January 27, 2017 – Victory! Aetna-Humana Merger Nixed!

Dr. Reid - MSSNY President
Dr. Malcolm Reid
January 27, 2017
Volume 17
Number 4


Dear Colleagues:

This week, in a landmark win for organized medicine and the nation’s patients, federal judge John D. Bates blocked the proposed Aetna-Humana merger. The judge found that the merger would have substantially lessened competition in Medicare Advantage and commercial health insurance markets. This is a comprehensive, fact-based ruling that acknowledges that meaningful action was needed to preserve competition and protect high-quality medical care from unprecedented market power that Aetna would acquire from the merger deal. The decision is a historic, stunning affirmation of the position urged by the American Medical Association (AMA) and the 17-state medical association antitrust coalition members of which MSSNY is an active member. The court’s ruling sets a notable legal precedent by recognizing Medicare Advantage as a separate and distinct market that does not compete with traditional Medicare.

MSSNY was vigorously opposed to this merger and joined with stakeholders, various patient coalitions, and the National Association of Attorneys General. The coalition presented physician surveys that gauged physician concerns about the merger and presented the compelling survey results to DOJ and state regulators; testified in or submitted memoranda in state insurance department hearings and/or attorney general investigations, and secured outside experts to demonstrate how the merger would harm patients and physicians.

We want to take this opportunity to thank our physicians and, all of our coalition partners for helping to achieve this historic victory on behalf of our physician members and their patients. Our collective work on these mergers is, without a doubt, a model for future advocacy success.

Malcolm Reid, MD, MPP
President, Medical Society of the State of New York

Save the Date:
MSSNY Physician Advocacy Day in Albany March 8!

Please send your comments to comments@mssny.org

Please Contact Your Legislators to Express Concerns in Proposed State Budget
As noted last week, Governor Cuomo released his proposed $152.3 billion spending plan for the 2017-18 Fiscal Year.   While the proposed Budget contains a number of positive provisions, it also includes several proposals that could have an adverse impact on physician care delivery.  Physicians are urged to contact their legislators to ask that these adverse provisions be removed from the Budget or, where appropriate, additional allocations be made.  For example,

  • We appreciate that funding for the Excess Medical Malpractice Insurance program is proposed be continued at previous years’ funding levels.  However, physicians would be required to receive a “tax clearance” as a pre-condition, potentially a cumbersome requirement that could unnecessarily endanger coverage for some physicians.  To send a letter to your legislators, click here.
  • Pharmacists would be permitted to enter into “comprehensive medication management protocols” with physicians or nurse practitioners to manage, adjust and change the medications of patients with a chronic disease or diseases who have not met clinical goals of therapy, are or at risk for hospitalization.  While similar “collaborative drug therapy” programs exist within the hospital environment, only physicians are currently permitted to enter into such protocols.  To send a letter to the Legislature, click here.
  • “Prescriber prevails” protections that currently exist in Medicaid and Medicaid Managed Care would be eliminated, except for atypical antipsychotic and anti-depressant medications, forcing physicians to go through even more burdensome prior authorization requirements.  To send a letter to your legislators, click here.
  • The State Budget fails to include a specific allocation to address the likely shortcoming in payments due physicians arising from the financial collapse of liquidated insurer Health Republic.  To send a letter to your legislators urging funding in the Budget to address this shortfall, click here.

Other Items of Note in the State Budget

  • Funding for MSSNY’s Committee for Physicians Health would be continued at past levels;
  • Re-appropriating $300,000 for MSSNY’s Veterans Health Care Initiative.
  • E-cigarettes would be taxed in the same manner as tobacco cigarettes.
  • Requiring the registration and regulation of Pharmaceutical Benefit Manager (PBMs)
  • Creating a 25 member “Healthcare Regulation Modernization Team” to look at developing numerous health care delivery change proposals including: modernizing Certificate of Need laws; “creating more flexible rules on licensing and scope of practice for clinicians and caregivers” and “increasing flexibility of state agency regulations governing the delivery of and reimbursement for telehealth programs;
  • Making the “inappropriate prescribing of opioids” an unacceptable provider practice in the Medicaid program, giving the State discretion to remove a physician or other prescriber from the program.
  • Reducing prescription drug costs by making drug companies pay a surcharge when costs exceed a certain benchmark to be determined by a Drug Utilization Review Board within the NYS Department of Health;
  • Requiring the testing of public water systems every 3 years for contaminants

The state Senate and Assembly have scheduled a February 16 public hearing to receive comments regarding concerns with the proposed Health Budget, at which MSSNY will testify.

