Health Policy Update

1. Health Policy Update Mark T. Edney, MD, FACS Peninsula Urology Associates, Salisbury, MD November 3, 2011 AUA Legislative Affairs Committee Young Urologist Committee Liaison to AUA Health Policy Council President, Maryland Urologists for Patient Access to Care

2. Overview • Joint Select Committee on Deficit Reduction • Independent Payment Advisory Board (IPAB) • Sustainable Growth Rate (SGR) • In-Office Ancillary Exception (IOAE) • PROSTATE Act, Urotrauma Bill • Other Legislation of Interest to Urology • UROPAC

3. Debt Ceiling Bill • Budget Control Act of 2011 • Passed Aug 2, 2011, became public law 112-25 • Establishes Joint Select Committee on Deficit Reduction

4. Committee Members Senate Members • Finance Committee Chair Max Baucus (D-MT) • Senate Foreign Relations Committee Chair John Kerry (D-MA) • Democratic Senatorial Campaign Committee Chair Patty Murray (D-WA) • Minority Whip Jon Kyl (R-AZ) • Pat Toomey (R-PA) • Rob Portman (R-OH) House Members • Energy & Commerce Committee Chair Fred Upton (R-MI-6) • Ways & Means Committee Chair Dave Camp (R-MI-4) • Jeb Hensarling (R-TX-5) • Assistant Democratic Leader James Clyburn (D-SC-6) • Budget Committee Ranking Member Chris Van Hollen (D-MD-8) • Ways & Means Social Security Subcommittee Ranking Member Xavier Becerra (D-CA-31)

5. Super Committee Process • Committee report due to Congress by November 23, 2011 • Congress must either accept or reject the recommendations without changes by December 23, 2011 • If successful, the debt ceiling can again be raised

6. What is on the Table? • EVERYTHING including but not limited to: • Graduate Medical Education cuts • Payment reductions (PC), and prior authorization for imaging services • Direct cuts to physician reimbursement • Loss of EHR incentive payments for meaningful use

7. Super Committee Process • If Congress fails to enact, debt ceiling would be automatically raised by $1.2 trillion and across-the-board cuts would be triggered (sequestration)- effective CY13 • Half of the savings would come from defense spending • Social Security and Medicaid are exempt • Medicare is not • Benefits and beneficiary cost sharing remains unchanged, 2 percent cut to providers • Deep cuts possible for CDC, NIH, HIV treatment and disease prevention programs

8. Independent Payment Advisory Board • 15 member appointed panel (<50% physician, non-practicing) • Broad authority to cut provider payments (hospitals and hospices exempt for 5 years) • Essentially no Congressional oversight • H.R. 452/S.668 – main repeal bills • David Roe MD (R-TN)- 209 cosponsors, currently in E+C subcommittee on health • President Obama is calling for a strengthening of IPAB • Senate shows no sign of willingness to repeal

9. Sustainable Growth Rate • 29.6% Cut Looming on Dec. 31 • If this is not addressed by the Committee, there will be little time to stop the cuts. • LATE BREAKING: CMS PFS CY12 final rule published 11/1- 27% cut • MedPAC Recommendation to fix the SGR • Cut specialists 5.9 percent per year for three years, freezing payments for the remaining seven years. Primary care frozen for 10 years without reduction. • Collect data on service volume and work time to establish “more accurate” work and practice expense values • Supplanting the extensive prior work of the RUC • Use data to identify over-priced physician services and reduce their relative value units (RVUs)

10. In-Office Ancillary Exception Urology has been and will continue to be under intense scrutiny from CMS and attack from organized radiology, radiation oncology and hospitals

11. In-Office Ancillary Exception • MedPAC Recommendations at April Meeting • Encourage the RUC to accelerate bundling of discrete services often provided during one encounter • Reduce payment rates for the professional component of multiple imaging studies provided during the same session • Reduce the professional component for imaging and other diagnostic tests ordered and performed by the same practitioner • Prior authorization for physician outliers

12. In-Office Ancillary Exception STATE ALERT • Maryland 2011- became 1st state to prohibit non-radiologists from owning and operating CT and MRI • American College of Radiology considers Maryland Patient-Referral Law “model legislation” • Heretofore unsuccessful attempts at passing same language in Pennsylvania, Washington, and Oregon • Be vigilant in your state

13. PROSTATE Act Prostate Research, Outreach, Screening, Testing, Access, and Treatment Effectiveness Act of 2011 – S. 1190/H.R. 2159 • Establishes an Interagency Task Force, led by the VA and includes the DoD and HHS that will: • Aligns federal agencies’ prostate cancer research, healthcare delivery programs, educational & outreach efforts, and messages • Makes recommendations for future funding • Expands prostate cancer programs in research, telehealth, minority outreach, and education and awareness. • Budget Neutral

14. Urotrauma – H.R. 1612 • Commission (sunset) led by DoD and includes VA and HHS • Will develop and recommend a long-range plan for utilization of national resources to effectively deal with battlefield urotrauma • Prevention, initial and subsequent/chronic management, public/private coordinated efforts • May get included in National Defense Authorization Act

