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Second Opinion Podcasts

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

Congress Recesses for August District Work Period

The House and Senate will adjourn Aug. 7 through Sept. 7 for the summer recess and Labor Day holiday. Both chambers will be in session starting Tuesday, Sept. 8. Washington Highlights will resume in September.


Ways and Means Members Introduce Bills to Reform Medicare Hospital Payments

July 31, 2015 —Members of the House Ways and Means Committee July 29 introduced three bills to reform Medicare hospital payments. The bills, which would likely become part of a larger hospital bill the committee would consider in the fall, were released shortly after two recent Health Subcommittee hearings focused on various Medicare hospital payment issues [see related story].

The three bills would drastically reform Medicare indirect graduate medical education (IME) payments, create a site neutral payment policy for certain inpatient and outpatient surgeries, and redesign disproportionate share hospital (DSH) payments.

The Medicare IME Pool Act of 2015 (H.R. 3292) introduced by Health Subcommittee Chair Kevin Brady (R-Texas), would fundamentally change Medicare IME payments by decoupling IME from hospital discharges and instead providing standardized lump-sum payments to teaching hospitals. This approach would also disregard the intent of such payments to help offset costs related to the unique missions of teaching hospitals and the care they provide to complex patient populations.

The bill creates a new formula that redistributes IME funding across hospitals in a “lump-sum, bi-monthly basis.” A newly created “IME pool” will be initially funded at $9.5 billion for fiscal year (FY) 2019 and available to each hospital at a flat amount, regardless of how many Medicare patients are treated, intensity of GME training, or availability of continuous specialized services.

Committee Chair Paul Ryan (R-Wis.) introduced The Medicare Crosswalk Hospital Code Development Act of 2015 (H.R. 3291), which would lay the groundwork for a new site-neutral payment system. The bill directs the Secretary of Health and Human Services (HHS) to develop a Healthcare Common Procedure Classification System (HCPCS) version of Medicare Severity Diagnosis Related Group (MS-DRG) codes for ten surgeries the Secretary determines to be comparable between the inpatient and outpatient settings.

The “crosswalk” would serve as a guide to compare the inpatient and outpatient payment systems and serve as the basis for site neutral payment reform. The crosswalk is required to be completed no later than Jan. 1, 2018.

Finally, The Strengthening DSH and Medicare Through Subsidy Recapture and Payment Reform Act of 2015 (H.R. 3288), introduced by Health Subcommittee member Rep. Kenny Marchant (R-Texas) and Human Resources Subcommittee Chair Charles Boustany, Jr., M.D. (R-La.), would reform the way Medicare pays hospitals who care for a disproportionate share of uninsured or under-insured patients.

The bill creates a new empirically justified DSH pool, annually funded at $3.3 billion, and reimburses DSH hospitals through “lump sum payments” rather than the current add-on payment structure, beginning in FY 2017. The bill also creates an additional DSH payment for qualifying inpatient prospective payment system (IPPS) hospitals located in states that have not expanded Medicaid under the Affordable Care Act (ACA, P.L. 111-148 and P.L. 111-152).

To offset the cost of the legislation, H.R. 3288 authorizes the Internal Revenue Service (IRS) to “recapture” 100 percent of improperly paid subsidies used to purchase insurance on the federal health care exchange.

Contact:

Len Marquez
Director, Government Relations
Telephone: 202-862-6281
Email: lmarquez@aamc.org

Courtney Summers
Legislative Analyst
Telephone: 202-862-6042
Email: csummers@aamc.org

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AAMC Endorses Medicare Cap Relief for Certain VA Affiliates

July 31, 2015 —AAMC President and CEO Darrell G. Kirch, M.D., July 31 sent a letter  to Sen. John Tester (D-Mont.) endorsing the Senator’s proposal to expand Medicare funding for Graduate Medical Education (GME) under the “Delivering Opportunities for Care and Services (DOCs) for Veterans Act” (S. 1676).  If passed, the bill would allow teaching hospitals at or above their Medicare GME cap to receive additional Medicare support for residents who rotate through Veterans Affairs (VA) positions created under the Veterans Access, Choice, and Accountability Act of 2014 (VACAA, P.L. 113-146) [see Washington Highlights, June 19].

In the letter, Dr. Kirch notes, “VA physician shortages are symptomatic of a broader trend, the proverbial ‘canary in the coal mine.’” While VACAA “instructs VA to add 1,500 GME residency slots over five years at VA facilities that are experiencing shortages,” the letter cautions, “simply increasing VA GME funding alone will not address the VA crisis.” Dr. Kirch explains that “VA residency programs rely upon the existing administrative and training infrastructure maintained by the nation’s medical schools and teaching hospitals,” and “[w]ithout a corresponding increase in Medicare GME support, VA medical centers will be unable to capitalize fully on increases in VA GME funding.”