MSSNY’s “Physician Advocacy Day” will be held on Wednesday, March 8th in the Lewis Swyer Theatre in the Egg located at the Empire State Plaza in Albany, New York.  Please register here  if you plan to attend.

A full slate of legislators and key policymakers have been invited to dialogue with Advocacy Day participants including:

  • Jason Helgerson, NYS Medicaid Director;
  • Troy Oechsner, Special Assistant to the Superintendent, Department of Financial Services;
  • Legislative Panel: Senate Health Chair Kemp Hannon; Assembly Health Chair, Richard Gottfried; Senate Insurance Chair, James Seward; Assembly Insurance Chair Kevin Cahill.

In addition, Assembly Speaker Carl Heastie, Assembly Majority Leader Joe Morelle and Senate Majority Leader John Flanagan have been invited.  A brief luncheon to which members of each House are invited to speak with their constituents will follow the morning program.   County Medical Societies will be scheduling appointments for physicians to meet with their elected representatives.

Come meet with your legislators to urge that they:

  • Reject burdensome new impediments to obtaining Excess Medical liability insurance coverage contained in the proposed State Budget;
  • Reject inappropriate scope of practice expansions such as the proposal contained in the proposed State Budget that would permit pharmacists to enter into medication management protocols with nurse practitioners
  • Reject changes to increase burdensome physician prior authorization requirements contained in the proposed State Budget;
  • Support legislation to reduce prior authorization hassles including legislation to permit physicians to collectively negotiate contract terms with health insurers;
  • Support legislation to reduce the extraordinary cost of medical liability insurance in New York and reject legislation that would drive up these costs; and
  • Reject legislation that would impose costly and time consuming mandates on physician delivery of patient care

Please come to Albany to make your legislators aware of these challenges!                   (GOVERNMENTAL AFFAIRS STAFF)

Your membership yields results and will continue to do so. When your 2017 invoice arrives, please renew. KEEP MSSNY STRONG!

ACA Discussions Continue in Washington
This week, several Senators proposed different pieces of legislation to repeal and replace pieces of the Affordable Care Act (ACA).

Under the Cassidy-Collins bill, called the Patient Freedom Act, states could enroll people who would otherwise be uninsured in health plans providing basic coverage and would allow consumers to buy additional coverage.  States could stay with the ACA, or they could receive a similar amount of federal money, which consumers could use to pay for medical care and health insurance.  The bill would eliminate the individual coverage mandate and the requirements for larger employers to offer coverage to full-time employees, but allow some protections to remain in place. Parents would still be allowed to keep children on their insurance until the age of 26, and insurers could not impose annual or lifetime limits on benefits.

Additionally, Senator Rand Paul announced the “Obamacare Replacement Act” which would eliminate several provisions of the ACA, including the individual mandate and minimum standards for care. It would also provide a two-year window for people with preexisting conditions to sign up for care.  It also allows insurers to sell plans in multiple states and a $5,000 tax credit that people can put toward a health savings account.

As reported previously, MSSNY has written to New York’s Congressional delegation to urge that the funding mechanism for ACA health insurance coverage programs not be repealed unless such proposals also specify how the current available coverage options will be repealed with improved coverage options that will increase the availability of comprehensive health insurance coverage.             (Belmont)

Governor Cuomo Announces Regulatory Action to Preserve Women Access to Reproductive Health Care
Governor Andrew M. Cuomo announced this week a series of New York State actions to protect access to women’s reproductive rights in New York State.  The Governor announced that New York State will take regulatory action to provide that contraceptive drugs and devices are covered by commercial health insurance policies without co-pays, coinsurance, or deductibles regardless of the future of the Affordable Care Act.

