment Advisory Commission 425 I Street, NW, Suite 701 Washington, D.C. 20001Dear Chairman Chernew:On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations; our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the �� Association (AHA) appreciates the opportunity to share our comments regarding the Medicare Payment Advisory Commission’s (MedPAC’s) March meeting recommendations on physician fee schedule payments.We appreciate the thoughtful discussions the Commission has had over the past three years regarding physician payments. This is a challenging issue, but one that is critical to address to ensure beneficiary access to quality primary care and specialty providers. Thus, given recent discussions at the March meeting, we urge MedPAC to:<ul><li>Recommend a full inflationary update to physician payment instead of an update based on a portion of the Medicare Economic Index (MEI).</li><li>Remove recommendations to update relative value unit (RVU) calculations.</li><li>Reiterate its concerns about expiring alternative payment model (APM) incentive payments.</li></ul>Detailed feedback on these recommendations is below.<h2>PHYSICIAN FEE SCHEDULE AND MEI RECOMMENDATION</h2>In the March meeting, commissioners reviewed a recommendation for Congress to replace the current law updates to the physician fee schedule with an annual update based on a portion of the growth in the MEI (e.g., MEI minus 1%). We value the commission’s continued focus on addressing the woeful inadequacy of physician payment. However, we are concerned that such an annual update is not sufficient to make up for the existing shortcomings in physician reimbursement. Addressing this issue is of utmost importance to ensure the continued provision of vital care to Medicare beneficiaries. As we have commented previously, updates to the physician fee schedule conversion factor have not kept pace with inflation.1,2 Medicare’s conversion factor, which determines physician payment, declined by over 13% in real dollars from 2001 to 2024. The actual reduction when accounting for inflation is a staggering 29%. Continued decrements are unsustainable, particularly in light of the physician shortages the country is facing. Therefore, we continue to urge MedPAC to recommend a higher update to physician reimbursement that more fully accounts for inflation.<h2>ACCURACY OF RELATIVE PAYMENT RATES RECOMMENDATION</h2>MedPAC also reviewed a recommendation for Congress to direct the secretary to improve the accuracy of relative payment rates by 1) updating cost data regularly and 2) ensuring that the methodology used to determine payment rates for different services reflects the settings in which clinicians practice medicine. We are encouraged that MedPAC is evaluating strategies to improve the accuracy of RVU calculations. However, we are concerned that the policy recommendations presented do not address the underlying issues with payment and may inappropriately penalize facility-based providers.For example, the recommendation to update cost data regularly (which would yield a rebased and revised MEI) does not address the overall issue of inadequate payment per RVU. Additionally, any updates to RVUs would cause a redistribution of payments based on physicians’ geography and specialty. As such, we urge MedPAC to further evaluate the potential redistributive effects of cost data updates, especially in light of physician shortages and pervasive underpayments.Moreover, the recommendation to revise the RVU methodology based on clinician setting could inappropriately penalize facility-based providers and potentially exacerbate the consolidation of physician practices by non-traditional providers. Unsustainable reimbursement has driven many physicians to pursue employment models that provide stable payment through salaries and enable physicians to focus on direct patient care. Cutting payment to facility-based providers would not solve these issues in physician reimbursement; rather, it would lead to decreases in access since hospitals may no longer be able to absorb additional reductions in reimbursement without cutting services. Indeed, hospitals already must subsidize inadequate payment to preserve access to care in communities, with recent data indicating that subsidies per physician have increased 5% in the last three years to over $306,000 (see figure 1 below).3Figure 1. Average Subsidy Per Physician<img src="/sites/default/files/inline-images/image_55.png" data-entity-uuid="81dc2055-dec5-4391-9da3-0ea1782d0467" data-entity-type="file" alt="Figure 1 Image - Average Investment / Subsidy Per Physician " width="459" height="393">Furthermore, decrements to facility-based providers will create a greater incentive for physicians to seek out employment from non-traditional providers. Of the physician acquisitions that occurred over the last 5 years, the majority have been acquired by private equity companies, other physician groups and health insurers. In fact, of the physician acquisition deals from 2019 to 2023, private equity-backed startups acquired 65% of physician practices, and insurers acquired 14% of practices in that same timeframe. This is compared to hospitals and health systems that only accounted for 6% of physician acquisition acquirers. Therefore, we oppose policy options to revise RVU methodology in ways that would decrease payment to facility-based providers.<h2>ALTERNATIVE PAYMENT MODEL INCENTIVES</h2>Finally, we urge MedPAC to reiterate its concerns about the pending expiration of advanced APM incentive payments. While it has previously discussed incentives to support transition to value-based care, the absence of formal policy recommendations related to this issue may be misconstrued to mean that incentives are no longer needed. These payments continue to support providers’ transitions to value-based payment models and support the provision of non-fee-for-service programs like meal delivery programs, transportation services and care coordinators that promote population health.We thank you for your consideration of our comments. Please contact me if you have questions or feel free to have a member of your team contact Shannon Wu, AHA’s director of payment policy, at <a href="mailto:swu@aha.org">swu@aha.org</a> or 202-626-2963.Sincerely,/s/Ashley B. Thompson Senior Vice President Public Policy Analysis and DevelopmentCc: Paul Masi, M.P.P. MedPAC Commissioners____________________1 <a href="/lettercomment/2024-12-09-aha-comments-medpac-re-physician-fee-schedule-payments-apm-incentives-and-medicare-advantage-network" target="_blank">/lettercomment/2024-12-09-aha-comments-medpac-re-physician-fee-schedule-payments-apm-incentives-and-medicare-advantage-network</a>2 <a href="/2025-01-10-aha-comments-advance-medpac-january-2025-meeting" target="_blank">/2025-01-10-aha-comments-advance-medpac-january-2025-meeting</a>3 <a href="https://www.kaufmanhall.com/insights/research-report/physician-flash-report-q4-2024-metrics" target="_blank" id="https://www.kaufmanhall.com/insights/research-report/physician-flash-report-q4-2024-metrics">https://www.kaufmanhall.com/insights/research-report/physician-flash-report-q4-2024-metrics</a>4 <a href="/system/files/media/file/2023/06/Private-Equity-and-Health-Insurers-Acquire-More-Physicians-than-Hospitals-Infographic.pdf" target="_blank" id="/system/files/media/file/2023/06/Private-Equity-and-Health-Insurers-Acquire-More-Physicians-than-Hospitals-Infographic.pdf">/system/files/media/file/2023/06/Private-Equity-and-Health-Insurers-Acquire-More-Physicians-than-Hospitals-Infographic.pdf</a> Fri, 04 Apr 2025 15:09:55 -0500 Letter/Comment AHA Comments on PTAC Total Cost of Care Model Proposal /lettercomment/2025-03-27-aha-comments-ptac-total-cost-care-model-proposal March 27, 2025Terry Mills Jr., M.D., M.M.M, Co-chair Soujanya Pulluru, M.D., Co-chair ATTN: Physician-Focused Payment Model Technical Advisory Committee&nbsp; Assistant Secretary for Planning and Evaluation, Room 415F U.S. Department of Health and Human Services 200 Independence Avenue, SW Washington, D.C. 20201RE: Request for Input Reducing Barriers to Participation in Population-Based Total Cost of Care Models and Supporting Primary and Specialty Care TransformationDear Co-chairs Mills and Pulluru,&nbsp;On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the �� Association (AHA) appreciates the opportunity to share our comments regarding the Physician‐Focused Payment Model Technical Advisory Committee’s (PTAC) request for input on barriers to transitioning to population-based total cost-of-care (PB-TCOC) and primary and specialty care models.In particular, we urge the PTAC to:<ul><li>Adopt common principles that will support the implementation of PB-TCOC, primary and specialty care models.</li><li>Recommend removal of high/low revenue thresholds, which inappropriately prevent certain providers from entering primary and specialty care models.</li><li>Recommend extension of the advanced alternative payment model (APM) incentive payments.</li><li>Recommend more sustainable reimbursement to support the transition to value better.</li></ul>Our detailed comments on these issues follow.<h2>COMMON PRINCIPLES FOR PB-TCOC, PRIMARY CARE AND SPECIALTY MODELS</h2>Our members support the U.S. health care system moving toward the provision of more outcomes-based, coordinated care, and we continue to redesign delivery systems to increase value and better serve patients. Over the last 15 years, our hospital and health system members participated in a variety of APMs, including primary care and specialty care models as well as total cost-of-care models.While the movement to value holds tremendous promise, the transition has been slower than anticipated and more needs to be done to drive long-term system transformation.There are principles that we believe should guide the design of such APMs to make participation more attractive for potential participants, including hospitals, health systems and independent providers. These include:<ul><li>Appropriate On-ramp and Glidepath to Risk. Model participants should have an adequate on-ramp and glidepath to transition to risk. They must have adequate time to implement care delivery changes (e.g., integrating new staff, changing clinical workflows, implementing new analytics tools) and review data prior to initiating the program.