Meanwhile, Sen. Tester offered and withdrew his legislative language at a July 22 Senate VA Committee business meeting. He stated, “Because of the current cap on Medicare funded residency positions, the VA’s effort to carry out the Choice Act provision to establish up to 1,500 additional residencies has been impeded.” He concluded, “Look, I don’t care if you’re in the VA or in the private sector, we don’t have enough docs.” In response, Senate VA Committee Chair Johnny Isakson (R-Ga.) indicated he would be happy to work with Sen. Tester on this issue.

Contact:

Matthew Shick, J.D.
Senior Legislative Analyst, Government Relations
Telephone: 202- 828-0525
Email: mshick@aamc.org

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AAMC Supports Bill to Expand and Improve Conrad 30 Physician Immigration

July 31, 2015 —AAMC President and CEO Darrell G. Kirch, M.D., July 28 sent a letter  to the sponsors of the “Conrad 30 and Physician Access Act” (S. 1189), with AAMC’s endorsement of the bill to improve and make permanent the State Conrad 30 J-1 visa waiver program [see Washington Highlights, May 8].

Dr. Kirch highlights the success of the program, “In the last decade alone, the Conrad 30 program has directed nearly 10,000 physicians into health professions shortage areas (HPSAs),” but notes that there are “more than 59 million people living in primary care HPSAs and it would take over 8,100 new primary care physicians to fill these deficits.”

Specific to the legislation, Dr. Kirch states, “Importantly, S. 1189 would provide up to three J-1 visa waivers per fiscal year per state for physicians in academic medical centers. Our nation’s medical schools and teaching hospitals train all J-1 visa physicians, but are often prohibited from recruiting these physicians.”

The letter also cautions that “the primary barrier for graduates of international medical schools to practicing in the U.S. is the cap on Medicare support for GME imposed by the Balance Budget Act of 1997,” and, “Eliminating this bottleneck in the medical education pipeline is critical to improving physician immigration and addressing national workforce shortages.”

Contact:

Matthew Shick, J.D.
Senior Legislative Analyst, Government Relations
Telephone: 202- 828-0525
Email: mshick@aamc.org

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House Ways and Means Hearing on Rural Health Disparities

July 31, 2015 —The House Ways and Means Health Subcommittee held a hearing July 28 on rural health care disparities and Medicare regulations.

Building on a July 22 hearing on hospital payment issues [see Washington Highlights, July 24] Health Subcommittee Chair Kevin Brady (R-Texas) opened the hearing stating, “We are in the midst of a great opportunity to reform how Medicare reimburses hospital and post-acute care providers.” The Chair expressed his desire to focus on rural hospital challenges; specifically physician workforce shortages, which he called “a reality in many parts of this country,” the 96-hour rule on patient status at critical access hospitals (CAHs), and physician supervision.

Ranking Member Jim McDermott, M.D. (D-Wash.) echoed Brady’s support for addressing disparities in rural communities, but urged “we also need to make long-term investments in our health professional workforce. The United States faces a growing shortage of physicians nationally, projected to reach between 46,000 and 91,000 by 2025.” 

McDermott then cautioned his colleagues saying, “We should be skeptical that the solution to this problem lies in gutting Medicare support for graduate medical education in urban areas. There is minimal evidence that this will result in more doctors practicing in rural areas. It will simply exacerbate the nationwide doctor shortage and lower the quality of training they receive. There are better ways to train physicians to serve in rural areas, and I encourage my colleagues to look to creative alternatives.”

Testifying before the subcommittee were Tim Joslin, CEO, Community Regional Medical Center (Calif.); Shannon Sorensen, CEO, Brown County Hospital (Neb.); Carrie Saia, CEO, Holton Community Hospital (Kan.); and Daniel Derksen, Director, Arizona Center for Rural Health.

Referencing testimony provided last week by MedPAC Executive Director, Mark Miller, Ph.D., Chairman Brady asked Joslin if he had seen problems in his local community regarding the lack of correlation between expanding rural GME residency slots and the physician retention.

Joslin responded that in his experience, physicians who train in rural areas are more likely to stay. However, he cited that there are still issues, including the need to fund additional residency positions, adding that Congress “needs to respectfully revisit” the caps imposed by the Balanced Budget Act of 1997, which fixed Medicare’s support for GME training slots at 1996 funding levels.

