Summary and Comments on House Tri-committee Draft Health System Reform Bill
U.S. House of Representatives
Tri-Committee Proposal on Health Care Reform
June 19, 2009
Comments of the American Medical Association
The American Medical Association (AMA) appreciates the opportunity to offer our comments on
the Tri-Committee proposal to provide affordable, high-quality health care to all Americans and
reduce the growth in health care spending. We commend the Committees on Ways & Means,
Energy & Commerce, and Education & Labor for their leadership in developing a framework to
transform our nation’s health care system and for inviting public input. The AMA is committed to
working with the Committees, Congress, Administration, and other stakeholders to advance
proposals that expand coverage, improve quality, reform government programs, reduce costs,
increase focus on wellness and prevention, and provide payment and delivery reforms.
We particularly want to express our appreciation for the House’s recognition that fundamental
Medicare reforms are essential to the effectiveness of a comprehensive health system reform plan.
The Medicare program has a significant influence on other health care coverage programs and
plans, and as a dominant force in the health care marketplace it has a profound impact on the
practice of medicine. Any efforts to build new payment models to promote health care delivery
system improvements and practice innovations simply cannot succeed without first addressing the
barrier presented by the Medicare sustainable growth rate (SGR) formula. We realize that
resolving this persistent problem requires a substantial financial commitment at a time when
Congress is challenged with financing system-wide reforms, and we agree with House leaders
and President Obama that the current budget baseline is an inaccurate projection of future
Medicare spending for physician services and cannot be allowed to impede efforts to build a
better health care system.
Of course, the AMA’s goals for health system reform extend far beyond the Medicare physician
payment system. We have a longstanding and unwavering commitment to working with
policymakers on expanding health care coverage to the uninsured, and have devoted significant
resources toward raising the public profile of this issue. The AMA and the physician community
at-large are deeply invested in efforts to improve health care quality, and we share a
comprehensive public health agenda. We have publicly acknowledged the need to rein in health
care spending growth to make our system financially sustainable and are currently engaged in
efforts to develop clinical measures to promote appropriate and cost-effective care. We want to be
part of a successful effort to enact comprehensive health system reforms this year.
Following are our detailed comments and recommendations on specific proposals set forth in the
Tri-Committee discussion draft. We look forward to working with you in the coming weeks to
refine your proposals and work toward passage of system-wide reforms.
Health Insurance Market Reform
We strongly agree that health insurance market reforms are required to ensure greater
accessibility to affordable health insurance coverage and to make the health insurance market
work better for both patients and physicians. Market reforms should create a more competitive
insurance market in which plans compete on price and quality, allowing patients to gain more
control over their choice of health insurance coverage and their own care. The AMA supports
the insurance market reform provisions in Title I of Division A of the Committees’ draft bill
relating to guaranteed renewability, modified community rating, pre-existing condition
limitations, nondiscrimination based on health status, adequacy
of provider networks, and transparency. We also support guaranteed issue in the context of an
individual mandate to purchase insurance.
With respect to medical loss ratios (section 116, Division A, Title I), the AMA supports
transparency to prospective enrollees and regulatory bodies regarding reporting of medical loss
ratios by insurers. We also support the development and implementation of a uniform, national
accounting and reporting system to report administrative expenses and medical expense ratios as
part of national uniformity in market regulation, and accordingly, we recommend that a
requirement for such a system be added to the bill text.
Health Insurance Exchange
We agree that individuals who currently have coverage and small employers who currently
provide insurance to their employees, and who are satisfied with their coverage, should be
allowed to keep it. For those individuals who do not have access to or do not select employer-
based insurance, we support establishing a national health insurance exchange (HIE) or
state-based exchanges, as proposed in the draft bill (section 201, Division A, Title I), to
increase choice, facilitate plan comparisons, and streamline enrollment to assist them in
choosing coverage that best suits their needs. We are pleased to see that qualified health
benefits plans would be required (section 133) to provide understandable and comparable
information about their policies, benefits, and administrative costs to empower patients,
employers, and other purchasers and consumers to make more informed decisions.
The AMA supports the delineated responsibilities of the Health Choices Commissioner (Division
A, Title II) with regard to providing public information and education to help individuals in
choose a health plan option. We believe that mechanisms must be in place to educate patients and
assist them in making informed choices, including transparency among all health plans regarding
covered services, cost-sharing obligations, out-of-pocket limits and lifetime benefit caps,
administrative costs, and excluded services.
We are concerned, however, that the Commissioner’s responsibilities in terms of oversight and
enforcement of health insurance plans operating within the HIE (as set forth in section 142) are
too broad and could interfere with and usurp the regulatory role of state insurance commissioners.
