Specialty Docs Set 2023 Federal Agenda

Payment Integrity Remains a Priority


Representatives of the Alliance of Specialty Medicine met virtually in early January to discuss their federal agenda for the newly convened 118th Congress. The specialty coalition also welcomed its newest member, the Society of Interventional Radiology (SIR).

The addition of SIR brings the Alliance membership up to 16 national medical specialty societies and adds 8,000 more doctors’ voices for a specialty docs’ total headcount of well over 100,000 specialty physicians nationwide.

Since its founding, the Alliance has focused on providing greater access to specialty care. With that focus in mind, the Alliance will renew its push to create a stable payment system for its Medicare providers this year. For several years, Medicare reimbursement rates have declined due to the budget neutrality requirement in the Medicare Physician Fee Schedule (MPFS) and the lack of an inflation adjustment in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Specialty practices across the nation cannot survive this trend of year-over-year cuts and will again press Congress for oversight hearings and reforms to MACRA as well as fairer treatment under the MPFS.

Patient access to specialty care is also hampered by abuses of prior authorization and step therapy requirements. These measures, crafted initially to save money in the healthcare system, have instead become arbitrary methods for insurance providers to deny care and protect their own profits. While the Alliance was pleased to participate in a roundtable discussion on prior authorization reform sponsored by the Centers for Medicare & Medicaid Services (CMS), we will continue to advocate for passage of the Improving Seniors’ Timely Access to Care Act and the Safe Step Act in the 118th Congress.

This year, the Alliance will also remain active in working with federal healthcare agencies to relieve regulatory burdens on specialty practices. The Alliance responded to proposals outlined in a recent rule addressing Affordable Care Act (ACA) or Exchange plans. In their formal comments, the specialty group highlighted considerable access to care challenges facing consumers in ACA plans due to flawed network adequacy criteria that fail to account for all specialists, particularly subspecialists. To address the problem, the Alliance urged CMS to revise its requirements so all specialists and subspecialists are considered and recommended establishing new plan-level quality measures to incentivize robust networks.

Paralleling its legislative push to reform prior authorization, The Alliance of Specialty Medicine also sent formal comments to the Centers for Medicare and Medicaid Services (CMS) urging the agency to finalize proposed policies that would meaningfully improve utilization management (UM) and plan marketing in the Medicare Advantage (MA) program. Specific to utilization management, the specialists highlighted the importance of the reforms for specialty physicians and their patients, who are often subject to prior authorizations and other UM tactics, and asked the agency to expand its proposals to Part D. In addition, the Alliance urged CMS to rescind its step therapy policies in light of the proposed changes, and at a minimum, revise the guidance, so it’s consistent with the continuity of care proposals.

More recently, CMS introduced its Advancing Interoperability and Improving Prior Authorization proposed rule, which proposes additional requirements on payers, including MA plans, to reduce provider burden and improve care coordination. This rule would make important updates to ensure patients and providers have more immediate access to patient data held by payers, including prior authorization information, and ensure that payers adopt standardized electronic prior authorization processes that are more transparent and timely. The Alliance is generally supportive of this rule and is currently working on a response to CMS.




Alliance of Specialty Medicine

The Alliance of Specialty Medicine (the Alliance) is a coalition of national medical societies representing specialty physicians in the United States.