Rep. Danny Davis (D-IL) then asked the panel what existing incentives could be “tweaked” to make a serious impact on the ability to recruit physicians and other medical personnel to rural areas other than destabilizing Medicare reimbursement rates.

Joslin highlighted two components to the problem stating it’s not just, “How you tweak the system, but I think you need to start with the fundamental realization that the system is flawed, because it just doesn’t produce enough.” He further suggested providing “some type of incentive for physicians to want to go and train in these areas, whether it’s financial incentives for educational purposes,” but urged, “The sheer magnitude of the issue is just the lack of enough slots.”

Both Sorensen and Saia agreed that Congress should leverage student loan forgiveness programs to incentivize physicians to stay in rural communities.

Inquiring of the vital partnership between community hospitals and larger medical centers, Rep. McDermott asked Sorensen how Brown County Hospital handles the care of stroke patients. Sorensen stated the hospital utilizes, “some of the stroke care they are doing through the University of Nebraska Medical Center” adding that while they are equipped to provide medication to such patients, the course of treatment “also depends on making sure they are stable before going on that lengthy of a transfer.”

Sorensen further highlighted that the total number of air transfers in the first half of the calendar year to the University of Nebraska Medical Center has exceeded the total number of air transfers of the last calendar year entirely, adding that the increase is likely due to “acuity and timeliness of patients.”

Contact:

Len Marquez
Director, Government Relations
Telephone: 202-862-6281
Email: lmarquez@aamc.org

Courtney Summers
Legislative Analyst
Telephone: 202-862-6042
Email: csummers@aamc.org

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NIH Releases Alzheimer’s Disease Professional Budget

July 31, 2015 —The National Institutes of Health (NIH) July 27 released its first Professional Judgment (PJ) Budget estimating the additional federal funds needed to find effective interventions to treat and prevent Alzheimer’s disease and related dementias by 2025—the primary research goal of the National Plan to Address Alzheimer’s Disease.

Entitled “Reaching for a Cure: Alzheimer’s Disease and Related Dementias Research at NIH,” the document outlines the toll Alzheimer’s takes on the nation and the scientific opportunities NIH could pursue with enhanced funding in fiscal year (FY) 2017. NIH estimates it will need an additional $323 million above its estimated base budget in FY 2017 to continue progress toward the goal of preventing and treating Alzheimer’s disease and related dementias by 2025.

The budget includes a set of specific, targeted milestones; areas poised for future discoveries; and areas of research that stand to benefit the most from intensified investment in FY 2017. 

National Institute on Aging (NIA) Director Richard Hodes, M.D., presented the budget to the Secretary of Health and Human Services’ Advisory Council on Alzheimer’s Research, Care and Services.

In a statement, NIH Director Francis Collins, M.D., Ph.D., said the plan “outlines the optimal approach NIH would take in an ideal world unconstrained by fiscal limitations to make real and lasting progress against this devastating group of disorders.”

“Through this plan, NIH is proposing an investment in hope—hope grounded in biomedical research,” Dr. Collins said, adding, “We believe that if we expand and build upon our base of scientific knowledge, we can identify and implement the strategies for combating Alzheimer’s disease that are so desperately needed.”

The Consolidated and Further Continuing Appropriations Act of 2015 (P.L. 113-235), Division G, Section 230, mandates NIH to prepare and submit to the president, for review and transmittal to Congress, an annual professional judgment budget for Alzheimer’s disease through 2025.

This approach is often referred to as a “bypass budget” because of its direct transmission to the president and then to Congress without modification through the traditional federal budget process. Cancer and HIV/AIDS are the only other areas of biomedical research that have been the subject of such special budget development.

Contact:

Dave Moore
Senior Director, Government Relations
Telephone: 202-828-0559
Email: dbmoore@aamc.org

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House Panel Explores DoD Anthrax Shipments

July 31, 2015 —The House Energy and Commerce Subcommittee on Oversight and Investigations July 28 held a hearing entitled, “Continuing Concerns with the Federal Select Agent Program: Department of Defense Shipments of Live Anthrax.” The hearing focused on shipments of live anthrax from a Department of Defense (DoD) laboratory at the Dugway Proving Grounds in Utah that occurred over nearly a 10-year period.

Subcommittee Chair Tim Murphy (R-Pa.) opened the hearing describing what he called “a pattern of recurring issues of complacency and a lax culture of safety.”

He said, “And despite the growing number of red flags, these incidents keep happening…. Apparently Dugway's process to inactivate anthrax spores was not fully effective. And the sterility testing used to validate and ensure that the anthrax spores were inactivated failed to detect the live anthrax spores. What's most troubling, however, is that Dugway used this potentially deadly process for years.”