We support maintaining the important regulatory role of state insurance commissioners with
regard to consumer protections such as grievance procedures, external review, oversight of agent
practices and training, and market conduct, as well as physician protections like state prompt pay
laws, protections against health plan insolvency, and fair marketing practices. We recommend
that the bill language be amended to make it clear that these state law protections are not
preempted. Moreover, we recommend that the language in section 151 be modified to clarify
which provisions in existing federal and state law are intended to be superseded under the draft
Public Health Insurance Option
We appreciate that the Committees have reconsidered earlier proposals that would have mandated
Medicare provider participation in a public health insurance plan and we view this as a significant
improvement. However, we continue have serious concerns about the use of federally
administered payment rates, especially given physician experiences with the Medicare and
Our interpretation of the language in section 223 is that payment to physicians would initially be
based on Medicare rates, with a floor of one percent for annual updates. However, the Secretary
would apparently have wide discretion to adjust such rates under the rules of construction in
subparagraphs (d) and (e) of section 223. We urge the Committees to clarify the intent of these
sections. The process for determining payment rates under the public plan option is critical if we
are to achieve our mutual goal of minimizing additional cost shifting to private carriers and
providers and ensuring access for patients to physician
services. A public program must offer rates that are competitive with private plans to avoid the
cost shifting we are currently experiencing under Medicare.
As we have stated on other occasions, the AMA does not believe that creating a government-run
health insurance option for non-disabled individuals under age 65 is the best way to expand
health insurance coverage and lower costs across the health care system. Indeed, a reformed
private insurance market, with a HIE that provides a variety of plans from which to choose,
would achieve our common objective of providing access for all consumers to a broad range of
coverage options. However, we remain open to considering an alternative that would provide
competition from a non-profit entity that is self-supporting, is subject to the same solvency
requirements as private plans, does not receive special advantages from government subsidies,
where rates are established through meaningful negotiations and contracts, and where enrollees
have access to the sort of out-of-network benefits that are available in private plans. In short, we
are open to exploring health system reform alternatives that are consistent with the principles of
pluralism, freedom of choice, freedom of practice, and universal access for patients.
The AMA supports an alternative approach to the language in Division A, Title I, Subtitle C that
requires the establishment of standard benefit options that plans must offer and that individuals
must obtain in order to qualify for affordability credits. In lieu of a mandate for a particular
benefit package or setting minimum benefit standards in statute, the AMA supports using
existing federal guidelines regarding types of health insurance coverage (e.g., Title 26 of the
US Tax Code and Federal Employees Health Benefits Program [FEHBP] regulations) to
assess whether a given plan would provide meaningful coverage. The AMA believes that a
principal goal of health system reform should be to expand rather than limit health plan choices
for consumers so that they can purchase the coverage that best suits their needs. Therefore, rather
than specifying options in statute, a regulatory environment should be established that enables
rather than impedes private market innovation in product development, benefit packages, and
purchasing arrangements. We are concerned that the bill as currently drafted will essentially
eliminate health savings accounts (HSAs) in the group health insurance market in the next five
years, which would serve to limit consumer choice. We recommend that the Committees
clarify that HSAs would be considered “acceptable coverage” under the draft bill.
We support the provisions in the bill (Division A, Title II, Subtitle C) that would provide
advanceable, sliding-scale subsidies to low-income individuals who need financial assistance
to purchase private health insurance. The premium assistance framework proposed in the draft
bill is consistent with AMA principles that tax credits should be inversely related to income,
refundable, and advanceable, and that the tax credits should be adequate to ensure that health
insurance is affordable for most people. We recommend, however, that affordability credits also
be extended to those individuals who have employer-sponsored insurance, to use either to pay
their premium costs for the employer’s plan or to purchase coverage through the HIE. The credits
must at least be sufficient to cover a substantial portion of the premium costs for individuals in
the low-income categories, and at the lowest income levels the credit should approach 100
percent of the premium. In addition, the size of tax credits should vary with family size to mirror
the pricing structure of insurance premiums, with premiums for family policies being less than
the sum of premiums for individual members.
The provisions in sections 301 and 401 (Division A) requiring individuals to have insurance
coverage or pay a tax penalty are generally consistent with AMA policy. We support
requiring individuals and families who can afford coverage to obtain it. Those earning more than
500 percent of the federal poverty level should be required to obtain at least catastrophic and
preventive coverage, or face adverse tax consequences. Those who cannot afford it and do not
qualify for public programs should receive tax credits for the purchase of health insurance. Upon
implementation of subsidies or tax credits for those who need financial assistance obtaining
coverage, the AMA believes everyone should have the responsibility to obtain health insurance.
The AMA supports finding solutions to achieve the simplification of health care
administration and its associated cost savings as proposed under Division A, Title V. We
recommend that the final bill include additional provisions to direct HHS to adopt the remaining
transactions named in Section 1173 of the Social Security Act that have not yet been adopted, and
to evaluate options for streamlining the updating process with respect to existing HIPAA
transaction and code set standards. We also recommend immediate investments to enable
increased enforcement, accuracy, and transparency of existing electronic HIPAA standard
transaction and code set (TCS) rules, including the rules governing patient eligibility and payment
transactions. In addition, we recommend a 2-year time frame for adoption of the new standards,
companion guides, and operational guidelines and instructions recommended in the draft bill.
