Advocacy and Public Policy

The following information and links are monthly updates of the College’s public and private sector advocacy efforts. Shortened versions of the current month’s updates are included below; more detailed information and previous updates can be found on the Monthly Advocacy Update page.

Advocacy Update

Lidocaine Shortage Information and Resources

Ongoing shortages of lidocaine are having a significant impact on Mohs surgical practices and skin cancer patients. The root cause of drug shortages and potential solutions are complex and multifactorial, and policymakers continue to debate the best path toward mitigating these challenges. To assist ACMS members facing lidocaine shortages, we have compiled a list of resources that provide information on drug supply chain and shortage issues. ACMS continues to monitor and work with policymakers to address these and other office-based compounding concerns. The last listed link, ASHP Shortage list is a searchable database. This database will provide anticipated release dates for products. Note that release date is when product is available to distributors. Where your practice falls within the distributor’s allocation process will determine when you receive product. Some options for you to consider: establish relationships with multiple distributors, utilize alternate local anesthetics, look to non-traditional sources such as dental suppliers. For small procedures like a tangential biopsy, draw up minimal amount of local anesthesia needed rather than filling the entire syringe.

FDA Drug Shortages Information Web Page

FDA Drug Shortages Database

2019 FDA Drug Shortages Task Force Report – Drug Shortages: Root Causes and Potential Solutions

ASHP Current Drug Shortages List

Provider Relief Fund PRF Portal Reopened (April 18, 2022)

Due to provider community advocacy, the Health Resources and Services Administration (HRSA) has reopened the PRF Portal, allowing physicians to submit a late Reporting Period 1 report request. The portal will close on Friday, April 22, 2022 at 11:59 PM ET. Physicians should receive an email from HRSA on how to submit a request, or they may contact HRSA directly through the provider support line: 1-866-569-3522 for technical assistance or with any questions.

CMS Considers Mohs Surgery, Skin Cancer for Episode-Based Cost Measures

This week, the Centers for Medicare and Medicaid Services (CMS) announced the next wave of its ongoing effort to develop episode-based cost measures for potential use under the Merit-Based Incentive Payment System (MIPS). Working with its contractor, Acumen, LLC, the agency indicated that it would be looking to form Clinical Subcommittee for a number of procedural, acute inpatient and chronic conditions, including a dermatologic clinical subcommittee that will focus on Basal or Squamous Cell Carcinoma, Melanoma Resection, and Mohs Surgery.

Howard Rogers, MD, PhD, Chair of the ACMS Private Sector Advocacy Committee and ACMS National Clinical Data Registry and Outcomes Committee, was the College’s representative in the agency’s previous episode-based measure development efforts, having served as the chair of the Oncologic Disease Management Clinical Subcommittee.

ACMS will continue to engage in the process, keeping members apprised of these activities and the impact on Mohs surgeons.

ACMS Seeking Nominees to Serve on Federal CLIA Committee

Recently, the Centers for Disease Control and Prevention (CDC) announced that it is seeking nominations for membership on the Clinical Laboratory Improvement Advisory Committee (CLIAC). According to CDC, the CLIAC consists of 20 experts including the Chair in the fields associated with microbiology (including bacteriology, mycobacteriology, mycology, parasitology, and virology), immunology (including histocompatibility), chemistry, hematology, pathology (including histopathology and cytology), genetic testing (including cytogenetics); from representatives in the fields of medical technology, public health, and clinical practice; and from consumer representatives. Nominations are being sought for individuals who have expertise and qualifications necessary to contribute to the accomplishments of the committee’s objectives. Members may be invited to serve for up to four-year terms. ACMS members that are interested in being nominated by the College should notify Executive Director Mary Riordan at mriordan@mohscollege.org, and provide a CV and letter of interest.

Dispatch from Washington, DC: Alliance of Specialty Medicine 2018

Erin S. Gardner, MD / July 17, 2018

Returning now from Washington, I wanted to report on advocacy activities pursued on behalf of the ACMS over the past several days. I arrived representing the Mohs College at both the Alliance of Specialty Medicine Annual Fly-In, as well as the American Academy of Dermatology’s Legislative Conference as Advisor Liaison for the ACMS. The two conferences were held basically contemporaneously. I met ACMS President Barry Leshin and ACMS Secretary-Treasurer Glenn Goldman at the ASM conference.

The ACMS has been a member of the Alliance of Specialty Medicine since the year after its founding in 2011. While the interests of generalists and other physician collectives have been raised by other organizations through the years, the interests of several constituent specialty organizations have found a forum at the ASM. Member specialty societies include our own sister American Society of Dermatologic Surgery, as well as several national surgical societies, an ophthalmologic society, and even a rheumatology society.

Both the ASM and the AAD/A put a lot of effort and work into generating good “asks” to make of our representatives in Washington. Of course, it seems there are always a plethora of potential asks, just so little time to make the most important ones. The intent of these legislative conferences is to focus attention on the legislative or regulatory issues that are most impacting the ACMS specifically, and sometimes the house of medicine generally but with an impact on Mohs surgeons too.

