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Second Opinion

Learn about policy issues important to medical schools and teaching hospitals, with Executive Vice President Atul Grover, M.D., Ph.D.

AAMC Opposes Senate Health Care Reform Bill

June 23, 2017—The Senate June 22 released a discussion draft of its health care reform bill, the Better Care Reconciliation Act of 2017 (BCRA). The bill would dramatically restructure Medicaid financing, modify the premium tax credits, and loosen 1332 waiver requirements, among other provisions.

AAMC President and CEO Darrell G. Kirch, MD, June 22 stated, “We are extremely disappointed by the Senate bill released today. Despite promises to the contrary, it will leave millions of people without health coverage, and others with only bare bones plans that will be insufficient to properly address their needs. As the nation’s medical schools and teaching hospitals see every day, people without sufficient coverage often delay getting the care they need. This can turn a manageable condition into a life-threatening and expensive emergency.”

Dr. Kirch added, “We urge members of the Senate to reject this bill and return to the drawing board to draft legislation that does not result in millions of Americans going without health insurance. The AAMC stands ready to work with Congress to craft a solution that protects and improves the health of all.”

The bill would make major changes to the financing of the Medicaid program. Beginning in fiscal year (FY) 2020, Medicaid would shift to a per capita system that would grow by the medical care component of the Consumer Price Index (CPI) for children, expansion adults, and other non-elderly/non-disabled/non-expansion adults. Beginning in FY 2025, the trend factor would be reduced for all eligibility groups to the growth of CPI-Urban. Additionally, beginning in FY 2020, states may opt to receive a black grant rather than federal Medicaid payments under a per capita cap. States would make the election for a five year period and could automatically continue their block grant programs for another five years.

The bill also phases-out enhanced funding for Medicaid expansion over three years beginning in 2021.Beginning in January 2024, states’ regular matching rates would apply to the expansion population.

The Senate bill largely maintains the advanceable and refundable tax credit structure as set forth by the House-passed American Health Care Act (AHCA, H.R. 1628). Beginning in 2020, individuals with incomes between 0-350 percent of the federal poverty level (FPL) will be eligible for a tax credit under BCRA, as opposed to 100-400 percent under current law. The bill also increases the amount individuals must contribute towards the cost of their coverage from between 2 to 9.5 percent under current law to 2 to 16.2 percent.

While the bill allows for an inpatient psychiatric service benefit, it lowers the level of specific funding for these services from $15 billion in the House-passed bill down to $2 billion. Finally, the bill allows states to apply for a waiver that would allow them to remove essential health benefit requirements, thus potentially permitting insurers to offer bare-bones plans.

The Senate is planning to vote on the legislation next week. However, several Senators have already expressed their opposition to the measure as currently drafted. It is unclear whether the legislation will be changed prior to being brought to the floor for a vote, or if it will be changed through the amendment process.

Contact:

Jason Kleinman
Sr. Legislative Analyst, Govt. Relations
Telephone: 202-903-0806
Email: jkleinman@aamc.org

Catie Spivey, JD
Sr. Legislative Analyst, Gov't Relations
Telephone: 202-862-6042
Email: cspivey@aamc.org

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AAMC Describes Consequences of Administration’s NIH Budget Request in Letter to OMB, HHS

June 23, 2017—AAMC President and CEO Darrell G. Kirch, MD, sent a June 16 letter to Secretary of Health and Human Services Thomas Price, MD, and Office of Management and Budget Director (OMB) Mick Mulvaney opposing the administration’s proposed $7.2 billion cut to the National Institutes of Health (NIH) in FY 2018 [see Washington Highlights, May 26].

The AAMC specifically highlighted how the administration’s proposal to reduce NIH facilities and administrative (F&A) support to 10 percent of NIH’s extramural research funding would jeopardize the viability of existing research programs, local economies, and the country’s global competitiveness. 

“Although also referred to as ‘indirect’ costs, F&A expenditures are directly related to and necessary for support of biomedical research at our member institutions – they are expenses that institutions incur because of the federal research they conduct,” the AAMC noted, while providing examples of expenses such as laboratory maintenance, data processing and storage, safety and security in use of chemicals and biologics that research institutions must provide in the performance of government sponsored research.

“Please make no mistake,” Dr. Kirch wrote, “a cut to F&A reimbursement is a cut to biomedical research.” The letter points out that allowable facilities and administrative charges are negotiated by academic institutions with strict federal auditing agencies based on actual records of real expenses incurred.  Additionally, the letter indicates that the current share of the NIH extramural budget spent for F&A reimbursements, approximately 27 percent, has not grown for more than a decade. The AAMC also noted that comparisons between federal F&A reimbursements and costs covered by private philanthropies and foundations are misleading, due to differing methodologies for accounting for costs related to research differing research missions and strategies between the two types of entities. 

