The Alliance of Specialty Medicine asks Congress to advance the following:

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1 The Alliance of Specialty Medicine is a collection of national medical specialty organizations established to advocate for sound federal health care policy that fosters patient access to the highest quality medical care for all Americans. The coalition represents more than 100,000 physicians. The Alliance of Specialty Medicine asks Congress to advance the following: MACRA Implementation: Quality Improvement and Health Information Technology Press CMS to delay Stage 3 Meaningful Use until a majority of providers are successfully attesting to earlier stages and CMS has had a chance to carefully study existing barriers to participation. Medicare Program Integrity Initiatives Improve transparency in Medicare audit initiatives, require public reporting of common coding and billing errors and omissions, replace financial penalties with Corrective Action Plans, enforce transparency in the development of local coverage and payment policies, and mandate physician review for Medicare denials. 21 st Century Cures Act (HR 6)/Innovation for Healthier Americans Integrate the patient s perspective into the regulatory process, facilitate responsible communication of scientific/medical developments and off-label uses, modernize clinical trials, foster the future of science, invest in advancing research, incentivize the development of new drugs and devices for unmet medical needs, promote interoperability, and support 21 st Century digital medicine. Access to Specialty Care/Physician Payment Reform Repeal the Independent Payment Advisory Board (IPAB) cosponsor S 141 Support the Medicare Patient Empowerment Act cosponsor HR 1650 or sponsor Senate companion bill Implementation of ICD-10 Continue to monitor and mitigate the negative impact of ICD-10 implementation. Graduate Medical Education Cosponsor the Resident Physician Shortage Reduction Act (HR 2124/S 1148) which increases Medicare residency training slots and allows up to half for specialty shortages. Medical Liability Reform Support meaningful medical liability reform that reduces growth in healthcare costs, preserves access to specialty care and encourages physician engagement in meaningful quality improvement activities. Cosponsor the Health Care Safety Net Enhancement Act (HR 836/S 884) and the Good Samaritan Health Professionals Act (HR 865).

2 MACRA Implementation: Quality Improvement and Health Information Technology Key Takeaway: The Alliance of Specialty Medicine supports efforts to improve the quality and overall value of healthcare so long as programs are meaningful to specialty physicians and their patients, driven by clinical expertise, carefully evaluated for feasibility and relevance, and provide physicians with flexibility to choose activities that are most appropriate for their practice. Until such policies are in place, physicians should not be held accountable for increasingly difficult and clinically irrelevant federal reporting mandates. At a minimum Stage 3 of Meaningful Use should be delayed. The Alliance thanks Congress for devoting a portion of the Medicare Access and CHIP Reauthorization Act (MACRA) to streamlining existing federal quality reporting mandates, addressing obstacles that currently prevent specialists from participating meaningfully in these programs, and reducing the amount of physician payment at risk. We also appreciate that MACRA affords medical specialty societies the opportunity to work closely with federal agencies to determine how best to interpret the law. In the interim, many of our societies members continue to struggle with satisfying the requirements of the Electronic Health Record (EHR) Meaningful Use program because the measures are not relevant to specialty medicine and the unique patient populations our providers treat. CMS attempted to address some existing participation barriers and simplify reporting requirements, but the program still fails to offer measures that meaningfully capture specialty care. The Alliance also believes it is counterintuitive to propose flexibility options for Meaningful Use in one proposed rule, while simultaneously proposing that all providers move to Stage 3 in 2018, regardless of previous participation status. The proposed requirements for Stage 3 include much more difficult measures and aggressively higher thresholds that will be virtually impossible for specialty providers to meet. Only about one-half of physicians eligible to participate in the EHR Incentive Program have done so, and only a small fraction have been able to satisfy Stage 2. Making changes to this program too quickly, without a sufficient evidence base, and at a time when the new Merit- Based Incentive Payment System (MIPS) under MACRA is being developed, will result in misguided policies that further discourage specialist engagement and erode the quality of patient care. Therefore, we ask Congress to press CMS to delay Stage 3 Meaningful Use until a majority of providers are successfully attesting to earlier stages and CMS has had a chance to carefully study existing barriers to participation. Guiding Principles: As CMS implements the new law and the details of MACRA are fine-tuned, the Alliance will continue to work to ensure that future policies: Recognize a wider array of quality improvement activities, measures, reporting mechanisms and alternative payment/delivery models so that physicians can choose those that are most relevant to their patient population and most appropriate for their practice. Ensure performance calculations recognize the attainment of thresholds and personal improvement over time. Enhance recognition of the value of clinical registry data. Ensure only data that proves to be accurate, actionable, and meaningful is reported to the public. Ensure EHR interoperability standards are developed and enforced and barriers to participation are more carefully evaluated prior to holding physicians accountable to increasingly difficult requirements.

