DISCLAIMER

The following is a preliminary report of actions taken by the House of Delegates at its 2013 Annual Meeting and should not be considered final. Only the Official Proceedings of the House of Delegates reflect official policy of the Association.

AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES (A-13)

Report of Reference Committee A

Jerry L. Halverson, MD, Chair

Your Reference Committee recommends the following consent calendar for acceptance: 1 2 RECOMMENDED FOR ADOPTION 3

4 1. Resolution 103 - Managed Care Contract Payment Should Be Above Medicare 5

Fees 6 7

2. Resolution 109 - Comprehensive Dental Coverage (including dental implants) for 8 Children with Orofacial Clefting 9 10

3. Resolution 114 - Oncofertility and Fertility Preservation Treatment 11 12

4. Resolution 121 - Need to Deactivate New Coding Edits that Bundle Evaluation and 13 Management Codes and Codes for Immunization Services, Resulting in 14 Decreased Immunization Rates for Children 15 16

RECOMMENDED FOR ADOPTION AS AMENDED OR SUBSTITUTED 17 18 5. Board of Trustees Report 14 - Direct-to-Consumer Advertising of Durable Medical 19

Equipment 20 21

6. Council on Medical Service Report 3 - Payment Variations Across Outpatient Sites 22 of Service 23 24

7. Council on Medical Service Report 5 - Delivery of Care and Financing Reform for 25 Medicare and Medicaid Dually Eligible Beneficiaries 26 27

8. Resolution 102 - Patient Satisfaction Surveys and Quality Parameters as Criteria 28 for Physician Reimbursement 29 30

9. Resolution 104 - Cost-Saving Public Coverage for Renal Transplant Patients 31 32

10. Resolution 106 - Surprise Fee in Patient Protection and Affordable Care Act 33 (PPACA) 34 35

11. Resolution 107 - Medicare's Non-Existent Relationship to Usual and Customary 1 (U&C) Fees 2 3

12. Resolution 108 - Vaccines for Children Program and the New CPT Codes for 4 Immunization Administration 5 6

13. Resolution 116 - Extending Medicaid Payment Increases to Primary Care 7 Physicians to Include Obstetrician/Gynecologists 8

14. Resolution 117 - Observation Status and Medicare Part A Qualification 9 In lieu of 10 Resolution 111 - Medicare Long-Term Care Prior Hospitalization Requirement 11 12

15. Resolution 120 - Patient Access to Anti-Tuberculosis Medications 13 14

RECOMMENDED FOR REFERRAL 15 16 16. Resolution 112 - Unfair Medicare Payment Practice 17

18 17. Resolution 118 - Pap Testing Guidelines: HEDIS versus USPSTF 19

20 18. Resolution 119 - Place of Service Code for Observation Services 21

22 19. Resolution 122 - Health Insurer Code of Conduct Principles 23

24 20. Resolution 115 - Medication Non-Adherence and Errors 25

26 RECOMMENDED FOR REAFFIRMATION IN LIEU OF 27 28 21. Resolution 101 - Affordable Access for Low Income Individuals 29

30 22. Resolution 105 - Reducing the Cost of Prescription Drugs to Low Income Seniors 31

32 23. Resolution 110 - Language and Hearing Impaired Interpreter Services 33

34 24. Resolution 113 - Making Medicare Price Standardization Accurate35

1 (1) RESOLUTION 103 – MANAGED CARE CONTRACT 2

PAYMENT SHOULD BE ABOVE MEDICARE FEES 3 4 RECOMMENDATION: 5 6 Mr. Speaker, your Reference Committee recommends that 7 Resolution 103 be adopted. 8

9 HOD ACTION: Resolution 103 adopted. 10 11

Resolution 103 asks that our AMA seek legislation and/or regulation to prevent managed 12 care companies from utilizing a physician payment schedule below the updated Medicare 13 professional fee schedule. 14 15 A preponderance of the testimony heard on Resolution 103 was supportive. The 16 resolution’s sponsor acknowledged the similarity of their request with existing AMA policy 17 (Policy D-400.990), which asks the AMA to use every means available to convince health 18 insurance companies and managed care organizations to immediately uncouple fee 19 schedules from Medicare conversion factors and to maintain a fair and appropriate 20 payment level. Your Reference Committee points to the AMA’s strategic focus area on 21 payment and care delivery, which builds upon ongoing legislative activities to shape 22 payment and delivery models that improve physician satisfaction. 23 24 The sponsor underscored the continued downward spiral of physician payment levels and 25 the trend among managed care companies to link physician payment to Medicare rates 26 plus or minus certain percentages. Multiple speakers also described insurers who have 27 uncoupled their fees from Medicare conversion factors in ways that negatively affect 28 physician payments. Because testimony on Resolution 103 was largely supportive, your 29 Reference Committee recommends that it be adopted. 30

31 (2) RESOLUTION 109 - COMPREHENSIVE DENTAL 32

COVERAGE (INCLUDING DENTAL IMPLANTS) FOR 33 CHILDREN WITH OROFACIAL CLEFTING 34 35 RECOMMENDATION: 36 37 Mr. Speaker, your Reference Committee recommends that 38 Resolution 109 be adopted. 39

40 HOD ACTION: Resolution 109 adopted. 41 42

Resolution 109 asks that our AMA advocate for appropriate funding for comprehensive 43 dental coverage (including dental implants) for children with orofacial clefting. 44 45 There was limited, yet unanimous positive testimony heard on Resolution 109. Speakers 46 urged the AMA to support comprehensive dental coverage to assist children with orofacial 47 clefting as this condition can be a tremendous burden for the children afflicted by this 48 disorder. Your Reference Committee notes that existing AMA Policy H-185.967[1] 49 supports insurance coverage for the treatment of a minor child's congenital or 50 developmental deformity or disorder due to trauma or malignant disease. Given 51

supportive testimony and consistency with existing AMA policy, your Reference 1 Committee recommends that Resolution 109 be adopted. 2

(3) RESOLUTION 114 - ONCOFERTILITY AND FERTILITY 3

PRESERVATION TREATMENT 4 5 RECOMMENDATION: 6 7 Mr. Speaker, your Reference Committee recommends that 8 Resolution 114 be adopted. 9

10 HOD ACTION: Resolution 114 adopted. 11 12

Resolution 114 asks that our AMA support payment for and lobby for appropriate federal 13 legislation requiring payment for fertility preservation therapy services by all payers when 14 iatrogenic infertility may be caused directly or indirectly by necessary oncologic treatments 15 as determined by a licensed physician. 16 17 Your Reference Committee heard extensive, impassioned testimony on Resolution 114. 18 Many speakers supported the adoption of Resolution 114 as written stating that providing 19 fertility preservation treatment is the standard of care although patients are often not able 20 to obtain this care because health insurers are not covering such treatment. One speaker 21 highlighted a series of adverse health conditions that have resulted from oncology care, 22 which are all covered by health insurers. Therefore, it was urged that oncofertility and 23 fertility preservation treatment should be covered as well. Given supportive testimony, 24 your Reference Committee recommends that Resolution 114 be adopted. 25 26 (4) RESOLUTION 121 - NEED TO DEACTIVATE NEW 27

CODING EDITS THAT BUNDLE EVALUATION AND 28 MANAGEMENT CODES AND CODES FOR 29 IMMUNIZATION SERVICES, RESULTING IN DECREASED 30 IMMUNIZATION RATES FOR CHILDREN 31 32 RECOMMENDATION: 33 34 Mr. Speaker, your Reference Committee recommends that 35 Resolution 121 be adopted. 36 37

HOD ACTION: Resolution 121 adopted. 38 39

Resolution 121 asks that AMA Policy H-60.969, Childhood Immunizations, be reaffirmed 40 and that our AMA work with the American Academy of Family Physicians and the 41 American Academy of Pediatrics to strongly encourage CMS to deactivate coding edits 42 that cause a decrease in immunization rates for children, and to make these edit 43 deactivations retroactive to January 1, 2013. 44 45 The sponsors of Resolution 121 expressed concern about the Center for Medicare and 46 Medicaid Services’ National Correct Coding Initiative, which has resulted in the bundling 47 of all evaluation and management services with immunization codes. The unintended 48 consequence of this bundling of services has resulted in making it more difficult for 49 physicians caring for children to provide preventive medicine, specifically immunizations. 50

Several speakers expressed strong concerns about barriers that make it difficult to 1 administer immunizations. Given supportive testimony, your Reference Committee 2 recommends that Resolution 121 be adopted. 3 4 (5) BOARD OF TRUSTEES REPORT 14 - DIRECT-TO-5

