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AOA

America’s frontline physicians offer recommendations for action to new administration

By AOA Staff

02.17.21

This letter, written on behalf of 590,000 physicians and medical students represented by six medical associations including the AOA, offers recommendations to the new administration on issues to be prioritized for action.

A copy of the letter is below:

February 17, 2021
The Honorable Joseph R. Biden
President
1600 Pennsylvania Avenue, NW Washington, D.C. 20500

Dear President Biden:

On behalf of America’s frontline physicians, we write to congratulate you on your election as the 46th president of the United States of America, and to offer our assistance in our shared goal of creating a better health care system for all Americans, especially as we together take on the challenge of ending the COVID-19 epidemic. We are encouraged by and supportive of many of the actions taken thus far by your administration to greatly expand federal support for public health initiatives to address the pandemic, including prioritizing underserved communities and populations. We strongly support the goals of the Executive Order Advancing Racial Equity and Support for Underserved Communities Through the Federal Government, including requiring federal agencies to review agency programs and policies to assess systemic barriers in accessing benefits and opportunities for marginalized and underserved communities; consider whether new regulations may be needed to advance equity in these programs; and direct resources towards underserved communities.

Our six organizations, and the more than 590,000 frontline physicians we represent, provide the overwhelming majority of care to our nation’s children, pregnant women, adults, and elderly for a full range of physical, mental, and substance use conditions. Each day, our physician members provide health care to patients in communities large and small, urban and rural, rich and poor, and play a critical role in caring for patients with COVID-19. Please see our website, America’s Frontline Physicians: The Group of 6, to learn more about our organizations and the issues that we address together.

We would like to be a resource to you and your administration in taking on the opportunities and challenges of improving U.S. health care. It is with that intent that we respectfully offer the following recommendations on issues to be prioritized for action:

Implement a Science-Based and Public Health Approach to End the COVID-19 Pandemic

Our organizations are greatly encouraged by your administration’s commitment to an evidence-based approach to ending the COVID-19 pandemic, and the reliance on medical and scientific leadership in this effort. We strongly support the goals announced in the National Strategy for the COVID-19 Response

and Pandemic Preparedness, and in related executive actions, including to massively expand access to treatment, vaccination, and testing; ensure an equitable pandemic response and recovery for communities that have been disproportionately impacted by the pandemic; and provide global leadership and engagement, including rejoining the World Health Organization. We support your commitment to ensuring that when scientific or technological information is considered in policy decisions, it should be subjected to well-established scientific processes, including peer review where feasible and applicable, with appropriate protections against political interference and for privacy as outlined in the Memorandum on Restoring Trust in Government Through Scientific Integrity and Evidence-Based Policymaking. As your administration continues to pursue an evidence-based approach to the COVID-19 pandemic, we ask that you prioritize the following actions:

