2018 Advocacy Summit Proposal Table of Contents - msv.org · 2018 Advocacy Summit Proposal . Table of Contents . 1. School Safety Initiative, Dr. Art Vayer & Dr. Adlai Pappy (p. 2)

2018 Advocacy Summit Proposal Table of Contents

1. School Safety Initiative, Dr. Art Vayer & Dr. Adlai Pappy (p. 2)

2. Reduce Firearm Risk, Richmond Academy of Medicine (p. 3)

3. Limit Sales of Assault Weapons, Richmond Academy of Medicine (p. 4)

4. Amending current Physician Assistant Code to reflect current practices in Medicine, Virginia Academy of

Physician Assistants (p. 5)

5. New Legislation, Dr. Kenneth Olshansky(p. 6)

6. Resolution To Regulate And License Pharmacy Benefit Managers Who Serve Virginians, Dr. Harry

Gewanter (p. 7)

7. Commonwealth of Virginia Health Insurance Protection Act: Establishment of a Reinsurance Program, Dr.

Bruce Silverman (p. 9)

8. Prior Authorization Elimination, Richmond Academy of Medicine (p. 10)

9. Step Therapy Appeal and Override Process Improvement, Richmond Academy of Medicine (p. 12)

10. Resolution on Tobacco Control, Richmond Academy of Medicine (p. 13)

11. Incentivize physicians to practice in underserved areas, Richmond Academy of Medicine (p. 14)

12. Tax on Sugar-Sweetened Beverages, Richmond Academy of Medicine (p. 15)

13. Ending Surprise Billing/Providing Fair Payment for Out-of-Network Physicians, Virginia College of

Emergency Physicians (p. 16)

14. Prohibit Maintenance of Certification in Virginia, Virginia Academy of Family Physicians (p. 17)

Title of Proposal: School Safety Initiative On behalf of: Arthur J Vayer, Jr, MD, FACS and Adlai Pappy, MD Describe the Idea or Issue: Given the tragic current events surrounding school shootings, and given the existing policy that the HOD has passed regarding such, we feel that the time is right to press for discussions with interested stakeholders to move forward with school safety plans. The MSV can reach out to Education Associations, State Education Boards, State Mental Health Agencies, Police Departments, Security Agencies, and perhaps others, as well as research what funds might be available via federal block grants to fund initiatives. Desired Outcome: Connection with stakeholders, formation of an action plan. Background/Supporting Information:

Resolution 16-208L was referred to the BOD, and was accepted as policy as amended.

Advocacy Summit Proposal No. 1

Title of Proposal: Reduce Firearm Risk On behalf of: The Richmond Academy of Medicine Describe the Idea or Issue: MSV has a number of policies supporting laws and regulations relating to firearms including: Policy 145.003 which promotes trauma control and increased public safety, Policy 17-204 which supports gun violence restraining orders as mechanisms to decrease gun related suicides and homicides and Policy 515.001 which opposes any type of domestic violence and supports the inclusion of educational material regarding resources, criminal laws, and prevention in government publications related to marriage and families. Research indicates that states which restrict access to firearms by abusers under restraining orders saw an 8% decrease in intimate partner homicides (Vigdor, et al). Research also indicates that individuals with prior misdemeanor convictions are at greater risk of future violence and firearm-related crimes (Wintemute, et al). District of Columbia vs. Heller upheld the right of individual states to impose restrictions on gun ownership. Desired Outcome: The Richmond Academy of Medicine requests that the Medical Society of Virginia staff seek to introduce (and actively support) legislation creating gun violence restraining orders (also known as extreme risk restraining orders) and legislation prohibiting gun ownership by individuals convicted of prior violent misdemeanors, such as 2018 SB 732. Furthermore, we ask the Medical Society of Virginia to oppose any legislation that would require reciprocal concealed carry permits in Virginia. Background/Supporting Information: SB732 from 2018 GA Session Background information can be found on pages 2-8 of appendix