CONSUMER ADVERTISING OF DURABLE MEDICAL 6 EQUIPMENT 7 8 RECOMMENDATION A: 9

10 Mr. Speaker, your Reference Committee recommends that 11 Recommendation 2b in Board of Trustees Report 14 be 12 amended by addition and deletion to read as follows: 13 14 (b) whenever feasible list the actual criteria (or a summary 15 thereof) from the appropriate source, such as the applicable 16 Certificate of Medical Necessity, DME Information Form 17 (DIF), “Dear Physician Letter” from DME Contractor Medical 18 Directors, Local Coverage Determination or associated 19 policy article; and 20

21 RECOMMENDATION B: 22 23 Mr. Speaker, your Reference Committee recommends that 24 Recommendation 3 in Board of Trustees Report 14 be 25 amended by addition and deletion to read as follows: 26 27 That our AMA recommend that DME companies stop 28 coercive acts which push inappropriately influence 29 physicians to sign these prescriptions for their patients. 30

31 RECOMMENDATION C: 32 33 Mr. Speaker, your Reference Committee recommends that 34 the recommendations in Board of Trustees Report 14 be 35 adopted as amended and that the remainder of the report be 36 filed. 37

38 HOD ACTION: Board of Trustees Report 14 adopted as 39 amended and the remainder of the report filed. 40 41

Board of Trustees Report 14 recommends that policies H-330.945 Durable Medical 42 Equipment Requirements, H-330.955 Prescription of Durable Medical Equipment and H-43 330.960 Cost of Medically Related Services and Supplies be reaffirmed. 44 45 Board of Trustees Report 14 also recommends that Resolution 505-A-12 be amended by 46 deletion to read as follows and adopted: That our AMA pursue legislation or regulation as 47 appropriate to require that direct-to-consumer advertising and any other media for durable 48 medical equipment and other medical supplies: (a) include a disclaimer statement to the 49 effect that eligibility for and coverage of the illustrated product is subject to specific criteria 50 and that only a physician can determine if a patient meets those criteria; (b) whenever 51

feasible list the actual criteria (or a summary thereof) from the appropriate Certificate of 1 Medical Necessity; (c) note that patients who knowingly obtain DME or other supplies 2 without meeting the eligibility criteria and the physicians who inappropriately certify such 3 patients may be subject to civil and/or criminal penalties for fraud; and, (d) (c) refrain from 4 statements to the effect that only a physician order or signature is required to obtain the 5 desired items. In addition, the report suggests that our AMA recommend that DME 6 companies stop coercive acts which push physicians to sign these prescriptions for their 7 patients. 8 9 Your Reference Committee commends the Board on its examination of durable medical 10 equipment (DME) and supplies sales, direct-to-consumer advertising of these products 11 and federal oversight activities of medical devices. Testimony on this report was generally 12 supportive. Your Reference Committee believes that the report’s recommendations 13 address the adverse effects of direct-to-consumer advertising of DME and supplies. 14 Moreover, the report includes compelling information in support of the recommendations. 15 Suggested edits to the body of the report, but not to the report’s recommendations, were 16 submitted by the U.S. Food and Drug Administration. An amendment to Recommendation 17 2b accounting for a range of sources of criteria was well-received and is recommended by 18 your Reference Committee. Your Reference Committee also concurs with a minor 19 amendment to Recommendation 3 that was suggested in online testimony. Accordingly, 20 your Reference Committee recommends that Board of Trustees Report 14 be adopted as 21 amended. 22

23 (6) COUNCIL ON MEDICAL SERVICE REPORT 3 – 24

PAYMENT VARIATIONS ACROSS OUTPATIENT SITES 25 OF SERVICE 26 27 RECOMMENDATION A: 28 29 Mr. Speaker, your Reference Committee recommends that 30 Recommendation 3 of Council on Medical Service Report 3 31 be amended by addition and deletion to read as follows: 32

33 1. That our AMA work with states to advocate that third party payers be required to: 34

35 a. Assess equal or lower facility coinsurance for lower-cost sites of service 36

(hospital outpatient department, ambulatory surgical center, or office-based 37 facility); 38

39 b. Publish and routinely update pertinent information related to patient cost-40

sharing; and 41 42 c. Allow their plan’s participating physicians to perform outpatient procedures at 43

an appropriate site of service as chosen by the physician and the patient. 44 (Directive to Take Action)45

RECOMMENDATION B: 1 2 Mr. Speaker, your Reference Committee recommends that 3 Council on Medical Service Report 3 be adopted as 4 amended and the remainder of the report be filed. 5 6

HOD ACTION: Original Council on Medical Service 7 Report 3 adopted. 8 9

Council on Medical Service Report 3 recommends that our AMA reaffirm Policies H-330.925, H-10 240.993 and D-330.997, which support equitable Medicare payments across outpatient settings, 11 and reaffirm Policy H-165.846, which supports mechanisms to educate patients and assist them 12 in making informed choices, including ensuring transparency among all health plans regarding 13 covered services, cost-sharing, out-of-pocket limits and lifetime benefit caps, and excluded 14 services. Council on Medical Service Report 3 also recommends that our AMA work with states 15 to advocate that third party payers be required to: (a) assess equal or lower facility coinsurance 16 for lower-cost sites of service (hospital outpatient department, ambulatory surgical center, or 17 office-based facility); (b) publish and routinely update pertinent information related to patient 18 cost-sharing; and (c) allow their plan’s participating physicians to perform outpatient procedures 19 at an appropriate site of service as chosen by the physician and the patient. 20 21 Your Reference Committee heard testimony that was supportive of Council on Medical Service 22 Report 3. Testimony noted that a variety of factors may justify higher payments to hospital 23 outpatient departments, such as hospital requirements to meet Joint Commission accreditation 24 standards and Medicare Conditions of Participation. Alternatively, physician offices are not 25 required to meet these standards. An additional comment suggested that our AMA explore 26 whether higher payments in certain settings are justified by patient safety concerns. Your 27 Reference Committee discussed possible reasons for higher payments to hospital outpatient 28 departments, including hospitals’ 24-hour access and the proximity of outpatient departments to 29 hospital emergency departments. Your Reference Committee concludes that data are not yet 30 available to substantiate whether pay disparities for services performed across outpatient 31 settings are in fact justifiable. Furthermore, there is no comprehensive evidence base to help 32 patients determine the optimal location to have a particular outpatient procedure performed. 33 34 Testimony also acknowledged the importance of cost transparency to help patients understand 35 that the amount of their cost-sharing may differ, depending on the site of service. Your 36 Reference Committee clarified that transparency regarding costs is important but does not 37 inform patients about actual quality of care. Additional testimony noted that the payment 38 disparities discussed in the Council’s report have led many cardiologists to migrate to the 39 hospital setting, thereby increasing costs of certain outpatient cardiac procedures. Speakers 40 also expressed concern that physician payments across sites of service will be equalized at the 41 lowest possible level. 42 43 Substitute language for Recommendation 3a was offered out of concern that the 44 recommendation as written does not sufficiently hold patients accountable to make quality and 45 cost-effective choices. Testimony was supportive of this language, and your Reference 46 Committee therefore recommends incorporating the substitute language into Recommendation 47 3a and adopting Council on Medical Service Report 3 as amended. 48 49

(7) COUNCIL ON MEDICAL SERVICE REPORT 5 - 1 DELIVERY OF CARE AND FINANCING REFORM FOR 2 MEDICARE AND MEDICAID DUALLY ELIGIBLE 3 BENEFICIARIES 4 5 RECOMMENDATION A: 6 7 Mr. Speaker, your Reference Committee recommends that 8 Recommendation 1a of Council on Medical Service Report 9 5 be amended by addition and deletion to read as follows: 10 11 1. That our American Medical Association (AMA) adopt the 12 following principles on the delivery of care and financing 13 reform for Medicare and Medicaid dually eligible 14 beneficiaries: 15 16 a. Various approaches to integrated delivery of care should 17 be promoted under demonstrations such as primary care 18 physician-led patient-centered medical homes with 19 adequate payment to physicians, provision of care 20 management and mental health resources. 21 22 RECOMMENDATION B: 23 24 Mr. Speaker, your Reference Committee recommends that 25 Council on Medical Service Report 5 be adopted as 26 amended and the remainder of the report be filed. 27 28

HOD ACTION: Council on Medical Service Report 5 29 adopted as amended and the remainder of the 30 report filed. 31 32