</li><li>Adequate Risk Adjustment. Models should include adequate risk adjustment methodologies to account for chronic risk factors and clinical complexity. This will ensure models do not inappropriately penalize participants for treating the sickest, most complicated and underserved patients.</li><li>Voluntary Participation and Flexible Design. Model designs should be flexible, incorporating features such as voluntary participation and options for participants to leave models.</li><li>Balanced Risk Versus Reward. Models should balance risk versus reward in a way that encourages providers to take on additional risk but does not penalize those who need additional time and experience before they are able to do so. A glidepath approach should be implemented, gradually migrating from upside-only to downside risk.</li><li>Guardrails to Ensure Hospitals Do Not Compete Against Their Own Best Performance. Models should provide guardrails to ensure that participants are not penalized over time when they achieve optimal cost savings and outcomes performance. Participants must have incentives to remain in models for the long term.</li><li>Resources to Support Initial Investment. Upfront investment incentives should be provided to support organizations in the transition to value-based payment. To be successful in such models, hospitals, health systems and provider groups must, for example, invest in additional staffing and infrastructure to support care delivery redesign and outcomes tracking.</li><li>Transparency. Models’ methodologies, data and design elements should be transparently shared with all potential participants. Proposed changes should be vetted with stakeholders.</li><li>Adequate Model Duration. Models should be long enough in duration to truly support care delivery transformation and assess the impact on outcomes. Historically, models have been too short and/or have had multiple, significant design changes even within the designated duration, making it difficult for participants to self-evaluate and change course when necessary.</li><li>Timely Availability of Data.&nbsp;Model participants should have readily available, timely access to data about their patient populations. Ideally, the Centers for Medicare &amp; Medicaid Services (CMS) would dedicate staff and technology to helping provide program participants with more complete data as close to real-time as possible.</li><li>Waivers to Address Barriers to Clinical Integration and Care Coordination. Models must include waivers to Medicare program regulations that inhibit care coordination and work against participants’ efforts to ensure that care is provided in the right place at the right time.</li></ul>We urge the PTAC to adopt these core principles for future APM model design.<h2>REMOVING PROBLEMATIC LOW-REVENUE THRESHOLDS AS CRITERIA FOR APM PARTICIPATION AND INVESTMENT PAYMENTS</h2>As mentioned above, hospitals and health systems are critical stakeholders in the journey to value. However, certain policies have hampered their ability to participate in certain models. For example, CMS has leveraged captured revenue to distinguish Accountable Care Organizations (ACOs) as “low-revenue” or “high-revenue,” and by proxy, to identify ACOs as either physician-led (low-revenue) or hospital-led (high-revenue). The agency has then limited participation in certain APMs or qualification for advanced investment payments (AIPs) to only physician-led or low-revenue ACOs. It has based this policy on the faulty assumption that low-revenue ACOs perform better than high-revenue ACOs. However, research shows there is no significant difference in performance between high- and low-revenue ACOs.1Furthermore, high-revenue ACOs often have more clinically complex, higher-cost patients attributed to their model. In addition, limiting eligibility for AIPs to only low-revenue ACOs inappropriately penalizes high-revenue ACOs, many of which are actually small organizations that critically need these resources for infrastructure investment to transition to APMs. For example, analysis suggests that critical access hospitals, federally qualified health centers and rural health centers are predominantly classified as high-revenue and therefore ineligible for AIPs. This partially explains the disparity in APM adoption in rural and underserved areas, which the PTAC has previously highlighted. We, therefore, urge PTAC to recommend the removal of these problematic high- and low-revenue thresholds that inappropriately preclude certain ACOs from obtaining necessary resources for infrastructure investment.<h2>EXTENSION OF ADVANCED APM INCENTIVE PAYMENTS</h2>The bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) provided incentive payments of 5% for providers participating in advanced APMs. These payments were designed to assist with the provision of non-fee-for-service programs like meal delivery programs, transportation services, digital tools and care coordinators that promote population health. However, MACRA statute only provided the advanced APM bonuses through the calendar year (CY) 2024 payment period. Congress has passed single-year extensions (although at lower rates) through the CY 2026 payment period. These incentive payments provide crucial resources for providers considering the transition to PB-TCOC, primary and specialty care APMs. As such, we urge PTAC to work with CMS to urge Congress to extend these incentive payments, which will better support providers transitioning to primary, specialty and total cost of care models.<h2>PHYSICIAN ACQUISITION AND PB-TCOC, PRIMARY AND SPECIALTY CARE MODELS</h2>Some presenters in the March PTAC meeting cited the acquisition of physician practices as a barrier to APM competitiveness. However, this discussion did not fully address the situation. Specifically, much like hospitals and health systems, physicians across the country face increased costs, inadequate reimbursements and administrative burdens from public and private insurer practices. These factors create major barriers to operating an independent practice. Furthermore, the transition to value-based programs often requires infrastructure investment for electronic health records, quality reporting, analytics and support staff, which many practices may not have the economies of scale to support. As a result, physicians are increasingly looking for alternative practice settings that will provide financial security so they can focus more on clinical care and less on managing their own practice.&nbsp;While a disproportionate amount of attention has been placed on hospitals’ acquisition of physician practices, the reality is that large commercial insurers have collectively invested billions in physician practice acquisitions. Based on an AHA analysis of Levin Associates data, private equity, physician groups and health insurers have acquired the vast majority of physician practices during the last five years.2 Comparatively, hospitals rank relatively low in the acquisition of physician practices. In fact, private equity-backed startups have acquired 65% of physician practices from 2019 to 2023, and insurers have acquired 14% of practices in that same timeframe. This is compared to hospitals and health systems that have only acquired 6% of physician practices.&nbsp;Therefore, we urge PTAC to recommend policies, such as more sustainable reimbursement aligned with inflation. Doing so will better support all providers’ abilities to transition to value-based care.&nbsp;We thank you for your consideration of our comments. Please contact me if you have questions, or feel free to have a member of your team contact Jennifer Holloman, AHA’s senior associate director of payment policy, at <a href="mailto:jholloman@aha.org" target="_blank">jholloman@aha.org</a>.