Title of Proposal: Limit Sales of Assault Weapons On behalf of: The Richmond Academy of Medicine Describe the Idea or Issue: On February 16, 2018 the American Academy of Family Physicians, American College of Physicians, the American Academy of Pediatrics, the American College of Obstetrics and Gynecology and the American Psychiatric Association all renewed their call on government to act on the public health epidemic of gun violence including placing constitutionally appropriate restrictions on the manufacture and sale of assault weapons and large capacity magazines. On February 28, 2018 the American College of Surgeons reiterated their continued support of restrictions on assault weapons and large-capacity ammunition clips. Multiple studies have demonstrated an inverse relationship between limits on firearm ownership and gun-related death rates. Current MSV policy expresses support for future laws and regulations relating to firearms which would promote trauma control and increased public safety (Policy 145.003) and current MSV Policy also opposes any type of Domestic violence and supports the inclusion of educational material regarding resources, criminal laws, and prevention in government publications related to marriage and families (Policy 515.001). District of Columbia vs. Heller upholds the right of individual states to impose restrictions on gun ownership. Desired Outcome: The Richmond Academy of Medicine asks that the Medical Society of Virginia to actively pursue and endorse any legislation that limits sale and ownership of large capacity magazines, bump stocks, and firearms with features designed to increase their rapid firing ability as defined in H.R. 3355 of the 103rd Congress. Additionally, we ask that the Medical Society of Virginia actively pursue and endorse any legislation which promotes uniform/universal background checks for gun sales. Background/Supporting Information: District of Columbia vs. Heller Background information can be found on pages 9-11 of appendix


Title of Proposal: Amending current Physician Assistant Code to reflect current practices in Medicine On behalf of: Virginia Academy of Physician Assistants Describe the Idea or Issue: To better reflect current medical practices, harmonize Code with existing regulations, and improve access to care Desired Outcome: The introduction of legislation that will; • Change the definition of Supervision to Collaboration, • Remove physician liability, except in cases of physician directed care, • Update Code to reflect current standards of practice, • Remove current required language requiring attestation in the practice agreement by the physician to allow the establishment of a final diagnosis or treatment plan, • and remove the barrier as to how many PAs a physician may supervise Background/Supporting Information:

The delivery of health care by the Physician-PA team continues to undergo change. With the

development of unique practice environments, practices need to have the flexibility to respond to

rapidly expanding demands. The practice of PAs working side-by-side with physicians on a daily

basis has grown to more remote relationships, simply to respond to the ever-increasing demand

for access.

The Physician-PA relationship has undergone change, when often the patient load is shared and the

care plan jointly determined. The PA profession has grown and proven itself; when initially critically

watched and directed (supervision), the practice standard now is more of jointly determined care

with willing assistance (collaboration). Indeed, the term supervision has been misunderstood in the

administrative world, risking disenfranchisement. The term collaboration will ensure ongoing

communication between the Physician and PA team, ensuring the delivery of safe, cost-effective,

and quality health care that the patients we serve will benefit from.

The recommended updates to Code will maintain & strengthen the Physician-PA team, while

removing unnecessary liability to other team members.


Title of Proposal: New Legislation On behalf of: Kenneth Olshansky, MD Describe the Idea or Issue: MSV to support working with state board of education to set guidelines for healthy food in school vending machines to deal with obesity crisis. School vending machines have sugared sodas, candy bars, ice cream, chips, cinnabuns, etc., which will often be eaten instead of cafeteria food. Desired Outcome: To educate by setting an example of healthy vs. unhealthy vending items in hopes of impacting obesity. Background/Supporting Information:


Title of Proposal: Resolution To Regulate And License Pharmacy Benefit Managers Who Serve Virginians On behalf of: Harry L Gewanter, MD, FAAP, MACR Describe the Idea or Issue: WHEREAS, Current prices for pharmaceuticals are rising more quickly than other health care costs, and; WHEREAS, Rising insurance premiums, pharmaceutical copays, and out-of-pocket costs often result in the patient/consumer not being able to adhere to proposed treatment plans, and; WHEREAS, Pharmacy Benefit Managers (PBMs) currently determine the content of most formularies for health care plans and companies providing health care within the Commonwealth of Virginia, and; WHEREAS, PBMs also provide the majority of all pharmacy claim processing services, including but not be limited to negotiating drug prices, processing and adjudicating prescription requests, contracting with pharmacists or pharmacies, maintain pharmacy benefits networks, receiving payments for pharmacist services, making payments to pharmacists, negotiating, disbursing or distributing rebates, and handling all appeals, and; WHEREAS, PBM use of restricted formularies, prior authorization, utilization review and step therapy protocols are resulting in the disruption of the physician-patient relationship and interference in the agreed-upon individualized treatment care plans, and; WHEREAS, PBM contracts with local pharmacies often result in limiting the pharmacist’s scope of care or ability to provide pharmacist services, thereby frequently resulting in increased costs to patients/consumers, and; WHEREAS, All PBM activities are not currently licensed or regulated by the Virginia Insurance Commisioner; therefore be it RESOLVED, That the Medical Society of Virginia, in concert and collaboration with local and specialty physician organizations, pharmacist organizations, patient organizations and any other interested and affected parties work to develop and institute appropriate legislative and/or regulatory processes to ensure that the Virginia Insurance Commissioner has authority to appropriately oversee the actions of PBMs providing services to Virginians similar to the recently enacted Arkansas legislation (HB 1010). Desired Outcome: PBM's are brought under oversight and held accountable for their actions in the pricing, management and dispensing of medications to their Virginians