Council on Medical Service Report 5 recommends that our AMA adopt the following principles 33 on the delivery of care and financing reform for Medicare and Medicaid dually eligible 34 beneficiaries: a. Various approaches to integrated delivery of care should be promoted under 35 demonstrations such as primary care medical homes with adequate payment to physicians, 36 provision of care management and mental health resources; b. Customized benefits and 37 services from health plans are necessary according to each beneficiary’s specific medical 38 needs; c. Care coordination demonstrations should not interfere with the established patient-39 physician relationships in this vulnerable population; d. Delivery and payment reform for dually 40 eligible beneficiaries should involve actively practicing physicians and take into consideration 41 the diverse patient population and local area resource; e. States with approved financial 42 alignment demonstration models should provide education and counseling to beneficiaries on 43 options for receiving Medicare and Medicaid benefits; f. Conflicting payment rules between the 44 Medicare and Medicaid programs should be eliminated; g. Medicare and Medicaid benefit plans 45 and the delivery of benefits should be coordinated and h. Care plans for beneficiaries should be 46 streamlined among all clinical providers and social service agencies. 47 48 Council on Medical Service Report 5 also recommends that our AMA reaffirm Policy D-290.978, 49 which calls for the Centers for Medicare & Medicaid Services to require all states to develop 50 forms and related processes to facilitate “opting out” of managed care programs by dually 51

eligible individuals, and that those forms and directives be available no less than 120 days 1 before the implementation date of a state’s dually eligible managed care program. 2 3 Your Reference Committee heard supportive testimony on Council on Medical Service Report 5. 4 A speaker acknowledged that the report provides a good summary of some of the issues and 5 solutions for providing health care services for Medicare and Medicaid dually eligible 6 beneficiaries. 7 8 Amendments were proposed for consideration. Testimony provided information that there are 9 National Committee for Quality Assurance standards for specialty medical homes as well as 10 primary care medical homes. Therefore, it was suggested that Recommendation 1a be 11 amended to read “patient-centered medical homes” rather than “primary care medical homes.” 12 In addition, an amendment was suggested to include “physician-led” at the beginning of 13 “patient-centered medical homes,” which was supported by the Council on Medical Service. 14 Your Reference Committee concurs with these amendments. 15 16 In addition, testimony suggested that recommendation 1f be more explicit so that the 17 administration of the dually eligible population takes into consideration physician payments, 18 medical office administration and patient empowerment. A speaker suggested amending the 19 recommendation to read “Conflicting payment rules between the Medicare and Medicaid 20 programs should be eliminated in a manner that benefits the physician-patient team.” Your 21 Reference Committee considered this amendment, but felt that the suggested new language 22 was too vague and questioned what examples of benefiting the physician-patient team would 23 apply in this situation. 24 25 A concern was raised that this report may allow for any willing provider provisions. A member of 26 the Council on Medical Service testified that the report does not advocate for any willing 27 provider provisions since it is focused on not disrupting continuity of care of dually eligible 28 patients when possible. It is not designed to allow any willing provider to care for any patient, 29 but rather to support the long term patient-physician relationships that have already been 30 established in this vulnerable population. As such, your Reference Committee recommends that 31 Council on Medical Service Report 5 be adopted as amended. 32 33 (8) RESOLUTION 102 - PATIENT SATISFACTION SURVEYS 34

AND QUALITY PARAMETERS AS CRITERIA FOR 35 PHYSICIAN PAYMENT 36 37 RECOMMENDATION A: 38 39 Mr. Speaker, your Reference Committee recommends that 40 the first resolve of Resolution 102 be amended by addition 41 and deletion to read as follows: 42

RESOLVED, That our American Medical Association work 1 with the Centers for Medicare & Medicaid Services (CMS) 2 and non-government payers to ensure that subjective 3 criteria, such as patient satisfaction surveys, be used only 4 as an adjunctive and not a determinative measure of 5 physician quality for the purpose of physician 6 reimbursement payment (Directive to Take Action) 7 8 RECOMMENDATION B: 9

10 Mr. Speaker, your Reference Committee recommends that 11 the second resolve of Resolution 102 be amended by 12 addition and deletion to read as follows: 13

14 RESOLVED, That our AMA work with CMS and non-15 government payers to ensure that reimbursement 16 physician payment determination, when incorporating 17 quality parameters, only consider measures that are under 18 the direct control of the physician. (Directive to Take 19 Action) 20 21 RECOMMENDATION C: 22

23 Mr. Speaker, your Reference Committee recommends that 24 Resolution 102 be adopted as amended. 25

26 HOD ACTION: Resolution 102 adopted as amended. 27 28

29 30

Resolution 102 asks that our AMA work with CMS and non-government payers to ensure that 31 subjective criteria, such as patient satisfaction surveys, be used only as an adjunctive and not a 32 determinative measure of physician quality for the purpose of physician reimbursement and that 33 reimbursement determination, when incorporating quality parameters, only consider measures 34 that are under the direct control of the physician. 35 36 Testimony on Resolution 102 was mixed. Several amendments were proposed, such as 37 replacing the term “reimbursement” with “payment” in both resolves. Your Reference Committee 38 concurs with this suggested language change. In addition, your Reference Committee notes 39 that existing AMA policy is consistent with the requests in Resolution 102. Policy H-406.991[5] 40 advocates that physician-profiling programs may rank individual physician members of a 41 medical group but should not use those individual rankings for placement in a network or for 42 payment purposes. Policy H-450.966 advocates that regarding the development and evaluation 43 of quality and performance standards, standards and measures should recognize and adjust for 44 factors that are not within the direct control of those being measured. Given the minor 45 amendments and consistency with AMA policy, your Reference Committee recommends that 46 Resolution 102 be adopted as amended. 47

(9) RESOLUTION 104 - COST-SAVING PUBLIC 1 COVERAGE FOR RENAL TRANSPLANT PATIENTS 2 3 RECOMMENDATION A: 4 5 Mr. Speaker, your Reference Committee recommends 6 that the first resolve of Resolution 104 be amended by 7 addition and deletion to read as follows: 8 9 RESOLVED, That our American Medical Association 10 support private and public mechanisms that would extend 11 insurance coverage for the full spectrum evidence-based 12 treatment of renal transplant care for the life of the 13 transplanted organ (New HOD Policy) 14

15 RECOMMENDATION B: 16 17 Mr. Speaker, your Reference Committee recommends 18 that the second resolve of Resolution 104 be amended by 19 addition to read as follows: 20 21 RESOLVED, That our AMA continue to offer technical 22 assistance to individual state and specialty societies when 23 those societies lobby state or federal legislative or 24 executive bodies to implement evidence-based cost-25 saving policies within public health insurance programs. 26 (Directive to Take Action) 27

28 RECOMMENDATION C: 29 30

Mr. Speaker, your Reference Committee recommends that 31 Resolution 104 be adopted as amended. 32

33 HOD ACTION: Resolution 104 adopted as amended. 34 35

Resolution 104 asks that our AMA support private and public mechanisms that would extend 36 insurance coverage for the full spectrum of renal transplant care for the life of the transplanted 37 organ and offer technical assistance to individual state and specialty societies when those 38 societies lobby state or federal legislative or executive bodies to implement evidence-based 39 cost-saving policies within public health insurance programs. 40 41 Mixed, yet mostly supportive testimony was heard on Resolution 104. Speakers in favor of 42 Resolution 104 identified the cost savings that would occur by covering a lifelong 43 immunosuppressive regimen in order to prevent failure of a kidney transplant. Furthermore, it 44 was cautioned that discontinuing this treatment in the midst of care would result in poor health 45 outcomes. Opposing testimony highlighted that our AMA does not support life-long public 46 support for other health care conditions and urged consistency with existing policy. 47 48 The first resolve requests AMA support for extending coverage for the “full spectrum” of renal 49 transplant care. Your Reference Committee is concerned that this language is too broad and 50 could include any type of treatments. Therefore, your Reference Committee recommends 51

replacing “full spectrum” with “evidence-based treatment.” In addition, the second resolve asks 1 our AMA to offer technical assistance to state and specialty societies when these entities lobby 2 to implement evidence-based cost-saving policies within public health insurance programs. Your 3 Reference Committee is aware that our AMA is available to provide this service and therefore 4 suggests additional language supporting our AMA to continue this service. As such, your 5 Reference Committee recommends that Resolution 104 be adopted as amended. 6

7 (10) RESOLUTION 106 - SURPRISE FEE IN PATIENT 8

PROTECTION AND AFFORDABLE CARE ACT 9 10 RECOMMENDATION A: 11

12 Mr. Speaker, your Reference Committee recommends that 13 Resolution 106 be amended by addition to read as follows: 14 15 RESOLVED, That our American Medical Association 16 advocate that any proposed assessment on ‘issuers of 17 insurance’ (scheduled to commence in 2014 for a 3-year 18 period), intended to fund a ‘risk adjustment program’ to 19 cushion insurers against any actual uncertainties 20 surrounding the health status of the uninsured, not be 21 passed along to consumers be taken from administrative 22 and medical management costs. (New HOD Policy) 23 24 RECOMMENDATION B: 25 26 Mr. Speaker, your Reference Committee recommends that 27 Resolution 106 be adopted as amended. 28