&nbsp;Sincerely,&nbsp;/s/&nbsp;Ashley B. Thompson&nbsp; Senior Vice President&nbsp; Public Policy Analysis and Development__________1 <a class="ck-anchor" href="https://premierinc.com/newsroom/blog/pinc-ai-analysis-hospital-led-acos-perform-as-well-as-physician-led-models" target="_blank" id="https://premierinc.com/newsroom/blog/pinc-ai-analysis-hospital-led-acos-perform-as-well-as-physician-led-models">https://premierinc.com/newsroom/blog/pinc-ai-analysis-hospital-led-acos-perform-as-well-as-physician-led-models</a>2 <a href="/system/files/media/file/2023/06/Private-Equity-and-Health-Insurers-Acquire-More-Physicians-than-Hospitals-Infographic.pdf" target="_blank">/system/files/media/file/2023/06/Private-Equity-and-Health-Insurers-Acquire-More-Physicians-than-Hospitals-Infographic.pdf</a> Thu, 27 Mar 2025 13:46:53 -0500 Letter/Comment Senate Letter from AHA, Other Organizations in Support of Conrad State 30 and Physician Access Reauthorization Act S.709 /lettercomment/2025-03-27-senate-letter-aha-other-organizations-support-conrad-state-30-and-physician-access-reauthorization-act <div class="container"><div class="row"><div class="col-md-8">March 26, 2025<div class="row"><div class="col-md-6">The Honorable David Valadao US House of Representatives 2465 Rayburn House Office Building Washington D.C., 20515</div><div class="col-md-6">The Honorable Brad Schneider US House of Representatives 300 Cannon House Office Building Washington D.C., 20515</div></div><div class="row"><div class="col-md-6">The Honorable Don Bacon US House of Representatives 2104 Rayburn House Office Building Washington D.C., 20515</div><div class="col-md-6">The Honorable Sylvia Garcia US House of Representatives 2419 Rayburn House Office Building Washington D.C., 20515</div></div></div><div class="col-md-4"><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2025/03/senate-letter-from-aha-other-organizations-in-support-of-conrad-state-30-and-physician-access-reauthorization-act-s709-3-26-2025.pdf" target="_blank">Download the Senate Letter PDF</a></div><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/lettercomment/2025-03-27-house-letter-aha-other-organizations-support-conrad-state-30-and-physician-access-reauthorization-act" target="_blank">Read the House Letter</a></div></div></div><div class="row"><div class="col-md-8">Dear Senators Klobuchar, Collins, Rosen, and Tillis:On behalf of the 45 undersigned organizations, we are writing to strongly support the introduction of the Conrad State 30 and Physician Access Reauthorization Act (S. 709).The healthcare workforce is under increasing strain. The aging U.S. population is increasing demand for healthcare services while also contributing to physician attrition. At the same time, reimbursement challenges in Medicare, along with insufficient investment in graduate medical education, have made the practice of medicine more difficult and constrained the pipeline of new doctors. These challenges are particularly acute in rural and underserved communities, where workforce shortages have led to severe access issues. Today, more than 80 million Americans lack adequate access to primary care, exacerbating health disparities across the country.Confronting this challenge will require a comprehensive approach from Congress. A key part of the solution is leveraging international medical graduates (IMGs). One in five physicians in the U.S. is foreign-born, and these doctors play an essential role in filling workforce shortages in areas and specialties that struggle to recruit and retain physicians. These include geriatric medicine, interventional cardiology, nephrology, neurology, and critical care medicine, where IMGs are disproportionately represented. The Conrad 30 program is an effective tool for incentivizing U.S.-trained international physicians to work in these high-need areas.Over the last 30 years, the program has facilitated placement of approximately 20,000 physicians in communities that otherwise might not have had access to health care. The program has also demonstrated success at retaining physicians beyond the three-year commitment. However, misaligned incentives and outdated policies are jeopardizing the future success of the program.The Conrad State 30 and Physician Access Reauthorization Act would make necessary updates to strengthen the program. In addition to gradually increasing the number of available waivers per state if certain thresholds are met, it also clarifies and improves the waiver process for both physicians and employers by making clear the transition period between receiving a waiver and beginning work. These commonsense changes will improve program efficiency and help ensure that more IMGs can pursue opportunities in underserved areas.One of the strengths of the Conrad 30 program is its flexible design, which allows each state to tailor the program to meet its specific healthcare needs. This reauthorization will reinforce that flexibility while providing needed clarity and incentives to attract and retain more highly qualified physicians. As workforce shortages worsen, Congress must act with urgency to advance this legislation and strengthen one of the most successful programs for addressing healthcare workforce shortages.Thank you again for your leadership on this important issue. We look forward to working with you to advance this bill and ensure that the Conrad 30 program continues to serve as a healthcare and economic lifeline for communities in need.Sincerely,Alliance for Headache Disorders Advocacy Ambulatory Surgery Center Association American Academy of Family Physicians American Academy of Neurology American Academy of Physical Medicine and Rehabilitation American Association of Child and Adolescent Psychiatry American Association of Neuromuscular &amp; Electrodiagnostic Medicine American Brain Coalition American College of Obstetricians and Gynecologists American College of Physicians American College of Radiology American College of Rheumatology American College of Surgeons American Gastroenterological Association American Geriatrics Society �� Association American Medical Association American Psychiatric Association American Society of Anesthesiologists American Society of Neuroradiology Anxiety and Depression Association of America Association for Advancing Physician and Provider Recruitment (AAPPR) Association of Clinicians for the Underserved (ACU) Association of American Medical Colleges Association of University Professors of Neurology College of American Pathologists Bobby Jones Chiari &amp; Syringomyelia Foundation Dystonia Medical Research Foundation Federation of ��s (FAH) Hope for HIE Hydrocephalus Association Infectious Diseases Society of America International Bipolar Foundation M-CM Network Miles for Migraine MLD Foundation NANOS (North American Neuro- opthalmology Society) National Ataxia Foundation The Niskanen Center Phelan-McDermid Syndrome Foundation Physicians for American Healthcare Access (PAHA) Premier Inc. Society of Hospital Medicine The Society of Thoracic Surgeons SynGAP Research Fund dba CURE SYNGAP1 &nbsp;</div></div></div> Thu, 27 Mar 2025 13:13:34 -0500 Letter/Comment House Letter from AHA, Other Organizations in Support of Conrad State 30 and Physician Access Reauthorization Act (H.R.1585) /lettercomment/2025-03-27-house-letter-aha-other-organizations-support-conrad-state-30-and-physician-access-reauthorization-act <div class="container"><div class="row"><div class="col-md-8">March 26, 2025<div class="row"><div class="col-md-6">The Honorable David Valadao US House of Representatives 2465 Rayburn House Office Building Washington D.C., 20515</div><div class="col-md-6">The Honorable Brad Schneider US House of Representatives 300 Cannon House Office Building Washington D.C., 20515</div></div><div class="row"><div class="col-md-6">The Honorable Don Bacon US House of Representatives 2104 Rayburn House Office Building Washington D.C., 20515</div><div class="col-md-6">The Honorable Sylvia Garcia US House of Representatives 2419 Rayburn House Office Building Washington D.C., 20515</div></div></div><div class="col-md-4"><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2025/03/house-letter-from-aha-other-organizations-in-support-of-conrad-state-30-and-physician-access-reauthorization-act-h-r585-letter-3-26-2025.pdf" target="_blank">Download the House Letter PDF</a></div><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/lettercomment/2025-03-27-senate-letter-aha-other-organizations-support-conrad-state-30-and-physician-access-reauthorization-act" target="_blank">Read the Senate Letter</a></div></div></div><div class="row"><div class="col-md-8">Dear Representatives Valadao, Schneider, Bacon, and Garcia:On behalf of the 45 undersigned organizations, we are writing to strongly support the introduction of the Conrad State 30 and Physician Access Reauthorization Act (H.R. 1585).The healthcare workforce is under increasing strain. The aging U.S. population is increasing demand for healthcare services while also contributing to physician attrition. At the same time, reimbursement challenges in Medicare, along with insufficient investment in graduate medical education, have made the practice of medicine more difficult and constrained the pipeline of new doctors. These challenges are particularly acute in rural and underserved communities, where workforce shortages have led to severe access issues. Today, more than 80 million Americans lack adequate access to primary care, exacerbating health disparities across the country.Confronting this challenge will require a comprehensive approach from Congress. A key part of the solution is leveraging international medical graduates (IMGs). One in five physicians in the U.S. is foreign-born, and these doctors play an essential role in filling workforce shortages in areas and specialties that struggle to recruit and retain physicians. These include geriatric medicine, interventional cardiology, nephrology, neurology, and critical care medicine, where IMGs are disproportionately represented. The Conrad 30 program is an effective tool for incentivizing U.S.