We believe that any proposed new HIPAA standards, such as claims attachments and quality
reporting, should be issued through the rule-making process so that stakeholders, including
physicians, have an opportunity to comment. We would also support establishing a National
Health Plan Identifier. We further recommend clarifying that the administrative simplification
requirements outlined in the draft bill are not intended to delay the scheduled implementation of
the Version 5010 electronic transaction update, to be effective on January 1, 2012, and
recommend adding a provision that requires the Secretary of HHS to adopt and make readily
available a single, mandated cross-walk for the transition from ICD-9-CM to ICD-10-CM as soon
Medicare Physician Payment Formula
The AMA greatly appreciates the Committees’ recognition in Division B that the Medicare
physician payment formula (the sustainable growth rate, or SGR) is fatally flawed and
needs to be addressed to avoid steep cuts that are inherent in the formula, threaten
Medicare access to care, and undermine broad-based health reform efforts. We also agree
that clinical laboratory and drug costs should be removed retroactively from the Medicare
physician payment formula, especially since they are not paid under the physician fee schedule.
We also are pleased that the new target growth rates are not limited to GDP growth; however, we
are concerned that the new system could still lead to significant pay cuts in future years and urge
the Committees to include design features that will preclude negative payment updates.
A stable Medicare payment foundation is essential for new payment models and delivery reforms.
Further, a stable, predictable physician payment system would allow physicians to plan ahead for
practice innovations, investments, and personnel decisions that are fundamental to improved care
coordination and chronic disease management, as well as help sustain the physician workforce.
The physician community understands that the status quo is not sustainable, and is willing to
embrace significant changes to help reform the Medicare program. This has been demonstrated
by our support for
comparative effectiveness research, our support for incentive programs to encourage electronic
prescribing and the adoption of health information technology, and our efforts to develop new
performance measures and appropriateness criteria. We also support and are encouraged by the
pilot programs in the Committees’ proposal (e.g., the medical home, accountable care
organizations, gainsharing) that will help develop and test innovative alternative payment
We believe these programs should be undertaken in a flexible and dynamic process in which
multiple models in a variety of practice settings can be tested and refined, and where information
about problems and solutions are collected and shared across programs and regions to facilitate
mid-course corrections. This effort will allow us to accumulate the data and experience needed to
enable wider implementation of beneficial reforms (although we would not support a mandatory
requirement that physicians participate in any particular reform model).
We fully expect that these initiatives, along with the waiver of cost-sharing for Medicare-covered
preventive services (which we support), will generate system-wide savings over the long-run by
avoiding hospitalizations and other costly interventions. However, with expanded access to these
services the volume of physician visits and other services will increase in the short-term. If a
target system remains in place, the activities policymakers want to promote are likely to trigger
additional payment cuts in future years.
While we continue to believe Medicare must move away from a target-based approach based on
volume rather than value, we appreciate that the Committees have made a considerable
investment dedicated to addressing the SGR and look forward to working with you to further
develop an approach that ensures that Medicare payments for physicians’ services accurately
reflect increases in medical practice costs while rewarding value-based, high-quality, cost-
At the our annual meeting earlier this month, the AMA House of Delegates renewed its support
for the enactment of federal legislation that ensures and protects the fundamental right of patients
to privately contract with physicians, without penalties for doing so and regardless of payer
within the framework of free market principles. The current two-year Medicare program
exclusions for physicians who privately contract unnecessarily limits choices for beneficiaries as
well as for physicians. We strongly urge the Committees to include language in the bill to ensure
that patients have the ability to privately contract with their physician, free of any penalties and
regardless of payer.
Primary Care Bonus
The AMA supports additional funding for primary care services, and we applaud you for focusing
on these critical workforce needs, as proposed in section 1303, Division B. Further, we
appreciate the Committees’ recognition that enhanced support for primary care should be
viewed as a national investment in improving the health of Medicare beneficiaries through
better chronic disease management and care coordination, and so should not be financed in
a budget-neutral manner through offsetting decreases in payments for other valuable
The AMA supports extension of the geographic practice cost index (GPCI) floor under section
1194, Division B.
Physician Quality Reporting Initiative
The improvements to the Physician Quality Reporting Initiative (PQRI), including more
timely feedback, an appeals process, and extension of PQRI bonus payments through 2012,
are welcome changes that will go a long way toward helping physicians participate
successfully in the program. We also recommend adding language in section 1124(a) (Division
B) that would provide physicians with a prior opportunity to verify that the data CMS uses to
determine whether they successfully participate in the PQRI are the correct data, as reported to
CMS by the physician. This verification process should be user-friendly as well.
