Osteopathic Advocacy: Partnering to Advance Sound Health Policy. Nicholas Schilligo, MS Associate Vice President, State Government Affairs

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1 Osteopathic Advocacy: Partnering to Advance Sound Health Policy Nicholas Schilligo, MS Associate Vice President, State Government Affairs

2 Our Work Work with a variety of stakeholders to promote AOA policies and support the osteopathic community Physicians Non-physician clinicians State & Federal Policymakers State and specialty societies Licensure boards

3 Support DOs Research and analyze health policy initiatives Develop policies to address emerging issues Coordinate activities with partners to address legislative & regulatory proposals

4 Public Policy Strategy

5 Enhancing Osteopathic Public Policy Influencing state and federal public policy to ensure a health care system optimized for osteopathic physicians and their patients Targeting issues that DOs can own and be recognized for our issues rather than every other physician groups Utilizing lobbying and grassroots advocacy to educate federal & state policymakers about who DOs are and their contributions to communities Enhancing and leveraging strategic partnerships & collaboration with stakeholders to advance our priorities

6 The Imperative of Osteopathic Medical Advocacy & Engagement Voice of the Profession Advocacy Tell Our Story Advocate Proudly

7 Why Should I Advocate? Advocacy Decisions of today affect your future It is your profession If you do not someone on the other side will You tell the story best

8 Public Policy Priorities

9 Strategic Objective - Patients Key Priorities Patient- Centered Care & Access Make AOA the recognized thought leader and advocate among patients, policymakers and legislators with respect to the need for access to high quality, holistic, patient-centered, and coordinated health care delivery. Prevention & Wellness Place AOA at the forefront of the movement toward preventative over curative care and the emphasis on wellness and patient education to improve the public health.

10 Strategic Objective - Physicians Key Priorities Workforce & Osteopathic Recognition To ensure the continued growth of osteopathic medicine through the development of osteopathic medical schools and osteopathic focused graduate medical education programs. Physician Practices as Small Businesses To make AOA the principal physician organization advocating for physician practices as small businesses, through the reduction of administrative burdens and the adoption of public policies that support small and solo private practice as a viable option for the delivery of health care services.

11 Key Priorities Strategic Objective Health Care Delivery Special Populations To make AOA the principal recognized physician organization advocate for improvements in the delivery of health care to special populations, including especially veterans and those in underserved rural and urban areas. Improved Health Care Delivery Models To make AOA the principal physician organization advocate for the development of health care delivery models that emphasize the cost efficient delivery of high quality and coordinated care, while preserving the patient physician relationship.

12 Key Issues

13 Key Issues Workforce & Osteopathic Recognition Opioids Scope of Practice Medicare and CHIP Reauthorization Act Health Insurance Regulation

14 Workforce and Osteopathic Recognition

15 Promoting DOs Osteopathic education, training & certification COMLEX-USA Anti-discrimination

16 Protecting DOs GME Funding Physician Loan Repayment & Forgiveness Assistant Physician

17 OMT Payment NGS Local Coverage Determination Successful in changing language Implementation TBD BCBS RI Letter to Governor on OMT Congressional meetings on OMT Sign-on letter across specialties to Insurance Commissioner Positioning potential allies CMS Removed from 2017 Fee Schedule, OMT only codes highlighted Met with CME on Nov 21

18 Opioids

19 Opioids Dramatic increase in misuse, addiction, and death related to opioids States, federal regulators, and Congress responding Regulate prescribing of opioids and treatment of related addiction Demonstrating physician leadership is critical

20 Opioids Federal Activity National Pain Strategy CDC Draft Guidelines for Prescribing Opioids for Chronic Pain in Primary Care Joined President Obama's initiative to address prescription drug abuse and heroin epidemic. Joined Surgeon General s convening of provider groups for his campaign to encourage better prescribing practices for opioids. Support Congressional bills. State Activity Significant increase in regulation establishing, regulating, or even mandating use of PDMPs. Regulating who can own and operate a pain clinic. States are increasingly setting prescribing guidelines surrounding dosage, duration, and type of opioid. Collaborating with the National Association of Boards of Pharmacy.

21 PDMPs Authorized in 49 states Decision making tool for prescribers and dispensers Reporting and use requirements vary greatly

22 Mandated Use of PDMPs

23 Interconnect Sharing data across state lines 42 states executed MOUs 33 states actively participate

24 CME Requirements 17 states require pain medicine/opioid prescribing CME General requirements vs. pain clinic practice

25 State Pain Regulation

26 Access to Naloxone Good Samaritan Laws First Responders Overdose Prevention

27 Interdisciplinary Collaboration AOA member complaints related to dispensing of prescription opioids at several large pharmacy chains BSGA examined issue further AOA participated in Stakeholder Workgroup formed by National Association of Boards of Pharmacy (NABP)