-trained international physicians to work in these high-need areas.Over the last 30 years, the program has facilitated placement of approximately 20,000 physicians in communities that otherwise might not have had access to health care. The program has also demonstrated success at retaining physicians beyond the three-year commitment. However, misaligned incentives and outdated policies are jeopardizing the future success of the program.The Conrad State 30 and Physician Access Reauthorization Act would make necessary updates to strengthen the program. In addition to gradually increasing the number of available waivers per state if certain thresholds are met, it also clarifies and improves the waiver process for both physicians and employers by making clear the transition period between receiving a waiver and beginning work. These commonsense changes will improve program efficiency and help ensure that more IMGs can pursue opportunities in underserved areas.One of the strengths of the Conrad 30 program is its flexible design, which allows each state to tailor the program to meet its specific healthcare needs. This reauthorization will reinforce that flexibility while providing needed clarity and incentives to attract and retain more highly qualified physicians. As workforce shortages worsen, Congress must act with urgency to advance this legislation and strengthen one of the most successful programs for addressing healthcare workforce shortages.Thank you again for your leadership on this important issue. We look forward to working with you to advance this bill and ensure that the Conrad 30 program continues to serve as a healthcare and economic lifeline for communities in need.Sincerely,Alliance for Headache Disorders Advocacy Ambulatory Surgery Center Association American Academy of Family Physicians American Academy of Neurology American Academy of Physical Medicine and Rehabilitation American Association of Child and Adolescent Psychiatry American Association of Neuromuscular &amp; Electrodiagnostic Medicine American Brain Coalition American College of Obstetricians and Gynecologists American College of Physicians American College of Radiology American College of Rheumatology American College of Surgeons American Gastroenterological Association American Geriatrics Society �� Association American Medical Association American Psychiatric Association American Society of Anesthesiologists American Society of Neuroradiology Anxiety and Depression Association of America Association for Advancing Physician and Provider Recruitment (AAPPR) Association of Clinicians for the Underserved (ACU) Association of American Medical Colleges Association of University Professors of Neurology College of American Pathologists Bobby Jones Chiari &amp; Syringomyelia Foundation Dystonia Medical Research Foundation Federation of ��s (FAH) Hope for HIE Hydrocephalus Association Infectious Diseases Society of America International Bipolar Foundation M-CM Network Miles for Migraine MLD Foundation NANOS (North American Neuro- opthalmology Society) National Ataxia Foundation The Niskanen Center Phelan-McDermid Syndrome Foundation Physicians for American Healthcare Access (PAHA) Premier Inc. Society of Hospital Medicine The Society of Thoracic Surgeons SynGAP Research Fund dba CURE SYNGAP1</div></div></div> Thu, 27 Mar 2025 12:45:25 -0500 Letter/Comment AHA Letter Opposing the Physician Led and Rural Access to Quality Care Act (H.R.2191) /lettercomment/2025-03-27-aha-letter-opposing-physician-led-and-rural-access-quality-care-act-hr2191 March 25, 2025The Honorable Morgan Griffith U.S. House of Representatives 2110 Rayburn House Office Building Washington, DC 20515Dear Representative Griffith:On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the �� Association (AHA) writes to express our opposition to H.R. 2191, the Physician Led and Rural Access to Quality Care Act.Rural hospitals are essential access points for care, economic anchors for their communities, and the backbone of our nation’s rural communities. These hospitals have maintained their commitment to ensuring local access to high-quality, affordable care despite continued financial and workforce challenges. The AHA strongly supports legislation that would enable rural hospitals across the nation to better care for their communities. However, we believe that H.R. 2191 is misguided legislation that would skew the health care marketplace in favor of physicians who self-refer patients to hospitals they own and would destabilize rural health care while failing to improve access to quality care.H.R. 2191 would result in additional gaming of the Medicare program, jeopardize patient access to emergency care, potentially harm sicker and lower-income patients, and severely damage the ability of 24/7 full-service community hospitals to provide care in rural areas.Physician self-referral — whether in rural, suburban or urban communities — is the antithesis of fair competition. The problematic practice allows physicians to steer their most profitable cases to facilities they own — facilities that often call 9-1-1 to handle their emergencies and are often located in the most affluent areas. By performing the highest-paying procedures for the best-insured patients, physician-owners inflate health care costs and drain essential resources from community hospitals, which depend on a balance of services and patients to provide indispensable treatment, such as behavioral health and trauma care. By increasing the presence of these self-referral arrangements, H.R. 2191 would only further destabilize community care.Since the Medicare Modernization Act of 2003, Congress has supported ending the egregious and costly practice of physician self-referral to hospitals they own. Current law represents a 15-year compromise that (1) allows existing physician-owned hospitals (POHs) to continue to treat Medicare patients, (2) permits the expansion of those physician-owned hospitals that meet communities’ needs for additional hospital capacity and treat low-income patients, and (3) prohibits Medicare from covering services in any new physician-owned hospitals established after Dec. 31, 2010. Congress established these guardrails to protect the Medicare program from overutilization, patient steering and the harmful patient selection practices that POHs employ.Data have shown time and time again that POHs select only the healthiest and most profitable patients, serving lower proportions of Medicaid, dual eligible and uncompensated care than full-service acute care hospitals. The <a href="https://www.cbo.gov/sites/default/files/111th-congress-2009-2010/costestimate/amendreconprop.pdf" target="_blank" title="Congressional Budget Office Website">Congressional Budget Office</a>, the <a href="https://www.medpac.gov/wp-content/uploads/import_data/scrape_files/docs/default-source/reports/Mar05_SpecHospitals.pdf" target="_blank" title="Medicare Payment Advisory Commission">Medicare Payment Advisory Commission</a> and the <a href="https://public-inspection.federalregister.gov/2023-16252.pdf" target="_blank" title="Center for Medicare &amp; Medicaid Services">Centers for Medicare &amp; Medicaid Services</a> all have concluded that physician self-referral leads to greater per capita utilization of services and higher costs for the Medicare program, among other negative impacts.For these reasons, the AHA strongly opposes the expansion of POHs — by either creating new categories of exceptions or allowing existing POHs to expand — and cannot support H.R. 2191. Congress should maintain current law, preserve the ban on physician self-referrals to new physician-owned hospitals, and retain restrictions on the growth of existing physician-owned hospitals, regardless of location.Sincerely,/s/Lisa Kidder Hrobsky Senior Vice President, Advocacy and Political Affairs Thu, 27 Mar 2025 10:36:14 -0500 Letter/Comment AHA Comments on DEA Proposed Rule on Special Registrations for Telemedicine Prescribing /lettercomment/2025-03-18-aha-comments-dea-proposed-rule-special-registrations-telemedicine-prescribing March 18, 2025Acting Administrator Derek Maltz Drug Enforcement Administration ATTN: DEA Federal Register Representative 8701 Morrissette Dr. Springfield, VA 22152Re: Docket No. DEA-407 Special Registrations for Telemedicine and Limited State Telemedicine RegistrationsDear Acting Administrator Maltz:&nbsp;On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations; our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the �� Association (AHA) appreciates the opportunity to share our comments regarding the Drug Enforcement Administration’s (DEA’s) proposed rule for Special Registrations for Telemedicine and Limited State Telemedicine Registrations.The AHA continues to support the concept of a special registration process to waive in-person evaluations prior to the prescribing of controlled substances. However, we are concerned that the proposed process would be inefficient and unnecessarily burdensome. We recommend the agency adopt a more streamlined process that would enable prescribers to register as part of the existing licensure framework. This approach would&nbsp;achieve the agency’s crucial goal of mitigating diversion while minimizing excessive burdens on our already overtaxed clinical workforce. Specifically, we urge the agency to:<ul><li>Expand the existing DEA registration forms to collect the information sought instead of creating separate registration forms and fees.</li><li>Expand the list of providers eligible for advanced telemedicine prescribing.</li><li>Remove the requirement for Prescription Drug Monitoring Program (PDMP) reviews for every state and territory.</li><li>Remove the requirement for Schedule II prescribers to be physically located in the same state as the patient.</li><li>Remove the requirement for Schedule II prescribers to have less than 50% of Schedule II prescriptions issued as special registration prescriptions.</li><li>Remove certain recordkeeping and reporting requirements, including the requirement to maintain a photographic record of patient identity verification.</li></ul>Given the scope of the proposed changes, we also encourage the DEA to extend the timeline for implementation, which we recognize would also&nbsp;require extension of the relevant waiver flexibilities until the final rule is published and in effect.