29 RECOMMENDATION C: 30 31 Mr. Speaker, your Reference Committee recommends that 32 the title of Resolution 106 be changed to read as follows: 33 34 TRANSITIONAL REINSURANCE FEES UNDER THE 35 AFFORDABLE CARE ACT 36 37

HOD ACTION: Resolution 106 adopted as amended 38 with a change in title. 39 40

Resolution 106 asks that our AMA advocate that any proposed assessment on ‘issuers of 41 insurance’ (scheduled to commence in 2014 for a 3-year period), intended to fund a ‘risk 42 adjustment program’ to cushion insurers against any actual uncertainties surrounding the health 43 status of the uninsured, not be passed along to consumers. 44 45 Testimony received on Resolution 106 was mixed. Your Reference Committee acknowledges 46 the sponsors’ concern that transitional reinsurance fees enacted under the ACA will be passed 47 along to consumers. These fees, which will be imposed on insurers beginning in 2014, are 48 intended to fund reinsurance payments that cover high-risk people in the individual market. Your 49 Reference Committee heard testimony on the appropriateness of insulating patients from the 50 costs of covering risk adjustment pools. Concerns regarding Resolution 106 largely focused on 51

the potential that physicians will ultimately bear the burden of these fees. In an effort to prevent 1 the reinsurance fees from being passed on to consumers or to physicians via payment 2 reductions, your Reference Committee recommends adding a clause at the end of the resolve 3 specifying that the transitional reinsurance fees “be taken from administrative and medical 4 management costs,” as suggested by one of the speakers. To clarify the fee program 5 addressed in the resolution, your Reference Committee also recommends that the title of 6 Resolution 106 be changed to Transitional Reinsurance Fees under the Affordable Care Act. 7 8 (11) RESOLUTION 107 - MEDICARE'S NON-EXISTENT 9

RELATIONSHIP TO USUAL AND CUSTOMARY (U&C) 10 FEES 11 12 RECOMMENDATION A: 13 14 Mr. Speaker, your Reference Committee recommends that 15 Resolution 107 be amended by addition and deletion to 16 read as follows: 17 18 RESOLVED, That our American Medical Association take 19 the position that there is no relationship between the 20 Medicare fee schedule and Usual, & Customary and 21 Reasonable Fees. (New HOD Policy) 22

23 RECOMMENDATION B: 24 25 Mr. Speaker, your Reference Committee recommends that 26 Resolution 107 be adopted as amended. 27

28 RECOMMENDATION C: 29 30 Mr. Speaker, your Reference Committee recommends that 31 the title of Resolution 7 be changed to read as follows: 32 33 MEDICARE’S NON-EXISTENT RELATIONSHIP TO 34 USUAL, CUSTOMARY AND REASONABLE (UCR) FEES 35

36 HOD ACTION: Resolution 107 be adopted as 37 amended with a change in title. 38 39

Resolution 107 asks that our AMA take the position that there is no relationship between the 40 Medicare fee schedule and usual and customary fees. Testimony on Resolution 107 was 41 supportive. It was suggested in the online testimony that “usual and customary” be defined for 42 those less familiar with these terms. Under Policy H-385.923, “usual” means a fee that the 43 physician usually charges to his/her private patients. “Customary” means the charge is within 44 the range of usual fees currently charged by physicians of similar training and experience for the 45 same service within the same limited geographic area. “Reasonable” is defined as a charge that 46 is usual and customary, and is justifiable considering the special circumstances of the case in 47 question, without regard to payments that have been discounted under governmental or non-48 governmental health insurance plans or policies. 49 50 Our AMA has been consistent in its position that Medicare payment rates are significantly lower 51

than the cost to provide medical services. Your Reference Committee concurs that there is no 1 relationship between the Medicare physician fee schedule and usual, customary and 2 reasonable (UCR) fees. Testimony regarding this position was supportive. Your Reference 3 Committee heard testimony offering an amendment to replace “fee schedule” with “payment 4 schedule” but notes that the correct terminology is “Medicare fee schedule.” To be consistent 5 with existing AMA policy, your Reference Committee also suggests adding the word 6 “reasonable” to the resolution and its title, and recommends that Resolution 107 be adopted 7 with these minor amendments. 8 9 (12) RESOLUTION 108 - VACCINES FOR CHILDREN 10

PROGRAM AND THE NEW CPT CODES FOR 11 IMMUNIZATION ADMINISTRATION 12

13 RECOMMENDATION A: 14

15 Mr. Speaker, your Reference Committee recommends that 16 Resolution 108 be amended by deletion to read as follows: 17

18 RESOLVED, That our American Medical Association work 19 with the American Academy of Pediatrics and other groups 20 to convince the Centers for Medicare & Medicaid Services 21 to allow state Medicaid agencies to pay physicians for using 22 the new immunization administration codes (90460, 90461) 23 to compassionately immunize eligible patients and to be 24 paid fairly for their participation in the Vaccines for Children 25 Program. (Directive to Take Action) 26

27 RECOMMENDATION B: 28

29 Mr. Speaker, your Reference Committee recommends that 30 Resolution 108 be adopted as amended. 31

32 HOD ACTION: Resolution 108 adopted as amended. 33 34

Resolution 108 asks that our AMA work with the American Academy of Pediatrics and other 35 groups to convince CMS to allow state Medicaid agencies to pay physicians for using the new 36 immunization administration codes (90460, 90461) to compassionately immunize eligible 37 patients and to be paid fairly for their participation in the Vaccines for Children Program. 38 39 Unanimous positive testimony was heard on Resolution 108. Your Reference Committee notes 40 that Resolution 108 is consistent with AMA policy D-440.956, which advocates for improved 41 financing mechanisms for vaccines, including the expansion of the Vaccines for Children 42 Program. Your Reference Committee agrees that this is an important issue for our AMA to 43 support. However, an amendment is suggested to strike the term “compassionately” since it 44 appears unnecessary given that the services provided by physicians are naturally 45 compassionate. 46 47

(13) RESOLUTION 116 - EXTENDING MEDICAID PAYMENT 1 INCREASES TO PRIMARY CARE PHYSICIANS TO 2 INCLUDE OBSTETRICIAN/GYNECOLOGISTS 3

4 RECOMMENDATION A: 5 6 Mr. Speaker, your Reference Committee recommends adoption of 7 the following Substitute Resolution 116: 8

RESOLVED, That our AMA advocate for the extension of 9 Medicaid payment increases to primary care physicians to include 10 all physicians who furnish a substantial portion (60%) of their 11 Medicare or Medicaid billings (allowable charges) for designated 12 primary care services. 13

14 RESOLVED, That our AMA advocate for the continuation of the 15 Affordable Care Act primary care rate increases after the 16 expiration of such provision on December 31, 2014. 17

18 RECOMMENDATION B: 19

20 Mr. Speaker, your Reference Committee recommends that the 21 title of Resolution 116 be changed to read as follows: 22

23 EXTENDING MEDICAID PAYMENT INCREASES 24

25 HOD ACTION: Resolution 116 referred. 26 27

Resolution 116 asks that our AMA advocate for the extension of Medicaid reimbursement rate 28 increases to primary care physicians to include obstetrician/gynecologists. 29 30 Extensive mixed testimony was heard on Resolution 116. One speaker stated that extending 31 the increase in Medicaid reimbursement rates for primary care physicians to include 32 obstetricians/ gynecologists would improve access to care for Medicaid-insured women. 33 Concern was voiced about inadequate payment for all other physicians. Several speakers 34 requested that other specialties, such as neurology, psychiatry and emergency medicine be 35 included in the increased payment rates. Several amendments were suggested. Your 36 Reference Committee considered these amendments and drafted a substitute resolution in 37 response. 38 39 Your Reference Committee notes that Medicare uses a fee schedule to pay physicians for the 40 services they furnish to beneficiaries. The ACA provides a 10 percent bonus payment on top of 41 the fee schedule payment for select primary care services furnished by primary care physicians 42 in calendar years 2011-2015. To qualify for the bonus, a physician must be self-designated in a 43 primary care specialty (general internal medicine, family practice, pediatrics, and geriatrics) and 44 a substantial portion (60 percent) of their Medicare billings, or allowable charges, must be for 45 the designated primary care services (mainly, office-and other outpatient visits) on which a 46 bonus payment is made. CMS will assess eligibility for the bonus by (1) checking a physician’s 47 specialty self-designation to ensure that they are in general internal medicine or in another 48 primary care specialty and (2) looking back on the percentage of designated primary care 49 services furnished by the physician during an earlier time period. 50

1 Given supportive testimony and the fact that existing AMA policy supports a sufficient supply of 2 primary care physicians, including obstetricians/gynecologists, your Reference Committee 3 recommends that Substitute Resolution 116 be adopted. 4

