• Volume 58, October 2018 CNS DC E-Newsletter

    • Oct 01, 2018

    Legislative Affairs

    Congress Urges CMS to Take Action on Prior Authorization

    Restricting abusive prior authorization tactics is a top issue for organized neurosurgery, as such the AANS and CNS are leading an advocacy effort to reduce the burdens of prior authorization practices for Medicare Advantage (MA) and other health plans. Due to neurosurgery’s advocacy, Reps. Phil Roe, MD, (R-Tenn.) and Ami Bera, MD, (D-Calif.) spearheaded a letter among their colleagues in the U.S. House of Representatives urging the Centers for Medicare & Medicaid Services (CMS) to improve how prior authorization works under MA. Signed by 103 bipartisan House members, the letter to CMS Administrator Seema Verma notes, “patients may be encountering barriers to timely access to care that are caused by onerous and often unnecessary prior authorization requirements.” It goes on to urge CMS do the following:

    • Issue guidance to MA plans to dissuade the widespread use of prior authorization and to provide direction to the health plans to increase transparency, streamline prior authorization and minimize the impact on patients;
    • Ensure that these requirements do not create inappropriate barriers to care for Medicare patients; and
    • Collect data on the scope of prior authorization practices — including denial, delay and approval rates.

    The AANS and CNS issued a press release thanking these lawmakers for asking CMS to take action on prior authorization. The statement was picked up by Inside Health Policy, which ran a story noting that the AANS and CNS were pleased with the letter because neurosurgeons often run into prior authorization hurdles before their patients can receive care. Quoting Ann R. Stroink, MD, chair of the AANS/CNS Washington Committee, the piece stated, “Prior authorization — a tool insurance companies use to limit the medical services they cover — is a cumbersome process that we believe is being inappropriately used by Medicare Advantage plans.”

    House Ways and Means Committee Sends Letters to CMS Asking for Burden Reduction

    On Sept. 4, House Ways and Means Committee chair, Kevin Brady (R-Texas), and health subcommittee chair, Peter Roskam (R-Ill.), released three letters to CMS as part of the committee’s Red Tape Relief Project. The letters addressed issues related to physicians, hospitals and post-acute care providers. The physician letter reflects the input that the AANS and CNS provided to the committee throughout the past year, incorporating many of the recommendations that neurosurgery made regarding prior authorization, appropriate use criteria for diagnostic imaging and the Medicare physician fee schedule. The letter acknowledges the fact that physicians are spending nearly two out of every three hours on additional paperwork and relief from these unnecessary regulatory burdens must be provided.

    Neurosurgery Submits Comments to Senate Regarding Surprise Billing Legislation

    On Sept. 18, Sen. Bill Cassidy (R-La.), along with five of his colleagues — Sens. Michael Bennet (D-Colo.), Chuck Grassley (R-Iowa), Tom Carper (D-Del.), Todd Young (R-Ind.) and Claire McCaskill (D-Mo.) — released draft legislation to end surprise medical bills. The draft bill is intended to jumpstart discussions in Congress about how to best stop the use of balance billing to charge patients for emergency treatment or treatment provided by an out-of-network provider at an in-network facility. On Oct. 10, the AANS and CNS submitted a comment letter — prepared with the assistance of neurosurgeons Luis M. Tumialán, MD; Michael H. Brisman, MD; and Jay Nathan, MD — recognizing that while Americans continue to struggle with rising health care costs, including high deductibles and other out-of-pocket expenses, a balanced solution for cost-sharing between patients, physicians and health plans is necessary. The letter concurs that legislation should protect patients from “surprise” bills, but points out that the practice of narrowing networks by commercial payers is a central reason physicians practice out-of-network and the root cause of many of these “surprise” bills. The AANS and CNS urged the senators to make a number of changes to the draft proposal to:

    • Ensure network adequacy;
    • Establish fair and transparent out-of-network payment rates based on the FAIR Health, Inc., database; and
    • Allow balance billing in certain limited circumstances.

    Senator Cassidy and his colleagues plan to introduce this legislation before the end of the year and neurosurgery will continue to stay engaged on the issue.

    Congress Passes Comprehensive Opioid Legislation

    On Oct. 3, by a vote of 98-1, the U.S. Senate passed H.R. 6, the “Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act,” bipartisan legislation aimed at combatting the opioid epidemic. The House approved the package on Sept. 28 by a vote of 398-8. The legislation reflects organized neurosurgery’s priorities, including:

    • No opioid prescribing limits;
    • Improved e-prescribing of opioids;
    • Enhanced prescription drug monitoring program (PDMP) interoperability; and
    • Improved payment for opioid alternatives and surgical pain therapies, such as neuromodulation.