  1. Ensure that community-based physicians and medical students are prioritized and have access to the COVID-19 vaccines. According to the Kaiser Family Foundation, the vaccine distribution strategies of all states and the District of Columbia place health care personnel in the highest priority group. A January 2021 survey shows 9 in 10 primary care clinicians intend to get vaccinated. However, reports from our members and the press have noted that in some areas, community-based primary care physicians are having difficulty getting vaccinated, despite being frontline, high-risk health care professionals. There are also reports of medical students not being included in state vaccine distribution plans, despite being listed among the qualifying health care personnel in the Centers for Disease Control and Prevention (CDC) guideline. In many areas, hospital and health system-based health care personnel, whether they are frontline physicians at high-risk of COVID-19 exposure or not, are being vaccinated before community-based primary care physicians. It is essential that steps be taken immediately to ensure that primary care and other community-based physicians are prioritized and able to get vaccinated. Additionally, we urge you to support physicians who wish to administer the COVID-19 vaccine by ensuring community-based practices are included in distribution plans. In a January 2021 survey, 71 percent of medical practices reported being unable to obtain COVID-19 vaccine for their patients, and independent medical groups were significantly less likely to have access than those owned by hospitals or health systems.
  2. All vaccinators, including those working in pharmacies and retail health clinics, should coordinate, collaborate, and communicate with the patient’s primary care team to ensure patient safety and continuity of care. This includes providing appropriate paperwork to patients, referring patients to their physician for any necessary counseling and follow-up care, and having a structured referral system to primary care settings.
  3. We urge the CDC, Food and Drug Administration (FDA), vaccine manufacturers, state and local health departments, and other stakeholders to widely distribute all vaccine-related educational materials, quality protocols, storage and handling information, documentation, and other requirements to the health care community for better patient education. This should include information about any potential adverse events and tools to educate patients in linguistically and culturally appropriate ways. We also support a national public education campaign about why and how to get vaccinated.
  4. Ensure reasonable efforts to track administration and document vaccination. We support funding for a coordinated effort to improve the electronic exchange of public health data to support public health registries.
  5. Require insurers to provide adequate payment for administration of all vaccines, including COVID-19 vaccines. Payers also need to inform care teams of billing, coding, and other information necessary to obtain prompt payment for not only administering the vaccine, but also for providing counseling and follow-up care.
  6. Work with Congress to increase funding for vaccine production and distribution, testing and tracing, public health, and physicians on the front lines delivering care to patients during the COVID-19 pandemic. We specifically support your proposals to invest $20 billion in a national vaccination program in partnership with states, localities, Tribes, and territories; expand the Federal Medicaid Assistance Percentage (FMAP) to 100 percent for the administration of vaccines; invest $50 billion to expand testing, provide funds for the purchase of rapid tests, expand lab capacity, and provide support to help schools and local governments implement regular testing protocols; fund 100,000 public health workers to work in their local communities to perform vital tasks like vaccine outreach and contact tracing; increase funding to provide health services for underserved populations, including expanding Community Health Centers; and investing in health services on tribal lands to increase access to COVID-19 treatment and care, as well as the ability to provide vaccination to underserved populations.
  7. Build public confidence in COVID-19 vaccines by appropriately preparing physicians and other vaccine providers to engage in effective conversations with patients and families. Despite the seriousness of the spread of COVID-19, a large number of Americans are still hesitant to take the vaccine, including many health care workers. Some are influenced by misinformation being spread about the vaccine’s safety and effectiveness, and others are wary due to the speed of the vaccine’s development and historical racism in medical research.

Physicians are frontline experts and will be among our most important messengers to instill confidence among the general public. Clinicians must have access to data and other information needed to be able to answer patients’ questions about vaccine safety and efficacy. It is imperative that the administration boost education efforts about the safety and effectiveness of the vaccines so frontline health care workers can in turn share this information with the general public. These efforts must also be complemented with awareness campaigns to address vaccine hesitancy by funding the newly authorized VACCINES Act (Sec. 313 of the Public Health Service Act).

Finally, we must also address the recent decline in non-COVID-19 immunization rates. One of the unfortunate side effects of the COVID-19 pandemic is the dramatic fall in regular immunization rates among children and adults. Unfortunately, this decline in immunizations threatens herd immunity levels. To ensure that children, adolescents, and adults are still receiving routine immunizations, we must focus not only on the COVID-19 vaccine rates over the next several months, but also routine immunizations by encouraging Americans to continue receiving recommended primary care.

  1. We applaud the use of the federal government’s authority to expand use of masks as part of a comprehensive strategy to slow the transmission of COVID-19.

Expand Health Care Coverage and Protect Access to Care

The Affordable Care Act (ACA) has played an essential role in extending coverage and patient protections to millions of Americans, including those with pre-existing conditions. Our organizations have championed policies to expand ACA coverage to reach more people and provide a greater level of protection from the costs of health care, and opposed actions that undermine coverage and patient protections. We offer the following recommendations to build and improve on the ACA:

