HELP Subcommittee Discusses Primary Care Workforce Challenges
April 11, 2014—The Senate Health, Education, Labor, and Pensions (HELP) Subcommittee on Primary Health and Aging April 9 held the third in a series of hearings focused on primary care access and workforce challenges.
Subcommittee Ranking Member Richard Burr (R-N.C.) acknowledged in his opening statement that physician supply would not keep up with the increasing demand and suggested a need to identify workforce programs with a “proven track record” of success.
He joined an April 9 letter with Senators Tom Coburn (R-Okla.) and Mike Enzi (R-Wyo.) requesting that the Department of Health and Human Services (HHS) provide details about the workforce programs under the department’s purview.
During the hearing, the subcommittee heard testimony from two panels of witnesses, including Rebecca Spitzgo, associate administrator of the Bureau of Health Professions at the Health Resources and Services Administration (HRSA), and Linda Kohn, Ph.D., director of health care at the Government Accountability Office (GAO).
Subcommittee members questioned the panels about the factors driving access challenges in primary care, such as reimbursement, prestige, and other incentives. Panelists also described the value of federal investments in workforce development initiatives such as the National Health Service Corps (NHSC) and other HRSA programs.
One witness, James Hotz, M.D., clinical services director of Albany Area Primary Care, referenced an April 7 letter from 50 member organizations of the NHSC Stakeholders, including AAMC, urging appropriators to extend funding for the NHSC, which expires at the end of FY 2015.
AAMC Chief Public Policy Officer Atul Grover, M.D., Ph.D., submitted an April 9 letter applauding the subcommittee for its attention to the need to invest in physician workforce development.
The letter describes the urgency of expanding Medicare graduate medical education (GME) support, noting that “[p]rescribing a static specialty composition or targeting increases to any singular discipline in legislation will preclude physician training efforts from adapting to varying and evolving local workforce needs.” It also characterizes the perils of proposals to reduce Medicare GME support, citing results from a recent survey by the Accreditation Council on Graduate Medical Education.
On the same day of the hearing, Subcommittee Chair Bernie Sanders (I-Vt.) introduced legislation (S. 2229) to extend and expand funding for community health centers, NHSC, and the teaching health centers program. The bill also expands Medicare support for family medicine residencies and imposes various requirements on medical schools and teaching hospitals.
Director, Government Relations
House and Senate Letters Support NIH Funding
April 11, 2014—A total of 186 House members, including 23 Republicans, signed an April 4 letter supporting increased funding for NIH in fiscal year (FY) 2015. The letter, organized by Reps. David McKinley (R-W.Va.), Susan Davis (D-Calif.), Andre Carson (D-Ind.), and Peter King (R-N.Y.), requests that NIH receive “at least $32 billion” in FY 2015.
The House letter, which was sent to the chairs and ranking members of both the full House Appropriations Committee and its Labor-HHS subcommittee, notes the critical role NIH plays “in better health outcomes, job creation, education, and economic growth.”
A total of 57 senators, including 11 Republicans, signed an April 3 letter requesting the chairs and ranking members of the Senate Appropriations Committee and Labor-HHS subcommittee “maintain a strong commitment” to funding for NIH.
The Senate letter, organized by Senators Bob Casey (D-Pa.) and Richard Burr (R-N.C.), does not mention a specific funding level for NIH but urges appropriators “to consider the tremendous benefits of a sustained investment in the NIH.”
Senior Director, Government Relations
Members of Congress Urge Support for Title VII Health Professions Programs
April 11, 2014—Representatives Michael Burgess, M.D., (R-Texas) and Diana DeGette (D-Colo.) led a March 31 letter urging House Labor, Health and Human Services, Education and Related Agencies (Labor-HHS) Appropriations Subcommittee Chair Jack Kingston (R-Ga.) and Ranking Member Rosa DeLauro (D-Conn.) to provide $280 million for the Health Resources and Services Administration (HRSA)’s Title VII health professions programs in FY 2015. A total of 96 members, including three Republicans, joined Reps. Burgess and DeGette on the letter.
Senator Jack Reed (D-R.I.) was joined by 24 colleagues on a similar April 4 letter urging Senate Labor-HHS Appropriations Subcommittee Chair Tom Harkin (D-Iowa) and Ranking Member Jerry Moran (R-Kan.) to provide $280 million for Title VII in FY 2015.