    President Trump is expected to sign the legislation into law.

    President Trump Signs Bipartisan Children’s Hospital GME Bill into Law

    On Sept. 18, President Trump signed , the “Dr. Benjy Frances Brooks Children’s Hospital GME Support Reauthorization Act of 2018,” into law (P.L.115-241), officially extending the Children's Hospitals Graduate Medical Education (CHGME) program for five years. Rep. Gene Green (D-Texas) originally introduced the bill, which increases funding for the program at $325 million per year until 2023. Hospitals that receive the funding represent less than one percent of all hospitals, but train half the country’s pediatricians and pediatric specialists. The program will ensure the longevity of a strong pediatric health care workforce for our nation’s freestanding children’s hospitals.

    President Trump Signs Health Appropriations Legislation

    On Sept. 28, President Trump signed H.R. 6157 (P.L. 115-245) into law, funding the U.S. Departments of Labor, Health and Human Services (HHS) and Education for FY 2019. Of interest to neurosurgery, the law provides a total of $39.1 billion for the National Institutes of Health (NIH) — an increase of $2 billion above FY 2018 funding. It also increases support for several neurologic research initiatives, including a $425 million increase for Alzheimer’s disease research and a $29 million increase for the Brain Research through Application of Innovative Neurotechnologies (BRAIN) initiative. Additionally, the legislation includes a total of $7.9 billion for the Centers for Disease Control and Prevention (CDC), with $475 million going to fund Opioid Overdose Prevention and Surveillance and $6.75 million going to fund traumatic brain injury (TBI). In a letter to appropriations negotiators, the AANS and CNS expressed support for increased NIH and CDC funding.

    House Passes the Local Coverage Determination Clarification Act

    On Sept. 12, the House of Representatives passed the Local Coverage Determination (LCD) Clarification Act, H.R. 3635, by voice vote, which aims to improve accountability and transparency in the process Medicare contractors use to make local coverage decisions. The AANS and CNS joined the Alliance of Specialty Medicine and others in advocating for passage of this bill. Following the House action, CMS announced its own plans to accelerate innovation and promote patient access to medical technology by reforming Medicare’s Local Coverage Determination process. The agency is taking the following steps to increase transparency and patient engagement:

    • Requiring a consistent, standardized summary of the clinical evidence supporting LCD decisions;
    • Including a beneficiary representative and other healthcare professionals in addition to physicians on Contactor Advisory Committees that inform LCDs; and
    • Ensuring that the Contractor Advisory Committee (CAC) meetings are open to the public.

    Congress Asks HHS to Improve EHR Interoperability and Stop Data Blocking

    During September, the AANS and CNS joined our colleagues from the American Academy of Dermatology and others to help gather signatures on a letter to HHS Secretary Alex Azar, regarding electronic health records and data blocking. Led by Reps. Mike Kelly (R-Fla.) and Mike Thompson (D-Calif.), more than 20 bipartisan members of the House signed this letter calling on HHS to address barriers to data sharing between qualified clinical data registries (QCDRs) and electronic health record (EHR) systems. The letter raises concerns about EHR vendor practices that are blocking the transfer of data between EHRs and clinical data registries and urges reforms, so neurosurgeons can better participate in Medicare’s Quality Payment Program (QPP).

    Coding and Reimbursement

    Neurosurgery Comments on Payment-related Provisions of the Proposed 2019 Medicare Physician Fee Schedule

    On Sept. 10, neurosurgery submitted a letter to CMS expressing concerns about several reimbursement-related provisions of interest to neurosurgeons contained in the 2019 Medicare Physician Fee Schedule proposed rule. In the letter, the AANS and CNS:

    • Opposed the agency’s proposal to collapse the evaluation and management (E/M) office visit codes from five to two payment levels and recommended that CMS take more time to consult with stakeholders;
    • Agreed that preliminary results of global surgical data collection are incomplete and cannot be used to change the value of existing codes.
    • Encouraged CMS to cover evidence-based, opioid-sparing surgical therapies as an effective strategy to reduce opioid prescribing and abuse; and
    • Opposed CMS’ plan to reduce the AMA/Specialty Society Relative Value Scale Update Committee (RUC)-passed values for five neurostimulator programming codes.

    Click here to view a CMS fact sheet on the proposed rule. Click here to review a summary prepared by the American Medical Association (AMA) and annotated by AANS/CNS Washington Office staff. In addition to the neurosurgery-specific letter, the AANS and CNS joined the AMA and 160 other national and state medical societies in a letter regarding the proposed E/M changes. Neurosurgery also joined the Alliance of Specialty Medicine in a letter addressing issues of concern to specialty medicine. CMS is expected to issue the final 2019 MPFS final rule by early November.

