2021 FEDERAL WRAP UP

Another Tough Year…But Important Wins for Physicians

By Elizabeth McNeil, CMA Vice President of Federal Government Relations

2021 proved to be another challenging year for physicians and a nation continuing to face a raging pandemic. It brought us tough confrontations over COVID-19 mask mandates and vaccination efforts, legal challenges that threatened to overturn the Affordable Care Act (ACA), a renewed fight for racial equity and an insurrection at the U.S. Capitol that challenged our democracy. But through it all, the California Medical Association (CMA) was there, fighting for physicians and ensuring that our nation’s healers were able to continue providing care to patients as the pandemic raged on.

The nation inaugurated a new President, Joseph Biden, and the first woman Vice President, California Senator Kamala Harris, who set out to heal a nation experiencing the worst public health crisis in history. As the Biden Administration settled in, key California leaders were placed in important positions in the federal government, giving CMA unprecedented access at the federal level. California Secretary of State Alex Padilla was appointed to the U.S. Senate to fill the vacancy left by Vice President Harris, while and California Attorney General Xavier Becerra was named Secretary of the U.S. Department of Health and Human Services. Californians Nancy Pelosi and Kevin McCarthy were both reelected to their respective positions as Speaker of the House and Minority Leader.

Unprecedented Challenges

The COVID-19 pandemic will be remembered as one of the most unprecedented and challenging times in our nation’s history. Physicians rose to their calling in heroic numbers to battle the virus, vaccinate the public, and fight for science and truth to protect public health. Physicians demonstrated their compassion and courage – risking their lives and the lives of their families to care for the sickest of patients.

CMA successfully fought alongside the American Medical Association (AMA) and others in organized medicine to ensure physicians were able to continue providing quality care to their patients during and beyond the public health emergency. Many physicians either implemented or expanded their use of telehealth as a treatment modality. CMA worked hard to ensure that Congress and the Biden Administration provided telehealth payment parity and waivers to allow physicians to provide a broad range of telehealth and audio-only services in a broad range of settings. CMA made sure policymakers understood how telehealth allowed physicians to meet their patients’ needs during the pandemic.

A Test of Stamina

The second year of the pandemic truly tested physician stamina. Frontline physicians fought burnout and massive health staffing shortages; all physicians worked to sustain the viability of their practices;

CMA Federal Wrap Up 2021

and physicians began to address the secondary impacts of the pandemic – worsening health conditions caused by delays in care, as well as a tsunami of mental health and substance abuse issues.

CMA warned Congress that the long-term fallout from the pandemic would be felt by patients for years to come and fundamentally alter the long-term stability of physician practices. Congress honored the sacrifices made by physicians and responded by dedicating substantial resources to help physicians fight the pandemic and sustain the viability of their practices for future patients. In 2020-21, Congress enacted legislation to address all aspects of the COVID-19 battle providing nearly $2 trillion in funding, including hundreds of billions for physician practices:

+ $190 billion to the Provider Relief Fund + $10 billion to reimburse physicians treating the uninsured + $1 trillion to the Paycheck Protection Program and fair tax treatment for such grants + 2% Medicare payment increase by waiving the sequestration cuts + Billions in funding for personal protective equipment, mental health, substance abuse, public health, testing and vaccines

Medicare Payment Cuts Stopped

As if the COVID-19 pandemic was not enough, physicians also faced 9.75% in Medicare payment cuts on January 1, 2022. It was a perfect storm of Medicare payment cuts resulting from an expiring 2% sequestration waiver, 3.75% budget neutrality cuts imposed by the fee schedule and an unintended 4% cut due to a legislative “pay as you go” budget neutrality rule.

In response to intense advocacy from CMA, AMA and other medical societies, Congress recognized that physicians could not continue to fight the pandemic, sustain their practices and care for patients under a 9.75% Medicare payment cut. Led by California physician Congressman Ami Bera (D-CA), Congress enacted legislation to stop most of the 9.75% payment cuts. The 2% sequestration cuts will be phased back in by July 1, 2022.

CMA also successfully worked with AMA and organized medicine to rally Congress to:

+ Double the Medicare COVID-19 vaccine administration payment rates + Provide a Merit-Based Incentive Payment System quality reporting exemption + Extend the telehealth waivers through the public health emergency + Delay mandatory e-prescribing for controlled substances until 2023 + Delay the Radiation Oncology Alternative Payment model and the Appropriate Use Criteria program until 2023

Fighting Back on Surprise Medical Billing

CMA continues to fight an ill-conceived federal regulation that disregards the balanced arbitration process in the No Surprises Act (NSA) law and threatens patient access to in-network physicians. While CMA strongly supports the parts of the law that protect patients from surprise medical bills, the arbitration regulation will harm patients and drive up costs in the long term.

CMA Federal Wrap Up 2021

In the NSA’s statutory language, Congress established a balanced process to fairly resolve payment disputes between physicians and insurers for certain unanticipated out-of-network medical bills, using several different criteria. However, the implementing regulations are blatantly inconsistent with the clear language of the statute and Congressional intent. They effectively upend the law, giving insurers an unfair advantage by relying almost exclusively on the insurers’ self-determined median in-network billing rate, instead of considering the multitude of factors called for under the law.