Background/Supporting Information: PBM's currently operate without regulation or oversight by anyone and are significantly responsible for the increasing costs of medications while also limiting the ability of prescribers and pharmacists to fully operate within our scope of practice. It is past time that they be subject to the same oversight as all other participants within the health care arena. Background information can be found on pages 12-44 of appendix

Title of Proposal: Commonwealth of Virginia Health Insurance Protection Act: Establishment of a Reinsurance Program On behalf of: Bruce A Silverman, MD Describe the Idea or Issue: The Federal government has sought to undermine the Affordable Care Act by eliminating the individual mandate, refusing to support the cost sharing reduction payments, withdrawing funds for promotion of the Health Insurance Exchange, as well as limited the open enrollment period. All of these factors have caused instability in the individual and small group marketplace for healthcare insurance. This has contributed to rising premiums and withdrawal of insurance carriers from this market. Desired Outcome: With this proposal we hope to bring additional insurance carriers into the individual and small group marketplace, in addition to creating a more favorable environment for lower premiums and coverage of persons with costly medical issues. Background/Supporting Information: There has been bipartisan support in the US Congress for establishment of a reinsurance program to help with this situation. Unfortunately due to the abortion issue among other factors they were unable to achieve agreement. Several other states, most recently Maryland, have successfully passed legislation to help improve the individual and small group marketplace. They have also sought to bring back the individual mandate at the state level and have restricted the use of non-ACA compliant or short-term insurance policies. Background information can be found on page 45 of appendix


Title of Proposal: Prior Authorization Elimination On behalf of: The Richmond Academy of Medicine Describe the Idea or Issue: Prescription prior authorization is a health plan cost-control process requiring providers to obtain approval before prescribing medications, which most often requires hours of uncompensated physician and staff work. Private offices and hospitals employ numerous people to cope with the added burdens of required prescription prior-authorizations which adds to overall health care costs. In addition, the lengthy processes may have negative consequences for patient outcomes when medications are delayed. In 2015 (with the help of the Medical Society of Virginia), Governor Terry McAuliffe signed a bill which was meant to improve transparency, uniformity and efficiency in the current prescription prior authorization process. Despite the current law existing, insurers still drag their collective feet when physicians try to settle prior authorization matters in a timely way for their patients. The current prior-authorization appeals process is arduous and oft impossible with the following common practices occurring: • Many appeals (unless “urgent”) take months to get a decision because most health plans don’t acknowledge receipt of appeal and often claim to not have received the appeal even though a fax confirmation exists; • Initial authorization requests are directed through an off-shore call center slowing down the authorization because of language barriers. • Some health plans require a written authorization from the patient in order to do an appeal, which is often required for medical services as well which slows down the process • When trying to get a drug authorized that is non-formulary, the health plan isn’t required to do a tier exception and the costs of the drug can be outrageous. • Generic drugs can be as expensive or more expensive than some brand name drugs • Health plans are requiring physicians to go through the prior authorization process to screen for contraindications, not trusting that the physician (and the pharmacy) is properly screening the patient Desired Outcome: The Richmond Academy of Medicine requests the Medical Society of Virginia make the elimination of Prior Authorization in Virginia a top legislative priority in 2018. We’d also like to see the Medical Society continue to work with Insurers and PBM’s and request they be more open and transparent about their approval (and rejection) processes and demand that they release information identifying the common evidence-based


parameters for insurers’ approval of the 10 most frequently prescribed chronic disease management prescription drugs, as required by the 2015 law. We would also like the Medical Society of Virginia to work with the General Assembly to push insurance companies to upgrade the electronic approval of prescription requests, which has been shown to bring cost savings in other states within a few years of its implementation. And finally, the Medical Society of Virginia should join the American Medical Association to aid in prior-authorization reform with a goal of building a dialogue between providers, health plans and their third parties to cut out needless administrative waste from the system and improve patient access to care including diagnostic testing, surgical procedures and medical therapies by eliminating prior authorization in Virginia. Background/Supporting Information: • Principles on Prior Authorization • Prior Authorization Editorial by Dr. Mark Monahan from 2.11.17 RTD Background information can be found on pages 46-60 of appendix