    AANS and CNS Comment on the Payment-related Provisions of the Medicare Outpatient Facility Proposed Payment Rule

    On Sept. 24, the AANS and CNS submitted a letter to CMS expressing concerns about several reimbursement-related provisions of interest to neurosurgeons included in the 2019 Medicare Hospital Outpatient Prospective Payment System (OPPS)/Ambulatory Surgery Center (ASC) proposed rule. In the letter, the AANS and CNS:

    • Supported a proposal to lower the threshold for device-intensive procedures from 40 percent of the total cost of the surgery to 30 percent, allowing more appropriate facility reimbursement for innovative procedures;
    • Urged CMS to study available data and consult appropriate stakeholders regarding the safety of performing surgery in the ASC setting, emphasizing that the site of service should be determined by the operating surgeon in consultation with the patient; and
    • Agreed with CMS that, in the ASC setting, separately paying for non-opioid pain management is an effective way to increase the use of non-opioid treatments for improved pain treatment.

    ‚ÄčAetna Updates Policy on Expandable Spinal Cage Devices for Lumbar Fusions

    Aetna recently updated their policy to extend coverage for expandable spinal cage devices from L2 to S1, consistent with the FDA labeling of the Elevate device (the previous version of the policy limited coverage to L5-S1). The AANS and CNS had requested this change in a letter drafted by Kurt M. Eichholz, MD, Stephen L. Reintjes, MD and other members of the AANS/CNS Section on Disorders of the Spine and Peripheral Nerves, sent to Aetna on July 25.

    MedPAC Releases Updated 2018 Payment Basics Series         

    On Oct. 12, the Medicare Payment Advisory Commission (MedPAC) announced the release of the updated 2018 Medicare Payment Basics series. Neurosurgeons may view the documents in the series, which provide an overview of 20 payment systems, by clicking here.

    Quality Improvement

    Neurosurgery Comments on Quality-related Provisions of the Proposed 2019 Medicare Physician Fee Schedule

    On Sept. 10, neurosurgery submitted a letter to CMS expressing concerns about several quality-related provisions in the 2019 Medicare Physician Fee Schedule proposed rule, of interest to neurosurgeons. In the letter the AANS and CNS:

    • Supported several policies meant to reduce the complexity of the Merit-Based Incentive Payment System (MIPS), including facility-based scoring and simplifications to the Promoting Interoperability category;
    • Urged CMS to move more aggressively toward a more simplified scoring methodology to further reduce reporting, including providing credit across performance categories burden; and
    • Opposed multiple proposals that would make the program more challenging and confusing, including shifting more weight to the Cost category, mandating the use of 2015 Edition Certified EHR Technology, scaling back on the use of claims-based reporting for quality measures and doubling the MIPS scoring threshold to avoid a penalty.

    Click here, to view a CMS fact sheet on the proposed rule. Click here, to review a summary prepared by the AMA and annotated by AANS/CNS Washington Office staff. Neurosurgery also joined the Alliance of Specialty Medicine in a letter addressing issues of concern to specialty medicine. CMS is expected to issue the 2019 MPFS final rule by early November.

    The AANS and CNS Comment on the Quality-related Provisions of the Medicare Outpatient Facility Proposed Payment Rule

    On Sept. 24, the AANS and CNS submitted a letter to CMS expressing concerns about several quality-related provisions of interest to neurosurgeons included in the 2019 Medicare Hospital OPPS/ASC proposed rule. In the letter, the AANS and CNS:

    • Opposed the removal of quality measures based solely on “topped-out” status;
    • Urged CMS to maintain ASC claims-based data collection and tracking for wrong side, wrong patient, wrong implant surgery and to continue to track the rate of ACS admissions requiring transfer to a hospital; and
    • Supported the removal of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) pain questions, given their tenuous link to higher quality.

    CMS will publish the final rule in early November 2018.

    Of Note

    Neurosurgical Resident Picked for White House Fellow Program

    Jeremy Hosein, MD, a neurosurgical resident at University of Colorado School of Medicine, has been named to the 2018-2019 White House Fellows class. The White House Fellows Program was created in 1964 by President Lyndon B. Johnson to give promising American leaders “first hand, high-level experience with the workings of the Federal government, and to increase their sense of participation in national affairs.” He joins 13 other individuals selected to participate in this prestigious program and follows in the footsteps of neurosurgeons Lindsey B. Ross, MD; Anand Veeravagu, MD; and Sanjay K. Gupta, MD, who also served as White House Fellows in the Obama/Trump Administrations (2016-2017), Obama Administration (2012-13) and Clinton Administration (1997-98), respectively.