Both highlight the unique role of Title VII programs in developing a workforce that reflects and is prepared to respond to the country’s changing health care needs.
The House letter discusses the “unprecedented provider shortages” and calls for a “strong commitment” to Title VII programs to ensure the distribution, quality, and diversity of the health professions workforce continues to improve. Similarly, the Senate letter says it is “critical” to demonstrate a strong commitment to Title VII.
Meanwhile, the Health Professions and Nursing Education Coalition (HPNEC) March 28 submitted a written statement for the record to the House Labor-HHS Appropriations Subcommittee, recommending $520 million for HRSA’s Title VII health professions and Title VIII nursing workforce programs in FY 2014.
Led by the AAMC, HPNEC is an informal alliance of more than 60 national organizations representing schools, programs, health professionals, and students dedicated to ensuring the health care workforce is trained to meet the needs of our diverse population.
Senate Finance Committee Holds Hearing on Administration’s FY 15 HHS Budget Request
April 11, 2014—Secretary of Health and Human Services (HHS) Kathleen Sebelius testified April 10 before the Senate Finance Committee on the president’s fiscal year (FY) 2015 HHS budget which calls for $402 billion in health-related cuts over 10 years. The administration proposes $354 billion in Medicare provider cuts, including nearly $15 billion in Medicare Indirect Medical Education (IME) payments, $68 billion in Medicare structural reforms, and $7 billion in Medicaid savings [see Washington Highlights, March 7].
In her testimony, Sec. Sebelius highlighted the administration’s new health care workforce initiatives stating, “The Budget makes new and strategic investments in our nation’s health care workforce to ensure rural communities and other underserved populations have access to doctors and other providers.”
The budget workforce proposal includes transferring $5.23 billion from the Medicare Hospital Insurance Trust Fund to establish a new graduate medical education grant program at the Health Resources and Services Administration (HRSA), a $3.9 billion funding increase for the National Health Service Corps, and $5.4 billion to extend the Medicaid “payment floor.”
During questioning, Sen. Robert Menendez (D-N.J.) raised concerns regarding the Centers for Medicare and Medicaid Services’ (CMS) “two midnight” policy that established new rules regarding how short hospital stays will be paid under Medicare, stating, “The rule fails to acknowledge an instance where a beneficiary needs a high level of inpatient care for shorter amount of time, even if the physician determines it’s medically necessary or appropriate” [see Washington Highlights, Aug. 9, 2013].
Sen. Menendez pointed out that serious questions around the “two midnight” rule have led CMS to enact multiple enforcement delays; prompted the introduction of his bipartisan legislation, along with Sen. Deb Fischer (R-Neb.), the Two-Midnight Rule Coordination and Improvement Act of 2014 (S.2082); and resulted in the most recent statutory delay of the rule included in the Protecting Access to Medicare Act of 2014 (P.L. 113-93).
Sen. Menendez closed by asking the Secretary if CMS’ existing authority would allow them to work with the provider community to better refine the rule without new legislation. Sec. Sebelius responded her staff would work with Sen. Menendez to determine what elements of proposed legislation could be handled on an “administrative basis.”
In his opening statement, Senate Finance Committee Chair Ron Wyden (D-Ore.) highlighted the year-long bipartisan, bicameral work to fix the Sustainable Growth Rate (SGR) stating, “Congress has made real progress on permanently repealing and replacing the broken and dysfunctional Medicare physician payment formula. The reforms agreed to would push Medicare to be driven by the quality and value of care. Today’s volume driven care isn’t good for seniors, their doctors or Medicare itself. The President’s budget proposal endorses the bipartisan, bicameral reform package, and I look forward to working with Secretary Sebelius to help push this over the finish line by years end.”
Ranking Member Orrin Hatch (R-Utah) voiced concerns with the budget request and its failure to seriously address entitlement reform saying, “the proposed budget would save a meager $414 billion over the next decade, or roughly 3.7 percent of total Medicare and Medicaid spending. And, it would do so primarily through provider cuts and government price controls. Anyone who has spent more than five minutes looking at our budget has concluded that these programs are in serious trouble,” further calling the programs “drivers of our debts and deficits.”