Title of Proposal: Step Therapy Appeal and Override Process Improvement On behalf of: The Richmond Academy of Medicine Describe the Idea or Issue: Step therapy or “fail first” protocols are policies, practices and programs established by utilization review agents that establish a specific sequence of interventions for specified medical conditions for enrollees. These protocols appear to be economically based in that they require patients to use a lower cost drug or service before permitting use of more expensive drugs or services. An increasing number of insurers are utilizing step therapy or fail first policies that require patients to try and fail one or more formulary covered medications before providing coverage for the originally prescribed non-preferred or non-formulary medicine, often at the expense of the health of the patient. For example, if a patient changes insurers or if a drug they are currently taking is moved to a non-preferred or non-formulary status, patients may be put through the step therapy process again even if the patient is stable. This could cause great harm to the patient. Step therapy is an established benefit management tool used by commercial carriers, self-insured employers, Medicare Advantage/Part D programs, and Medicaid as well as other utilization review agents such as pharmacy, radiology and therapy benefit managers and specialty pharmacies. The decision-making process and/or clinical evidence for the step therapy or fail first protocols and appeal/override decisions are frequently not revealed and often with no transparent, efficient or expedited step therapy or fail first protocol appeal process in exceptional clinical situations. Delays in appropriate treatment can result in significant and potentially permanent complications for patients. The act of appealing these protocols creates an undue burden on health care providers, their staff and patients, wasting valuable health care resources and increasing costs. Desired Outcome: The Richmond Academy of Medicine would like the Medical Society of Virginia, in collaboration with local and specialty physician organizations throughout the Commonwealth of Virginia (ideally in concert with local, state and national patient organizations), work to improve the step therapy appeal and override processes in Virginia using legislation similar to that passed in 18 other states as a model. Background/Supporting Information: Background information can be found on pages 61-62 of appendix


Title of Proposal: Resolution on Tobacco Control On behalf of: The Richmond Academy of Medicine Describe the Idea or Issue: Cancer incidence and overall health care costs in Virginia are clearly related to the use of tobacco products by our citizens. Virginia’s tax on cigarettes is only 30 cents per pack compared to the national average of $1.65 per pack. The tobacco habit resulting from nicotine frequently begins in youth where price is especially important. Increasing the tobacco tax and increasing funding for tobacco use prevention programs will dissuade young adults from initiating the use of tobacco products. Desired Outcome: The Richmond Academy of Medicine would like the Medical Society of Virginia to strongly support a tobacco tax equivalent to at least the national average as a measure to reduce tobacco use in our population and to support legislation which would require that the funds generated by an increase in the state tobacco tax be used to support health related programs for the citizens of the Commonwealth. Furthermore, RAM asks MSV to make this issue a high priority in 2019 to coincide with the American Cancer Society’s efforts in the next General Assembly Session. Background/Supporting Information: Background information can be found on pages 63-67 of appendix


Title of Proposal: Incentivize physicians to practice in underserved areas On behalf of: The Richmond Academy of Medicine Describe the Idea or Issue: Approximately one-fifth of the nation’s population lives in a rural area but only about 10 percent of the nation’s physicians are located there. This is considered to be one reason rural Americans have higher rates of death, disability and chronic disease than their urban counterparts. Rural communities often face challenges in maintaining an adequate health workforce, making it difficult to provide needed patient care or to meet staffing requirements for their facilities. Declining interest in primary care by medical students, a large number of rural primary care practitioners nearing retirement age and an increased demand for practitioners because of the aging baby-boomer generation all contribute to the primary care practitioner shortage in rural America. Much of the responsibility to combat these challenges falls on the states to find new ways to fill existing and future gaps in the health care delivery system. Desired Outcome: The Richmond Academy of Medicine asks the Medical Society of Virginia to support a line-item in the Commonwealth’s Budget that will offer matching grants with localities to create incentives to practice in rural communities. RAM would like MSV to work with local and federal agencies to find funding for incentives which may include housing and office set up and maintenance expenses. Furthermore, RAM would like for MSV to support the creation of and funding for a low interest loan-repayment program that uses interest-rate incentives for practicing in high-need specialties and in underserved communities in the Commonwealth of Virginia which would be open to any student enrolled at a Virginia Medical School. Finally, RAM would like MSV to support funding for the Commonwealth’s current loan repayment program as further incentive to practice in underserved areas. Background/Supporting Information: • Financial Incentives for practicing in underserved areas Background information can be found on pages 68-70 of appendix