He also proposed that contraceptives are available in amounts exceeding one month’s supply at a time; and all medically necessary abortion services are covered by commercial health insurance policies without co-pays, coinsurance, or deductibles. The announcement coincided with the Women’s Marches in Washington D.C., across New York State and across the country, as well as the 44th anniversary of the landmark United States Supreme Court ruling in Roe v. Wade.  Further information can be obtained HERE and HERE.

The Governor’s action followed action by the New York State Assembly. The Assembly passed the Reproductive Health Act, (A.1748), sponsored by Assemblymember Deborah Glick,  which amended the public health law and placed the abortion procedure in the public health law rather than the penal law.   Additionally, the Assembly also passed A. 1378, the Comprehensive Contraception Coverage Act (CCCA), sponsored by Assemblymember Kevin Cahill.  This measure would require New York State insurers to cover all FAD approved contraceptive methods without out-of-pocket costs, and would ease the multiple barriers experienced by women in obtaining contraceptives and from using them effectively and consistently.                                                                          (CLANCY)

Advocates for Aid in Dying Legislation Hold Press Conference
This week, advocates for “aid in dying” legislation, along with members of the New York State Legislature, held a press conference to push for legislation that would allow a terminally ill patient in New York State to request and use medication to aid in dying.   Advocates from Compassion and Choices joined with Assembly members Amy Paulin and Richard Gottfried and Senator Diane Savino, sponsors of the bill A. 2383/S3151, at the January 23 press conference.  Susan Rahn, who has Stage IV breast cancer, spoke about advocating for the right to “die with dignity.”  The legislation is currently in the Assembly Health Committees.  A similar measure S. 2045 has also been introduced by Senator John Bonacic and is in the Senate Health Committee.

MSSNY position on Physician Assisted Suicide and Euthanasia 95.989 states: Patients, with terminal illness, uncommonly approach their physicians for assistance in dying including assisted suicide and euthanasia. Their motivations are most often concerns of loss of autonomy, concerns of loss of dignity, and physical symptoms which are refractory and distressing. Despite shifts in favor of physician-assisted suicide as evidenced by its legality in an increasing number of states, physician-assisted suicide and euthanasia have not been part of the normative practice of modern medicine. 

Compelling arguments have not been made for medicine to change its footing and to incorporate the active shortening of life into the norms of medical practice. Although relief of suffering has always been a fundamental duty in medical practice, relief of suffering through shortening of life has not.  Moreover, the social and societal implications of such a fundamental change cannot be fully contemplated. MSSNY supports all appropriate efforts to promote patient autonomy, promote patient dignity, and to relieve suffering associated with severe and advanced diseases.  Physicians should not perform euthanasia or participate in assisted suicide.”            (HARRING, CLANCY)

NYS Assembly Codes Committee Approves Expedited Partner Therapy Bill
The New York State Assembly Codes and Health committees approved legislative (A.313, Bichotte) supported by MSSNY, which would allow expedited partner therapy for sexually transmitted infections that the Centers for Disease Control and Prevention (CDC) recommend for the sexual partner or partners of someone having been diagnosed with the disease. Currently, the CDC has recommended the use of EPT for Chlamydia Trachomatis and in November 2012 also recommended EPT in cases of gonorrhea.

In 2005, the New York State passed a law to allow health care providers to provide EPT for Chlamydia infection.  This law was made permanent, along with immunity protections for prescribers as part of the 2013-14 NYS budget process.   This bill will expand the current law to include other sexually transmitted infections that the CDC recommends for expedited partner therapy. EPT helps physicians and other health care providers decrease rates of sexually transmitted infections. While expedited partner therapy in no way replaces a face to face interaction with a health care provider, it can help patients who otherwise would not reach out for treatment.