28 Interdisciplinary Collaboration Goals Combat misuse and diversion Educate on red flags Increase interprofessional collaboration and communication Ongoing Efforts Disseminate information to the public Educate prescribers and dispensers Improve communications

29 Osteopathic Approach OMT as a Nonpharmacological Modality Congress DO Day on Capitol Hill key message Opioid legislation, conferencing Administration HHS Surgeon General CDC States Ohio Oregon

30 Scope of Practice

31 Scope of Practice APRNs Chiropractors Physical Therapists CNMs Optometrists Podiatrists Psychologists

32 Independent Practice 21 states allow APRNs to practice independent of physician supervision or collaboration 17 states have opted out of CMS supervision requirements for CRNAs to be supervised by an anesthesiologist

33 VHA Proposal Preempts state law Allows independent nursing practice Limited to VA System

34 Protecting Patients Protecting patient safety and the delivery of high quality care Ensure adequate education and training for those diagnosing and treating patients

35 AOA Position Support team-based, patient-centered care model Physician is the leader of the team Every provider within the team Provides value Brings their own skills/knowledge Practices within their scope

36 Scope of Practice Partnership Collaborative effort between the AOA, AMA, 13 national specialty societies and 79 medical and osteopathic state societies Focus the resources of organized medicine to oppose scope of practice expansions by non-physician providers

37 Scope of Practice Partnership Funded 13 projects in the past two years to support state efforts on the ground Oklahoma Lawsuit Grant PTs Ohio Partnership Grant APRNs Arizona Media Grant Nurses

38 Medicare Access & CHIP Reauthorization Act

39 MACRA Moves Medicare from fee-for-service (FFS) to a system paying for quality of care Aligns with the osteopathic principle of providing patientcentered care Repeals the SGR and provides predictability in physician payments Provides positive payment incentives via annual updates for five years July % update period of stability MIPS incentives, or 5% APM bonus 2026 and beyond.75% update in APM;.25% update in FFS

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41 MACRA Merit-Based Incentive Payment System (MIPS) Preserves fee-for-service Streamlines EHR Meaningful Use, PQRS, and the Value-Based Modifier into one reporting program Reduces administrative burdens Adds bonuses, instead of just penalties Bonuses and penalties determined on a sliding scale by comparing composite performance score to average of all physicians OR Advanced Alternative Payment Models (AAPMs) Exempts physician from MIPS Earn shared savings, plus: o 5% annual bonus in o 0.75% in 2026 and beyond Models include: o CPC+ o Medicare Shared Savings Track 2,3 o NextGen ACOs o Others to be developed, including specialty APMs

42 Performance Categories MIPS Advancing Care Information (EHR) Quality 25% 15% 60% Clinical Improvement Activities Resource Use Cost Measures 0% for 2017

43 APMS Receive financial incentives (on top of model s shared savings) 5% bonus in payment years, as an annual lump sum 0.75% update in 2026 and beyond Must bear risk for monetary losses to qualify Required percentage of revenue in model: : 25% of Medicare revenue : 50% of Medicare, OR 25% of Medicare + 50% allpayer 2023 and on: 75% of Medicare, OR 25% of Medicare + 75% allpayer

44 MACRA NPRM The AOA supports three basic principles of the new system: 1. Patient-centered; 2. Practice-driven, and flexibility; and, 3. Simplified

45 MACRA NPRM The AOA also has several concerns: 1. Effect on small and solo practices 2. Interpretation of intent on recognizing PCMH 3. Proposal for the ACI performance category 4. Narrow definition of Advanced APMs

46 Health Insurance Regulation

47 Background The National Association of Insurance Commissioners (NAIC) released an updated Health Benefit Plan Network Access and Adequacy Model Act (the Model Act), which: Establishes network adequacy, transparency and quality standards for health carriers Creates requirements for the carrier-provider relationship

48 Background CMS will look to states to regulate health insurance products available on exchanges States have begun introducing legislation based on the Model Act and we expect more in 2017

49 Key Sections 1. Network adequacy 2. Requirements for participating providers 3. Provider Directories 4. Requirements for participating facilities with non-participating providers

50 AOA Position The AOA supports provisions related to: Providing coordinated care Increasing access for special populations Requiring carriers to provide accurate network information to the public Strengthening protections for provider directories Defining tiered networks Recognizing that discrimination against patients who need large amounts of care needs to be addressed

51 AOA Concerns The AOA has concerns about: Balance billing restrictions Out-of-network billing provisions Establishment of a mediation process Benchmarking out-of-network provider payments to contracted rates Utilizing telemedicine to meet network adequacy requirements

52 State Action Several states introduced health insurance regulation bills in These bills are similar to the Model Act, but vary significantly in the details and rigor of their requirements. Connecticut Senate Bill 433 (became law June 7, 2016) New Jersey House Bill 4444 / Senate Bill 20

53 Next Steps We anticipate the introduction of more bills related to insurance transparency and network adequacy in The AOA seeks feedback in order to develop policy for future advocacy efforts.

54 Questions?