Further, it is important to recognize that the PQRI’s limited success is due in no small part to a
lack of resources and poor implementation by CMS. Along with PQRI improvements and
other demands that will accompany health system reform, we believe it is vital for Congress
to support the staffing and financial resources CMS will need to implement these programs.
For example, more timely feedback reports for physicians are critical throughout the performance
period but, based on current staffing, we do not believe CMS has the resources to meet this
requirement. We urge the Committees, therefore, to provide funding to CMS to ensure adequate
resources to appropriately implement the PQRI and all other programs proposed in the legislation.
Finally, we greatly appreciate the Committees’ agreement that PQRI should remain a
positive incentive program that does not include financial penalties. Physician practices
already confront challenges in implementing staffing and workflow changes, as well as making
substantial financial investments, to comply with incentive programs for the adoption of
electronic prescribing and health information technology. Some practices would be unable to
simultaneously absorb yet another set of requirements in order to avoid financial penalties.
We appreciate the Committees’ support for a process to identify national priorities for
performance improvement and develop quality measures, including the testing and updating of
measures. As part of the Stand for Quality (SFQ) Coalition, the AMA and more than 165
organizations have developed a framework for improving the quality and affordability of health
care through a public-private partnership. Based on this framework, the SFQ Coalition has
developed legislation for identifying national priorities for performance improvement along with
improving how quality measures are developed, selected, and implemented under federal quality
improvement programs, including Medicare. We urge the Committees to adopt the SFQ
legislation as this proposal builds on existing resources, ensures a private-public
partnership, and helps develop broad-based agreement on priorities, processes, and
In providing additional funding for the development of quality measures, we urge that the
legislation specifically recognize the Physician Consortium for Performance Improvement
(PCPI) as an entity qualified to develop physician-level performance measures. This will
ensure that physician measures are developed and accepted by their end users.
Misvalued Codes Under the Physician Fee Schedule
We appreciate that the draft bill authorizes the Secretary to use existing processes in identifying,
adjusting, and validating relative values for potentially misvalued CPT codes, and support
providing funds for CMS to carry out these efforts. In the past, the AMA/Specialty Society RVS
Update Committee (RUC) has requested resource-intensive data from CMS to review relative
values, and because of limited
CMS resources, it has been a hardship to produce the data. Additional funding will greatly
facilitate this process.
We are also concerned about repeal of Section 4504(d) of the Balanced Budget Act of 1997.
While this provision includes obsolete requirements that could be repealed, it also includes
important requirements specifying that that actual and valid data are used in determining practice
expense relative value units and that physician organizations are consulted about methodology
and data to be used in developing these relative values. We urge that these provisions be retained
in the law.
Payment for Imaging Services
We believe the provision assuming a higher utilization rate for imaging equipment under
section 1147(a) (Division B) is too broad, and should permit a more refined approach
allowing medical specialties that represent users of the various imaging modalities to submit
data to CMS to determine an appropriate assumption for utilization. We also cannot support
the provision in section 1147(a) that would increase the multiple procedure payment reduction to
50 percent. In fact, this provision may not be necessary. Where procedures are predominantly
performed together (i.e., abdominal and pelvic CT), the RUC and CPT Editorial Panel have
already asked medical specialties to develop a code proposal to bundle the codes together as one
Finally, in the event that either of the above provisions is retained, we urge that any resulting
savings remain in the physician pool.
Accountable Care Organizations
The AMA supports allowing groups of providers (physicians and/or hospitals) to meet
certain requirements and quality thresholds to share Medicare cost-savings through an
Accountable Care Organization (ACO). We also support allowing an ACO to be comprised of
physicians only, without requiring a hospital to be involved. If a hospital is part of the ACO,
however, there must be shared decision-making. Further, we support implementing beneficial
components of the pilot program on a broad-scale basis, but we would not support a mandatory
requirement that physicians participate in an ACO.
Section 1301 (Division B) allows the Secretary of HHS to determine a “base period” for
performance measurement for an ACO. If the base period involves multiple years, we would be
very concerned that without some financial incentives to encourage patients to stay within the
ACO for their care, these entities will be at substantial financial risk for expenditures over which
they have no control. We also anticipate significant logistical problems with patients who want to
have serious procedures performed in another state so they can be near a child or other family
member, and with “snowbirds” and others who live in different states for significant portions of
each year. Multiple year “base periods” would magnify these problems. Further, we have
concerns about possible logistical and administrative difficulties in implementing the ACO
provision, and we look forward to working with the Committees to work through any such
We recommend that the Committees include explicit language in the bill confirming that the
ACO pilot program would be exempt from antitrust laws. Also, as the draft bill recognizes,
physicians may pursue similar care coordination activities in the private market. We believe that
for a program such as this to be successful, especially in the private market, changes to the
antitrust laws are required to allow physicians to participate in care coordination programs, such
as ACOs, that will require joint negotiation of contracts with payers.