Director, Government Relations
MACPAC Discusses June Report to Congress
April 11, 2014—The Medicaid and CHIP (Children’s Health Insurance Program) Payment and Access Commission (MACPAC) April 10-11 met to discuss its June report to Congress, which will include chapters on the future of CHIP, state capacity to administer Medicaid and CHIP, Medicaid population health, and long-term services and supports (LTSS).
While MACPAC’s March report to Congress included a section on the short-term future of CHIP [see Washington Highlights, March 21], the June report will focus on long-term concerns with the program.
Under current law, federal CHIP funds will run out shortly after fiscal year (FY) 2015. States with Medicaid expansion programs must maintain these enrollees’ Medicaid coverage, resulting in higher state expenditures for these children. States with separate CHIP programs would no longer be required to finance coverage. As a result, the rate of uninsured children would increase significantly.
The commission discussed several options to alleviate this problem and unanimously approved a recommendation that “Congress should extend federal CHIP funding for a transition period of two additional years during which time the key issues regarding the affordability and adequacy of children’s coverage be addressed.” The recommendation calls on Congress to provide funding through FY 2016 and FY 2017, which is two years beyond the current allocation.
MACPAC staff also provided an overview of the draft June chapter on building state capacity to administer Medicaid and CHIP. Administrative capacity constraints currently hinder states’ ability to meet program requirements, be proactive, and integrate into broader reforms. This chapter will not include any recommendations, but will list several approaches to strengthen state capacity, including increasing the effectiveness of existing resources, sharing resources among states, and leveraging other state assets.
The foundational chapter on Medicaid population health will consist of sections on current population health initiatives and programs, partnerships to improve population health, challenges with these partnerships, and approaches to monitor population health among Medicaid enrollees.
Commission staff also provided a summary of the draft chapter on LTSS. The chapter will include an overview on the fundamentals of LTSS, focusing on which services are covered and who uses them, as well as an analysis of the impact of state variation on LTSS services. Additionally, the chapter will list several ways that MACPAC can address current problems with LTSS, including new options under the Affordable Care Act (ACA, P.L. 111-48 and P.L. 111-52), the expansion of managed LTSS, and how states are using home and community-based services (HCBS) waivers.
The final session of the meeting focused on policy implications of the CHIP Reauthorization Act (CHIPRA) bonus payments, which were authorized under the ACA for FY 2009 through FY 2013 to promote enrollment of eligible but unenrolled children in Medicaid and CHIP.
States were given bonuses for meeting benchmarks in child Medicaid enrollment. During this time, the number of eligible but uninsured children declined by 18 percent, and the national average for Medicaid and CHIP participation rose by 6.4 percent. Overall it was unclear whether the number of uninsured declined due to enrollment strategies that were newly required in the ACA or to the bonus payments. The commission will not include this issue in the June chapter.
Program & Policy Specialist, Government Relations
Senior Specialist, Health Care Affairs
Eshoo Introduces American HEALS Act
April 11, 2014—Rep. Anna G. Eshoo (D-Calif.) April 3 introduced the American HEALS (Helping Encourage Advancements in Lifesaving Science) Act (H.R. 4384) to expand support for medical research at the National Institutes of Health (NIH), the Centers for Disease Control (CDC), the Department of Defense Health Program (DHP), and the Department of Veterans Affairs (VA) Medical & Prosthetics Research Program.
In a statement Rep. Eshoo said, “Investment in biomedical research, including at the National Institutes of Health, is at unprecedented lows, jeopardizing our national health and preventing future breakthroughs. More than half of basic research funding in the U.S. comes from the federal government, yet we spend two-thirds less on research and development than we did in 1965. A trust fund for our biomedical research agencies can reverse this dangerous trend and ensure that the United States is the leader in scientific discovery.”
In an April 10 letter endorsing the bill, AAMC President Darrell G. Kirch, M.D., thanked Rep. Eshoo for her leadership in making medical research a national priority and said, “By providing steady and predictable funding increases…, your proposal will help ensure that the nation’s scientists and research institutions will continue to advance medical science to improve the health and well-being of all Americans.”
The American HEALS Act would augment federal appropriations for biomedical research with a mandatory trust fund dedicated to steady growth in research conducted at NIH, CDC, DHP, and the VA. The bill would increase funding for each agency and program every year at a rate of inflation indexed to the gross domestic product (GDP) plus 5 percent.