&nbsp;Patients, practitioners, platforms, pharmacies and other stakeholders must have adequate pre-implementation periods to prepare for changes in process.Below are our detailed comments.BackgroundThe Ryan Haight Act of 2008 established specific requirements for in-person evaluations prior to the prescribing of controlled substances. This law also outlined seven&nbsp;categories of instances in which telemedicine, rather than in-person evaluations, could be utilized. One of these categories was a special registration process, and the law specified that the Attorney General&nbsp;shall&nbsp;promulgate regulations specifying circumstances in which a special registration for telemedicine prescribing may be issued as well as the procedures for obtaining such a special registration. The SUPPORT Act of 2018 again mandated that the DEA, in coordination with the Department of Health and Human Services (HHS), promulgate special registration regulations. The law specified: (1) the circumstances in which a special registration for telemedicine may be issued that authorizes prescribing of controlled substances without an in-person evaluation; and (2) the procedures for obtaining a special registration.The AHA has continuously supported a special registration process to waive in-person visit requirements for those prescribers who register. Indeed, a streamlined special registration process that ensures appropriate tracking of virtual prescribers would help safely ensure access to critical services. As such, we have recommended that the DEA establish such a process based on the existing registration process.1 Over the last five years, waivers of in-person visits and broad utilization of virtual prescribing have demonstrated significant benefits to patients in accessing lifesaving medication. Meanwhile, data have indicated no increased risk for diversion. As such, we support the agency’s pursuit of a permanent pathway for practitioners to waive in-person visit requirements. However, we have both concerns with and recommendations to improve the agency’s proposed special registration process.<h2>TYPES OF SPECIAL REGISTRATION</h2>The DEA proposes three types of special registration:<ul><li>Telemedicine prescribing registration, which would authorize qualified clinician practitioners to prescribe Schedule III-V controlled substances via telemedicine.</li><li>Advanced telemedicine prescribing registration, which would authorize certain practitioners to prescribe select Schedule II-V controlled substances via telemedicine.</li><li>Telemedicine platform registration, which would authorize online telemedicine platforms to dispense Schedule II-V controlled substances.</li></ul>Under the proposed framework, clinician practitioners would be considered clinician special registrants, and platform practitioners would be considered platform special registrants.In general, we urge the agency to issue clarifying guidance on how post-graduate hospital trainees (also known as residents) would register under this scheme. Residents typically utilize a hospital DEA registration number when prescribing controlled substances in accordance with their residency program. The proposed rules did not address applications in training settings, and therefore we request clarifying.Additional feedback on the proposed registration types follows.Advanced Telemedicine Prescribing Registration. In addition to demonstrating a legitimate need for this type of special registration, the DEA proposes that only certain clinician practitioners would be eligible. These include:<ul><li>Psychiatrists.</li><li>Hospice care physicians.</li><li>Palliative care physicians.</li><li>Physicians rendering treatment at long-term care facilities.</li><li>Pediatricians.</li><li>Neurologists.</li><li>Mid-level practitioners and physicians from other specialties who are board-certified in the treatment of psychiatric or psychological disorders, hospice care, palliative care, pediatric care, or neurological disorders unrelated to the treatment and management of pain.</li></ul>The list does not include other specialties or clinical applications that serve patients who would benefit from virtual prescribing flexibilities. For example, a geographically remote patient with cancer receiving pain medications from an oncologist and a home-bound patient with a sleep disorder receiving sleep medication from a pulmonologist could both benefit greatly from access to these services. In these instances, seeing a practitioner in person is simply not an available option. As such, virtual prescription pathways should also be available to these practitioners and patients. Therefore, we urge the agency to expand the list of eligible providers able to register for advanced telemedicine special registration to include all practitioners who can prescribe these medications in person.&nbsp;Doing so also would include, for example, oncologists or pulmonologists registered with the DEA.Telemedicine Platform Registration.&nbsp;The DEA proposes a separate process for telemedicine platform registration, which would authorize virtual practitioners practicing only on telemedicine platforms (as opposed to seeing some patients in person and some via telemedicine) to prescribe controlled substances. While we agree that it would be beneficial to track these practitioners separately, we urge the agency to issue clarification on this registration process.&nbsp;We agree that platform providers should maintain certain records of clinicians who enter into a platform relationship (including disciplinary actions and complaints). However, we disagree that the threshold for clinical need should be lower for this category. Specifically, in the proposed rule, platform providers under this designation would be able to prescribe Schedule II-V drugs, the same as advanced registration clinicians; however, the requirements to demonstrate need are aligned instead with the standard telemedicine registration clinicians who are able to prescribe only Schedule III-V drugs. It is unclear why platform special registrants would be held to a different, less rigorous standard than advanced special registrants. This essentially penalizes clinicians leveraging hybrid models of care (in-person and virtual appointments). If the intent was for platform practitioners to also register as either general or advanced telemedicine prescribers in addition to platform registrants, then we request that the DEA issue such a clarification. Otherwise, we encourage the agency to adopt parallel requirements based on the schedule of drug prescribed.&nbsp;<h2>STATE REGISTRATION</h2>In addition to the aforementioned special registration categories, the DEA proposes that practitioners would need to complete a state registration for every state in which they treat a patient. The agency proposes that the state registration would be a novel, separate and ancillary credential administered by the DEA (not the states). We are concerned that this additional layer of licensure is overly burdensome without providing clear benefit, particularly considering existing licensure standards.&nbsp;Specifically, to require practitioners to submit separate registration forms for each state in which a patient is located is redundant, since the same information is already provided on other forms. That is, the existing general DEA registration process already asks for information on state medical licenses; the proposed process would duplicate efforts without providing additional safeguards.It is unclear what purpose registering for each individual state would serve given the existing DEA registration process, the proposed special registration questions and state medical licensure processes. If the purpose is to track the states that a telemedicine practitioner is not only licensed in but also wishes to prescribe certain controlled substances to, then a question about this could be added to the general registration form. For example, the DEA could add a question to the existing general registration form such as, “In which states do you have patients that you will virtually prescribe special-registration controlled substances? (check all that apply).” To avoid unnecessary and duplicative administrative burden, we urge the DEA to remove the requirements for practitioners to complete state-specific registration forms and adopt this approach instead.If the agency does move forward with this proposal, we request it provide guidance on state responsibility for enforcement as the proposed rule also does not address the notification and enforcement process for state registrations. Specifically, it does not address enforcement responsibilities in states where practitioners are licensed and in good standing through state medical boards, are registered and in good standing with the DEA, and have completed the general special registration process but are not registered for an individual state. Enforcement activities are often complex, involving the DEA, state medical boards and state law enforcement. If this policy is adopted, we request further guidance on both agency and state responsibilities for enforcement.&nbsp;<h2>SPECIAL REGISTRATION AND STATE REGISTRATION APPLICATIONS</h2>The DEA proposes two new forms (224S and 224S-M for modifications) that practitioners completing special registration and state registration would need to submit. However, as we previously noted, the establishment of a separate form would be redundant, creating undue administrative burden for both practitioners and the DEA, which would need to develop separate systems for processing and tracking the new forms. Specifically, practitioners, hospitals, clinics, pharmacies and others are already required to complete applications for registration and renewal of registrations for prescribing controlled substances through forms 224 and 224a. This process has established guardrails that build upon state medical licensure processes and Medicare reporting. State medical boards screen applicants for education and training as part of licensure processes and are responsible for investigating complaints, monitoring compliance and disciplining providers when necessary. Given the DEA’s unique role in mitigating risk of diversion for controlled substances, the registration process complements existing state-based processes. The DEA collects supporting information from physicians about state licensure, locations and adverse actions on the existing applications. Therefore, rather than creating a novel and separate process or form, we urge the DEA to add any additional information it needs on special registration to the forms 224 and 224a that are already in use. This way, the special registration process would include both key elements that providers already report — such as practitioner contact information, employer, practice address, state medical licenses, liability history, etc. —&nbsp;and providers&nbsp;could add unique attestations.