  1. We strongly support your decision to establish a COVID-19 open enrollment period for individuals and families to be able to enroll in an ACA marketplace plan as included in the Executive Order Strengthening Medicaid and the Affordable Care Act.
  2. We appreciate that the same executive order requires agency review of policies that undermine protections for people with pre-existing conditions, demonstrations, and waivers under Medicaid and the ACA that may reduce coverage or undermine the programs; policies that undermine the Health Insurance Marketplace or other markets for health insurance; policies that make it more difficult to enroll in Medicaid and the ACA; and policies that reduce affordability of coverage or financial assistance, including for dependents.
  3. We specifically urge you to prioritize halting and reversing the “Short-Term, Limited Duration Insurance” (STLDI) final rule (CMS-9924-F). Our joint recommendations on coverage urge Congress and the administration to preserve essential coverage, benefits, and consumer protections established under current law. STLDI is designed to fill temporary gaps in coverage. This type of coverage is exempt from the ACA’s consumer protections, and therefore, many of these plans exclude coverage for critically important health care services; vary premium rates by gender, health status, and age; and put individuals and families at significant financial risk. That exemption extends to pre-existing conditions and essential health benefits. An evaluation of these plans found uniform exclusion of coverage for pre-existing conditions and maternity coverage, and no coverage of outpatient prescription drugs in more than 70 percent of plans. This rule, which allows insurers to discriminate against patients with pre-existing conditions, must be suspended and reversed as quickly as possible.
  4. We urge you to expand the 45-day ACA annual enrollment period to at least 90 days.
  5. We strongly recommend that funding and support for ACA outreach and navigators be increased.
  6. We urge you to work with the 117th Congress to expand coverage by lifting the 400 percent cap on premium subsidies, reducing cost-sharing amounts under ACA marketplace plans, and expand competition and consumer choice by supporting health insurance exchanges’ ability to offer a public insurance option that reimburses physicians at rates which are no less than those of traditional Medicare.
  7. We urge you to reverse the public charge rule. Our organizations spoke out forcefully in opposition to the public charge final rule. The public charge regulation that forced families to choose between accessing critical services or remaining together in our country has created a chilling effect that is going to take extensive work to address, and it requires the attention of policymakers at all levels. We appreciate that you have taken bold action early on in your administration to begin the process of reversing this rule.

Expand and Strengthen Medicaid

Medicaid provides an essential source of coverage for more than 75 million children, pregnant women, adults, and seniors. The ACA created policies, including federal funding for Medicaid expansion, that have allowed many more people to qualify for coverage, yet more can and must be done to strengthen and expand Medicaid, including reversing current restrictions at state and national levels that are creating barriers to care. We are encouraged by your executive order requiring agencies to examine policies or practices that may present unnecessary barriers to individuals and families attempting to access Medicaid or ACA coverage, and that may reduce the affordability of coverage or financial assistance for coverage, including for dependents. Our organizations specifically recommend that you:

  1. Seek enactment of legislation to increase the Federal Medicare Assistance Percentages (FMAP) during the public health emergency (PHE) and at least through the end of CY 2021. We support the goals of your January 21 memorandum to increase reimbursement and other assistance to states.
  2. Continue your efforts to revise agency guidance and review existing state waivers to ensure guidance and waivers are consistent with the intent of the Medicaid program and appropriately increase beneficiaries’ access to needed care. Specifically, we strongly support withdrawing the 1115 Community Engagement Initiative guidance and the Healthy Adult Opportunity guidance, and rescinding approval for waivers that reduce coverage, such as those that condition eligibility on work requirements and those that reduce benefits via eliminating retroactive eligibility.
  3. Rescind approval for waivers that reduce coverage, such as work and community engagement requirements; that include high premiums and cost sharing on beneficiaries; or that seek to eliminate or pare back retroactive coverage, non-emergency medical transportation, and other crucial benefits.
  4. Approve pending waivers that broadly expand coverage, including waivers that allow payment for behavioral health treatment services provided in Institutions for Mental Diseases and proposals to extend postpartum Medicaid coverage beyond 60 days without narrow applications to subpopulations.
  5. Work with Congress to create incentives for remaining states to expand Medicaid, such as reinstating a three-year FMAP incentive.
  6. Urge Congress to enact legislation to address inadequate Medicaid payment levels and increase enrollees’ access to care by aligning Medicaid payments for primary care services with Medicare payment levels.