We urge the Committees to include reforms that provide relief from legal and regulatory
impediments to physician collaboration. Antitrust reforms should be considered an essential
element of health system reform. Further, we urge enactment of antitrust reforms that apply
regardless of payer. For groups of physicians to effectively reengineer their practices to improve
care coordination and quality, they cannot be organized under two separate corporate models—
one for Medicare and another for privately insured patients. Greater clinical integration of
physician practices would enable care coordination and quality improvements for all patients.
Medicare will not be able to achieve improvements in quality and accountability unless
physicians are able to take a holistic approach, including joint contracting with private payers.
Medical Home Pilot Program
The AMA supports testing different models for the medical home (section 1302, Division B).
We also support implementing beneficial medical home models on a broad-scale basis upon a
thorough evaluation, but we do not support a mandatory requirement that physicians participate in
a medical home. In addition, while the AMA recognizes nurses as valuable members of the health
care team, we do not support nurse practitioners practicing independently, without at least regular
consultation with a physician. It is the AMA’s policy that a multidisciplinary health care team
should be led by a physician who is in the best position to provide coordination of disciplines to
assure delivery of high quality patient care.
The education and training between a physician and an advance-practice nurse (APRN), of which
nurse practitioners are a subset, are not equivalent nor are their competencies. When it comes to
clinical experience alone, a typical family medicine resident spends approximately 10,000 hours
involved in direct responsibility for patients in inpatient and outpatient settings. Family medicine
residents typically see approximately 1,650 to 2,000 patients in their continuity clinics alone.
Notably, this does not include the myriad of patients who will be seen through their other
rotations. In contrast, the American Association of the Colleges of Nursing recommends that
APRNs have a minimum of 500 hours in direct clinical practice during their education program.
An in-depth AMA study on APRN education and training further found that clinical-hour
requirements for direct patient care range from approximately 500 to 720 hours. In addition,
AMA only supports APRN practice as authorized by state scope of practice laws.
The AMA agrees that it is important to address the issue of hospital readmissions and we
support the study on how the readmissions policy could be applied to physicians. We urge
the Committees to clarify in section 1151 (Division B) that the Secretary of HHS should
consult with physician organizations in conducting the study, especially with regard to
critical issues such as attribution. The study should also require the Secretary to consider
existing efforts in this regard, such as those of the PCPI. Further, we believe that transitions
of care across various health care settings should be addressed as well.
Recently, the American Board of Internal Medicine (ABIM) Foundation, American College of
Physicians, Society of Hospital Medicine, and PCPI jointly formed a Care Transitions Work
Group (CTWG) to identify and define quality measures geared toward improving outcomes for
patients undergoing transitions between the inpatient and outpatient settings. The group identified
several processes of care demonstrated to improve outcomes during care transitions, and
recommended that these be added to the existing portfolio of quality measures. The CTWG is
also working with the Agency for
Healthcare Research and Quality toward promoting improved patient understanding of and
adherence to the post-discharge treatment plan through the addition of appropriate questions to
the CAHPS® Hospital Survey.
In implementing the hospital readmissions policy, Congress should ensure that there are
exceptions to this policy, such as planned readmission or readmission related to cancer care, burn
care, trauma care, scheduled surgical procedures, or other admissions deemed appropriate. This
policy should also recognize that there will inevitably be times where patients may be re-
hospitalized within a 30-day or other designated time period. For example, a patient could be
hospitalized for a heart condition, and within 30 days or other designated time period could
experience shock due to an unrelated traumatic event. This may ultimately complicate the
underlying condition that was the basis for the original hospitalization, and therefore a second
hospitalization may be necessary for high-quality care.
The AMA supports risk adjustment of all payment methodologies used in the foregoing health
reform pilot and other programs, and strongly recommends that Congress provide funding to the
Secretary to develop improved risk adjustment methodologies that reflect the characteristics of
the patient population being treated, including but not limited to such factors as whether an
individual smokes or is obese.
Health-Care Acquired Conditions
The AMA remains concerned that some of the current inpatient health-care acquired conditions
(HACs) do not meet the criteria of being “reasonably preventable” through the application of
evidence-based guidelines, as developed by appropriate medical specialty organizations based on
non-biased, well-designed, prospective, randomized studies. Until there is broader-based
consensus about which HACs should be included in the Medicare non-payment policy, we
do not support allowing states to include additional HACs for non-payment in their
respective Medicaid programs, as proposed under section 1851(b) (Division B).
The AMA supports the disclosure of physician ownership and investment information. We
oppose the proposal to eliminate the whole hospital exception to the Stark self-referral law.
The draft bill (section 1156, Division B) would essentially: prohibit physician-owned hospitals
from growing, except under very limited circumstances; force physician-owned facilities
currently under construction to be abandoned; and uniformly deter the establishment of new
physician-owned facilities by prohibiting them from treating Medicare and Medicaid patients.