&nbsp;Indeed, the proposed rule highlighted that the special registration would be contingent on good standing of other DEA registrations and that the special registration location would need to already be registered with the DEA. As such, it would make sense to link special registration questions to the existing form.<h2>SPECIAL REGISTRATION PRESCRIPTIONS</h2>In addition to abiding by state laws where the provider is located, the patient is located and the practitioner is registered with the DEA, under the agency’s proposal, providers also would need to follow several provisions related to the prescriptions administered under special registration.Nationwide PDMP Review.&nbsp;The DEA proposes that for the first three years after the rule is finalized, providers would need to complete PDMP checks for the states where the patient is located, the clinician is located and for any state with a reciprocity agreement to the patient/clinician locations. After three years, the DEA proposes that providers would need to review the PDMPs of all 50 states and territories when prescribing a controlled substance via telemedicine for each patient.While PDMPs can provide useful information on patients’ prescription histories, the proposal to perform PDMP reviews for all 50 states and territories is simply operationally infeasible and is unlikely to offer additional protection against diversion.&nbsp;Performing a PDMP check for all 50 states is not as easy as visiting one website, entering a patient’s name and receiving a list of results.&nbsp;First, interoperability infrastructure does not currently exist to support providers reviewing information across all 50 states and territories from a single platform. Interstate data-sharing partnerships vary, with some states limiting data sharing to noncontiguous states. Additionally, “ownership” of the PDMP within state health departments or other agencies (like law enforcement) can also hinder accessibility and data transfer across state lines. According to the Assistant Secretary for Technology Policy, only 31 states reported sharing data with more than 30 states through data-sharing systems like RxCheck or PMP InterConnect.2 This lack of data sharing means that physicians would have to maintain separate logins for different state PDMP portals, which is incredibly burdensome. In addition, 10 territories do not have PDMPs. There also are large gaps in integration with electronic health records (EHRs). Interfaces between state PDMP databases and EHRs minimize resource requirements, since physicians can seamlessly access prescription histories while reviewing the patient’s medical record. However, building PDMP/EHR interfaces can be resource intensive and requires providers to leverage an EHR of sufficient size and scope to support multi-state PDMP interfaces or interfaces with data-sharing systems (like the ones mentioned above). This lack of interoperability means that most physicians would need to manually check individual state PDMP portals, which would, in effect, negate their ability to use this waiver.Second, PDMP reviews themselves are often time consuming and administratively burdensome. Research (which typically involved just one state) shows that these reviews vary based on specialty. Using psychiatrists as an example, the estimated amount of time used to retrieve PDMP reports is around 22 hours annually.3 Extrapolating to all 50 states and 14 territories means that the physician would need over 1,400 hours annually just to perform PDMP reviews. That equates to 1,400 fewer patient hours and a cost of over $174,000 per year per prescriber to retrieve this information (using the Bureau of Labor Statistics’ average hourly rate for psychiatrists of $124).4 It is unlikely any provider could absorb this level of burden, especially given the already high degree of burnout among physicians.&nbsp;Finally, barriers to accessing and interpreting PDMP data are not limited to data interoperability and time challenges. Indeed, the specific data elements, standards and formats also vary from state to state. For example, while there are some common reporting elements, specific data elements are dictated by state-level statute and regulation. This variation hampers the ability of physicians to have a holistic view across all PDMP reports. Also, some states have the ability to create aggregate and custom reports to summarize data longitudinally, whereas others do not and the onus is on the physician to manually aggregate the data. Again, this highlights the cumbersome nature of PDMP review in the current environment.To be clear, PDMPs are helpful state-level interventions that can improve surveillance on inappropriate prescriptions; however, as we noted in our response to the Assistant Secretary for Planning and Evaluation’s <a href="/system/files/media/file/2019/08/hhs-rfi%20ensuring-patient-access-and-effective-drug-enforcement-8-23-2019.pdf" target="_blank">Request for Information</a> on Ensuring Patient Access and Effective Drug Enforcement, there is significant room for improvement in each state’s PDMP and serious limitations on interoperability across state programs. As such, we once again urge DEA to coordinate with HHS and other agencies to develop strategies to enhance the data interoperability of PDMPs. This will maximize the utility of PDMP data in the long term and better support physicians in mitigating risk of diversion. In the meantime, we urge the DEA to remove the requirements for additional PDMP reviews beyond current standards for in-person prescribing of controlled substances and limit the requirement to the state where the provider and patient are located.&nbsp;Special Registration Audio-Video.&nbsp;In the proposed rule, the DEA would mandate that a clinician special registrant utilize both audio and video components of an audio-video telecommunications system to prescribe under the special registration framework. This unnecessarily restricts patients’ access to virtual prescribing when video technology may not be available. CMS has identified the services that are eligible for audio-only encounters. Similarly, we encourage the DEA to provide parameters or exceptions where audio-only prescribing may be appropriate.Schedule II Special Registration Prescriptions.&nbsp;The agency proposes two additional requirements for special registration prescriptions of Schedule II drugs. First, the agency proposes that clinician special registrants prescribing Schedule II drugs be physically located in the same state as the patient. However, this arbitrary requirement defeats the purpose of virtual prescribing flexibilities and limits patient choice. Physician shortages are impacting some states and specialties more acutely than others. For example, Texas has over 13 million people living in mental health care provider shortage areas and would need 614 additional practitioners to remove that designation.5 Restricting special registration practitioners to prescribing these drugs only to patients in their state would not help with existing shortages such as these. Often practitioners are simply not available in some communities, and telemedicine provides options for patients to access geographically dispersed practitioners located in other states. So long as practitioners are abiding by federal and state statute and conforming to standards issued by state licensing boards, we urge the DEA to not arbitrarily limit access to services. As such, we ask that the DEA remove the requirement for providers and patients to be located in the same state for prescribing of Schedule II drugs.Additionally, the agency proposes to require that the number of special registration Schedule II drugs constitute less than 50% of the total number of Schedule II drugs issued by the clinician in their telemedicine and non-telemedicine practice in a calendar month. We are unclear from the discussion in the rule why the agency proposed this standard, and without further rationale, we recommend removing it. There is no evidence to suggest that requiring practitioners to prescribe less than 50% of drugs virtually would mitigate risk of diversion. Rather, the agency relies on a general assumption that because controlled substances can be misused, an increase in access results in increased risk.<h2>RECORDKEEPING AND REPORTING</h2>The DEA also proposes additional recordkeeping and reporting requirements. For example, it proposes that clinician special registrants be required to capture a photographic record of the patient presenting federal- or state-issued identification cards. If the patient does not feel comfortable with the clinician taking a picture, the patient could provide a copy of their ID. We are concerned that this requirement could raise fair concerns by patients about their privacy, while at the same time not adding additional protection against diversion.