The AAMC concluded, “A cap or flat rate could well have the unintended long-term consequences of consolidating remaining research programs into fewer institutions by making research costs prohibitive for smaller and geographically diverse academic medical centers…It could also discourage institutions from pursuing cutting-edge research requiring specialized facilities. Reduced F&A recovery would also result in layoffs and losses of skilled jobs, not because of gains in efficiency but from institutions cutting back on their research programs.”

Contact:

Tannaz Rasouli
Sr. Director, Public Policy & Strategic Outreach
Telephone: 202-828-0525
Email: trasouli@aamc.org

Stephen Heinig
Director, Science Policy
Telephone: 202-828-0488
Email: sheinig@aamc.org

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AAMC, Academic Medicine Caucus Host Hill Briefing on VA Affiliations

June 23, 2017On behalf of the Congressional Academic Medicine Caucus (CAMC), the AAMC hosted a June 20 congressional briefing titled VA and Academic Medicine: Partnering for Veterans’ Health . The briefing highlighted the role of the Department of Veterans Affairs’ (VA) affiliated medical schools and teaching hospitals across their three shared missions of patient care, education, and research, as well as how these partnerships ultimately benefit veterans and all Americans.

House Committee on Veterans Affairs Chair Rep. Phil Roe, MD, (R-Tenn.), who also co-chairs the CAMC and the GOP Doctors Caucus, provided opening remarks, opining, “The VA has seen a lot of changes since I left medical school.” Dr. Roe, who attended the James H. Quillen College of Medicine at East Tennessee State University, a medical school created with federal support in conjunction with VA, highlighted administrative demands on physicians, and the need to “clear the field and bring the joy back into medicine.”

The session was moderated by AAMC Chief Public Policy Officer Karen Fisher, JD, and featured VA Deputy Chief Academic Affiliations Officer Karen Sanders, MD, and AAMC Chief Academic Affairs Officer John Prescott, MD, as speakers. “You can’t tell us apart,” Dr. Sanders said describing the seamless overlap of VA and academic affiliate staff, trainees, programs, and research.

Doctors Sanders and Prescott outlined how the 70-year partnerships have improved Veteran’s health care, including:

  • Improved access to complex specialized care at the nation’s leading teaching hospitals;

  • A history of ground-breaking veteran-centric research advancements; and

  • Developing the clinical and cultural competence of the next generation of physicians who will care for veterans both inside and outside the VA system.

Ms. Fisher and the panelists also discussed recommendations to build on past success, including expanding VA graduate medical education, increased funding for the VA research program, streamlining clinical contracting, and ensuring the relationships are maintained in upcoming VA health reform legislation [see Washington Highlights, June 9]

Contact:

Matthew Shick, JD
Director, Gov't Relations & Regulatory Affairs
Telephone: 202-862-6116
Email: mshick@aamc.org

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AAMC Joint Letter Requesting an Extension to the Compliance Date for the Common Rule

June 23, 2017—The AAMC June 21 joined the Association of American Universities (AAU), the Association of Public and Land Grant Universities (APLU), and the Council on Government Relations (COGR) in a letter to the Department of Health and Human Services (HHS) Director of the Office for Human Research Protections (OHRP) Jerry Menikoff, MD, JD.

The letter requests a delay in the compliance date of the Federal Policy for the Protection of Human Subjects (“the Common Rule”) to January 19, 2019, one year from the January 18, 2018 effective date, which would allow institutions to implement the changes to the regulation throughout that one year period instead of having to be compliant with the regulations on the effective date.

On January 19, 2017, HHS and 15 other federal departments and agencies released the final revisions to the Common Rule which governs federal supported research involving human subjects [see Washington Highlights, Jan. 19].  These revisions represent the first changes to the regulations since it was issued in 1991. The AAMC submitted a letter to HHS in response to the agency’s request for comments on the Notice of Proposed Rulemaking [see Washington Highlights, Oct. 28, 2011] and the Advanced Notice of Proposed Rulemaking [see Washington Highlights, July 29, 2011].

Signatories to the letter express significant concerns about the process for implementing these changes, which include educational efforts, drafting policies, and establishing new processes and information technology systems. The letter adds, “[a]s a result of the uncertainty surrounding the status of the revised Common Rule over the course of the last five months, and the significant costs involved, universities, medical schools, and other entities have been hesitant to fully move forward in implementing the rule.”

Further, since there are several guidance documents and templates that have not been issued and for which institutions will rely to draft their policies, the letter notes that “[…] such a delay in the compliance date of the Common Rule will be beneficial for all affected institutions and relevant agencies. Importantly, this time could be used to advance harmonization efforts to align the FDA’s human subject protection regulations with the Common Rule as required by the 21st Century Cures Act.”