The CDC has found through randomized controlled tests that EPT has the potential for the same success that it has shown with Chlamydia with other sexually transmitted infections (STIs).  EPT can be highly effective in decreasing infection rates with other STIs that can be cured by taking antibiotics by mouth, such as gonorrhea.  The bill is expected to go to the Assembly floor for a vote and its companion measure, S. 2545, sponsored by Senator Kemp Hannon, is in the Senate Health Committee.                                      (CLANCY) 

AG Schneiderman Announces Settlement with Cigna to Resolve Mental Health Coverage Investigation
New York Attorney General Eric Schneiderman announced a settlement with Cigna this week to require the health insurer to eliminate a written ban on coverage for claims for neuropsychological testing of psychiatric conditions and autism spectrum disorder.

According to the press release the AG’s Health Care Bureau launched an investigation into Cigna’s administration of mental health benefits following a complaint about its written policy for neuropsychological testing. The policy said that “Cigna does not cover neuropsychological testing” for psychiatric conditions and autism spectrum disorder “because such testing is considered educational in nature and/or not medically necessary.”

Under the terms of the settlement, the company agrees to comply with Timothy’s Law, which requires New York group health plans provide “broad-based coverage for the diagnosis and treatment of mental, nervous or emotional disorders or ailments … at least equal to the coverage provided for other health conditions.”   The settlement also requires Cigna to revise its policies, pay autism claims previously rejected, and pay a penalty of $50,000.  Cigna also clarified its policy regarding concussion and mild cognitive impairment.                                                                            (AUSTER)

MSSNY, AMA and Others Release Principles Urging Reduction in Prior Authorization Burdens
Noting that 75% of surveyed physicians described prior authorization burdens as “high or extremely high”, the American Medical Association released a document this week calling on health insurers and benefit managers to reform prior authorization requirements imposed on medical tests, procedures, devices and drugs.  The document, entitled “Prior Authorization and Utilization Management Principles” lists 21 principles where prior authorization hassles could be reduced.  MSSNY was one of a handful of state medical societies to assist I the development of the principles.

While some of the principles that are already imposed on health insurers under New York law, many other principles listed, if implemented, would help reduce some of the PA burdens faced by New York physicians and their staff.  These suggested reforms include:

  • Utilization review entities should offer an appeals system for their utilization management programs that allows a prescribing/ordering provider direct access, such as a toll-free number, to a provider of the same training and specialty/subspecialty for discussion of medical necessity issues;
  • A drug or medical service that is removed from a plan’s formulary or is subject to new coverage restrictions after the beneficiary enrollment period has ended should be covered without restrictions for the duration of the benefit year;
  • Eligibility and all other medical policy coverage determinations should be performed as part of the prior authorization process.
  • If a utilization review entity requires prior authorization for non-urgent care, the entity should make a determination and notify the provider within 48 hours of obtaining all necessary information. For urgent care, the determination should be made within 24 hours of obtaining all necessary information.   (AUSTER)

CMS Again Institutes Audits to Check Physician & Home Care Compliance with Medicare Face to Face Requirements
All physicians should be aware that CMS is again instructing its Medicare Administrative Contractors (MACs), including National Government Services (NGS) covering New York, to conduct Home Health “Probe-and-Educate” medical review audits relating to claims submitted by home health agencies (HHAs) for Medicare home health services including the face-to-face (F2F) requirement.

As many physicians know, the F2F provision requires a certifying physician to document that he or she, or a non-physician practitioner (NP or PA) working with the physician, has seen the patient, as a condition of eligibility for Medicare home health services.  Many home care agencies and physicians have noted that the CMS regulations implementing this provision have created unnecessary and overly burdensome documentation requirements that are delaying or denying coverage for needed home care services.  MSSNY has been working the Home Care Association of New York State (HCA) on efforts to eliminate or reduce the hassles in Medicare and Medicaid associated with this requirement.  Dr. Evelyn Dooley-Seidman chairs a MSSNY-HCA working group that also has the participation of Suffolk County geriatrician Dr. Jay Slotkin.