3 Improving Medicare s Program Integrity Initiatives Key Takeaway: The Alliance is increasingly concerned with Medicare s various program integrity initiatives, including the Recovery Auditor Contactor (RAC) program, and supports a comprehensive review of the Centers for Medicare and Medicaid Services (CMS) program integrity activities, as well as subsequent improvements that would address efforts to curb fraud and abuse without burdening physician practices with inappropriate audits that may unfairly limit beneficiary access to care. The Alliance urges Congress to: Improve transparency in Medicare audit initiatives, by requiring the Secretary of HHS to clarify the function and scope of authority of the various Medicare program integrity auditors; establish a new web portal for consolidating information on program integrity efforts and information/education on various program integrity contractors, including contractor sampling and extrapolation methodologies; and require CMS to annually publish key data related to various audits, including the number of denials and appeals, net denials (defined as total denials minus denials overturned on appeal) and each auditor s appeal rate. Medicare auditors should also be required to submit potential audits for review and approval by the Secretary, and approved audits should be made public. In addition, Medicare auditors should face a financial penalty when their denials are overturned on appeal. Require public reporting of common coding and billing errors and omissions using various metrics (e.g., error type, omission type, physician specialty, contractor, and region, among others). Congress should also require the Secretary to enhance educational offerings to physician practices on how to avoid common coding and billing mistakes, especially given the impending move to ICD-10. Replace financial penalties with Corrective Action Plans (CAPs), as well as institute a program that would provide technical assistance to physician practices while they work to address internal deficiencies that may have led to a high volume of coding and billing errors and inappropriate payments that have not been deemed fraudulent. CMS Quality Improvement Organizations (QIOs) could administer such a program through an expanded scope of work. Enforce transparency in the development of local coverage and payment policies, by requiring contractors to adhere to CMS established requirements for soliciting comments, recommendations, and obtaining input from representatives of relevant specialty societies, as part of the contractor s notice and comment period for new or revised local coverage determinations (LCDs). Local contractors must also be required to provide a formal notice and comment process for any and all changes it intends to implement that would revise coverage and payment policies. Mandate physician review for Medicare denials, by requiring a physician practicing in the same specialty or sub-specialty and with clinical expertise or knowledge of the service in question, to validate whether a medical necessity denial is warranted.

4 H.R. 6, 21 st Century Cures Act/Innovation for Healthier Americans Key Takeaway: The Alliance of Specialty Medicine supports the bipartisan effort to improve the discovery, development and delivery that support continued innovation in our health care system. The Alliance thanks House members for their overwhelming support in passing H.R. 6, the 21 st Century Cures Act. We look forward to continue to work with the Senate as they craft language for their Innovation for Healthier Americans initiative. Specialty physicians encourage support for medical innovation that integrates the patient s perspective into the regulatory process; facilitates responsible communication of scientific and medical developments; modernizes clinical trials; fosters the future of science, including encouraging young scientists; invests in advancing research; incentivizes the development of new drugs and devices for unmet medical needs; promotes interoperability; and supports 21 st Century digital medicine by facilitating data sharing and the use of new technologies. Issues of Interest The Alliance has watched the development of legislation in this area and is particularly interested in the following: Reauthorizing the National Institutes of Health (NIH); Establishing a streamlined process for qualifying and utilizing surrogate endpoints in clinical research trials; Permitting data sharing without relinquishing data ownership; Facilitating responsible communication of scientific and medical developments, including offlabel uses (see the Alliance s position statement entitled Physician Directed Applications 1 ); Creation of an innovation fund to foster the discovery, development, and delivery of medical innovation; Standardizing data in clinical trial registry data banks; Developing a centralized institutional review board (IRB); Fostering telemedicine/telehealth; Promoting interoperability; and Clarifying the continuing medical education (CME) exemption for the Sunshine Rule. 1

