A look behind…and ahead

2018 was a busy year for the College’s Advocacy Council as we worked hard to provide substantive advocacy services to College members. We’ve had some great victories and there are issues that still need our attention. So, what did we accomplish in 2018? And what’s on deck for this year?

Day-to-day dealings with insurance

We field many calls to our executive office each day; half are questions regarding coding, and the rest are usually about insurance carrier issues. We are discovering more and more misunderstanding and/or abuse of coding and reimbursement among managed Medicare and managed Medicaid plans. We suspect there may be an industry consulting group responsible for this growing phenomenon. Our legal counsel has developed talking points for state, regional and local leaders to use with their carriers for some of the more common issues.

Medicare’s proposed 2019 Physician Fee Schedule

We have been working with the American Medical Association (AMA) to stave off Medicare’s proposed changes to collapse evaluation and management (E/M) service codes and restructure reimbursement. Through these combined efforts, we’ve succeeded in convincing The Centers for Medicare and Medicaid Services (CMS) to postpone any changes until at least 2021. We will use the next two years to work together to develop a more rational way of coding E/M visits as well as how Medicare – and other payers – will reimburse for them.

Mixing allergen extracts in-office

Since 2015, the Advocacy Council has been very engaged with the United States Pharmacopeia (USP) and the U.S. Food and Drug Administration (FDA) on what we generally call physician in-office mixing. USP proposed major changes in their long-standing policies on the standards for preparing allergen extracts and rewrote the organization’s policies on compounding of all types. The physician in-office mixing standards are included in USP Chapter 797. We immediately started a multi-pronged offensive funded by College member donations through our Defend Affordable Shots (DASH) campaign.

Last year, the Advocacy Council, in cooperation with the American Academy of Allergy, Asthma and Immunology and the American Academy of Otolaryngic Allergy, arranged a series of meetings and calls with the relevant USP committee members and several allergy/immunology leaders to discuss their proposals, our concerns and possible alternatives. The people we met with were impressed with our data and input.

We also began an aggressive outreach campaign to key members of Congress who were strong supporters of our specialty and were personally aware of the benefits of allergen immunotherapy. The work of Congress members proved invaluable to our campaign to get USP to develop more reasonable guidance on physician in-office mixing.

In the summer of 2017, we worked with the AMA to put together a large group of physician specialty societies who were similarly affected by the proposed mixing changes. We increased our collaboration to pursue our common goals related to mixing.

This past summer, all these efforts began to bear fruit as both USP and the FDA came out with new proposals on physician in-office preparation of allergen immunotherapy. Your Advocacy Council continues to provide input to USP and the FDA on the compounding issue. However, in general, we believe the new draft of USP Chapter 797 is reasonable and workable in the allergists’ office. USP’s final rule on Chapter 797 is scheduled to be published this June.

Furthermore, the FDA now believes that what we do every day with allergy antigens should be called “mixing” rather than “compounding” and have given allergy a “carve out” from their more rigorous commercial regulations.

What lies ahead?

We expect that 2019 will continue to be a year marked by a great deal of attention on health care by federal and state health policy makers.

More merging

Mergers and acquisitions among and between health care organizations will continue as all search for the magic formula for delivering efficient, high-quality, cost-effective care. We expect the federal government to try to slow down the “mega-merger train” – arguing that in many markets and service lines, we are dangerously close to having health care monopolies.

Medication cost reduction

The federal government – both Congress and the agencies – will be exploring ways to reduce the cost of prescription drugs. States, for their part, will continue to explore ways to reduce the cost of Medicaid programs by shifting more Medicare recipients to managed care and instituting work requirements for able-bodied individuals as a condition for receiving Medicaid.

Health care cost control

We believe the Trump Administration will aggressively advance the Doctrine of Choice and Competition as the answer for skyrocketing health care costs. Trump Administration officials believe we can achieve efficiency and retain quality by providing consumers with more choices and greater competition in health care. These new forms of health insurance will compete with Affordable Care Act health plans, telehealth, and state scope of practice laws that allow physician assistants and nurse practitioners to work at the top of their licensure.

Both political parties are in agreement that the cost of health care is too high, and something must be done to lower the cost of health insurance and change how health care is delivered. Despite the mutual recognition of the problem, a bipartisan solution has not yet emerged. Expect lots of hearings on how to solve the health care crisis but no consensus on just what that solution should be.

Congress won’t be able to ignore the problem for long, however, and 2019 could be a watershed year for health care reform. The repeal of the penalty for failure to maintain health insurance, combined with the inability of health plans to deny coverage for any reason, could result in a highly volatile insurance market subject to wild swings in premiums over the next 12 months.

To paraphrase Betty Davis’ character in the movie “All About Eve” – “Fasten your seatbelts; it’s going to be a bumpy ride.”

Stephen Imbeau, MD, FACAAI
Chair of the College’s Advocacy Council

Advocacy Issue: 
Mixing Allergen Extracts
Billing, Coding & Payments