The limits that would be placed on existing physician-owned hospitals would put them at a
competitive disadvantage and make it difficult for them to respond to the health care needs of
their communities. Similarly, the prohibition on treating Medicare and Medicaid patients for new
or developing physician-owned hospitals would make it impossible for them to survive,
effectively destroying this hospital sector.
Limiting the viability of physician-owned hospitals will only serve to reduce access to high-
quality health care for patients and have a destructive effect on the economy in communities these
hospitals serve. Physician-owned hospitals are a benefit to patients and their communities and
represent the type of coordinated care, efficiency, and aligned incentives that are being proposed
for the future of health care delivery. Several studies have shown high levels of quality care and
patient satisfaction in physician-owned hospitals. In addition, government studies have found
fewer complications, like infections and hip fractures, in physician-owned hospitals. Studies have
also shown that these hospitals provide more net community benefits through uncompensated
care and taxes than not-for-profit competitors as a share of
total revenues. Further, the Center for Studying Health System Change recently released a study
that found physician-owned hospitals do not adversely affect general hospitals’ ability to care for
patients. These hospitals provide tens of thousands of jobs nationally, a local economic engine
through property taxes and higher-wage jobs, and patient access to the best quality health care
available. We strongly urge the Committees to remove this provision.
Medicare Advantage Reform
The AMA strongly supports fiscal neutrality between Medicare Advantage (MA) and
Medicare fee-for-service, as well as the elimination of the MA Regional Plan Stabilization Fund,
by returning any remaining sums to the Federal Supplementary Medical Insurance Trust Fund. In
addition, the AMA is equally supportive of proposed MA provisions in the bill (Division B, Title
I, Subtitle D) establishing enhanced beneficiary protections including limitations on cost sharing
for dual eligibles and qualified Medicare beneficiaries, limitations on out-of-pocket costs for
individual health services, continuous enrollment for enrollees with MA enrollment suspension,
provision of information to beneficiaries on MA plan administrative costs (medical loss ratios),
and providing HHS with the explicit authority to deny MA plan bids. The AMA also generally
supports provisions to ensure the MA special needs plans provide services consistent with the
overall purpose of such plans (i.e., coordination of care).
Improvement to Medicare Prescription Drug Benefit
The AMA generally supports reforms to the Medicare Prescription Drug Benefit (Part D)
that increase plan transparency, enhance the quality and uniformity of information about
plan options available to beneficiaries, and provide meaningful access to plan options
including those that eliminate the coverage gap. We strongly support the proposed changes in
to the Part D program (Division B, Title I, Subtitle E) that would permit mid-year changes in
beneficiary enrollment for formulary changes that adversely impact beneficiaries (such as
reduction in coverage or increase in cost-sharing) as well as provisions that would include the
costs incurred by AIDS drug assistance programs and the Indian Health Service in providing
drugs toward the annual out-of-pocket threshold under Part D.
Medicare Rural Access Protections
The AMA generally supports efforts to fund and support CMS demonstration projects to evaluate
the effect of care delivered by physicians using telemedicine-related technology on costs, quality,
and the physician-patient relationship. Thus, we support provisions in Division B, Title I, Subtitle
F that would extend existing authorities related to telemedicine.
Comparative Effectiveness Research
The AMA concurs that a critical component of health care reform is sustained federal
funding for comparative effectiveness research (CER). However, the AMA strongly
supports establishing an independent entity that is charged with setting national priorities
and supporting the conduct of such research. We also believe that physicians, including
practicing physicians, must have a central and substantial role in the governance of the
independent CER entity. While the proposed CER Commission provides for physician
representation, it is minimal and the Commission would not be independent of HHS since the
Commission is subject to the authority of the HHS Secretary. We strongly urge modification to
the governance provision in Division B, Title IV, Subtitle A, and recommend the
establishment of an independent Commission with a central and significant role for
physicians, including clinicians.
The AMA supports CER as a tool to assist patients and clinicians in making informed health care
decisions, not to dictate them. Physicians will embrace and use clinical guidelines that
incorporate CER findings only if they trust the independence and objectivity of the process and
the validity and rigor of the standards used to produce the research. Physicians are much more
likely to have access to and adopt CER findings if they are involved in its development. Active
physician participation in the governance and work of the CER entity will facilitate uptake and
reliance on the research findings.
We support provisions that mandate transparent practices and require ongoing, regular
stakeholder input. In order to ensure the involvement of those impacted by CER findings, patient
safeguards must include, among other things, a means of accounting for population variation to
avoid exacerbating health disparities. The addition of a patient ombudsman is welcome and
language that specifies the limitations of CER findings must be clearly delineated. Furthermore,
the AMA supports dissemination of findings, but recommends the inclusion of language that
prohibits the development of clinical practice guidelines by the Center. In addition, we strongly
urge the inclusion of provisions that ensure that the final uses and application of CER findings do
not undermine patient-physician decision-making nor efforts to tailor diagnostics and treatment to
the particularized needs of individual patients. The AMA supports provisions that will ensure
secure and sufficient funding necessary to produce high-quality CER. Funding source(s) that are
not subject to the political process safeguard the independence of the CER entity.
