AVLS Advocacy 2022 and Beyond: Fair Payment is Key to our Future

By Stephen Daugherty, MD, FACS, FAVLS, RVT, RPhS

The COVID-19 Public Health Emergency in March 2020 caused many AVLS members to suspend operations. By June 2020, most vein care offices started to serve patients once again. This rapid adaptation to a changing reality is part of our culture as venous and lymphatic clinicians and serves as an organizing principle for our Advocacy activities.

The American College of Phlebology (ACP), now the AVLS, functioned as an educational organization from its inception. The ACP tackled advocacy issues in a limited way, but in 2017, this changed. A Board level committee was formed to formally address advocacy issues. In 2018, the HealthCare Policy and Advocacy Committee (HPAC), and a subcommittee, the HealthCare Advocacy Advisory Committee (HAC), was formed to expand participation by committee members. A full-time staff position was created in 2018 to serve members and give this issue the attention it deserved.

OUR 3 CORE OBJECTIVES OF ADVOCACY:

• Patient Access to Quality Care

• Fair Reimbursement & Coverage from Payers

• Support Research and Guidelines

The AVLS sought and received financial support from the Foundation to hire Robert White as support staff and fund participation in important meetings with payers, governmental, and regulatory agencies.

Robert White, Director of HealthCare Policy & Advocacy

The HPAC is composed of members of the AVLS Board of Directors who setadvocacy policy and are accountable to the full Board of Directors. The HAC works to implement policy through members committed to at least three years on the committee for the sake of continuity. The HAC, including the members of the HPAC, meets by conference call monthly to review input from membership as teams work on specific assigned projects or interests.

Beginning with the Annual Congress in November 2019, the HAC holds monthly conference calls with the American Venous Forum (AVF) leadership in a collaborative effort to align our shared advocacy efforts and expand our combined influence in medicine.

The HAC includes our representatives who serve multiple-year terms to whom we refer to as “Senators” because of the importance of the service and the value of building long-term relationships with other organizations.

These positions include:

• American Medical Association House of Delegates

» Vineet Mishra, MD, FAVLS, FAAD, Delegate

• American Medical Association CPT Editorial Panel Advisor

» Satish Vayavegula, MD, MS, FAVLS

» Michael Graves, MD, Alternate Advisor

• American Medical Association Resource- Based Relative Value Update Committee (RUC)

» John Blebea, MD, MBA, FACS

» Marlin Schul, MD, MBA, RVT, FAVLS, DABVLM

• Medicare Carrier Advisory Committees

» Chris Pittman, MD, FAVLS, FACR—First Coast Services

» Stephen Daugherty, MD, FACS, FAVLS, RVT, RPhS—Palmetto

» Michael Graves, MD—Novitas

• Intersocietal Accreditation Commission—Vein Center Division, Board of Directors

» Ken Nguyen, DO

» Carl Fastabend, MD

HOW DO WE ADVOCATE?

AVLS Advocacy Insider (Monthly): We digitally publish the Advocacy Insider to the membership to provide a monthly review of new topics of interest. While not comprehensive, the intent is to make members aware of critical issues alongside contact information, so they can reach out to learn more.

The American Medical Association (AMA): As a professional medical society devoted to the care of venous disorders, the AVLS has representation at the AMA House of Delegates (HOD), the AMA CPT Editorial Panel (CPT Panel), and the Resource-Based Relative Value Update Committee (RUC). The AMA HOD is the AMA policy-making body where decisions are made that affect medicine, and we engage in relationships to influence our effectiveness in our other AMA endeavors. Each of our AVLS “Senators” serves a multiple-year term in their role that require several days out of their practice at least two-to-three times per year.

The AMA CPT Editorial Panel writes and revises descriptions of medical services under the close supervision of CMS. The existence of a code and an accurate, detailed description of the service is essential for correct payment for the professional services and supplies necessary to perform each specific service. The RUC assigns value to the physician’s work and other expenses, including supplies necessary to perform the procedures described for each CPT code, under CMS supervision with CMS veto power. An accurate description of the service from the CPT Panel and accurate assessment of the physician’s work and practice expenses from the RUC are essential to appropriate and fair payment for old and new technologies. We are working to build our influence at the CPT Panel and the RUC.