“[T]his is completely unacceptable,” the chairman said, adding, “These dangerous safety lapses at our high-containment labs are threatening our nation's security and public health.”

Rep. Frank Pallone (D-N.J.), the ranking member on the full committee, said that “incidents in the past year involving anthrax, Ebola, and highly-pathogenic avian flu raise questions about whether we need to strengthen our federal oversight of labs that are working with dangerous pathogens.”

Reiterating a question posed by other subcommittee members, Ranking Member Rep. Diana DeGette (D-Colo.), asked, “Do we need to have 200 labs working with anthrax, or is it possible that we could limit the number of labs and therefore limit the risk while still being able to do this important research?” She urged the chairman to hold another hearing in the fall after the agencies have figured out what improvements in standardization and oversight are going to occur.

Department of Defense Deputy Assistant Secretary of Defense for Chemical and Biological Defense David Hassell told the subcommittee the recently completed comprehensive review of the causes of the incident found “the primary systemic issue is the lack of specific validated standards to guide the development of protocols, processes and quality assurance measures.” He acknowledged during questioning that “different chains of command has been one of the fundamental problems here, because each laboratory reports up to a different chain.”

Centers for Disease Control (CDC) Deputy Director of the Office of Public Health Preparedness and Response Daniel Sosin, M.D., M.P.H, testified, “The Federal Select Agent Program relies primarily on sterility testing to assure that a select agent can no longer grow. We remain unsure whether there was a problem with the execution of this testing at Dugway, or if the biology of spores as not sufficiently understood to make the procedure reliable.”

He said CDC is “maintaining a moratorium on the use and transfer of inactivated anthrax spores until we have an acceptable and credible approach to increasing safety and security, and we are developing a research agenda on spore biology to answer questions about inactivation and sterility, and we will help to conduct some of that research.”

Health and Human Services (HHS) Office of Inspector General (OIG) Chief Counsel to the Inspector General Greg Demske told the subcommittee that OIG is expanding its audits and evaluations of Select Agent management, and will focus on CDC’s oversight of the Select Agent Program and on the operation of HHS laboratories that handle select agents.

Government Accountability Office (GAO) Healthcare Director Marcia Crosse, Ph.D., testified that “the incidents you are examining today are part of a long series of safety lapses. Since 2007, GAO has reported on these issues and has made multiple recommendations to improve federal oversight of high-containment laboratories.”

Dr. Crosse noted the federal departments “have not implemented our key recommendation to establish a single federal entity with responsibility for oversight of all high-containment laboratories.” She added that “the lapses we've seen are indicative of failures in a system that is supposed to have multiple levels of control, including cross checks, inspections, training, procedures, and validated protocols that should prevent such accidents from occurring, and certainly should prevent such incidents from recurring.”

Asked to expand on GAO’s oversight recommendation Dr. Crosse continued, “I think that we're concerned that there hasn't been kind of a consistent set of standards in place, a consistent understanding of what the needs are, a consistent plan developed for where these laboratories ought to be built and maintained, and what the costs are going to be over the long-term for maintaining this kind of infrastructure, and whether it is in line with the needs.”

Contact:

Dave Moore
Senior Director, Government Relations
Telephone: 202-828-0559
Email: dbmoore@aamc.org

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BPC Briefing Discusses Development of Cures Companion

July 31, 2015 —Senate Health, Education, Labor, and Pensions (HELP) Committee Chair Lamar Alexander (R-Tenn.), House Energy and Commerce Committee Ranking Member Diana DeGette (D-Colo.), and Rep. Michael Bennet (D-Colo.), July 27 spoke at a Bipartisan Policy Center (BPC) briefing that centered on a recently released  BPC report entitled, Advancing Medical Innovation for a Healthier America.

The report recommends accelerating the pace by which drugs and medical devices become available to patients by improving the regulatory environment for approval. The BPC panel included former Sen. Bill Frist, M.D. (R-Tenn.), former Rep. Bart Gordon (D-Tenn.), and several researchers and health advocates. The speakers aired strong support for medical research at the National Institutes of Health. 

The report includes four broad categories of recommendations:

  • Improving the medical product development process, and to ensure patient perspectives are included in the benefit-risk assessment associated with regulatory decision-making;
  • Increasing regulatory clarity regarding the development of  a precision medicine framework, health information technology (HIT), and laboratory developed tests (LDT); 
  • Strengthening the Food and Drug Administration’s (FDA) ability to carry out its mission; and
  • Improving patient access to medical products for unmet and public health needs.