Physician Payments Sunshine Provisions
The AMA supports adoption of reasonable measures that will increase transparency in the
relationship between physicians and applicable manufacturers of drugs, medical devices,
and medical supplies with respect to payments and other transfers of value and physician
ownership or investment interests in such manufacturers. A national registry that provides
information on transfers of value to physicians by these industries will provide information that
can be used by physicians, patients, and researchers. However, establishing a national registry
that would involve reporting on a greatly expanded group of entities and persons as well as
mandating reports on indirect payments or transfers of value including through third parties
would result in a flood of information, some of which would be of questionable validity and
value. In particular, reporting on indirect transfers of value where unrestricted manufacturer
funding used to support a conference would actually result in a perverse outcome—where
detailed information on each conference participant must be provided to the manufacturer, thus
arming it with information that can be used to target marketing and track participant activities.
Currently, manufacturers who provide unrestricted funding are not entitled to such information.
Given the existing patchwork of reporting requirements at the state level and the number of states
considering such legislation, the AMA strongly urges the Committees to amend Division B, Title
IV, Subtitle D and adopt a single comprehensive reporting regime for industry, as well as
preemption of state laws. This will provide a much needed apples-to-apples comparison of
information across the country and minimize the potential for an administrative quagmire. We
also recommend: requiring disclosure of only the health professional’s name and business
addresses in publicly available registries; including specific language that prohibits the public
disclosure of National Provider Identifiers (NPIs) to decrease the possibility of identity theft and
fraud in health programs; providing physicians a reasonable opportunity to review and correct
reports on transfers of value attributed to them prior to public disclosure; and removing the
requirement to report ownership interest by a member of a physician's immediate family in any
non-publicly held manufacturer regardless of its relevance to the physician’s practice.
Graduate Medical Education (GME)
The AMA believes that the Medicare GME proposal under Division B, Title V, to fill vacant
GME resident slots alone, will not be enough to address the predicted physician shortages.
A peer-reviewed study published in the Journal of the American Medical Association (JAMA) in
2008 projects an additional 21,000 residency positions will be needed within the next decade to
ensure that we have a fully trained physician workforce available to serve the needs of patients.
The AMA recommends the following additional GME actions to ensure an adequate physician
workforce: (1) maintain adequate and stable Medicare and Medicaid GME funding levels and
investigate additional sources of GME funding (e.g., private payers); (2) increase Medicare
supported GME positions in primary care, general surgery, and other undersupplied specialties, as
well as in underserved areas with new funding; and (3) bring together a variety of health care
experts to assess and make recommendations on our physician workforce needs, including the
number of needed GME positions and the use of GME funds, and how meeting these needs
should be funded. The AMA is also very concerned about the draft bill’s proposal to require a
study and report on medical residency training programs, including curriculum requirements. We
do not support efforts by the government to dictate the content of medical school or residency
curricula either directly or as a condition for receiving funds and we believe this study would
duplicate work already underway by MedPAC.
Program Integrity Funding and Reporting Requirements
The AMA supports increased funding for program integrity since many of the programs currently
being administered are severely under-funded and result in significant problems for physicians.
However, any increased funding should go toward properly supporting currently under-funded
integrity programs first before establishing new programs, and any new programs should be
properly coordinated with existing ones.
Fraud and Abuse Compliance and Penalties
The AMA supports efforts to combat fraud and abuse. However, we believe that efforts must be
made to clearly define health care fraud, as opposed to honest mistakes. In addition, efforts to
curb fraud and abuse must ensure due process rights for physicians and verifying the accuracy of
claims submitted by other providers and suppliers should not take away time from physicians'
patient care activities. We are opposed to the requirement for face-to-face meetings to certify
home health care given that many of these patients, by definition, are unable to get to a
physician’s office. Finally, we are opposed to the requirement that physicians who order durable
medical equipment must sign a Medicare Participation Agreement. This could be disruptive to
long-established physician-patient relationships.
In addition, we do not believe that creation of a payment modifier that would have to be added to
claims for evaluation and management services when a physician ordered another service would
substantially improve the government's ability to identify questionable ordering or referral
practices. These services can already be matched up by beneficiary and we question the need to
impose yet another administrative cost and burden on physicians. As a practical matter, much of
this new burden will fall on primary care physicians and penalize them for the very kinds of
coordination of services that policymakers want to encourage. For these reasons, we would like to
work with the Committee staffs to clarify the rationale for this section and determine whether
there are less burdensome ways of achieving the goal.