Contact:

Heather Pierce, JD, MPH
Sr. Director, Science Policy & Regulatory Counsel
Telephone: 202-478-9926
Email: hpierce@aamc.org

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Senate Panel Slams Administration’s NIH Budget Request, F&A Proposal

June 23, 2017—Both Republican and Democratic members of the Senate Labor-HHS-Education Appropriations Subcommittee rejected the president’s fiscal year (FY) 2018 budget request for the National Institutes of Health (NIH) [see Washington Highlights, May 26] – including the administration’s proposal to limit NIH reimbursement for facilities and administrative (F&A) expenses – at a June 22 hearing featuring NIH Director Francis Collins, M.D., Ph.D. and the directors of six NIH institutes.

Subcommittee Chair Roy Blunt (R-Mo.) characterized the administration’s proposed cut to NIH as “unacceptable,” describing the job losses and decreased economic activity that would result.

Senators in both parties also expressed strong concerns over the budget proposal to limit NIH F&A support, also referred to as “indirect costs.” Senator Lamar Alexander (R-Tenn.), who chairs the Senate Health, Education, Labor, and Pensions (HELP) Committee, slammed the recommendation as “harebrained” and an “awful idea” that is “bad policy,” noting that institutions use their own funds to pay for many expenses that current F&A reimbursement does not cover. “The net effect [of proposals to reduce F&A support] would be less research,” he chided, “and less research ... means more jobs moving overseas.”

Senator Alexander also warned the administration, “If there’s to be any changes to this, Congress wants to be involved. I’m going to get in the middle of that, and I’ll bet I can get a bipartisan group up to make sure we are.” Instead, he said, the administration should be looking at opportunities to reduce the administrative burden associated with research, a point Senator James Lankford (R-Okla.) also encouraged.

Full Committee Ranking Member Patrick Leahy (D-Vt.) and Subcommittee Ranking Member Patty Murray (D-Wash.) described the expected consequences of the F&A proposal on research institutions in their states. In response to a question from Senator Murray about what the impact would be if the F&A limitation were applied to the NIH’s intramural program, Dr. Collins responded, “I’m having a hard time imagining how we would manage that.”

Dr. Collins also noted that NIH is hoping to work with the community to identify and potentially address some administrative burdens, such as regulations on conflicts of interest, animal care, and effort reporting, but indicated, “Frankly, I don’t think it would add up to an enormous difference in what we’re currently asking our grantee institutions to do, and they are the ones who do the work. We depend on them.”

Chairman Blunt also inquired about the administration’s proposal to eliminate the NIH’s Fogarty International Center (FIC), which Anthony Fauci, M.D., director of the NIH’s National Institute of Allergy and Infectious Disease (NIAID), described as central to recent efforts to combat Ebola and Zika by training scientists abroad, since “Infectious disease knows no borders.”

In response to a question from the chairman about the budget request’s establishment of a new NIH institute to replace the Agency for Healthcare Research and Quality (AHRQ), Dr. Collins described the two agencies’ work as complementary, and acknowledged that an alternative model to the president’s proposal would be to disperse AHRQ’s existing work throughout NIH’s existing institutes and centers.

Senators Dick Durbin (D-Ill.) and Jerry Moran (R-Kan.) both suggested opportunities to help NIH attract better name recognition within the general public, with Senator Durbin hinting at an interest in labelling products that originate from NIH-funded research.

Senator Moran also asked how NIH research differs from research supported through the Department of Veterans Affairs and expressed concern over NIH’s support for researcher salaries, which he indicated he planned to revisit after the hearing.

In addition to the questions about NIH’s work, Senators Murray and Jeanne Shaheen (D-N.H.) also alluded to legislation released the same day to replace the Affordable Care Act (see related story). Both senators described challenges that would result from the efforts, including reduced access for patients seeking treatment for substance use disorders and other conditions.

Tannaz Rasouli
Sr. Director, Public Policy & Strategic Outreach
Telephone: 202-828-0525
Email: trasouli@aamc.org

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CMS Proposes Changes to the Quality Payment Program for 2018

June 23, 2017—The Centers for Medicare and Medicaid Services (CMS) June 20 released a proposed rule that would make changes to the Quality Payment Program under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA, P.L. 114-10) for 2018.  In the rule, CMS includes a number of provisions that address concerns raised by the AAMC and other physician groups that would alleviate burden.