Improve Health Care for Women; End Interference in the Patient-Physician Relationship

We applaud your commitment to supporting women’s and girls’ sexual and reproductive health and rights in the United States, as well as globally. Immediate action is needed to address critical women’s health issues; reverse harmful women’s health policies; and advance policies that protect, enhance, and promote the health of women and families across the country.

  1. As stated above, we urge the administration to approve Section 1115 waivers that seek to extend Medicaid coverage for pregnant individuals beyond 60 days postpartum. HHS has affirmed that Medicaid plays a critical role in protecting our nation’s mothers from adverse maternal health outcomes, including maternal mortality. Continuous access to Medicaid is crucial to addressing our nation’s shameful rising rate of maternal mortality. Medicaid paid for 43 percent of U.S. births in 2018, including 50 percent of births in rural areas, 60 percent of births to Hispanic women, and 66 percent of births to Black women. Approving these waivers could mean the difference between life and death for many women.
  2. We appreciate your swift action in issuing an executive order requiring a review of the Compliance with Statutory Program Integrity Requirements rule and any other regulations governing the Title X program that impose undue restrictions on women’s access to complete medical information. We strongly urge the administration to rescind this rule immediately, reverse other harmful policies that interfere with the patient-physician relationship, and implement policies that affirm a woman’s right to comprehensive, evidence-based, essential health care. The current Title X regulation threatens women’s lives by severely restricting access to medically accurate, preventive health care for millions of low-income women and adolescents who depend on the Title X family planning program. This regulation has caused family planning providers in 34 states to leave the Title X family planning program, resulting in limited, reduced, or no access to essential health services for over 1.5 million patients, including an estimated 750,000 in California alone. This regulation exacerbates racial and socioeconomic inequities in access to care for the program’s disproportionately Black and Latinx patients, which have also disproportionately experienced the harmful impacts of the COVID-19 pandemic. Restoring this critical program so that it can meet the needs of some of our most under-resourced patients is crucial to mitigating the impacts of the COVID-19 pandemic and ensuring access to essential health services for the millions of patients who depend on it.
  3. Rescind the Religious Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act and the Moral Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act regulations, which undermine the ACA by undercutting access to contraception without cost-sharing. These rules created a dangerous new standard for employers to deny their employees coverage based on their own religious or moral objections. This interferes in the personal health care decisions of our members’ patients, and inappropriately inserts a patient’s employer into the patient- physician relationship. In addition, these rules open the door to religious or moral exemptions for other essential physician-recommended preventive services, such as immunizations. No- copay coverage of contraception has an undeniable positive effect on the health of women and families everywhere, as well as the economic health of the nation by saving money for taxpayers and state and federal governments. In 2010, unintended pregnancies cost approximately $21 billion in government expenditures. Likewise, before the ACA, women were spending between 30 percent and 44 percent of their total out-of-pocket health costs just on birth control. After the ACA, women saved approximately $1.4 billion in out-of-pocket costs for contraception in one year. Prompt rescission of these rules is vital to upholding women’s ability to maintain a vital component of their health care.

Address Physician Workforce Issues

Our nation is facing a significant shortage of primary care and mental health physicians. We look forward to working with your administration to grow the physician pipeline and ensure a robust and diverse health care workforce.

  1. Our organizations recommend you reverse the Strengthening Wage Protections for Temporary and Permanent Employment of Certain Aliens in the United States rule. By significantly increasing the minimum required salary that hospitals and clinics must pay physicians with H-1B visas, this regulation will make it challenging for health systems to hire physicians with H-1B visas. More than 10,000 H-1B physicians are employed each year to provide essential health services across the nation, particularly in rural and other under-resourced communities. As a result, this rule will exacerbate existing physician shortages and disrupt access to care.
  2. We strongly support your revocation of Executive Order 13950, which prohibited federal agencies and contractors from offering or supporting certain forms of implicit bias training, including in medical schools and residency programs that receive federal funding.
  3. Our organizations appreciate your proclamation to extend the pause on federal student loan payments and collections through September 30, 2021, and keep the interest rate at 0 percent. This is especially important for our frontline physicians who are experiencing substantially reduced revenue and salaries while treating patients with COVID-19 and other acute and chronic conditions. We urge you to work with Congress to enact legislation to provide permanent relief for high medical student debt beyond temporary relief during the PHE.