(14) RESOLUTION 111 – MEDICARE LONG-TERM CARE PRIOR 5

HOSPITALIZATION REQUIREMENT 6 RESOLUTION 117 - OBSERVATION STATUS AND MEDICARE 7 PART A QUALIFICATION 8 9 RECOMMENDATION A: 10 11 Mr. Speaker, your Reference Committee recommends that 12 Resolution 117 be amended by addition and deletion to read as 13 follows: 14

15 RESOLVED, That our AMA advocate for Medicare Part A coverage for a 16 patient’s direct admission to a skilled facility if directed by their physician 17 and if the patient’s condition meets skilled nursing criteria. (Directive to 18 Take Action) 19

20 RECOMMENDATION B: 21

22 Mr. Speaker, your Reference Committee recommends that 23 Resolution 117 be adopted as amended in lieu of Resolution 111. 24

25 HOD ACTION: Resolution 117 adopted as amended in lieu of 26 Resolution 111. 27 28 29

Resolution 111 asks that our AMA work to eliminate the “three day” requirement for inpatient 30 hospital admission prior to skilled nursing facility admission as a prerequisite for Medicare 31 coverage and substitute other appropriate criteria that would allow for timely and appropriate 32 skilled nursing facility placement of Medicare patients. 33 34 Resolution 117 asks that our AMA seek and/or support a requirement that a 72-hour hospital 35 stay, either under inpatient status or under observation status, will qualify a patient for Medicare 36 Part A coverage for skilled services after discharge. 37 38 Testimony heard on Resolution 111 supported reaffirmation of existing policy; however, some 39 testimony favored adoption of this resolution out of concern that reaffirmation would not help 40 eliminate the three-day inpatient hospital requirement for Medicare coverage of skilled nursing 41 facility services. Testimony heard on Resolution 117 was very supportive. Multiple speakers 42 emphasized that current federal observation care policy is archaic and problematic. Others 43 spoke about the costs associated with hospitalizing patients for 72 hours for non-acute 44 treatments to qualify for post-hospital skilled nursing facility care. It was repeatedly suggested 45 that legislative and/or regulatory relief is very much needed, and that our AMA has had policies 46 in place to eliminate the three-day stay for several years. There was discussion of requiring no 47 hospital stay; however, your Reference Committee believes the resolution as amended captures 48 the spirit and intent of Resolution 117. 49 50

Your Reference Committee points out that our AMA is actively working with Congress and the 1 Centers for Medicare & Medicaid Services (CMS) on solutions to coverage problems associated 2 with hospital observation stays and subsequent skilled nursing facility care. Our AMA is working 3 in support of federal legislation (S 569; HR 1179) that would count observation care toward the 4 three-day stay requirement. Our AMA has also repeatedly requested that CMS review its policy 5 on the three-day stay requirement. Your Reference Committee recognizes similarities in intent 6 between Resolutions 111 and 117 and existing AMA policy on the three-day hospital stay 7 requirement. After hearing discussion of several amendments suggested during testimony, your 8 Reference Committee recommends asking our AMA to continue to advocate that hospital stays 9 of any duration, under either inpatient or observation status, will qualify a patient for Medicare 10 Part A coverage of skilled nursing facility services after discharge. Your Reference Committee 11 recommends that Resolution 117 be adopted as amended in lieu of Resolution 111. 12

13 (15) RESOLUTION 120 - PATIENT ACCESS TO ANTI-14

TUBERCULOSIS MEDICATIONS 15 16 RECOMMENDATION A: 17 18 Mr. Speaker, your Reference Committee recommends that 19 Resolution 120 be amended by addition to read as follows: 20

21 RESOLVED, That our American Medical Association support 22 state and federal policy to cover TB testing for individuals 23 deemed to have a high risk for contracting TB infection and 24 to provide anti-tuberculosis medications to patients with both 25 active and latent TB free of charge or insurance co-pays or 26 deductibles in order to prevent the transmission of this 27 airborne infectious disease. (New HOD Policy) 28

29 RECOMMENDATION B: 30 31 Mr. Speaker, your Reference Committee recommends that 32 Resolution 120 be adopted as amended. 33

34 HOD ACTION: Resolution 120 adopted as amended. 35 36

Resolution 120 asks that our AMA support state and federal policy to provide anti-tuberculosis 37 medications to patients with both active and latent TB free of charge or insurance co-pays or 38 deductibles in order to prevent the transmission of this airborne infectious disease. 39 40 Your Reference Committee heard mostly supportive testimony on Resolution 120. While 41 support was voiced for adopting this resolution, several concerns were raised. One speaker 42 questioned if there were widespread issues with anti-tuberculosis medications not being 43 covered for free. Another speaker felt that the resolution did not take into account the continuing 44 emergence of drug resistance to common TB regimens, the challenge of drug shortages or the 45 fact that TB is a global problem. In addition, it was cautioned that offering free medication for 46 any condition should be carefully considered. 47 Your Reference Committee considered the issues raised in testimony, but notes that while most 48 states provide free TB medications for both active and latent TB, there are a few states where 49 this is the responsibility of the local health departments. In addition, your Reference Committee 50 is aware that there has been a shortage of TB medications, which has caused some states to 51

either decrease the dosage to make it last longer or have temporarily restricted free TB 1 medications to only high priority patients. Given the shortage of TB medications in addition to 2 drug resistant TB, this is a growing problem that your Reference Committee believes needs to 3 be further addressed. Your Reference Committee recommends additional language to include 4 the coverage of testing for individuals deemed to have a high risk for contracting TB infection in 5 order to increase the efforts to eliminate this disease. 6 7 (16) RESOLUTION 112 - UNFAIR MEDICARE PAYMENT PRACTICE 8

9 RECOMMENDATION: 10 11 Mr. Speaker, your Reference Committee recommends that 12 Resolution 112 be referred. 13

14 HOD ACTION: Resolution 112 referred. 15 16

Resolution 112 asks that our AMA seek legislation to fairly compensate procedures across all 17 service sites (physician office, ambulatory surgical centers, and hospital outpatient departments) 18 to include a single formula for reimbursement that recognizes the different average resource 19 costs to provide each procedure and a single update formula (such as the Consumer Price 20 Index for all Urban Consumers) for all sites with an appropriate conversion factor that 21 recognizes different average resource costs for the different sites. 22 23 Testimony on Resolution 112 was mixed, and included suggestions for referral. A member of 24 the Council on Medical Service noted that Council on Medical Service Report 3-A-13 addresses 25 payment variations across outpatient sites of service, and asked what additional information 26 would be expected from referral. A concern was expressed that adopting the resolution as 27 written will not increase payments for physicians in solo practice or those in rural or at-risk 28 areas. Alternatively, the sponsors noted that hospital-based care is more expensive but may not 29 produce better outcomes than outpatient facilities owned and operated by independent 30 physicians. Your Reference Committee discussed the complexity associated with transitioning 31 existing payment update formulas into a single update formula, as requested by the resolution. 32 Your Reference Committee concurs that this is a complex issue worthy of further study and 33 therefore recommends referral. 34 35 (17) RESOLUTION 118 - PAP TESTING GUIDELINES: HEDIS 36

VERSUS USPSTF 37 38 RECOMMENDATION: 39 40 Mr. Speaker, your Reference Committee recommends that 41 Resolution 118 be referred. 42

43 HOD ACTION: Resolution 118 referred. 44 45

Resolution 118 asks that our AMA urge third party payers not to withhold payment to physicians 46 for preventive health services that fall under accepted guidelines, even if they differ from the 47 payer’s own guidelines. 48 49 While testimony was supportive of the topic in general, concern was raised that physicians 50 should practice according to the specific needs of each individual patient rather than according 51

to guidelines created by other entities. In addition several speakers felt that this was a 1 complicated issue that deserved more consideration and therefore urged referral. 2 3 In addition, your Reference Committee had several concerns. First, the reference to “acceptable 4 guidelines” is not defined in the resolve, which is preferable if adopting policy so that our AMA’s 5 position is clear. In addition, the resolve is much broader than the subject of the resolution. Your 6 Reference Committee suggests that the terminology “pap smear testing” should be in the 7 resolve so that it reflects the resolution’s subject matter. Finally, referencing “guidelines” in the 8 resolve is of concern as the guidelines could change and our AMA may not remain supportive. 9 For these reasons, your Reference Committee recommends that Resolution 118 be referred. 10 11 (18) RESOLUTION 119 - PLACE OF SERVICE CODE FOR 12

OBSERVATION SERVICES 13 14 RECOMMENDATION: 15 16 Mr. Speaker, your Reference Committee recommends that 17 Resolution 119 be referred. 18