Specifically, CMS is directing MACs to sample five claims for pre-payment review from each HHA within their jurisdictions.  Based on the results of these reviews, MACs will conduct provider-specific educational outreach. CMS will instruct MACs to deny each non-compliant claim and to outline the reasons for denial in a letter to the HHA, which will be sent at the conclusion of the probe review portion of the process. CMS will also instruct the MACs to offer individualized phone calls/education to all providers with errors in their claim sample. During such calls, the MAC will discuss the reasons for denials, provide pertinent education and reference materials, and answer questions.  For those providers that are identified as having moderate or major concerns (two to five denials out of five), the MACs will repeat the probe-and-educate process for dates of services occurring after education has been provided.

The “probe and educate” initiative, in turn, will likely result in increased efforts to assure physicians are providing the necessary certification.  It is another example of the burdensome paperwork hassles associated with complying with the F2F requirement for physicians and home care agencies. As such, MSSNY will continue to work with HCA to convince New York’s Congressional Delegation to work towards repeal or substantial modification of this rule.  Moreover, we are hopeful that the new Trump Administration Executive Order to reduce regulatory burdens on health care providers and patients will provide a new opportunity to revisit this rule.  With the requirement also slated to go into effect for Medicaid patients as of July 1, 2017, MSSNY is also working with HCA to advocate to the NYS Department of Health to reduce the burdens associated with complying with this rule.                           (AUSTER)

Register Now for Upcoming Medical Matters 2017 CME Webinar Series
The Medical Society of the State of New York encourages you to register for its next Medical Matters webinar on Wednesday, February 15, 2017 at 7:30 a.m. with The Mental Health Impact of Active Shooter/Bombing on the Healthcare Team.  Faculty for this program is Craig Katz, MD, member of MSSNY’s Emergency Preparedness and Disaster/Terrorism Response Committee.  Registration is now open for this webinar here just click on “Upcoming”.

The educational objectives are: 1)  Describe the psychological problems and stress symptoms that can result from caring for victims of an active shooter/bombing event.  2) Identify means by which members of the healthcare team can address stress before, during and after an active shooter/bombing event.  3) Review resources and methodologies available to address the mental health impact of an active shooter/bombing on the healthcare team.

The Medical Matters program for March 15, 2017 at 7:30 a.m. is Exercise Response to Novel Influenza Strains.  Faculty for this program is Pat Anders, MS, MEP, Manager, Health Emergency Preparedness Exercises, New York State Department of Health, Office of Health Emergency Preparedness.

The educational objectives are: 1) Understand preparedness and response actions of public health and healthcare to a novel pandemic influenza, simulated in full-scale exercise.  2) Describe two delineated strategies in which public health and office-based physicians would interact in a pandemic influenza.

A copy of the flyer can be accessed here.  Additional information or assistance with registration may be obtained by contacting Melissa Hoffman at mhoffman@mssny.org. 

Medical Matters is a series of CME webinars sponsored by MSSNY’s Committee on Emergency Preparedness and Disaster/Terrorism Response. 

The Medical Society of the State of New York (MSSNY) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. 

MSSNY designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credits™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.                                               (Clancy, Hoffman)

Activism Matters
The New York Times published an article highlighting the importance of activists to call and meet with legislators. Several lawmakers and staff indicated the value that a large volume of calls on an issue can have on legislator’s positions.  Even if you don’t speak directly to the lawmaker, staff members often pass the message along in one form or another.  From our firsthand experience, lawmakers have always expressed the importance that phone calls and meetings with their constituents can have on their position.

How can I help?
Your participation in the legislative and political process remains critical.  We need to make sure our elected officials know where we stand when their positions helps or hurts you.  MSSNY’s input is valued by many of our elected officials.  Throughout our website, MSSNY provides various resources to make sure you have the tools to fight back when harmful proposals are introduced.

Proposals are constantly introduced that directly affect you and your family.  As many know, physician activism is essential to making a difference in Albany.  MSSNY needs resources and activist like you to so that we will be a united force to be reckoned with.   Every MSSNY member has an opportunity to get involved in one form or another.  Becoming a member of MSSNY allows you to receive the latest information on legislative and budgetary proposals that impact you.

