番茄社区

CHICAGO -- Members of the American Medical Association (AMA) House of Delegates disagreed sharply Saturday on whether Medicare should be allowed to negotiate prescription drug prices, as well as whether physicians should benefit from any savings generated by doing so.

"Congress is currently debating legislation that would allow drug price negotiation within the Medicare system," said Tatiana Spirtos, MD, a delegate from the California Medical Association (CMA), during a reference committee hearing at the AMA Special Meeting of its House of Delegates.

She spoke on behalf of the CMA, which offered a resolution asking the AMA to lobby in favor of Medicare drug price negotiation. "Current AMA policy does not support basing drug prices on the average international market price, especially as single-payer countries are included, and so AMA has left out of any discussion and negotiation attempts that includes these elements. This handicaps our advocacy team, this limits our contributions at the bargaining table, and this allows an unfettered voice for the market-driven pharmaceutical industry," Spirtos stated.

"Our proposed amendment to existing policy allows AMA the flexibility of ... considering multiple pricing standards under discussion at the federal level and [having] a stronger AMA voice in the ongoing debate, and tips the scales in Congress in favor of more meaningful drug pricing reforms for our patients," she added. "We're asking to aggressively advocate for passage of this legislation to amend the current policy to at least allow the AMA to enter the drug pricing debate with all options on the table."

Possible Effects on Part B

Stephen Epstein, MD, speaking on behalf of the Council on Medical Service, which is considering the resolution, disagreed. "While we are supportive of the intent of the resolution, we identified two areas of concern," he said. "First, the amendments would allow for the use of international price indices that include countries with some form of price controls. Our AMA has strong policy against applying price controls to any sector in healthcare, as price controls could ultimately be applied to physicians. While the council appreciates the call for flexibility, we caution against opening this particular door."

In addition, he noted, the resolution asks to change existing AMA policy -- a policy which addresses drugs provided by physicians under Medicare Part B as well as drugs covered under Part D. "The council believes that this proposal, which will allow for the incorporation of countries with price controls and international price indices, could have uncertain effects on Part B drugs. This is not hypothetical," he said. "There have already been regulatory proposals, and legislative proposals could be on the horizon ... The council believes our AMA needs consistent policy covering both parts of Medicare, and this is best addressed by reaffirmation of current policy."

Former AMA president Barbara McAneny, MD, an oncologist in Albuquerque, New Mexico who spoke for herself, agreed. "I just worked with a group of patient advocates and other specialty societies to get rid of this law in New Mexico when it was proposed," she said. "The reason is that it is not clear where the limit on pricing would occur. And many providers, particularly of part B drugs -- expensive infusion therapies -- purchase those drugs and then if we are reimbursed less than the purchase price ... we've ended up very soon being unable to deliver those drugs to the patients who need them."

Barbara Weissman, MD, an alternate delegate from California who was speaking for herself, disagreed."This resolution both reaffirms current policy and also takes it forward several steps," she said. "I hope it'll be passed as this topic is being actively discussed in Congress." Weissman said that as a physician who does home visits to elderly patients, "I've had patients who have not taken medications based solely on the cost of the pill. For example, one woman chose to take only her side-effect pill and not her antipsychotic, because the side effects pill was cheaper. Decreasing the cost of medications is essential for our patients' health."

What Should Be Done With the Savings?

The New England delegation objected to a portion of the resolution suggesting that any savings generated from price negotiation be used to increase payments to physicians under the Medicare Physician Fee Schedule. "The way that's worded now, it sounds a bit self-serving," said Dennis Dimitri, MD, a Massachusetts delegate speaking on behalf of the New England delegation; he proposed that instead, the savings be used to increase coverage of services to Medicare beneficiaries related to social determinants of health. "We could redirect some of our money that we spend now on drugs into social determinants of health and improve the well-being of our population."

Joe Heyman, MD, a delegate from the American College of Obstetricians and Gynecologists, also panned that portion of the original resolution. "Just think of what will happen during a debate, when they say, 'Well, they passed this resolution in order to increase their own income,'" he said. "It just looks terrible to anybody on the outside."

Sherif Zaafran, MD, who spoke for the Texas delegation, disagreed. "The American Medical Association, first of all, is representing physicians and their ability to take care of patients," he said. "Medications in this country are prescribed by physicians. It's not going to do us any good to have access to medications if you don't have any physicians left to be able to prescribe them, with the Medicare fee cuts that are out there ... We have to be able to advocate for ourselves."

Coding for Telehealth Services

Delegates also discussed a resolution sponsored by the American Association of Clinical Urologists, the Private Practice Physicians section, and 10 state delegations calling for the AMA to lobby for simplifying coding for services provided via telehealth. The resolution notes that even though "telehealth services are easily identified by using place of service (02) on claims submitted for reimbursement, many private payers additionally require a 'modifier 10' to indicate the service was performed using telemedicine."

"There is no reason for health insurers to require modifiers to express what is already described via the 'place of service' code," said Josephine Nguyen, MD, an alternate delegate from Virginia, one of the state delegations supporting the resolution. "The extra exercise leads to confusion, complexity, administrative burden, and denied claims."

Peter Hollmann, MD, a delegate from Rhode Island who was speaking for the New England delegation, offered an alternative resolution that he said would work better. "If we were successful in implementing the resolution as submitted -- using only patient service 02 -- it would actually lead to an immediate decrease in payments for telehealth services," he said. "Medicare today applies only a non-facility payment which is about 25% less, whereas if you use place of service where you usually see the patient (11) and modifier 95, which is the CPT modifier, one receives the full payment, just as if you saw them in the office."

But Nguyen objected to that idea. "While we appreciate the amendment from Rhode Island, the place of service code 02 or 10, which will be effective January 1, 2022, is in fact the optimal choice for coding telehealth, and not using it due to current Medicare reimbursement policies -- which likely will change in the foreseeable future -- and adding modifiers goes against the clear intent of this resolution," she said. "Reimbursement for telehealth services is an important parallel issue and can only be properly addressed with uniform and straightforward coding."

Comment