15. Other Legislation of Interest to Urology • H.R. 5 (Gingrey, R-GA-11)/S. 218 (Ensign, R-NV) – the HEALTH Act – comprehensive liability reform • H.R. 816 (Gingrey, R-GA-11) – nothing in the ACA (guideline or standard) can create a new cause of action

16. Other Legislation of Interest to Urology • H.R. 674 (Herger, R-CA-2)/S. 164 (Brown, R-MA) – repeals the required withholding of 3% of government payments to contractors starting Jan 1, 2012 • Tax Increase Prevention and Reconciliation ACT (2005), section 511 • 3% withholding on government payment for contracted services (Federal, State and any state political subdivision making payments >$100M annually) as down-payment on federal tax liability • Passed House 10/27/2011 405-16 • Senate expected take it up this week

17. Other Legislation of Interest to Urology • H.R. 969 (Price, R-GA-6) - Prohibits the HHS Secretary or any state from requiring any health care provider to participate in any health plan as a condition of licensure of the provider in any state STATE ALERT This issue being considered in a few states 2011 – model legislation prohibiting participation-based licensure in Kansas, Virginia

18. Other Legislation of Interest to Urology • H.R. 1700 (Price, R-GA-6) - establishes a Medicare payment option for patients and physicians or practitioners to freely contract, without penalty, for Medicare fee-for-service

19. Other State Issues • Insurance Exchanges- MD, DC, MA • Assignment of Benefits • Wins: MD, DE • Loss: WV • Scope of Practice- NJ, MD, WV, CT • MA Healthcare Act 2006- Dr. Hopkins • VT single payer system

21. What is UROPAC? • UROPAC is the only political action committee dedicated exclusively to advancing the public policy interests of urology. • Voluntary, nonpartisan political action committee that organizes urologists, residents and students who share an interest in electing and retaining pro-urology candidates in Congress. • UROPAC is co-sponsored by the American Association of Clinical Urologists (AACU) and the American Urological Association (AUA).

22. UROPAC Income 1992-Present

23. UROPAC- 10th Largest Specialty Physician PAC

24. Physicians in Congress- 111th Congress (16) Family Medicine Vic Snyder (D- AR 2) John Flemming (R- LA 4) Paul Broun (R- GA 10) Donna Christensen (D-VI) Psychiatry Jim McDermott (D- WA 7) OB/GYN Tom Coburn (R-OK) Michael Burgess (R –TX 26) Ron Paul (R- TX 14) Phil Roe (R- TN 1) Phil Gingrey (R- GA 11) Allergist Steve Kagan (D- WI 8) GI Bill Cassidy (R- LA 6) CT Surgery Charles Boustany (R- LA 7) Radiation Onc Parker Griffith (R- AL 5) Orthopedics John Barrasso (R- WY) Tom Price (R- GA 6)

25. Physicians in Congress- 112th Congress (20) Family Medicine John Flemming (R- LA 4) Paul Broun (R- GA 10) Donna Christensen (D-VI) Psychiatry Jim McDermott (D- WA 7) OB/GYN Tom Coburn (R-OK) Michael Burgess (R –TX 26) Ron Paul (R- TX 14) Phil Roe (R- TN 1) Phil Gingrey (R- GA 11) GI Bill Cassidy (R- LA 6) CT Surgery Charles Boustany (R- LA 7) Larry Bucshon (R- IN 8) Orthopedics John Barrasso (R- WY) Tom Price (R- GA 6) General Surgery Dan Benishek (R-MI 1) Anesthesia Andy Harris (R- MD 1) Ophthalmology Nan Hayworth (R- NY 19 Rand Paul (R-KY) Emergency Medicine Joe Heck (R- NV 3)

26. Ways to Get Involved • Leadership Program (sectional program) • Northeastern 2 South Central 3 • New England 2 Western 3 • New York 2 North Central 3 • Mid Atlantic 2 Southeastern 3 • AACU States Society Network Annual Meeting • Every September in Chicago • Joint Advocacy Conference • AUA/AACU, annually in March in Washington DC

27. Ways to Get Involved • Gallagher Health Policy Scholarship • Annual award in its 7th year • Biannual HP meetings • Brandeis (ACS) Health Policy/Leadership course (1 week) • AMA RUC meeting • Section Level Participation • Section representatives to • AUA Board • Practice Management Committee • Young Urologists Committee • Health Policy Council

28. Ways to Get Involved • State-level advocacy development • Critical unmet need • Opportunity for the motivated to immediately assume a leadership role • Assemble critical mass of practices • Mix of all practice models • Get experienced healthcare counsel • Get a lobbyist • Incorporate • Start making relationships with lawmakers • Attend/host fundraisers

29. “IF YOU ARE NOT AT THE TABLE YOU WILL SURELY BE ON THE MENU”

30. Ways to Get Involved Contribute

31. THANK YOU mtedney04@hotmail.com