MSSNY is an important avenue to make sure our collective voices are heard.  Every physician should be a part of MSSNY and MSSNYPAC in order to be able to continue our efforts.  And please avail yourself of our resources that make it easier for you to contact your elected officials.                                                                  (BELMONT)

For more information relating to any of the above articles, please contact the appropriate contributing staff member at the following email addresses:

pschuh@mssny.org mauster@mssny.org         pclancy@mssny.org   jbelmont@mssny.org

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Council Notes: January 19, 2017

  • Council approved the Board of Trustees report, which included the pricing policy for the opioid training modules that MSSNY has developed in accordance with the regulations set by the Bureau of Narcotics. The course will be free to MSSNY members. The cost for Non-Members will be $150 for the 3 Module course. However, this $150 will be applied towards deferring the cost of MSSNY membership dues in the event that non-members decide to join MSSNY.
  • Michael R. Privitera, MD, presented a report of MSSNY’s Physician Burnout Task Force. In 2015, the MSSNY House of Delegates passed resolution 2015-200, titled “Physician Health Programs and Membership Recruitment” to develop a series of programs to assist physicians in early identification and management of stress. Council approved the following recommendations from the Task Force:
  1. Development of CME programs on physician stress and burnout, as well as the peer support model and recruitment of a cadre of doctors to do such CME presentations and presentations to leaders and other stakeholders.
  2. Seeking grants or other funding to support CME, burnout study and program activities in an enduring way.
  3. Continued collaboration with other organizations on burnout reduction and wellness efforts.
  4. Seek grants or other funding to help develop a peer support model to all county societies, hospitals and hospital systems and practices in an ongoing way.
  • Council approved the following mission and vision statements from MSSNY’s Committee to Eliminate Health Care Disparities:
    Mission Statement:
    The mission of the Committee to Eliminate Healthcare Disparities is to increase awareness of how factors such as race, ethnicity, culture and religious beliefs, sexual orientation, gender and gender identity contribute to both health and healthcare disparities.

Vision Statement:
The vision of the Committee to Eliminate Health Care Disparities is a New York State healthcare system that bridges gaps and identifies potential bias in order to provide the highest quality care to all people throughout the state with respect for their race, ethnicity, culture and religious beliefs; sexual orientation, gender and gender identity.

  • Speaker Dr. Kira Geraci-Ciardullo announced that Health Commissioner Howard Zucker, MD, JD, will address the 211th House of Delegates on Friday morning, April 21.
  • Don Moy, Esq. spoke briefly about the Overtime Pay Final Rule that was effective on December 31, 2016. Click here for more information.

MSSNYPAC – The Political Voice for New York’s Physicians
Advocating for our profession is both a duty and an honor and physicians are a force for change in New York State healthcare. Our patients deserve excellent care and we strive to provide that in our practices and in policy formation. Participation in MSSNYPAC is an important step in helping to elect physician-friendly candidates, and MSSNYPAC’s President’s Circle and Chairman’s Club help to develop the strong relationships that are necessary for effective political action.  It is essential that physicians not only have a seat at the discussion table but speak with a strong united voice. Join or increase your support and participation today at www.mssnypac.org/contribute. 

AARP Medicare Complete Is Not AARP Medicare Mosaic
For physicians who participate in a Medicare “Advantage” plan called AARP Medicare Complete, there is another plan called AARP Medicare Complete – Mosaic.

They are not the same and if a physician participates in AARP Medicare Complete, he/she does not necessarily participate in the Mosaic product.

When a patient calls for an appointment and says they have AARP Medicare Complete, the practice’s office staff should confirm if the patient is enrolled in the AARP Medicare Complete or the Mosaic product. UHC’s Mosaic plan is a limited language network for patients who speak Chinese, Korean, or Spanish.

The practice will only be paid for services from their contracted plan.