    Neurosurgeon Appointed to Medicare Advisory Committee

    Ahmed M. Raslan, MD, has been appointed to the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC). He joins Joseph S. Cheng, MD, in representing neurosurgery on this CMS panel. The AANS and CNS nominated Dr. Raslan at the end of last year. MEDCAC is a group of 100 appointed individuals — including physicians, patients and industry representatives. CMS calls on MEDCAC members when it is considering National Coverage Determinations (NCDs). 

    Neurosurgeon Selected for National Academies Committee for Opioid Pain Guidelines

    Christopher J. Winfree, MD, was selected to serve on the National Academies of Science, Engineering, and Medicine’s (National Academies) new study committee titled “Evidence-based Clinical Practice Guidelines for Prescribing Opioids for Acute Pain.” Nominated by the AANS and CNS, his clinical, health policy and leadership experience related to pain medicine and opioids make Dr. Winfree ideally suited to serve on this important committee. The FDA is funding this effort, which will help advance the development of evidence-based guidelines for appropriate opioid analgesic prescribing for acute pain resulting from specific conditions or procedures.

    Neurosurgeons Elected to Prestigious National Academy of Medicine

    On Oct. 15, the prestigious National Academy of Medicine announced the election of two neurosurgeons to its ranks. Linda M. Liau, MD, PhD,, the W. Eugene Stern Professor and chair of the department of neurosurgery at the University of California, Los Angeles, was recognized for her achievements in understanding the immunology of malignant brain tumors and designing clinical trials of dendritic cell-based vaccines for glioblastoma. Robert M. Friedlander, MD, chair of the department of neurological surgery, and Walter E. Dandy Professor at the University of Pittsburgh Medical Center, was recognized for demonstrating the role of caspases in cell-death pathways in neurologic diseases and for groundbreaking discoveries that have led to the development of novel therapies to improve outcomes for patients suffering from stroke, brain and spinal cord injury, Huntington’s disease and ALS.


    Neurosurgery Issues Press Release on Cutting Red Tape in the Medicare Program

    On Sept. 7, the DC office issued a press release highlighting a letter sent to lawmakers on Capitol Hill seeking regulatory relief from a burdensome program that will require clinicians who order advanced diagnostic imaging to consult with appropriate use criteria (AUC) each time they order a test. The letter was sent to the leaders of the Senate Finance and House Ways and Means and Energy and Commerce Committees and was signed by physician organizations representing primary, specialty and surgical care. Following this release, Bloomberg Law wrote an article, “Doctors Lobby Against Medicare Hurdle for Ordering MRIs,” which not only highlighted our letter, but also quoted Katie O. Orrico, Esq., director of the AANS/CNS Washington Office, who noted:

    It’s great that they’ve acknowledged that the appropriate use program should be folded into MACRA’s quality payment program … Unfortunately, we don’t see that CMS has the statutory authority to remove the separate requirement for physicians to consult the imaging criteria. We’d like legislation to acknowledge that you don’t have to comply with two different programs. Nonetheless, the medical societies will both continue to educate Congress on the issue and to advocate for the CMS to take steps to incorporate the programs.

    Neurosurgery Blog’s Pediatric Neurosurgery Focus Month a Huge Success!

    Throughout September and part of October, Neurosurgery Blog hosted a pediatric neurosurgery focus awareness campaign. To maximize attention on pediatric neurosurgery-related issues, we launched the campaign during the back-to-school months. The goal is to shed important light on pediatric neurosurgery facts, innovations and the role of pediatric neurosurgeons. The first guest post was authored by Nathan R. Selden, MD, PhD, who discussed the changing face of pediatric epilepsy surgery. Our second guest post, which highlighted the newly released CDC evidence-based guideline on mTBI (including concussion) among children, was written by Grant Baldwin, PhD, Director, Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. The Neurosurgery Blog team also developed an animation titled, “What's a Pediatric Neurosurgeon?” highlighting the superheroes who care for the littlest neurosurgical patients. Other blogs from the neurosurgical community incorporated into this series include:

    We invite all neurosurgeons to continue the conversation using the #PedsNeurosurgery hashtag so we can grow awareness through social media. In the meantime, if you have not already done so, we also encourage you to visit the blog and subscribe to it, as well as connect with us on our various social media platforms. Subscribe to stay informed on this and other important topics facing neurosurgery. 

    For more information on these or other health policy issues, please contact Katie O. Orrico, director of the AANS/CNS Washington Office at korrico@neurosurgery.org.

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