19 HOD ACTION: Resolution 119 referred. 20 21

Resolution 119 asks that our AMA conduct a study of the impact on patient cost-sharing, 22 physician payment, physician administrative cost, and the quality of care if a specific place-of-23 service code is created for observation services, consult with the AHA and other stakeholders in 24 this study on place of service code for observation services and that based on the findings of 25 the study our AMA and other interested stakeholders petition CMS to recognize a new place-of-26 service code for observation services. 27 28 Testimony on Resolution 119 was limited to one comment in support of adoption. Your 29 Reference Committee interprets this resolution as a call for a high-level AMA study on a 30 complex issue (new place of service codes for observation services). As stated previously in this 31 report, our AMA is working with Congress and CMS to advocate for solutions to Medicare 32 coverage problems associated with hospital observation status. Your Reference Committee 33 believes that our AMA should look into the use of new place-of-service codes for observation 34 services before committing to the study called for in Resolution 119, and therefore recommends 35 referral. 36 37 (19) RESOLUTION 122 - HEALTH INSURER CODE OF CONDUCT 38

PRINCIPLES 39 40 RECOMMENDATION: 41 42 Mr. Speaker, your Reference Committee recommends that 43 Resolution 122 be referred. 44 45

HOD ACTION: Resolution 122 referred. 46 47

Resolution 122 asks that our AMA update the AMA Health Insurer Code of Conduct Principles 48 and report back at the 2014 Annual Meeting. 49 50

Your Reference Committee heard limited, yet supportive testimony on Resolution 122. The 1 sponsor highlighted the fact that the AMA Health Insurer Code of Conduct Principles were 2 developed before health system reform legislation was adopted and therefore certain sections 3 may no longer be relevant. The sponsor and a member of the Board of Trustees suggested that 4 Resolution 122 be referred for additional consideration of appropriate updates. Therefore your 5 Reference Committee recommends that Resolution 122 be referred. 6

7 (20) RESOLUTION 115 - MEDICATION NON-ADHERENCE AND 8

ERRORS 9 10 RECOMMENDATION: 11 12 Mr. Speaker, your Reference Committee recommends that 13 Resolution 115 be referred. 14

15 HOD ACTION: Resolution 115 referred. 16 17

Resolution 115 asks that our AMA work with the Centers for Medicare & Medicaid Services or 18 seek federal legislation to require Medicare to provide the option of prescribing, according to 19 patient need, timed calendar blister packs to be filled locally with pharmacist counseling with no 20 or minimal extra cost to the patient. 21 22 Testimony on Resolution 115 was mixed, and included comments on the costs of providing 23 timed calendar blister packs as well as the potential cost savings from the use of blister packs if 24 they prevent emergency room visits and hospitalizations. The sponsor spoke of senior citizens 25 who, lacking blister packs and/or pharmacist counseling, may take medications incorrectly and 26 end up in the hospital. The sponsor also testified that blister packs have been shown to increase 27 medication adherence and save money on hospitalizations. 28 29 Your Reference Committee discussed the considerable expenses associated with having timed 30 calendar blister packs filled locally with pharmacist counseling. Your Reference Committee is 31 aware that current regulations require Medicare Part D plans to cover unit dose packaged drugs 32 in the long-term care setting and believes further study is warranted before asking our AMA to 33 advocate for broader Medicare coverage. Accordingly, your Reference Committee recommends 34 that Resolution 115 be referred. 35 36 (21) RESOLUTION 101 - AFFORDABLE ACCESS FOR LOW 37

INCOME INDIVIDUALS 38 39 RECOMMENDATION: 40 41 Mr. Speaker, your Reference Committee recommends that 42 Policies H-165.855, D-165.955 and H-165.848 be reaffirmed in 43 lieu of Resolution 101. 44

45 HOD ACTION: Policies H-165.855, D-165.955 and H-165.848 be 46 reaffirmed in lieu of Resolution 101. 47 48

Resolution 101 asks that our AMA adopt policy that all individuals under 400% FPL should be 49 eligible for refundable tax credits to provide premium assistance for coverage of a qualified 50 health plan and that the refundable tax credit for all individuals with incomes below 100% FPL 51

should be based on the exchange plan that covers the highest percentage of benefit costs and 1 has the lowest out of pocket limits, and have a taxpayer’s applicable percentage (out of pocket 2 limit) of 0%. 3 4 Your Reference Committee heard mostly supportive testimony on Resolution 101. However, 5 one speaker acknowledged that AMA policy already addresses the issues asked for in this 6 resolution. Concerns were raised that the ACA did not foresee the fact that some states would 7 not expand Medicaid services. It was questioned what would happen to the individuals who live 8 below 100 percent of the federal poverty level and may not have access to health insurance in 9 the states that are not expanding Medicaid. Current AMA policies support this population having 10 health insurance. A member of the Council on Medical Service testified in favor of reaffirmation 11 and cautioned that the impact of the ACA will be realized in the future, but it is too early now to 12 determine the outcome. 13 14 Policy H-165.855[1] advocates that states be allowed the option to provide health care coverage 15 to their Medicaid beneficiaries who are nonelderly and nondisabled adults and children with 16 premium tax credits that are refundable, advanceable, inversely related to income and 17 administratively simple for patients, exclusively to allow patients and their families to purchase 18 coverage through programs modeled after the state employee purchasing pool or the Federal 19 Employee Health Benefits Program (FEHBP) with minimal or no cost-sharing obligations based 20 on income. This policy also advocates that children qualified for Medicaid must also receive 21 Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program benefits and have 22 no cost-sharing obligations. 23 24 Policy D-165.955[2] advocates for individually selected and owned health insurance through the 25 use of adequately funded federal tax credits as a preferred long-term solution for covering all 26 Americans. Furthermore, Policy H-165.848[2] supports refundable advanceable tax credits in 27 the form of a voucher to be provided on a sliding scale basis for the purchase of health care 28 insurance for individuals living below 500% of the federal poverty level. 29 30 Given that existing AMA policy is broader in scope and more generous in suggested benefits, 31 your Reference Committee was concerned that Resolution 101 would weaken existing policy. 32 Therefore, your Reference Committee recommends that Policies H-165.855, D-165.955 and H-33 165.848 be reaffirmed in lieu of Resolution 101. 34 35 H-165.855 Medical Care for Patients with Low Incomes 36 37

It is the policy of our AMA that: (1) states be allowed the option to provide coverage to 38 their Medicaid beneficiaries who are nonelderly and nondisabled adults and children with 39 the current Medicaid program or with premium tax credits that are refundable, 40 advanceable, inversely related to income, and administratively simple for patients, 41 exclusively to allow patients and their families to purchase coverage through programs 42 modeled after the state employee purchasing pool or the Federal Employee Health 43 Benefits Program (FEHBP) with minimal or no cost-sharing obligations based on 44 income. Children qualified for Medicaid must also receive Early and Periodic Screening, 45 Diagnosis, and Treatment (EPSDT) program benefits and have no cost-sharing 46 obligations. (2) in order to limit patient churn and assure continuity and coordination of 47 care, there should be adoption of 12-month continuous eligibility across Medicaid, 48 Children’s Health Insurance Program, and exchange plans. (3) to support the 49 development of a safety net mechanism, allow for the presumptive assessment of 50 eligibility and retroactive coverage to the time at which an eligible person seeks medical 51

care. (4) tax credit beneficiaries should be given a choice of coverage, and that a 1 mechanism be developed to administer a process by which those who do not choose a 2 health plan will be assigned a plan in their geographic area through auto-enrollment until 3 the next enrollment opportunity. Patients who have been auto-enrolled should be 4 permitted to change plans any time within 90 days of their original enrollment. (5) state 5 public health or social service programs should cover, at least for a transitional period, 6 those benefits that would otherwise be available under Medicaid, but are not medical 7 benefits per se. (6) as the nonelderly and nondisabled populations transition into 8 needing chronic care, they should be eligible for sufficient additional subsidization based 9 on health status to allow them to maintain their current coverage. (7) our AMA 10 encourages the development of pilot projects or state demonstrations, including for 11 children, incorporating the above recommendations. (Modify Current HOD Policy) (8) 12 our AMA should encourage states to support a Medicaid Physician Advisory 13 Commission to evaluate and monitor access to care in the state Medicaid program and 14 related pilot projects. (CMS Rep. 1, I-03; Reaffirmed in lieu of Res. 105, A-06; 15 Reaffirmation I-07; Modified: CMS Rep. 1, A-12) 16 17 D-165.955 Status Report on Expanding Health Care Coverage to all Individuals, with an 18 Emphasis on the Uninsured 19 20 1. Our AMA will continue to: (1) place a high priority on expanding health insurance 21 coverage for all; (2) pursue bipartisan support for individually selected and owned health 22 insurance through the use of adequately funded federal tax credits as a preferred long-23 term solution for covering all; and (3) explore and support alternative means of ensuring 24 health care coverage for all. 2. Our AMA Board of Trustees will consider assisting 25 Louisiana, and other Gulf Coast States if they should desire, in developing and 26 evaluating a pilot project(s) utilizing AMA policy as a means of dealing with the 27 impending public health crisis of displaced Medicaid enrollees and uninsured individuals 28 as a result of the recent natural disasters in that region. (CMS Rep. 1, I-05) 29