5 Ensuring Access to Specialty Care: Physician Payment Reform Key Takeaways: The Alliance urges Congress to repeal the Independent Payment Advisory Board (IPAB) and to cosponsor legislation that allows Medicare beneficiaries to freely contract with the physician of their choice. Repeal the Independent Payment Advisory Board (IPAB): Cosponsor S The IPAB will require a board of non-elected government officials to recommend Medicare cuts when spending exceeds a targeted growth rate. These recommendations automatically go into effect unless blocked by a Congressional threefifths supermajority. Although hospitals and long-term care facilities comprise over one-third of Medicare spending, they are exempted from IPAB cuts until This means that a disproportionate share of the burden will fall onto physicians, who make up only 12 percent of total Medicare expenditures. The Alliance thanks the House of Representatives for passing H.R. 1190, the Protecting Seniors' Access to Medicare Act. Introduced by Reps. Phil Roe, MD (R-TN) and Linda Sánchez (D-CA), this legislation fully repeals the IPAB. Sen. John Cornyn (R-TX) has introduced the companion bill, S. 141, in the Senate. Please cosponsor this bill by contacting: Beth Nelson (Sen. Cornyn) at or Beth_Nelson@cornyn.senate.gov Support the Medicare Patient Empowerment Act: Cosponsor H.R or Sponsor Senate companion bill. The current structure of Medicare restricts the ability of seniors to see the physician of their choice by limiting beneficiary access to all physicians. One way patients can overcome this hurdle is to privately contract for services directly with their physicians. Unfortunately, under current law, beneficiaries who wish to privately contract with their physician must pay for the service entirely out of their own pocket, despite having paid into Medicare for many years. Furthermore, if a doctor has opted out of Medicare, in order to contract privately with even one patient, the physician is ineligible for Medicare reimbursement for two years. The Alliance urges Representatives to cosponsor the Medicare Patient Empowerment Act, introduced by Rep. Tom Price, MD (R-GA), and encourages Senators to consider introducing companion legislation. The legislation removes the two-year Medicare ban for physicians who privately contract and allows patients who privately contract to recoup the amount Medicare would otherwise pay for the service. Please cosponsor this bill by contacting: Carla DiBlasio (Rep. Price) at or Carla.DiBlasio@mail.house.gov

6 Implementation of ICD-10 Key Key Takeaway: The The Alliance of Specialty Medicine Medicine supports supports efforts efforts that would that would mitigate mitigate the negative the negative impact of moving to the International Classification of Diseases 10 th Revision, or ICD-10, code set. impact of moving to the International Classification of Diseases 10 th Revision, or ICD-10, code set, including the recent CMS announcement to provide a one-year grace period. We urge Congress to continue to monitor implementation. The Alliance appreciates the attention Congress gave to mitigate the negative impact of ICD-10 implementation, especially the need to establish a grace period, during which physicians will not be penalized for honest coding errors, mistakes or malfunctions of the system. In addition, we believe the Center for Medicare and Medicaid Services (CMS ) plan to provide a grace period, as well as establish an ICD-10 Ombudsman, authorize advance payments if Medicare contractors are unable to process claims within established time limits, and ensure providers are not penalized for ICD-10 issues within quality reporting programs, will help alleviate many of the problems providers may encounter during the ICD-10 transition. We urge Congress to continue to monitor the implementation, including an assessment of the impact on private and small physician practices, and encourage CMS to publicly report the most common ICD-10 coding mistakes, by specialty and other appropriate metrics, which would help physicians and their staff improve ICD-10 coding during the transition. Snapshot of the Issue. Specialty physicians are seriously concerned about the significant disruptions to their practices and patient care as our country moves to the new coding and classification set, which is scheduled for permanent implementation on October 1, Therefore, we appreciate CMS recent announcement that the agency will provide a one-year grace period. This is a significant step in the right direction and recognizes a smooth conversion and avoidance of major disruptions is in the best interest of patient care. Implementing ICD-10 will result in a five-fold increase in diagnosis codes from 13,000 codes to approximately 68,000 codes. Because CMS General Equivalence Mappings (GEMs), which map the current ICD-9 codes to new ICD-10 codes, are not a direct cross-walk between the two classification systems, most specialty practices particularly those that cannot afford to hire a certified coder will be forced to hunt through nearly 68,000 codes in hopes of finding the right code. Also, most of the resources and ICD-10 training materials developed by CMS have been designed with primary care practices in mind; very little has been made available for specialty medicine providers, and even less for sub-specialty providers.