Reps. Zoe Lofgren (D-Calif.), Doris Matsui (D-Calif.), Andre Carson (D-Ind.), Jared Huffman (D-Calif.), Juan Vargas (D-Calif.), and Scott Peters (D-Calif.) are original cosponsors of H.R. 4384.
Senior Director, Government Relations
House Appropriations Committee Passes VA Spending Bill
April 11, 2014—The House Appropriations VA Subcommittee April 9 approved the fiscal year (FY) 2015 Military Construction and Veterans Affairs (Mil.Con.-VA) Appropriations bill. The draft measure includes $58.7 billion in FY 2016 advance appropriations for VA medical care and $588.9 million for VA Medical and Prosthetic Research, a $3.2 million (0.6 percent) increase over FY 2014 [see Washington Highlights, April 4].
Draft report language accompanying the bill “encourages the VA to strengthen its collaborations with research universities and teaching hospitals for the treatment and research of mental health disorders … to improve the psychological health of veterans and train mental health professionals so they will understand the unique needs of Veterans.” The committee requests a report on current VA-university partnerships on mental health research and training no later than 90 days after enactment.
The Friends of VA Medical Care and Health Research coalition (FOVA) April 9 submitted testimony on appropriations for the VA Medical and Prosthetic Research program to the committee. For FY 2015, FOVA recommends $611 million for VA Research, $50 million for up to five major construction projects in VA research facilities, and $175 million for nonrecurring maintenance and minor construction. AAMC serves on the FOVA Executive Committee.
The Senate Appropriations Committee is expected to take up its Mil.Con.-VA spending bill later in May.
Matthew Shick, J.D.
Senior Legislative Analyst, Government Relations
Telephone: (202) 828-0525
HRSA Posts Revised Requirements for 340B Drug Discount Program
April 11, 2014—The Health Resources and Service Administration (HRSA) Office of Pharmacy Affairs (OPA) April 8 posted revised requirements for new hospital registrations. In addition to completing an online registration, hospitals must submit on the same day all required documents, including Worksheet S, Worksheet S-2, Worksheet E, Part A (for disproportionate share hospitals (DSH), rural referral centers (RRC), sole community hospitals (SCH), and freestanding cancer hospitals (CAN)), and Worksheet S-3 (children’s hospitals (PED) only).
HRSA notes that all outpatient services located outside the four walls of the hospital must register in the 340B program and must appear on the hospital’s most recently filed cost report. In addition, if several services are being provided, each clinic/department/service must be registered separately.
HRSA provides the following example: “if there is a single off-site location that provides radiology services, physical therapy services, and pediatric services, the covered entity should register that one location as 3 separate 340B listings if they would like to provide the patients of all 3 services with 340B drugs.”
HRSA expects to issue a notice of proposed rulemaking about the 340B drug discount program in June. The AAMC will be working with members to understand the implications of the proposal and intends to comment.
Ivy Baer, J.D.
Sr. Director and Regulatory Counsel
On the Hill…
April 11, 2014—Secretary of Health and Human Services (HHS) Kathleen Sebelius April 11 announced her resignation. During her tenure at HHS, Sec. Sebelius oversaw implementation of the Affordable Care Act (ACA, P.L. 111-48, P.L. 111-52) and the roll out of healthcare.gov. Under her stewardship, ACA enrollment topped 7.5 million, as she announced at an April 10 Senate Finance Committee hearing (see related story).
In a Rose Garden ceremony, President Obama announced his nomination of Sylvia Mathews Burwell, current director of the Office of Management and Budget, to replace Sec. Sebelius.
On the Agenda in Washington
April 22: PCORI Board of Governors Meeting
12 p.m.; Teleconference/Webinar
The Patient-Centered Outcomes Research Institute (PCORI) Board of Governors will meet via webinar/teleconference. The meeting is open to the public, though no public comment period is scheduled.
April 24: Health IT Standards Committee Meeting
9 a.m.; 10 Thomas Circle N.W., Washington, D.C.
The Office of the National Coordinator (ONC) for Health Information Technology (HIT) Standards Committee will meet to discuss standards implementation specifications and certification criteria for the electronic exchange of health information.
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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Senior Director, Government Relations