&nbsp;Telehealth providers generally document in the medical record an attestation that patient identification was verified. There are also standards at the state level on types of data fields required for identity verification, some of which may not be on a state or federal ID card. Therefore, having photographic evidence of identity presentation is unnecessary and adds administrative burden to take and preserve a photo in the medical record. This detracts from the clinical time that the practitioner is engaging with the patient, is costly to maintain and poses unnecessary risk (i.e., capture and maintenance of additional sensitive data). Just as a practitioner would not be expected to take a picture of a patient in an exam room to verify identity, the same standard applies to virtual appointments. Finally, there is no evidence to suggest that this added requirement would minimize risk of diversion. As such, we urge the DEA to defer to state requirements for identity verification and not impose additional requirements.&nbsp;We also are concerned that additional reporting requirements, like the requirement for pharmacies to generate monthly reports of special registration prescriptions filled and the requirement for practitioners to generate annual special registrant reports, are overly burdensome and will not lead to reduced risk of diversion. According to the proposed rule, the DEA would require pharmacies to report aggregate data within the first seven days of every month on the special registration prescriptions filled during the preceding month for each Schedule II controlled substance and certain Schedule III-V controlled substances. These requirements could result in further limiting access since providers may simply elect to no longer virtually prescribe medications or fill telemedicine prescriptions since it is too burdensome to keep up with the recordkeeping and reporting requirements. This has already been an issue with “red flags” for prescriptions issued in remote geographies, where pharmacists have declined filling prescriptions for controlled substances from outside states. There are many reasons a virtual prescription may be filled in a remote state or geography: a patient is on vacation, a student is in college, a patient is maintaining the same provider after moving out of state, a patient is seeing a specialist in a different state when they cannot find a doctor locally, etc. Nonetheless, distance from the prescriber and patient has been identified as a “red flag” and has hampered access as many pharmacies are simply opting to not fill virtual prescriptions. The potential risk to access in these cases may outweigh potential risk of diversion. In addition to removing the requirements for additional annual and monthly reports, we urge the agency to also remove reference to geography as a red flag for risk of diversion.Given the scope of a new special registration process and breadth of potential changes, we also urge the agency to delay implementation to allow adequate time for stakeholders to prepare. Specifically, we request that the DEA provide at least a one-year pre-implementation period after rules are finalized to ensure that practitioners can appropriately prepare for changes. Simultaneously, we urge the agency to extend the current in-person visit waivers to avoid gaps in access until rules are finalized.We thank you for considering our comments on this proposed rule. If you have any questions concerning our comments, please feel free to contact me or have a member of your team contact Jennifer Holloman, AHA’s senior associate director of policy, at jholloman@aha.org or Caitlin Gillooley, AHA’s director of behavioral health and quality policy, at cgillooley@aha.org.Sincerely,/s/Ashley Thompson Senior Vice President Public Policy Analysis and Development<div><hr><div id="ftn1">1<a href="/system/files/media/file/2023/03/aha-comment-letter-to-dea-on-telemedicine-prescribing-of-controlled-substances-proposed-rule-3-29-23.pdf" target="_blank">/system/files/media/file/2023/03/aha-comment-letter-to-dea-on-telemedicine-prescribing-of-controlled-substances-proposed-rule-3-29-23.pdf</a>.</div><div id="ftn2">2<a href="https://www.healthit.gov/buzz-blog/health-it/physicians-have-widespread-access-to-state-pdmp-data-but-data-sharing-varies-across-states" target="_blank">https://www.healthit.gov/buzz-blog/health-it/physicians-have-widespread-access-to-state-pdmp-data-but-data-sharing-varies-across-states</a>.</div><div id="ftn3">3<a href="https://pmc.ncbi.nlm.nih.gov/articles/PMC6176751/" target="_blank">https://pmc.ncbi.nlm.nih.gov/articles/PMC6176751/</a>.</div><div id="ftn4">4<a href="https://www.bls.gov/oes/2023/may/oes291223.htm" target="_blank">https://www.bls.gov/oes/2023/may/oes291223.htm</a>.</div><div id="ftn5">5<a href="https://www.kff.org/other/state-indicator/mental-health-care-health-professional-shortage-areas-hpsas/" target="_blank">https://www.kff.org/other/state-indicator/mental-health-care-health-professional-shortage-areas-hpsas/?currentTimeframe=0&amp;sortModel=%7B%22colId%22:%22Practitioners%20Needed%20to%20Remove%20HPSA%20Designation%22,%22sort%22:%22desc%22%7D</a>.</div></div> Tue, 18 Mar 2025 15:41:23 -0500 Letter/Comment AHA Comments on the Assistance for Rural Community Hospitals Act (H.R. 1805) /lettercomment/2025-03-04-aha-comments-assistance-rural-community-hospitals-act-hr-1805 &nbsp;March 4, 2025<table><tbody><tr><td>The Honorable Carol Miller U. S. House of Representatives 465 Cannon House Office Building Washington, DC 20515</td><td>The Honorable Terri Sewell U. S. House of Representatives 1035 Rayburn House Office Building Washington, DC 20515</td></tr></tbody></table> Dear Representatives Miller and Sewell:&nbsp;On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the �� Association (AHA) is pleased to support the Assistance for Rural Community Hospitals (ARCH) Act (H.R. 1805).Rural hospitals are essential access points for care, economic anchors for communities and the backbone of our nation’s rural public health infrastructure. These hospitals have maintained their commitment to ensuring local access to high-quality, affordable care in spite of continued financial and workforce challenges in recent years.Your legislation will help keep the doors open at rural hospitals and allow them to continue serving their local communities during this time of sustained financial pressure and historic changes in care delivery.To support small rural hospitals for which Medicare patients make up a significant percentage of inpatient days or discharges, Congress established the Medicare- dependent hospital (MDH) program in 1987, allowing eligible hospitals to receive the sum of their prospective payment system (PPS) payment rate plus three-quarters of the amount by which their cost per discharge exceeds the PPS rate. These payments allow MDHs greater financial stability and leave them better able to serve their patients and communities. Your legislation would extend this important program for six additional years, helping to provide needed financial stability to rural hospitals.In addition, the ARCH Act would extend the enhanced low-volume Medicare adjustment for six years. Factors beyond providers’ control can affect the costs of furnishing services. Patient volume is one such factor and is particularly relevant in small and isolated communities where providers frequently cannot achieve the economies of scale possible for their larger counterparts.Although a low-volume adjustment existed in the inpatient PPS prior to fiscal year 2011, the Centers for Medicare &amp; Medicaid Services had defined the eligibility criteria so narrowly that only two or three hospitals qualified each year. The current, improved low-volume adjustment better accounts for the relationship between cost and volume, helps level the playing field for low-volume providers, and improves access to care in rural areas. Extending the enhanced low-volume adjustment ensures that these providers can continue to serve their patients and communities.Again, we are pleased to support this legislation and look forward to working with you and your colleagues to achieve its passage.Sincerely,/s/Lisa Kidder Hrobsky Senior Vice President, Advocacy and Political Affairs Tue, 04 Mar 2025 14:08:51 -0600 Letter/Comment AHA Comments to MedPAC on Rural Medicare Beneficiary Cost-sharing /lettercomment/2025-02-28-aha-comments-medpac-rural-medicare-beneficiary-cost-sharing February 28, 2025 Michael Chernew, Ph.D. Chairman Medicare Payment Advisory Commission 425 I Street, NW, Suite 701 Washington, D.C. 20001Dear Dr. Chernew:&nbsp;On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations; our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the �� Association (AHA) appreciates the opportunity to share our comments regarding Medicare beneficiary cost-sharing in rural facilities.In particular, we thank the Medicare Payment Advisory Commission (MedPAC) for recognizing that critical access hospitals (CAHs) are vital care access points for their communities and, as such, their financial stability and sustainability are critical. We support the Commission’s recommended changes to beneficiary cost sharing in CAHs, including to ensure that total payments to CAHs remain unchanged. However, rural health clinics (RHCs) also serve as important access points; as such,&nbsp;we encourage the commission to&nbsp;examine&nbsp;more closely the potential impact of its proposed changes to their beneficiary cost-sharing structure.