                                    From Regina McNally, VP of MSSNY Socio-Med Division

Nonmedical Vaccine Exemptions on the Rise in NY, Other States, CDC Data Show
STAT (1/20l7) reported that nonmedical vaccine exemptions are on the rise in some states, even as they decline nationally, according to data from the Centers for Disease Control and Prevention. The number of children not being vaccinated for nonmedical reasons in 11 states – Connecticut, Florida, Iowa, Kentucky, Maryland, New York, North Carolina, North Dakota, Ohio, Oklahoma, and Virginia –”is higher than at any point in the past five years.”

Deadline for Abstract submission Is Tuesday, Jan. 31 for Poster Symposium

Resident/Fellow/Medical Student

The Annual Poster Symposium will be held on:

Friday, April 21, 2017
Westchester Marriott
Tarrytown, New York
2 pm – 4:30 pm

In the words of past participants, the MSSNY symposium is an “excellent networking opportunity,” a place to “meet fellow residents and attendings” and “learn from other presentations” that they “would highly recommend.” 

Click here for detailed guidelines.

Check out last year’s Abstract Book here.

We welcome the participation of your residents and fellows. Participants must be MSSNY members, and membership is free for first-time resident members. Join online.

Physician Lobby Day in Albany
Wednesday, March 8th, 2017
Call Your County Medical Society for Details

Health Care Coalition Calls for Prior Authorization Reform
Releases new principles to improve timely access to care and reduce administrative burdens

CHICAGO – Responding to unreasonable hurdles for patients seeking care, a coalition including the American Medical Association (AMA) and 16 other health care organizations this week urged health plans, benefit managers and others to reform prior authorization requirements imposed on medical tests, procedures, devices and drugs.

The coalition, which represents hospitals, medical groups, patients, pharmacists and physicians, says that requiring pre-approval by insurers before patients can get certain drugs or treatments can delay or interrupt medical services, divert significant resources from patient care and complicate medical decisions.

Given the potential barriers that prior authorization can pose to patient-centered care, the coalition is urging an industry-wide reassessment of these programs to align with a newly created set of 21 principles. Prior authorization programs could be improved by applying the principles’ common-sense concepts grouped in five broad categories:

  • Clinical validity,
  • Continuity of care,
  • Transparency and fairness,
  • Timely access and administrative efficiency, and
  • Alternatives and exemptions.

The data entry and administrative tasks associated with prior authorization reduce time available for patients. According to a new AMA survey, every week a medical practice completes an average of 37 prior authorization requirements per physician, which takes a physician and their staff an average of 16 hours, or the equivalent of two business days, to process.

The AMA survey illustrates that physician concerns with the undue burdens of preauthorizing medical care have reached a critical level. Highlights from the AMA survey include:

  • Seventy-five percent of surveyed physicians described prior authorization burdens as high or extremely high.
  • More than a third of surveyed physicians reported having staff who work exclusively on prior authorization.
  • Nearly 60 percent of surveyed physicians reported that their practices wait, on average, at least 1 business day for prior authorization decisions—and  more than 25 percent of physicians said they wait 3 business days or longer.
  • Nearly 90 percent of surveyed physicians reported that prior authorization sometimes, often, or always delays access to care.

The AMA and other coalition organizations welcome the opportunity to work collaboratively with health plans and others to create a partnership that lays the foundation for a more efficient prior authorization process. In addition to the AMA, the coalition includes the: American Academy of Child and Adolescent Psychiatry, American Academy of Dermatology, American Academy of Family Physicians, American College of Cardiology, American College of Rheumatology, American Hospital Association, American Pharmacists Association, American Society of Clinical Oncology, Arthritis Foundation, Colorado Medical Society, Medical Group Management Association, Medical Society of the State of New York, Minnesota Medical Association, North Carolina Medical Society, Ohio State Medical Association and Washington State Medical Association.

CMS: New Participants Join Several CMS Alternative Payment Models
CMS announced over 359,000 clinicians are confirmed to participate in four of CMS’s Alternative Payment Models (APMs) in 2017. Clinicians who participate in APMs are paid for the quality of care they give to their patients. APMs are an important part of the Administration’s effort to build a system that delivers better care and one in which clinicians work together to have a full understanding of patients’ needs. APMs also strive to ensure that patients are in the center of their care, and that Medicare pays for what works and spends taxpayer money more wisely resulting in a healthier country.