Title of Proposal: Tax on Sugar-Sweetened Beverages On behalf of: The Richmond Academy of Medicine Describe the Idea or Issue: More than two-thirds of Americans are clinically obese or overweight, and numerous medical studies indicate those individuals are at a significantly higher risk of developing cancer, diabetes, heart disease, and other related medical ailments. The rising consumption of sugary drinks has been a major contributor to the obesity epidemic. Studies have shown that reducing sugary-sweetened beverages – defined by the CDC as any liquids that are sweetened with various forms of added sugars like brown sugar, corn sweetener, corn syrup, dextrose, fructose, glucose, high-fructose corn syrup, honey, lactose, malt syrup, maltose, molasses, raw sugar and sucrose with examples including but not limited to regular soda (not sugar-free), fruit drinks, sports drinks, energy drinks, sweetened waters, and coffee and tea beverages with added sugars – can lead to better weight control among those who are overweight. Studies have also shown that “a modest tax on sugar-sweetened beverages could both raise significant revenues and improve public health by reducing obesity.” Additionally, the AMA recognizes that taxes on beverages with added sweeteners is one means by which consumer education campaigns and other obesity-related programs could be financed in a stepwise approach to addressing the obesity epidemic. In cities where a sugar-sweetened beverage tax has been implemented, sales of sugar-sweetened drinks are falling and sales of water, unsweetened teas and milk are going up which suggests that people are substituting sugar-sweetened drinks with healthier alternatives. Desired Outcome: The Richmond Academy of Medicine asks the Medical Society of Virginia to support a statewide tax on sugar-sweetened beverages as a measure to help decrease obesity. Furthermore, funds raised by the tax should be used to develop effective and evidence-based approaches to addressing childhood obesity or health education. Background/Supporting Information: • Mexico’s sugar tax leads to fall in consumption for second year running • Obesity-related health care spending on the rise, study finds Advisory Board Daily Briefing • Soda Tax in Berkeley – Does Taxing Sugar Really Work, Time article • Time Article on Taxing Soda Background information can be found on pages 71-84 of appendix


Title of Proposal: Ending Surprise Billing/Providing Fair Payment for Out-of-Network Physicians On behalf of: VACEP Describe the Idea or Issue: Surprise coverage gaps are created by insurance carriers narrowing networks, a lack of transparency in pricing and costs, and a proliferation of high deductible plans that offer affordable premiums, but often leave patients underinsured. Our intent is to draft a comprehensive solution that benefits patients and physicians by banning surprise billing or ‘balance billing’ if a doctor is out of network, if they agree to receive a fair payment that is determined by using a neutral database and reimbursement schedule. Specifically, we believe such a comprehensive solution should include: - Require that surprise billing be banned if the OON physician accepts a fair payment; - Require that insurers pay the providers directly, not the patient. - Create a payment structure that establishes a reimbursement schedule at the 80th percentile of clinician Usual and Customary Charges (UCC), maintained by an independent non-profit not affiliated, financially supported and/or otherwise supported by an insurance carrier. - Create penalties for non-compliance by insures or providers Desired Outcome: VACEP, in coordination with the Virginia Academy of Family Physicians, VA Society of Anesthesiologists, VA Orthopaedic Society, VA Society of Eye Physicians and Surgeons, American College of Radiology- VA Chapter, VA Society of Plastic Surgeons, the American Academy of Pediatrics, VA Chapter, and the VHHA, will be introducing legislation in the 2019 session and would like the Medical Society to be an active member of the coalition and make this a top issue on their 2019 Legislative Agenda. Background/Supporting Information:


Title of Proposal: Prohibit Maintenance of Certification in Virginia On behalf of: Virginia Academy of Family Physicians Describe the Idea or Issue: Maintenance of Certification injects a burdensome, high-cost, bureaucracy into the practice of medicine. Desired Outcome: Prohibit hospitals and other entities that have organized medical staff or a process for credentialing physicians as members of staff or employ or enter into contracts for employment with physicians and are required to be licensed from requiring any Maintenance of Certification or Osteopathic Continuous Certification, as defined in the bill, as a condition of granting or continuing staff membership or professional privileges to a licensed physician. Prohibit accident and sickness insurance plans, health services plans, and health maintenance organizations from requiring any Maintenance of Certification or Osteopathic Continuous Certification as a condition of participation or reimbursement for a physician licensed by the Board of Medicine; and prohibit the Board of Medicine from requiring any Maintenance of Certification or Osteopathic Continuous Certification as a condition of licensure to practice medicine in the Commonwealth. Background/Supporting Information:


Documents

2018 Advocacy Summit Proposal Table of Contents - msv.org · 2018 Advocacy Summit Proposal . Table of Contents . 1. School Safety Initiative, Dr. Art Vayer & Dr. Adlai Pappy (p. 2)