We have significant concerns about combining and/or expanding data banks (Title VI, Division
B) with sensitive physician information. We support eliminating duplicative physician databases.
given that NPDB data have been shown to be incomplete, duplicative, and inaccurate, we
recommend that any expansion or consolidation of the database contain sufficient measures and
protections to ensure the accuracy, relevancy, and confidentiality of the information it contain. In
addition, we recommend that the legislation ensure that physicians are accorded full due process
rights to contest, appeal, and respond to all alleged charges reported to the database.
The AMA supports helping low-income individuals obtain health insurance coverage, and
believes the safety net provided by public programs needs to be maintained and
strengthened. We support basic national standards of uniform eligibility for all persons
below the poverty line, and the elimination of the existing categorical requirements, which
would allow for the coverage of low-income individuals based solely on financial need.
We support the provisions in section 202, Division A that would allow Medicaid-eligible
individuals to purchase insurance through the health insurance exchange.
The AMA also supports setting Medicaid payment rates at a level that encourages widespread
physician participation in the program. We support the enhanced payments in the draft bill
(section 1821, Division B, Title VIII) for primary care practitioners, but urge that these enhanced
rates be provided to all physicians participating in the Medicaid program, since access to
specialty care is already a problem for beneficiaries.
The proposal to expand the array and extent of preventive and wellness promotion services under
Medicaid is commendable and much needed. We support the requirements in the draft bill
(section 1811, Division B) for coverage of prevention services that are graded “A” or “B” by the
United States Preventive Services Task Force (USPSTF), as well as coverage of vaccines
recommended by the Centers for Disease Control and Prevention (CDC). The use of the USPSTF
and CDC’s Advisory Committee on Immunization Practices (ACIP) provide widely respected
and utilized guides for designation of recommended preventive services and are often used in
both private and public clinical practices. We also support the draft bill’s elimination of cost-
sharing for such services. Moreover, we support the expansion of tobacco cessation counseling
for pregnant women, as well as dropping the tobacco exception from covered outpatient drugs
(section 1812, DivisionB).
The AMA supports the Workforce provisions (Division C, Title II) that would increase
funding for the National Health Service Corps (NHSC) and Title VII health profession and
diversity programs to ensure a well-prepared, well-distributed, and diverse health care
workforce. We also recommend including provisions that would alleviate high medical student
debt burdens through tuition assistance, loan deferment, and loan forgiveness for service
programs for all undersupplied specialties, including programs for medical teaching faculty. The
AMA generally supports programs that increase basic nursing education opportunities, provide
workforce incentives, as well as other initiatives in order to increase the supply of registered
nurses. In lieu of the proposed nurse-managed health centers, the AMA supports fully integrated
multidisciplinary health care teams that are comprised of nurses and other health care
professionals, which are led by physicians to ensure that patients get the best possible care. While
we support the establishment of a health care workforce advisory committee, we do not support
limiting the number of physicians and health educational professionals to be appointed to the
committee. In addition, the AMA supports health care workforce assessments that cover all
specialties, not just primary care.
Prevention and Wellness
It is imperative that we invest in prevention and wellness to promote a healthy America. We will
be unable to achieve the goals of improving quality of care and reducing the rate of growth in
health care costs without such investments. Billions in savings can be achieved through a large-
scale national effort of health promotion and disease prevention to reduce the prevalence of
chronic disease and poor health status, which leads to unnecessary sickness and higher health
costs. Reform should include a specific focus on obesity prevention commensurate with the scale
of the problem. These initiatives are crucial to transform health care in America and to achieve
our goal of reducing the rate of growth in health costs. Insurance benefit designs should be
aligned with current evidence on disease prevention. Public investments are needed in education,
community projects, and other initiatives that promote healthy choices, as well as core public
We support the provisions in Title III, Division C that require the Secretary to develop a
national prevention and wellness strategy and to expand the capacity of the USPSTF and
the Task Force on Community Preventive Services to undertake rigorous, systematic
reviews of existing science to recommend the adoption of proven and effective preventive
services. We also support the focus on prevention and wellness research, with regard to
coordinating such research and expanding research through new grant programs. The community-
based prevention and wellness services grants are also to be commended, especially the focus on
reducing health disparities. The AMA recognizes racial and ethnic health disparities as a major
public health problem in the United States and a barrier to effective medical diagnosis and
treatment. Eliminating such disparities is one of our highest priorities.
Medical Liability Reform
The AMA believes strongly that medical liability reform is a critical component of health
system reform, especially as a means of protecting patients’ access to care and slowing the
rising cost of health care. Various states have passed effective medical liability reforms that, in
addition to including a cap on non-economic damages, also contain innovative approaches. The
AMA strongly favors a $250,000 limitation on noneconomic damages as the optimal solution.
However, we also support federal funding for state or local-based demonstration programs to
collect information on the efficacy of alternative reforms that have the potential to improve the
current litigation climate, including but not limited to: health courts; early disclosure and
compensation programs; administrative determination of compensation model; expert witness
qualifications; and liability protections for use of evidence-based medicine guidelines.