The AMA and most major United States medical societies are working to educate Congress and CMS about the serious adverse effects of the BUDGET NEUTRAL Federal law. This law severely limits payment for office-based care with no provision for increased costs of care, including inflation, more Medicare beneficiaries, increased complexity of care, and increasingly complex office procedures. The AVLS views Congressional action to account for these issues as a critical priority.

Intersocietal Accreditation Commission—Vein Center Division (IAC-VC): The IAC-VC was formed in 2012 as an initiative from the AVLS due to mounting concern about low-quality and possibly unsafe practices in vein clinics. Two representatives on the IAC- VC Board of Directors represent the AVLS. Several other AVLS Board of Directors members also serve on the IAC—VC Division board representing other societies. The IAC—VC Division has engaged in efforts to convince payers to require IAC—VC Division accreditation as a condition for payment for vein treatment. This effort is controversial and not supported by the AVLS board. The AVLS holds that there are several different pathways to attest to quality work and credentialing.

Centers for Medicare and Medicaid Services (CMS): CMS views the patient as a consumer and providers as accountable entities with payment for outcomes and prevention of illness and complications. CMS policy announcements come almost daily, but some of the more critical activities and policies that we continue to monitor for action as appropriate include:

• Merit-based incentive payments (MIPs)

• Alternative payment models (APMs)

• Physician-Focused Payment Model Technical Advisory Committee (PTAC)

• Revision of Evaluation and Management codes

• Annual July draft physician fee schedule regulations and valuations

• Annual November final physician fee schedule regulations and valuations

• Four-year phase-in of office-based supply costs determined by a private contractor with obvious gross errors

• Recently announced targeting of the thermal ablation codes for Recovery Audit Contractors (RACs)

In the summer of 2021, CMS announced a change in its office-based payment formula that is already impacting office-based specialists in 2022. Termed the “Clinical Labor Update,” this new CMS policy cuts practice expenses for a range of office-based procedures. We are actively working on multiple fronts to rectify this policy and convince Congress to implement a hold-harmless approach to the Clinical Labor Update.

STOP CMS22: AVLS members make unprecedented donations to Make our Voice Heard and roll-back Clinical Labor update!

At 2021 AVLS Congress, a special appeal was made to members to donate and fund a wide range of quick reaction Advocacy services. Members donated over $100,000, which was committed for use in Capitol Hill outreach and data analysis services. We are actively deploying these funds and making strategic investments right now to influence and enact positive changes for 2023.

Bold action to advocate to stop cuts to office payment:

As a professional society where officebased members are the majority, CMS’s 2021 announcement of the Clinical Labor Update policy mobilized the Society to enact all efforts to protect patient access to care and ensure future fair reimbursement. AVLS volunteers Dr. James Albert and Dr. Lornell Hansen stepped forward to lead an effort to mobilize fundraising, enabling the AVLS to commit to multiple projects to get our message out. The CMS22 campaign raised well over $100,000, which the Society invested in data analysis and Capitol Hill outreach efforts. This effort is carrying over to 2022 and beyond, and AVLS is committed to ongoing work for a result that will benefit our patients and the long-term viability of office-based care.

KEY ADVOCACY ACTIONS AND ISSUES ON OUR RADAR

In July of 2021, when CMS proposed changes to the office-based payment formula, it became apparent these changes could have a long-term impact on access to care, especially officebased vein care. The Healthcare Policy and Advocacy Committee undertook numerous projects to inform and guide our response.

Site of service and payment incentives: Michael Richards, MD, PhD, and Jonathan Seward, MS, analyzed claims and produced a detailed report showing that even modest cuts in office-based payment likely will lead to a reallocation of services to the more costly hospital outpatient setting. These site-of-service shifts are quite steep and will cost Medicare more for the same services. AVLS used this data in our 2021 proposed rule Comment letter to CMS, and Dr. Richards summarized the research in a presentation at the AVLS 2021 Annual Congress in Denver, CO.

Impact on AVLS members: Using our member NPI data to approximate if a specialty of venous & lymphatic medicine existed, we engaged a leading research firm to approximate the impact of the CMS cuts from 2022 to 2025. Because of the Clinical Labor update, office-based reimbursement cuts to key CPT codes used by our members were among the steepest in medicine. This data is now being analyzed for possible manuscript publication in a peer-reviewed journal. AVLS surveyed our membership regarding the impact of the CMS cuts on their practices and their likely responses, such as retirement or shifting sites-of-service. This data is being published to educate CMS and Congress regarding the severity of the problem.