<h2>COST SHARING FOR OUTPATIENT SERVICES AT CAHS</h2>During the January 2025 meeting, commissioners discussed patient cost sharing for outpatient services in CAHs and its impact on care access. The commission voted to recommend that CAH outpatient beneficiary cost-sharing be set at 20% of the payment amount and subject to a cap equal to the inpatient deductible. The AHA appreciates MedPAC’s consideration of outpatient patient cost sharing in CAHs and agrees it poses challenges to Medicare beneficiaries.Currently, CAHs receive cost-based fee-for-service (FFS) Medicare payments. As the commission concluded, these payments provide them with much-needed financial support. However, under this system, Medicare calculates beneficiaries’ cost-sharing for outpatient services as a percentage of charges, as compared to the outpatient prospective payment system (PPS) where beneficiary cost-sharing is a percentage of the outpatient PPS payment rate. As a result, half of CAH FFS Medicare outpatient payments are from beneficiary coinsurance.1,2 The majority of rural Medicare beneficiaries do not directly pay this coinsurance because many have supplemental coverage in Medigap or Medicaid. However, for the small proportion that do not have this coverage, these costs may be an undue financial burden and a barrier to accessing care. We share in the concerns presented by the commission regarding the implications of this cost-sharing structure for patient access to care and financial burden, especially in these historically underserved communities.Commission staff presented a policy solution to reduce beneficiary cost-sharing for outpatient services in CAHs. Under this solution, cost-sharing would be reduced from 20% of charges to 20% of the outpatient PPS payment rate. Additionally, a cap would be placed on the CAH outpatient coinsurance amount equal to the inpatient deductible; for 2025, this amount is $1,676. Importantly, the policy solution also would ensure that total payments to CAHs remain unchanged. That is, any reductions in CAH payments resulting from reductions in beneficiary cost-sharing would be made up by the Medicare program. We agree with this framework and emphasize the importance of maintaining stable and consistent total payments for CAHs. Indeed, any reductions in CAH payments would be extremely detrimental to their financial sustainability and, in turn, to beneficiary access to care. The commission itself recognized that “many CAHs would struggle financially if they did not receive [cost-based] FFS payment rates.” In fact, 70 CAHs have already closed or had to significantly scale back their services since 2005, including the closure of inpatient units.3Staff indicated that its recommendation, however, would mean an additional $1.3 billion would flow to MA plans in capitation payments. The fact that this would happen at a time when MedPAC itself has found that MA plans were overpaid by $88 billion is of great concern to the AHA.4 As such, we continue to urge the commission to fully study the role MA plays in rural communities and the impact plan policies and practices have on patients’ access to care and the financial solvency of rural providers.&nbsp;In particular, both the AHA and MedPAC have detailed numerous problems with MA prior authorization denials and other utilization review practices and their effects on timely access to care for patients.5 These dynamics are increasingly problematic as MA penetration grows in rural areas. Specifically, some plans are restricting patient access to Medicare-covered services, delaying patient care, and adding tremendous administrative burden to small hospitals without the resources to absorb these costs.6 Paying plans more in the face of such practices is misguided.<h2>COST SHARING FOR RURAL HEALTH CLINICS</h2>Commissioners also discussed challenges to RHC patient cost sharing and its impact on patient access to care. The AHA appreciates MedPAC’s consideration of this important topic and agrees that wide variation in RHC cost-sharing poses challenges to Medicare beneficiaries. However, we urge the commission to consider the impact payment cuts to RHCs would have on their financial sustainability, especially given payment cuts implemented in recent years.RHCs must be located in nonurbanized areas and predominantly serve underserved and rural populations. They provide outpatient services and are intended to increase access to primary care. Currently, Medicare pays RHCs 80% of an all-inclusive rate (AIR) per visit.7 Medicare beneficiary cost sharing at RHCs is set at 20% of RHC charges. Therefore, RHC payments are 80% of the AIR (from Medicare) and 20% of charges (from patient cost-sharing).8 As such, there is wide variation in beneficiary liability. For example, in independent RHCs, the average beneficiary cost sharing as a share of the AIR is 34%, whereas in provider-based RHCs, the average beneficiary cost sharing as a share of the AIR ranges from 17% to 38%.Staff presented a potential policy solution to address this variation — to reduce cost sharing by capping it at 20% of an RHC’s AIR. MedPAC found that for 2022, this would have reduced beneficiary cost sharing by 43% in independent RHCs and 8% to 49% in provider-based RHCs. However, unlike for CAHs, staff did not propose to ensure that total payment to RHCs remains unchanged. As such,&nbsp;AHA’s analysis indicates that the proposed policy would have translated to a $111 million payment cut to RHCs in 2024.These cuts come at a time when RHCs are still working to reconcile existing Medicare payment reductions. Specifically, the Consolidated Appropriations Act of 2021 set new payment limits capping reimbursement and only allowing growth by medical inflation. These cuts are particularly troubling because these facilities predominantly serve historically underserved communities and provide increased access to primary care, mental health care, pharmacy and dental services for these communities. RCHs act as safety net clinics designed to increase access to care for rural residents.9 Research has shown that over half of RHCs have night or weekend hours and the majority accept walk-in services and provide language interpretation services. Therefore, we urge MedPAC to carefully consider the impact these payment cuts would have on patient access to care. In particular, we urge the commission to&nbsp;ensure that total payments to RHCs remain unchanged. That is, any reductions in RHC payments resulting from reductions in beneficiary cost-sharing would be made up by the Medicare program.We thank you for your consideration of our comments. Please contact me if you have questions or feel free to have a member of your team contact Shannon Wu, AHA’s director of policy, at <a href="mailto:swu@aha.org">swu@aha.org</a> or 202-626-2963.Sincerely, /s/ Ashley B. Thompson Senior Vice President Public Policy Analysis and Development&nbsp;Cc: Paul Masi, M.P.P. MedPAC Commissioners<div>__________<div id="ftn1">1 RTI International. (2016). Medicare Copayments for Critical Access Hospital Outpatient Services – Update.&nbsp; <a class="ck-anchor" href="https://www.medpac.gov/wp-content/uploads/import_data/scrape_files/docs/default-source/contractor-reports/medicare-copayments-for-critical-access-hospital-outpatient-services-update.pdf" id="https://www.medpac.gov/wp-content/uploads/import_data/scrape_files/docs/default-source/contractor-reports/medicare-copayments-for-critical-access-hospital-outpatient-services-update.pdf">https://www.medpac.gov/wp-content/uploads/import_data/scrape_files/docs/default-source/contractor-reports/medicare-copayments-for-critical-access-hospital-outpatient-services-update.pdf</a> 2 HHS Office of the Inspector General. (2014). Medicare Beneficiaries Paid Nearly Half of the Costs For Outpatient Services at Critical Access Hospitals.&nbsp;<a class="ck-anchor" href="https://oig.hhs.gov/reports/all/2014/medicare-beneficiaries-paid-nearly-half-of-the-costs-for-outpatient-services-at-critical-access-hospitals/" id="https://oig.hhs.gov/reports/all/2014/medicare-beneficiaries-paid-nearly-half-of-the-costs-for-outpatient-services-at-critical-access-hospitals/">https://oig.hhs.gov/reports/all/2014/medicare-beneficiaries-paid-nearly-half-of-the-costs-for-outpatient-services-at-critical-access-hospitals/</a> 3&nbsp;<a class="ck-anchor" href="https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/" id="https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/">https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/</a> 4&nbsp;<a class="ck-anchor" href="https://www.medpac.gov/wp-content/uploads/2023/10/MedPAC-MA-status-report-Jan-2024.pdf" id="https://www.medpac.gov/wp-content/uploads/2023/10/MedPAC-MA-status-report-Jan-2024.pdf">https://www.medpac.gov/wp-content/uploads/2023/10/MedPAC-MA-status-report-Jan-2024.pdf</a> 5&nbsp;<a class="ck-anchor" href="/lettercomment/2023-11-30-aha-urges-medpac-examine-medicare-advantage-denials-hospital-market-basket" id="/lettercomment/2023-11-30-aha-urges-medpac-examine-medicare-advantage-denials-hospital-market-basket">/lettercomment/2023-11-30-aha-urges-medpac-examine-medicare-advantage-denials-hospital-market-basket</a> 6<a href="/guidesreports/growing-impact-medicare-advantage-rural-hospitals-across-america">/guidesreports/growing-impact-medicare-advantage-rural-hospitals-across-america</a> 7 As of 2021, they have been subject to a national statutory payment limit per visit (i.e., in 2025, this payment limit is $152). 8&nbsp;In contrast, beneficiary cost-sharing for clinician services in other settings such as federally qualified health centers (FQHCs) is set at 20% of the lesser of the physician fee schedule or FQHC charges. 9 University of Minnesota, Rural Health Research Center. (Dec. 2019). Access and Capacity to Care for Medicare Beneficiaries in Rural Health Clinics.&nbsp;<a href="https://rhrc.umn.edu/wp-content/uploads/2019/12/UMN-access-to-care-RHCS-policy-brief-12.10.19.pdf">https://rhrc.umn.edu/wp-content/uploads/2019/12/UMN-access-to-care-RHCS-policy-brief-12.10.19.pdf</a>&nbsp;</div></div> Fri, 28 Feb 2025 10:02:03 -0600 Letter/Comment