Sen. Alexander stated that the HELP committee would closely consider the recommendations as it develops legislation complimentary to the 21st Century Cures Act (H.R. 6), bipartisan legislation developed in the House Energy and Commerce Committee and approved July 10 by the House [see Washington Highlights, July 10].

Contact:

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

Anurupa Dev, Ph.D.
Science Policy Analyst
Telephone: 202-862-6048
Email: adev@aamc.org

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Forum on Bipartisan Support for NIH, and Publicly Funded Science

July 31, 2015 —The Congressional Middle Class Prosperity Project held a public forum July 27 entitled, “Building the Economy of the Future: Why Federal Investments in Science and Innovation Matter.”  Former House Speaker Newt Gingrich, Ph.D. (R-Ga.), as well as academic scholars of science and technology policy, provided expert testimony on the importance of strengthening federal investments in scientific research to grow our economy and create jobs.

The Middle Class Prosperity Project is a collaborative effort by Sen. Elizabeth Warren (D-Mass.), ranking member of the Banking, Housing, and Urban Affairs Subcommittee on Economic Policy and Rep. Elijah Cummings (D-Md.), ranking member of the House Committee on Oversight and Government Reform, aimed at focusing greater congressional and public attention on the challenges facing the middle class, and to formulate and implement concrete policy changes in order to address these challenges. 

Gingrich called for substantial expansion of funding for the National Institutes of Health (NIH), arguing that diseases like Alzheimer’s present a liability of trillions of dollars, dwarfing the current level of investment in medical research. He proposed that it will be impossible to balance the federal budget again without a greater investment in NIH, although he also would consider alternative mechanisms, such as bond issues and prizes to stimulate funding, given the challenges of the appropriations process.

Gingrich further emphasized the importance of federal investments in research and development, noting examples from the nation’s history in which the government played a decisive role in emerging markets: scientific explorations of the Western frontier, establishing the patent office within the Constitution, telegraphy, aviation, and computer technology.

The expert panel included: Aaron Kesselheim, M.D., J.D., M.P.H., Harvard Medical School and Brigham and Women’s Hospital; Carol Espy-Wilson, Ph.D., University of Maryland; and Marian Mazzucato, Ph.D., University of Sussex, U.K.

The panelists spoke to the importance of publicly supported science in shaping drug development and other later stage technologies, and the entrepreneurial dimensions of academic science. Sen. Warren, lead sponsor of the Medical Innovation Act of 2015 (S.320) which proposes increasing NIH funding, focused panel discussion on the role of basic research. Rep. Cummings also expressed repeated concern over the high cost and limited availability of pharmaceuticals developed with federal funding.

Contact:

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

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NIH Selects Riley to Lead Behavioral, Social Sciences Office

July 31, 2015 —National Institutes of Health (NIH) Director Francis Collins, M.D., Ph.D., July 30 announced the selection of William Riley, Ph.D., as the next Director of the Office of Behavioral and Social Sciences Research (OBSSR). He has served as Acting Director of the OBSSR since May 2014.

Dr. Riley first came to the NIH in 2005, where he served as Deputy Director of the Division of AIDS and Health & Behavior Research at the National Institute of Mental Health. In 2009, he joined the National Heart, Lung, and Blood Institute as Program Director of the Clinical Applications and Prevention Branch, Division of Cardiovascular Sciences.  He moved to the National Cancer Institute in 2012, where he was Chief of NCI’s Science of Research and Technology Branch in the Division of Cancer Control and Population Sciences. Prior to his employment at the NIH, Dr. Riley worked in the private sector as Director of Research at PICS, Inc., and taught at Virginia Commonwealth University and the Medical College of Georgia.

Contact:

Dave Moore
Senior Director, Government Relations
Telephone: 202-828-0559
Email: dbmoore@aamc.org

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On The Hill

July 31, 2015 — Rep. Chaka Fattah (D-Pa.) July 29 was indicted over allegations of political corruption, including racketeering, conspiracy, bribery, and wire fraud. He will step down as Ranking Member of the House Appropriations Subcommittee on Commerce, Justice, and Science. Rep. Mike Honda (D-Calif.) will assume that role.

 


On The Agenda

Aug. 5: Senate HELP Hearing on Higher Education Act
10 a.m.; 430 Dirksen Senate Office Building
The Senate Health, Education, Labor, and Pensions Committee will hold a hearing to discuss reauthorizing the Higher Education Act and opportunities to improve student success. Testimony will be posted to the committee’s website when available.

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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

Dave Moore
Senior Director, Government Relations
Telephone: 202-828-0559
Email: dbmoore@aamc.org