“By listening to physicians and engaging them as partners, CMS has been able to develop innovative payment reforms that bring physicians back to the core practice of medicine – caring for the patient,” said Acting Administrator Andy Slavitt. “By reducing regulatory burden and paying for quality, CMS is offering solutions that improve the quality of services our beneficiaries receive and reduce costs, to help ensure the Medicare program is sustainable for generations to come.”

The Medicare Shared Savings Program (Shared Savings Program), Next Generation Accountable Care Organization (ACO) Model, Comprehensive End-Stage Renal Disease (ESRD) Care Model (CEC) and Comprehensive Primary Care Plus (CPC+) Model all apply the concept of paying for quality and effectiveness of care given to patients in different health care settings.


Modern/High End Office (Upper East Side)
Large and Modern office to share.  Located on the ground floor.  2+ treatment/exam rooms, large waiting room, private office, storage.  Price is negotiable for 1-3 day/week.  Call Dr. Austin 5189284819 or email ian@caneandaustin.com No broker fee.  Craig Austin, M.D. 120 East 64th Street, NYC 10065

Prime Astoria Medical Office for Rent or Lease
23-15 Astoria Boulevard, Astoria, New York
Customizable Lower Level
7,500 Sq Feet Gross For Lease
Prime Location Close To Hospital and Other Medical Facilities.
Direct Street Access Private Elevator plus Direct Access From  
Street Level Stairs.
AB Building Management LLC
George Miltiadou
718-482- 7262

Upper East Side Medical Office for Sale
Suitable for a solo practice or shared multi- specialist group. Large unit, about 1100 Sq Ft, located on the ground floor of a cooperative building with own entrance to office, 2 or 3 equipped exam rooms with exam tables and work station areas, front waiting room with reception area with storage unit of shelves for medical charts, a consultation office, 1 and a half bathrooms and kitchenette. Lots of shelves throughout exam rooms, 2 EKGs, one PC computer that comes equipped with a PFT machine and operating software, an operating X-ray machine suitable for chest X-rays with film processor. No brokers, call office manager, Diana Peron @ 212-861-9012

Elegant Plastic Surgery Office (Upper East Side Manhattan)
Very large and classy office to share. Located in the ground floor of a 25′ x 100′ carriage house opposite the 66th Street Armory with large consult room, 2+ treatment/exam rooms, large waiting room, business office, storage. See video of office — you won’t believe it: www.youtube.com/watch?v=Uli8Cck_eRA   $5000/month incl utilities. no brokers. Call Doctor Fischman at (212) 472–3300.Jeffrey R. Fischman, M.D.  110 E 66th Street.

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Physician Opportunities

A Private Multidisciplinary Medical Group is seeking an Internal Medicine/Family Medicine Physician in Manhattan
A well-established Manhattan based private multidisciplinary medical group is seeking to hire an Internal Medicine/Family Medicine Physician. This is a great opportunity to start your own practice in a modern office in midtown Manhattan. Attractive base salary plus comprehensive benefits package offered (Malpractice, 3 weeks paid vacation, 1 week CME, CME allowance, paid health insurance, etc).If you are a solo practitioner in private practice looking to join a private group practice, we will work with you to make the transition seamless. Please email your CV to tsrgexpress@gmail.com. No recruiters please.

A Private Multidisciplinary Medical Group is seeking a Podiatrist in Manhattan
A well-established Manhattan based private multidisciplinary medical group is seeking to hire a Podiatrist. This is a great opportunity to start your own practice in a modern office in midtown Manhattan. Attractive base salary plus comprehensive benefits package offered (Malpractice, 3 weeks paid vacation, 1 week CME, CME allowance, paid health insurance, etc).If you are a solo practitioner in private practice looking to join a private group practice, we will work with you to make the transition seamless. Please email your CV to tsrgexpress@gmail.com. No recruiters please.