7 Workforce Shortages/Graduate Medical Education Key Takeaway: The United States will face an overall shortage of nearly 100,000 physicians by 2025, with half of that shortage coming from specialty physicians. Congress must act now to increase the number of residency slots to ensure access to specialty care. The Alliance of Specialty Medicine urges Congress to address the workforce shortages in many specialties that will jeopardize access to care by cosponsoring the bipartisan Resident Physician Shortage Reduction Act (H.R. 2124/S. 1148) introduced by Reps. Joseph Crowley (D-NY) and Charles Boustany, MD (R-LA); and Sens. Bill Nelson (D-FL) and Charles Schumer (D-NY). Legislation. The Resident Physician Shortage Reduction Act will improve the nation s GME system and help to preserve access to specialty care by: Increasing the number of Medicare-supported GME residency slots by 15,000 over the next 5 years; Directing half of the newly available positions to training in shortage specialties; Specifying priorities for distributing the new slots (e.g., states with new medical schools); and Studying the needs of the U.S. healthcare system and allocating residencies accordingly. Please cosponsor this bipartisan legislation by contacting: Nicole Cohen (Rep. Crowley) at or nicole.cohen@mail.house.gov; Melissa Gierach (Rep. Boustany) at or Melissa.Gierach@mail.house.gov; Corey Malmgren (Sen. Nelson) at or Corey.Malmgren@nelson.senate.gov; or Veronica Duron (Sen. Schumer) at or Veronica_Duron@schumer.senate.gov Snapshot of the Issue. According to a 2015 report by the Association of American Medical Colleges (AAMC), the United States will face an overall shortage of between 46,000-90,000 physicians by Specialty shortages will be particularly large, including neurosurgeons, urologists, cardiologists, gastroenterologists, plastic and reconstructive surgeons, and orthopaedic surgeons. A 2008 report by the Health Resources and Services Administration found that by 2020, ophthalmology and orthopedic surgery are each expected to need more than 6,000 physicians over current levels, while other specialties like urology will see shortfalls of more than 4,000 physicians. Growth in future demand for physicians will be highest among specialties that predominantly serve the elderly. Specialty physicians require up to seven years of post-graduate residency training. By the time crisis further manifests itself, we will be unable to quickly correct it. With 10,000 seniors aging into the Medicare program every day, along with the influx of patients seeking access to care as a result of the Affordable Care Act, the need for specialist services will increase significantly. We must take steps now to ensure a fully trained specialty physician workforce for the future.

8 Medical Liability Reform Key Takeaway: The Alliance supports meaningful medical liability reform that reduces growth in health care costs, stabilizes professional liability insurance premiums, preserves access to specialty care, and encourages physician engagement in meaningful quality improvement activities. Principles for Comprehensive Reform. Meaningful medical liability reform should fully compensate patients for medical/economic damages, while placing a $250,000 limit on noneconomic damages and making a defendant liable only for damages equal to his/her share of responsibility; maximize patient awards and discourage frivolous lawsuits through sliding scale contingency fees; and eliminate double recovery by accounting for evidence of collateral source benefits paid. In addition to traditional tort reforms, the Alliance supports additional ways to improve the medical liability system. Support Medical Liability Reform: Cosponsor H.R. 836/S. 884 and H.R. 865 H.R. 836/S. 884, the Health Care Safety Net Enhancement Act of 2015 was introduced in the House of Representatives by Reps. Charlie Dent (R-PA), Joe Wilson (R-SC), Raul Ruiz (D-CA), and Andy Harris (R-MD); and in the Senate by Sen. Roy Blunt (R-MO). This legislation would extend Federal Tort Claims Act liability protections to physicians providing emergency care including on-call specialists pursuant to the Emergency Medical Treatment and Labor Act (EMTALA). The inherently risky life-saving care provided by on-call specialists exposes these providers to an increased likelihood of litigation because emergency and trauma patients are often sicker, have more serious complications, and usually have no pre-existing relationship with the treating physician. Please cosponsor this bipartisan bill by contacting: Andrea Uckele (Rep. Dent) at or Andrea.Uckele@mail.house.gov or Desiree Mowry (Sen. Blunt) at or Desiree_Mowry@blunt.senate.gov H.R. 865, the Good Samaritan Health Professionals Act of 2015 was introduced in the House of Representatives by Reps. Marsha Blackburn (R-TN) and David Scott (D-GA). The legislation limits the liability of health care professionals who volunteer to provide services in response to a declared natural disaster. Such protections would not be extended in cases of willful or criminal misconduct, gross negligence, or reckless misconduct. Please cosponsor this bipartisan bill by contacting: Karen Summar (Rep. Blackburn) at or Karen.Summar@mail.house.gov or Lauren Lattany (Rep. Scott) at or Lauren.Lattany@mail.house.gov