Expanding payment for vaccination, public option fuels debate among WADA delegates

Should doctors be compensated for administering vaccines to Medicare beneficiaries? Should the government provide a public option for health insurance? These were among the most heated debates on Sunday at the interim meeting of the American Medical Association (AMA) House of Delegates.

Participating virtually and in person in Honolulu, AMA members who took the mic during the Medical Services and Practice Advocacy Committee also called for a more assertive stance to persuade the Centers for Medicare & Medicaid Services (CMS ) to crack down on less-next Medicare Advantage plans, and push for reimbursement to meet guidelines on early detection of colon cancer and coronary artery calcium scoring by CT scan.

Reimbursement of vaccination by health insurance

Members expressed frustration with how Medicare’s payment policy prevents many doctors from being compensated for vaccinating patients in their offices under Part B, which covers outpatient services. Instead, patients are required to get vaccinated from a pharmacy through their drug plan Part D.

The AMA’s Senior Physicians Section proposed that the AMA advocate moving money into Part B to correct this situation and, as resolution author Doug DeLong, MD, put it, “bring back vaccines where they belong, in the doctor’s office”.

However, an overriding concern expressed by several speakers was the impact on payments for other Part B services, since Medicare policy states that all Part B payments must be budget neutral; if medical practices are reimbursed for vaccinating patients, that money would be subtracted from another Part B service.

It would reduce “the resources available to all medical services when we add anything to it, and therefore further split the pie, just as many physicians are trying to recover financially from the pandemic,” said Daniel Gold, MD, of the delegation. from New York. .

“Many family doctors have expressed concern and frustration that they are not being paid to administer vaccines – such as shingles and Tdap [tetanus, diphtheria and pertussis] – in their offices because they are only covered by Part D. Sending patients to the pharmacy disrupts continuity of care and decreases uptake of vaccines,” said Alex McDonald, MD, delegate for the American Academy of Family Physicians.

“This is not a resolution to discuss budget neutrality,” said Carolyn Francavilla, MD, speaking on behalf of the Private Practice Physicians Section, which supports the submission of patient vaccination requests through the B. “Our Medicare patients cannot get their Tdap and shingles vaccines at our clinics, so they are referred to the pharmacy,” she said. not always.”

Francavilla, president-elect of the Physicians in Private Practice Section, added that this basic preventative care “is not an esoteric procedure…If we save a case of shingles, we’re probably saving a lot of money.”

“It really hurts and frustrates me that I can’t provide this very important care to my patients,” said William Fox, MD, delegate of the American College of Physicians. Regarding concerns that a policy change would take needed funds away from other services, Fox said the AMA shouldn’t “be afraid to add new codes” to doctors’ fee schedules. “This is how we advance medicine.”

The AMA’s position “should be that we don’t believe in budget neutrality, and that is the stated position of this house,” Fox said.

Robert Gilchick, MD, of the American College of Preventive Medicine, noted the huge amount of misinformation about vaccines currently circulating. “Vaccination has been a bit under fire lately, and we need to remove all the barriers we can.”

Public Options Redux

Debate over a resolution that, if passed, would push WADA to advocate for a public option to expand health coverage was particularly long and polarized, as it has been in many previous WADA meetings. ‘AMA.

While the ACA has reduced the number of uninsured, market plan costs are out of reach for many and “too expensive to actually use” due to high premiums, deductibles and other out-of-pocket costs, depending on the resolution. Additionally, many plans have “tight provider networks, which reduces access to care.”

Sarah Marsicek, MD, delegate of the American Academy of Pediatrics, noted that before the pandemic, 29 million people in the United States did not have health insurance, and an additional 5.4 million lost their coverage during the pandemic. pandemic due to job loss. Another 15 million will lose Medicaid when the pandemic is over.

“Creating a public option will allow Americans who fall into coverage gaps to seek and get the health care they need and deserve,” Marsicek said.

“We know that our patients are suffering and that access to health care in this country is woefully inadequate,” said Alain Chaoui, MD, of the New England delegation, who spoke in support of the resolution. . “It’s wrong for us to sit around and wait for someone else to give us an idea of ​​how health care should be run in this country.”

But many in the room were adamantly against the resolution, fearing that a public option would lead to Medicare, or even lower, payment rates for medical services.

Shawn Baca, MD, of the Florida delegation, called the resolution “a sneaky way to fundamentally change AMA policy when you’re directly advocating for the public option, and essentially on the path to a single-payer system.” “, did he declare.

“I get it, we don’t like insurance companies. They don’t do a good job. They put profits before patients,” Baca said. “The problem is that the government is putting the spending in front of the patients and doing the exact same thing.”

A public option, Baca said, “would make the situation worse.”

Greg Fuller, MD, of the Texas delegation, said he’s concerned the resolution doesn’t include any language to improve federal payment, and historically doctors have kept their practices viable by having patients covered by multiple payers, since Medicare generally pays lower rates than commercial coverage. . “Medicare rates are not market-based and have not kept up with inflation,” he said.

A public option “would lead to predatory pricing and starve the other market, and then paradoxically reduce access,” added Asa Lockhart, MD, of the Texas Medical Association delegation.

Action on Medicare Advantage plans

Another hot topic was a resolution calling on CMS to act on Medicare Advantage plans by demanding “an accurate and up-to-date list of physicians.” The resolution also said all plans should state whether doctors are accepting new patients, which is often not provided.

“Many recipients of these plans have faced unclear benefits, hidden costs, and delays in care compared to traditional health insurance,” said Nikita Changlani, regional delegate for Mississippi medical students. The plans are structured around coverage networks that are too narrow, she said, adding that “WADA should continue to strongly support efforts to hold these entities accountable, protect the doctor-patient relationship and promote the Health care access”.

Michael Butera, MD, delegate from the Infectious Diseases Society of America, also spoke. said, adding that knowing which doctors are in which networks is important for maintaining the doctor-patient relationship.

Registrants should understand, Butera continued, “there may be inadequate networks with prior authorization that may deny coverage of necessary diagnostic procedures, access to medications and other services,” including rehabilitation. and access to specialist care.

But Dale Mandel, MD, an alternate delegate from Pennsylvania, urged the AMA to step back and study the issue. He said not only does the Medicare Plan Comparison Tool show what services are covered and provide some of what the resolution would attempt to accomplish, but it is “impractical to try to maintain such a list. It’s a huge task.”

Some other resolutions discussed at Sunday’s meeting, if passed by the House of Delegates this week, would push WADA to advocate:

• For first-dollar coverage of Coronary Artery Calcium Score CT, approximately $49 to $1,209, for patients who meet American College of Cardiology/American Heart Association guidelines
• For payers, healthcare systems, and clinicians to adopt the U.S. Preventive Services Task Force’s updated recommendations for routine colorectal cancer screening starting at age 45
• Against the practice of suing patients with medical debt, given “the detrimental cost to a patient’s well-being”
• For immediate, timely, and transparent negotiations on how Medicare drug prices are incorporated into law, closing loopholes such as “patent renewal,” and banning direct-to-consumer drug advertising on prescription within 5 years