30 H-165.848 Individual Responsibility To Obtain Health Insurance 31 32 1. Our AMA will support a requirement that individuals and families earning greater than 33 500% of the federal poverty level obtain, at a minimum, coverage for catastrophic health 34 care and evidence-based preventive health care, using the tax structure to achieve 35 compliance. 2. Upon implementation of a system of refundable, advanceable tax credits 36 inversely related to income or other subsidies to obtain health care coverage, our AMA 37 will support a requirement that individuals and families earning less than 500% of the 38 federal poverty level obtain, at a minimum, coverage for catastrophic health care and 39 evidence-based preventive health care, using the tax structure to achieve compliance. 40 (CMS Rep. 3, A-06; Modified: CMS Rep. 8, A-08; Reaffirmation A-10; Reaffirmed: CMS 41 Rep. 9, A-11) 42

(22) RESOLUTION 105 - REDUCING THE COST OF PRESCRIPTION 1 DRUGS TO LOW INCOME SENIORS 2 3 RECOMMENDATION: 4 5 Mr. Speaker, your Reference Committee recommends that 6 Policies H-110.990 and H-330.902 be reaffirmed in lieu of 7 Resolution 105. 8 9

HOD ACTION: Policies H-110.990 and H-330.902 reaffirmed in lieu 10 of Resolution 105. 11 12

Resolution 105 asks that our AMA engage in a dialogue with appropriate stakeholders (i.e., 13 state medical associations, national specialty societies, consumer organizations, patient 14 advocacy groups, etc.), in support of the concepts in the “Senior Protection Plan,” that would 15 reduce the excessive costs of prescription drugs incurred by low income seniors. 16 17 Mixed testimony was heard on Resolution 105. Supportive testimony agreed with conceptual 18 support by our AMA for strategies to make medication more affordable. Opposing testimony 19 raised a concern that the resolution could unintentionally shift costs to our country’s younger 20 generations who are already paying for the seniors’ Medicare program. In addition, there was 21 concern about what the “Senior Protection Plan” contains and if it would be appropriate for our 22 AMA to support Resolution 105 without first reviewing this document. 23 24 Your Reference Committee agrees with being cautious about supporting a resolution containing 25 a lengthy document before first reviewing its contents. Given that our AMA has policy supporting 26 the consideration of personal income and means testing when determining cost-sharing and the 27 subsidization of prescription drugs, your Reference Committee recommends that Policies H-28 110.990 and H-330.902 be reaffirmed in lieu of Resolution 105. 29 30

H-110.990 Cost Sharing Arrangements for Prescription Drugs 31 32 Our AMA: 1. believes that cost-sharing arrangements for prescription drugs should be 33 designed to encourage the judicious use of health care resources, rather than simply 34 shifting costs to patients; 2. believes that cost-sharing requirements should be based on 35 considerations such as: unit cost of medication; availability of therapeutic alternatives; 36 medical condition being treated; personal income; and other factors known to affect 37 patient compliance and health outcomes; and 3. supports the development and use of 38 tools and technology that enable physicians and patients to determine the actual price 39 and out-of-pocket costs of individual prescription drugs prior to making prescribing 40 decisions, so that physicians and patients can work together to determine the most 41 efficient and effective treatment for the patient’s medical condition. (CMS Rep. 1, I-07; 42 Reaffirmation A-08; Reaffirmed: CMS Rep. 1, I-12) 43

44 H-330.902 Subsidizing Prescription Drugs for Elderly Patients 45 46 Our AMA strongly supports subsidization of prescription drugs for Medicare patients 47 based on means testing. (Res. 122, A-03) 48 49

(23) RESOLUTION 110 - LANGUAGE AND HEARING IMPAIRED 1 INTERPRETER SERVICES 2 3 RECOMMENDATION: 4 5 Mr. Speaker, your Reference Committee recommends that 6 Policies D-385.978, H-285.985 and H-160.924 be reaffirmed in 7 lieu of Resolution 110. 8

9 HOD ACTION: Policies D-385.978, H-285.985 and H-160.924 10 reaffirmed in lieu of Resolution 110. 11 12

Resolution 110 asks that our AMA work with CMS and other public and private entities to 13 require the payment of interpreter services by all public and private payers. 14 15 Testimony was supportive of payment for interpreter services, but also acknowledged that our 16 AMA has policy that sufficiently addresses this issue. A member of the Council on Medical 17 Service (CMS) stated that AMA Policies D-385.978, H-285.985 and H-160.924 in addition to 18 CMS Report 5-I-11, Interpreter Services and Payment Responsibilities, adequately address the 19 requests in Resolution 110. The identified policies and report address the need for language 20 interpretive services to be a covered benefit by all health plans, that physicians practicing in an 21 office setting should not incur the costs for qualified interpreters and that physicians should not 22 be required to participate in payment arrangements for interpreter services. 23 24 Regarding the requests for AMA advocacy, our AMA has been and continues to be active on 25 this issue. Our AMA has long been involved in efforts to promote patient-centered 26 communication and collaborate with multiple stakeholders to address critical issues in providing 27 medical care to patients with limited English proficiency (LEP). 28 29 In 2010, the US Government Accountability Office released a report on LEP and interpreter 30 services. Our AMA was interviewed for this report and made the case that LEP requirements 31 are unfunded mandates. Importantly, as required by AMA policy, the AMA continues to monitor 32 and weigh in on federal and congressional activity around LEP and interpreter services. 33 Specifically, our AMA highlights the financial constraints as a factor that must be addressed in 34 providing interpretation services for LEP patients. Our AMA has also participated in the 35 development of the Ethical Force program, which is being actively promoted and includes a 36 toolkit that organizations can use to assess their communication climate, including health 37 literacy and language services. 38 39 Given that existing policy adequately addresses this issue and our AMA is actively advocating 40 that LEP requirements are unfunded mandates for physicians, your Reference Committee 41 recommends that Policies D-385.978, H-285.985 and H-160.924 be reaffirmed in lieu of 42 Resolution 110. 43 44

D-385.978 Language Interpreters 45 46 Our AMA will: (1) continue to work to obtain federal funding for medical interpretive 47 services; (2) redouble its efforts to remove the financial burden of medical interpretive 48 services from physicians; (3) urge the Administration to reconsider its interpretation of 49 Title VI of the Civil Rights Act of 1964 as requiring medical interpretive services without 50 reimbursement; (4) consider the feasibility of a legal solution to the problem of funding 51

medical interpretive services; and (5) work with governmental officials and other 1 organizations to make language interpretive services a covered benefit for all health 2 plans inasmuch as health plans are in a superior position to pass on the cost of these 3 federally mandated services as a business expense. (Res. 907, I-03; Reaffirmed in lieu 4 of Res. 722, A-07; Reaffirmation A-09; Reaffirmation A-10; Reaffirmed: CMS Rep. 5, A-5 11) 6 H-285.985 Discrimination Against Physicians by Health Care Plans 7 Our AMA: (1) will develop draft federal and model state legislation requiring managed 8 care plans and third party payers to disclose to physicians and the public, the selection 9 criteria used to select, retain, or exclude a physician from a managed care or other 10 provider plans; (2) will request an advisory opinion from the Department of Justice on 11 the application of the Americans with Disabilities Act of 1990 to selective contracting 12 decisions made by managed care plans or other provider plans; (3) will support 13 passage of federal legislation to clarify the Americans With Disabilities Act to assure that 14 coverage for interpreters for the hearing impaired be provided for by all health benefit 15 plans. Such legislation should also clarify that physicians practicing in an office setting 16 should not incur the costs for qualified interpreters or auxiliary aids for patients with 17 hearing loss unless the medical judgment of the treating physician reasonably supports 18 such a need; (4) encourages state medical associations and national medical specialty 19 societies to provide appropriate assistance to physicians at the local level who believe 20 they may be treated unfairly by managed care plans, particularly with respect to 21 selective contracting and credentialing decisions that may be due, in part, to a 22 physician's history of substance abuse; and (5) urges managed care plans and third 23 party payers to refer questions of physician substance abuse to state medical 24 associations and/or county medical societies for review and recommendation as 25 appropriate. (BOT Rep. 18, I-93; Appended by BOT Rep. 28, A-98; Reaffirmation A-99; 26 Reaffirmation A-00; Reaffirmed: BOT Rep. 6, A-10) 27