Reducing Administrative Burden in Health Care

Our organizations believe that as the health care system continues to evolve to one based on the value of care over the volume of services, and as we strive toward ensuring more equitable care to underserved communities, it is critical to expand and accelerate efforts to meaningfully reduce administrative burden. We recognize that this has been a focus of some efforts to date by the CMS office of Burden Reduction and Health Informatics―and believe that it is critically important to put patient care first by reducing unnecessary administrative burden. However, while well-intentioned, not all of these approaches have achieved their intended outcome; therefore, we encourage your administration to prioritize the following actions:

  1. Continuously evaluate the impact of regulations and administrative tasks on clinicians and patients. We are encouraged by the Biden administration’s recently released Memorandum regarding Modernizing Regulatory Review and stand ready to work with you to ensure its implementation in a manner that includes assessments of the financial, time, and quality-of-care impacts for new and existing regulations on clinicians and patients. We sincerely appreciate that the modernization effort will also focus on how the regulatory review process can promote public health, social welfare, and racial justice.
  2. Our organizations believe strongly in the importance of streamlining and/or eliminating prior authorization. We believe that all industry stakeholders (e.g., private payers, public payers, and vendors) should standardize and automate prior authorization processes and requirements across the health care system in order to minimize restrictions that prohibit timely access to medically necessary health care services. The previous administration recently finalized a rule titled Reducing Provider and Patient Burden by Improving Prior Authorization Processes, and Promoting Patients’ Electronic Access to Health Information, and while the goals of this rule are laudable, the process for its review and finalization was problematic. Therefore, as part of the implementation of the administration’s Memorandum regarding Regulatory Freeze Pending Review, we ask that this rule be frozen for further review in order to allow a greater opportunity for stakeholder input prior to implementation. The regulation includes an aggressive set of requirements that could improve the care delivery process; however, implementing this rule as finalized will require substantially revised business workflows based on new technical standards―and yet only 25 days were allowed for stakeholders to comment. The rule was then issued shortly after those comments were due, which likely made it impossible to fully account for all of the comments received. It is critical that CMS be able to receive comprehensive, thoughtful, and detailed feedback from impacted stakeholders.
  3. Reissue the Requests for Information (RFIs) that were originally included in “Reducing Provider and Patient Burden by Improving Prior Authorization Processes, and Promoting Patients’ Electronic Access to Health Information” for a 60-day comment period to allow for full consideration and input by all stakeholders. The rule contained RFIs on a wide range of topics, including the control patients “provider” organizations, and clinicians, would like to have over the sharing of health information; how to advance electronic data exchange among behavioral health providers; input on processes and uses of electronic prior authorization transactions exchanged between payers, clinician organizations, clinicians, and patients; how CMS can reduce the use of fax technology across programs; and opportunities to improve adoption of standards related to social risk data. Each of these RFIs will require careful consideration and may require outreach to our members to appropriately respond.
  4. Continue and expand upon efforts to leverage health information technology (IT) to reduce administrative burdens and improve usability and interoperability of health IT, clinical workflows, and patient access to electronic health information. It will be critical to collaborate with stakeholders, including frontline clinicians to make better use of new and existing health IT.
  5. Improve health care performance measurement by continuing to engage with specialty societies, frontline clinicians, patients, and health IT vendors in the development, refinement, testing, and implementation of measures with a focus on decreasing clinician burden and integrating the measurement of performance with quality improvement, care delivery, and clinical workflow.

We appreciate the opportunity to work with you and your administration, and hope you will view our organizations as trusted resources, as we work collectively to create a health care system that provides every American with the care they need, at the time they need it, with equity and justice for all.

Sincerely,

American Academy of Family Physicians
American Academy of Pediatrics
American College of Obstetricians and Gynecologists
American College of Physicians
American Osteopathic Association
American Psychiatric Association