Key proposals from CMS include:

  • Increasing the low volume threshold to exempt more clinicians in small practices from participation in the program;
  • Continuing to allow the use of 2014 Edition CEHRT (Certified Electronic Health Record Technology) in year two of the program;
  • Adding bonus points to the scored for eligible clinicians for caring for complex patients;
  • Rewarding eligible clinicians for performance improvement under the merit-based incentive payment system (MIPS) through changes to the scoring method;
  • Allowing facility-based scoring for facility-based clinicians based on the Hospital Value Based Purchasing Program;
  • Extending the 0 percent weight of the cost performance category in the 2020 MIPS payment year. For 2021 and beyond, the weight of the cost category would be increased to 30 percent;
  • Providing more detail on how eligible clinicians in Alternative Payment Models (APMs) will be assessed under the APM scoring standard;
  • Adding a fourth snapshot date of Dec. 31 for the purpose of determining participating in full taxpayer identification number (TIN) MIPS APMs;
  • Giving more detail on how the All-Payer Combination option used to determine whether eligible clinicians meet the threshold to be qualified participants in an Advanced APM is calculated; and
  • Exempting Round 1 participants in the Comprehensive Primary Care Plus Model (CPC+) from the requirement that the medical home standard applies only to APM entities with fewer than 50 clinicians in their parent organization.

The AAMC is analyzing the provisions of the proposed rule and will submit comments to CMS by the August 18 deadline. A CMS fact sheet on the proposed rule provides more details.

Contact:

Gayle Lee
Director, Regulatory Counsel
Telephone: 202-741-6429
Email: galee@aamc.org

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NQF Proposes Changes to Measure Endorsement Process

June 23, 2017—The National Quality Forum (NQF) recently released a draft report outlining recommended changes to their Consensus Development Process (CDP) that governs how quality measures are reviewed and endorsed. The NQF, Centers for Medicare and Medicaid Services (CMS), and other stakeholders met for a two-day process improvement event (also referred to as a Kaizen) in May to address improving coordination and streamlining the measure evaluation process. The report summarizes the discussion and recommendations from this event.   

In the report, NQF recommends the following changes to the measurement review and endorsement process:

  • Establishing a technical advisory panel in conducting methodological reviews of submitted measures;
  • Requiring that measure developers and stewards notify NQF in advance of their intent to submit measures for review;
  • Expanding the measure evaluation commenting period to 12 consecutive weeks;
  • Enhancing education and training for stakeholder participation and engagement; and
  • Allowing only NQF members to signal support for measures under review.

Comments on the draft report are due Friday, June 23. The AAMC will submit comments on these proposals.

Contact:

Scott Wetzel, M.P.P.
Lead, Quality Reporting
Telephone: 202-828-0495
Email: swetzel@aamc.org

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NQF Releases Trial Period Evaluation Report

June 23, 2017—The National Quality Forum (NQF) June 8 released a draft report evaluating their two year sociodemographic status (SDS) trial period, which concluded in April 2017. Under the trial, a prohibition on including social risk factors in the risk adjustment models of NQF-endorsed measures was lifted and certain measures could be adjusted to account for patient economic and demographic factors. The AAMC and other stakeholders have emphasized concerns that SDS factors impact a provider’s ability to influence patient outcomes, including readmissions and cost.

As noted in the report, approximately 300 measures were reviewed during the two-year trial, of which 17 were endorsed with an SDS adjustment. While a number of measures used in the Medicare hospital reporting and performance programs were reviewed, none were adjusted to account for social risk in the risk adjustment methodology.

The report cited a number of key findings and challenges from the trial period, including the following:

  • Overall lack of patient-level data in which to adjust measures;

  • Use of race and ethnicity as a proxy for SDS, despite previous recommendations not to do so;

  • Variability among measure developers concerning which social risk factors to test;

  • Variability in defining the conceptual basis for SDS adjustment; and

  • Limited implementation of measures adjusted for social risk.

The Disparities Standing Committee, which has been tasked with evaluating the totality of the trial period, met in June to discuss these challenges and next steps.The NQF Board of Directors is expected to make a decision on future inclusion of SDS factors in quality measurement in July 2017.

Contact:

Scott Wetzel, M.P.P.
Lead, Quality Reporting
Telephone: 202-828-0495
Email: swetzel@aamc.org

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On the Hill

June 23, 2017—Republican Ralph Norman won a June 20 special election in South Carolina to fill a seat vacated by Office of Management and Budget Director Mick Mulvaney.

Republican Karen Handel won a June 20 special election in Georgia to fill a seat vacated by Health and Human Services Director Tom Price, MD.

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Washington Highlights, a weekly electronic newsletter, features brief updates on the latest legislative and regulatory activities affecting medical schools and teaching hospitals.


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For More Information

Jason Kleinman
Sr. Legislative Analyst, Govt. Relations
Telephone: 202-903-0806
Email: jkleinman@aamc.org