Venous Policy Navigator: In partnership with the AVF, AVLS offers members a monthly insurance medical policy tracking service focused on vein care. This tool allows offices to quickly stay on top of multiple payers in their region or state.

Medicare Administrative Contractors:

Novitas/First Coast: In late December 2020, these Medicare Administrative Contractors (MAC) announced their final LCDs for vein care and venous stent coverage. Capping almost two years of interactions and personal communications with Carrier Medical Directors, the final policies represented a broad expansion of allowable vein care technologies and an option for prompt treatment in cases of advanced venous disease.

Palmetto GBA: In April of 2022, this regional carrier implemented a new LCD for vein care. In conjunction with the American Venous Forum and the Society for Vascular Surgery, AVLS provided written comments and made verbal comments on the draft LCD. Overall, while the new LCD has many features which support effective patient care, AVLS has some suggestions and comments, which we have sent to Palmetto as a joint letter with the AVF and the Society for Vascular Surgery.

Venous Stenting: The AVLS has been engaged since 2015 with MACs regarding venous stenting policy. The AVLS urged the withdrawal of a poorly written draft LCD in 2016 and 2017. The AVLS, AVF, and OEIS actively engaged Novitas Solutions in 2018 as it developed a new LCD regarding venous stenting. Based on comments from the AVLS and other stakeholders, new LCDs for venous stenting are now in effect in some jurisdictions that we feel are fair and reasonable. Further review of venous stent medical policies is underway, and there remains considerable variation in coverage between MACs jurisdictions.

Phlebectomy Task Force: To better define clinical patterns and possible treatment zones, the AVLS rolled out an easy-to-use application to collect data. This first-of-its-kind tool is instrumental in better delineating patterns of care and typical treatments to inform our future reimbursement strategy.

Venous & Lymphatic Medicine Specialty Workgroup: This group seeks to develop a specialty board with membership in the American Board of Medical Specialties to properly recognize the unique knowledge and skill sets that existing boards do not recognize. One key component of this process is that physicians with many different primary specialty certifications are skilled contributors to the specialty, and they must be included in this process. In the long term, the development of fellowships is an essential element of specialty recognition and patient care.

Capitol Hill and Washington DC: Though not historically a focus or part of our Society, the AVLS pivoted in 2021 and developed a Federal outreach capacity. Several AVLS members stepped up and made personal overtures to their legislators. The AVLS also joined as an Executive member of a group called United Specialists for Patient Access. This advocacy group interacts with Congress on office-based reimbursement and physician payment issues. We worked with political consultants to learn and participate in the legislative and regulatory process as advocates for patients and clinicians.

AVLS is also a member of the Alliance for Wound Care Stakeholders. The Alliance advocates to CMS and Capitol Hill on matters regarding wound care, access to care, new technologies, and payment.

THE FUTURE

The HPAC and HAC will continue working on the active issues referenced above and will add to the list as new issues develop. Our top priority is urging Congressional action to remedy the Clinical Labor Update for 2023 and ensuing years to reform Federal payment for care constrained by budget-neutral legislative mandates.

We hope to increase advocacy to payers regarding medical policy problems and issues regarding access to care, such as refusal by payers to cover care based solely upon a primary physician’s specialty. Payer acceptance of ABVLM certification is a critical step. Finally, we are exploring how venous and lymphatic practices may be able to function in “fee-for-value” models, which soon will become more common.

HEALTHCARE POLICY & ADVOCACY COMMITTEE MEMBERS

• Stephen Daugherty, Chairman

• Chris Pittman, Vice-Chairman

• Mark Meissner, AVLS President

• Marlin Schul

• Steve Elias

• John Blebea

• Vineet Mishra

HEALTHCARE ADVOCACY COMMITTEE MEMBERS

• Chris Pittman, Chairman

• Vineet Mishra, Vice-Chairman

• Marlin Schul

• Stephen Daugherty

• Steve Elias

• John Blebea

• Mark Meissner

• Satish Vayavegula

• Khahn “Ken” Nguyen

• Margaret Mann

• Lornell Hansen

• Robert Worthington-Kirsch

• Zoe Deol

• James Albert

• Michael Graves

• Francis Lee

• Thomas Wright

• James St. George

• Carl Fastabend

• Robert Tahara

• Theresa Soto

• Ken Harper

• Michael Di Iorio

• Ali Wazni

• Marcus Stanbro

• Dev Batra