Nearly 200 Members of Congress and the Chairman of the powerful Ways and Means Committee stood with physicians, objecting to the regulations in multiple bipartisan letters.

CMA also submitted extensive comments to the regulators warning that the NSA regulations would produce the same unintended consequences that physicians and patients have experienced under California’s Assembly Bill 72. CMA provided detailed evidence from California that demonstrated how insurers cancelled long-standing contracts or imposed significant rate reductions that forced physicians out-of-network and reduced patient access to in-network physicians, particularly regarding on-call panels of physician specialists who treat patients in emergencies.

Several lawsuits have been filed against the federal government over its misguided implementation of the NSA. The suits argue that the regulations are a clear deviation from the law as written and all but ensure that hospitals, physicians and other providers will routinely be undercompensated by commercial insurers, and that patients will have fewer choices for access to in-network services. Through the Physicians Advocacy Institute, CMA, along with other state and national specialty societies, filed amicus briefs in support of a lawsuit brought by the Texas Medical Association and the AMAAmerican Hospital Association lawsuit. The American College of Emergency Physicians, American Society of Anesthesiologists and American College of Radiology also filed a joint legal action.

Public Service Loan Forgiveness

In 2021, CMA continued to aggressively fight for a legislative or regulatory change to allow California and Texas physicians to participate in the Public Service Loan Forgiveness (PSLF) program like their colleagues in the other 48 states.

Congress established the PSLF program in 2007 to improve access to care by encouraging physicians to pursue careers working in nonprofit settings. When implementing regulations were issued, they were severely narrowed to require physicians to be “hired and paid by” hospitals in order to receive loan forgiveness. Because California and Texas law prohibit hospital employment of physicians, most physicians in California and Texas are precluded from participating in the program, while their counterparts in all other 48 states receive loan forgiveness.

With an average $250,000 in student loan debt, the narrow regulation places California and Texas at a severe disadvantage in recruiting new physicians, thereby harming patient access to care in our underserved communities.

On behalf of CMA, California Congressman Josh Harder (D-Stanislaus) introduced HR 1133, the “Stopping Doctor Shortages Act,” and has led an intense advocacy effort in the House to fix this problem with the

CMA Federal Wrap Up 2021

support of his co-authors, Congressmen Jay Obernolte (R-San Bernardino), Joaquin Castro (D-TX) and Van Taylor (R-TX). Identical legislation was introduced in the Senate (S 311) by Senators Dianne Feinstein (D-CA), John Cornyn (R-TX) and Alex Padilla (D-CA).

Throughout 2021, CMA urged Congress to pass a legislative fix but the high cost has made it extremely difficult.

Also in 2021, the U.S. Department of Education reopened its regulations to make changes to the Higher Education Act, which includes the PSLF. CMA testified before the education department and organized a joint bipartisan letter from the majority of the California and Texas Congressional delegations. Speaker Pelosi, Rep. Harder and Senator Feinstein have also met with the Secretary of Education on CMA’s behalf.

This is a top priority for CMA; we will continue to urge regulators and Congress to resolve the problem as soon as possible.

Access to Affordable Health Care

CMA has urged Congress to address two of our nation’s highest health care priorities in President Biden’s Build Back Better social programs infrastructure legislation – permanent access to more affordable health insurance through the ACA and lowering prescription drug costs.

Although the 2021 American Rescue Plan Act (ARPA) expanded eligibility for ACA health insurance tax credits and assistance, these provisions were only authorized for two years. CMA is urging Congress to ensure the long-term affordability and effectiveness of the ACA by making the provisions of the ARPA permanent.

The Medicare drug pricing provision in the Build Back Better plan would allow Medicare to negotiate drug prices on many of the highest-priced drugs directly with pharmaceutical companies – including all insulin drugs. The legislation is estimated to save Medicare and privately insured patients 40-60% on drug costs.

Pathways to Practice

President Biden’s Build Back Better legislation would also authorize 4,000 new graduate medical education (GME) residency positions. The nation is currently facing a 15,000 residency position shortage. This CMA-supported provision would add residency slots to allow more medical students to match with a residency program and increase the overall supply of physicians.

The legislation also includes the new CMA-supported “Pathways to Practice” program – an innovative program that will allow more marginalized and minority students to go to medical school and choose a career in medicine. It provides tuition assistance, living stipends and expands the number of GME positions. It requires such students to serve in underserved areas for six years.

CMA Federal Wrap Up 2021

This program is a significant step forward in helping our nation address racial injustice and advance health equity. It will lead to real improvements in building a more equitable health care system for providers and patients.

Also this year, CMA supported multiple bills that addressed racial injustice and health care disparities and promoted adoption of AMA’s plan to “Embed Racial Justice and Advance Health Equity.”

Conclusion

CMA was honored to fight for physicians in the virtual halls of Congress this year and we will keep fighting so that you can focus on your patients and not be hindered by administrative burdens, declining reimbursements or a devastating virus.

While Congress did not finalize all of CMA’s priorities, important groundwork was laid for Congress to enact a more stable Medicare payment system that keeps pace with increasing practice costs, Medicare Advantage prior authorization reforms, public service student loan forgiveness for California physicians, the health care provisions in the Build Back Better plan, permanent telehealth waivers and bills that address physician workforce shortages. CMA will continue to stand with you and advocate on your behalf.

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