28 H-285.985 Discrimination Against Physicians by Health Care Plans 29 30 Our AMA: (1) will develop draft federal and model state legislation requiring managed 31 care plans and third party payers to disclose to physicians and the public, the selection 32 criteria used to select, retain, or exclude a physician from a managed care or other 33 provider plans; (2) will request an advisory opinion from the Department of Justice on 34 the application of the Americans with Disabilities Act of 1990 to selective contracting 35 decisions made by managed care plans or other provider plans; (3) will support 36 passage of federal legislation to clarify the Americans With Disabilities Act to assure that 37 coverage for interpreters for the hearing impaired be provided for by all health benefit 38 plans. Such legislation should also clarify that physicians practicing in an office setting 39 should not incur the costs for qualified interpreters or auxiliary aids for patients with 40 hearing loss unless the medical judgment of the treating physician reasonably supports 41 such a need; (4) encourages state medical associations and national medical specialty 42 societies to provide appropriate assistance to physicians at the local level who believe 43 they may be treated unfairly by managed care plans, particularly with respect to 44 selective contracting and credentialing decisions that may be due, in part, to a 45 physician's history of substance abuse; and (5) urges managed care plans and third 46 party payers to refer questions of physician substance abuse to state medical 47 associations and/or county medical societies for review and recommendation as 48 appropriate. (BOT Rep. 18, I-93; Appended by BOT Rep. 28, A-98; Reaffirmation A-99; 49 Reaffirmation A-00; Reaffirmed: BOT Rep. 6, A-10) 50

51

H-160.924 Use of Language Interpreters in the Context of the Patient-Physician 1 Relationship 2 3 AMA policy is that: (1) further research is necessary on how the use of interpreters--both 4 those who are trained and those who are not--impacts patient care; (2) treating 5 physicians shall respect and assist the patients’ choices whether to involve capable 6 family members or friends to provide language assistance that is culturally sensitive and 7 competent, with or without an interpreter who is competent and culturally sensitive; (3) 8 physicians continue to be resourceful in their use of other appropriate means that can 9 help facilitate communication--including print materials, digital and other electronic or 10 telecommunication services with the understanding, however, of these tools’ limitations--11 to aid LEP patients’ involvement in meaningful decisions about their care; and (4) 12 physicians cannot be expected to provide and fund these translation services for their 13 patients, as the Department of Health and Human Services’ policy guidance currently 14 requires; when trained medical interpreters are needed, the costs of their services shall 15 be paid directly to the interpreters by patients and/or third party payers and physicians 16 shall not be required to participate in payment arrangements. (BOT Rep. 8, I-02; 17 Reaffirmation I-03; Reaffirmed in lieu of Res. 722, A-07; Reaffirmation A-09; Reaffirmed: 18 CMS Rep. 5, A-11) 19

20 (24) RESOLUTION 113 - MAKING MEDICARE PRICE 21

STANDARDIZATION ACCURATE 22 23 RECOMMENDATION: 24 25 Mr. Speaker, your Reference Committee recommends that 26 Policies D-450.964, H-400.984, H-400.988 and H-400.966 be 27 reaffirmed in lieu of Resolution 113. 28 29

HOD ACTION: Policies D-450.964, H-400.984, H-400.988 and H-30 400.966 reaffirmed in lieu of Resolution 113. 31 32

Resolution 113 asks that our AMA advocate with the Centers for Medicare & Medicaid Services, 33 MedPAC, and Congress to ban the use of proxies of non-physician incomes that have been 34 used to adjust prices (spending) for the Quality and Resource Use Reports (QRUR) and Value-35 Based Payment Modifier (VBPM), and that no price adjustment/ standardization of physician 36 spending shall be performed, as the actual amount paid to physicians is the most accurate data 37 for QRUR and VBPM. 38 39 Testimony on Resolution 113 was limited. The sponsor spoke against reaffirmation and in favor 40 of an amendment asking our AMA to testify before Congress and in comments to CMS and 41 MedPAC on inaccurate price adjustment or price standardization methodology. A member of the 42 Council on Medical Service pointed to Policy D-450.964 as an appropriate policy to reaffirm in 43 lieu of Resolution 113. 44 45 Your Reference Committee acknowledges the concerns expressed by some states regarding 46 the data sources and methodologies used to calculate the Geographic Practice Cost Index 47 (GPCI). Your Reference Committee also recognizes the significant challenges involved in 48 developing consensus on the use of GPCIs or potential improvements to them. Furthermore, 49 your Reference Committee points to our AMA’s recent work on GCPI-related issues as 50 exemplified in Council on Medical Service Reports 4-A-11 and Council on Medical Service 51

Report 1-I-11. Numerous policies guide AMA advocacy on geographic variation, including 1 Policies H-400.984, H-400.988 and H-400.966. Policy D-450.964 directs our AMA to continue to 2 work with the Centers for Medicare & Medicaid Services to improve the design, content and 3 performance indicators included in the QRURs for physicians, so that the reports reflect the 4 quality and cost data associated with these physicians in calculating VBPMs. Therefore, your 5 Reference Committee recommends that these policies be reaffirmed in lieu of Resolution 113. 6

D-450.964 Medicare Quality and Resource Use Reports 7 8 Our AMA will: (1) continue to work with the Centers for Medicare & Medicaid Services to 9 improve the design, content, and performance indicators included in the Quality and 10 Resource Use Reports (QRURs) for physicians, so that the reports reflect the quality 11 and cost data associated with these physicians in calculating Value-Based Payment 12 Modifiers (VBM); and (2) continue to advocate, educate and seek to delay 13 implementation of the VBM program. (Res. 810, I-12) 14

15 H-400.984 Geographic Practice Costs 16 17 1. Our AMA will work to ensure that the most current, valid and reliable data are 18 collected and applied in calculating accurate geographic practice cost indices (GPCIs) 19 and in determining geographic payment areas for use in the new Medicare physician 20 payment system. 2. Our AMA supports the use of physician office rent data, along with 21 other practice expense data, to measure geographic variation in rent costs and to 22 determine the proportion of overall costs that relate to rental expense. These data 23 should be obtained through new or existing data sources that are accurate, 24 standardized, verifiable and include per unit costs in physician offices. (Sub. Res. 25, A-25 90; Modified: Sunset Report, I-00; Reaffirmation A-09; Modified: CMS Rep. 4, A-11; 26 Reaffirmed and Appended: CMS Rep. 1, I-11; Reaffirmed in lieu of Res. 119, A-12; 27 Reaffirmed in lieu of Res. 122, A-12; Reaffirmation: I-12) 28 29 H-400.988 Medicare Reimbursement, Geographical Differences 30 31 The AMA reaffirms its policy that geographic variations under a Medicare payment 32 schedule should reflect only valid and demonstrable differences in physician practice 33 costs, especially liability premiums, with other non-geographic practice cost index 34 (GPCI) -based adjustments as needed to remedy demonstrable access problems in 35 specific geographic areas. (Sub. Res. 82, A-89; Reaffirmed: BOT Rep. DD, I-92; 36 Reaffirmed: CMS Rep. 10, A-03; Reaffirmation A-06; Reaffirmation I-07; Reaffirmation 37 A-08; Reaffirmation A-09; Reaffirmed: BOT Action in response to referred for decision 38 Res. 212, A-09; Modified: CMS Rep. 4, A-11; Reaffirmed: CMS Rep. 1, I-11; Reaffirmed 39 in lieu of Res. 122, A-12) 40 41 H-400.966 Medicare Payment Schedule Conversion Factor 42 43 (1) The AMA will aggressively promote the compilation of accurate data on all 44 components of physician practice costs and the changes in such costs over time, as the 45 basis for informed and effective advocacy with Congress and the Administration 46 concerning physician payment under Medicare. (2) The AMA will work aggressively with 47 CMS, the Bureau of Labor Statistics, and other appropriate federal agencies to improve 48 the accuracy of such indices of market activity as the Medicare Economic Index and the 49 medical component of the Consumer Price Index. (CMS Rep. B, I-92; Reaffirmed: CMS 50 Rep. 10, A-03; Reaffirmed: CMS Rep. 6, I-08; Reaffirmed: CMS Rep. 1, I-11; 51

Reaffirmation: I-12)1

1 Mr. Speaker, this concludes the report of Reference Committee A. I would like to thank R. Dale 2 Blasier, MD, Brooks F. Bock, MD, Jesse M. Ehrenfeld, MD, Sally J. Trippel, MD, Michael A. 3 Wasylik, MD, David Welsh, MD, and all those who testified before the Committee. 4

R. Dale Blasier, MD American Orthopedic Association Brooks F. Bock, MD American College of Emergency Physicians Jesse M. Ehrenfeld, MD (Alternate) American Society of Anesthesiologists

Sally J. Trippel, MD Minnesota Michael A. Wasylik, MD Florida David J. Welsh, MD (Alternate) Indiana Jerry L. Halverson, MD American Psychiatric Association Chair