Most asks for 2018 addressed legislation that has either been passed in one house or the other, or which has been introduced and is awaiting mark-up and further action. The first ask on the ASM docket addressed the importance of retaining a fee-for-service option in Medicare, as some groups have called for abandoning the MACRA programs (i.e. MIPS and Advanced-APMS) in favor of a proposed value-based program based on withholds from Medicare payments. MedPAC, an independent congressional agency, recently recommended just such an approach. While the MACRA programs have a number of challenges and problems, the concern with the new withhold-centered, value-based approach is that specialist’s interests are given short shrift. The MedPAC concept envisions a patient-centered medical home, but leaves unanswered how specialists will find their best role within this home. ASM asserts that we specialists must continue to retain a seat at the table, and a fee-for-service option preserves this role.

Another ASM ask requested support for the Local Coverage Determination Clarification Act. As we Mohs surgeons are all too aware, our regional Medicare Administrative Contractors periodically and peremptorily hand down decisions which adversely affect coverage for the Mohs surgery we can deliver to our patients—these are called local coverage determinations. The act is intended to bring transparency and a specified paradigm to these sometimes arbitrary-seeming decisions.

The ASM again urged support for the USPSTF Transparency and Accountability Act. Introduced in an earlier session of Congress, the name of the bill speaks for itself. You may recall that the United States Preventive Services Task Force in 2016 recommended against routine skin cancer screening for asymptomatic adults, stating that their collected evidence didn’t support the expenditure. This recommendation was controversial, because medical specialists were not included in the decision-making on the Task Force. The Act would require the USPSTF to openly publish all studies used to generate a final recommendation, and to include physician-input within the decision-making process.

Physician shortages have become commonplace in rural regions, but are becoming an issue within metropolitan tracts as well—just ask any dermatologist trying to recruit a new colleague. The recent Burden of Skin Disease Report sponsored by the AAD showed that only one-third of skin disease is treated by dermatologists, and the dermatology workforce was about 10,000-dermatologists short of actual need (2013 data). The Resident Physician Shortage Reduction Act was introduced to address the shortfall. The Act would increase the number of Medicare-sponsored GME residency slots by 15,000 over the next five years.

Moving to the AAD-sponsored legislative conference, the asks revolved around reducing unnecessary regulatory burdens and increasing transparency, and addressed issues more generally applicable to the realm of dermatology. Asks were made related to legislation that addressed the high cost of prescription drugs, which affects all of our patients. Legislation that streamlines access to prior authorization-drugs was also promoted. Finally, efforts to increase interoperability, which will facilitate the electronic exchange of records between physician offices, was also touted.

Each of the offices that we visited welcomed us warmly, and listened openly to our appeals. Our representatives vowed to consider our various asks carefully. We will continue the efforts to bring more sensible legislative and regulatory policy to the practice of Mohs surgery and the house of medicine generally.

UPDATE

Just prior to the gathering in Washington, CMS released the proposed rule for 2019 updates and modifications to both the Physician Fee Schedule and the Quality Payment Program (i.e. MIPS and Advanced APMs). This nearly 1500-page document has several proposals that do not align with the interests of the ACMS. Glenn Goldman, current ACMS Treasurer, raised one important issue with Senator Rand Paul, who was one of the guest speakers at the conference. Specifically, the proposed cut to modifier-25 E&M visits was highlighted, and its detrimental impact on a broad group of medical specialties, if not primary care, was emphasized. The ACMS will be submitting a comment letter to CMS on the proposed rule within the next several weeks, opposing the modifier -25 proposal and other proposals that adversely affect the ability to provide high quality care to our patients with skin cancer.

MIPS for Mohs: What you need to know

On October 14, 2016, the Centers for Medicare and Medicaid Services (CMS) released its long-awaited final rule implementing provisions outlined in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which repealed the Sustainable Growth Rate (SGR) reimbursement formula and replaced it with a two-track Medicare physician payment system–the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs)–collectively referred to as the Quality Payment Program (QPP). These new policies become effective January 1, 2017.

How to avoid the 4% penalty in 2019
CMS has implemented a “pick your pace” reporting strategy for year one – the first “transition year” of MIPS. Providers who are subject to the program but submit no data in 2017 are assured a financial penalty of -4 percent in 2019. Avoiding this penalty can be accomplished by simply reporting as little as one quality measure for one patient, which would yield 3 points – the 2017 performance threshold. See “Avoiding the 2019 Penalty” in the document below for additional details.

View the full MIPS for Mohs document (PDF)

Compounding and the FDA

By Erin S. Gardner, MD, FACMS

Here is an update on the College’s ongoing efforts to shape the upcoming guidance for compounding as issued by the FDA.

Regulatory Review Newsletters

A weekly overview of the most recent news and updates from the Centers for Medicare & Medicaid Services, Centers for Disease Control and Prevention, Health and Human Services, Food and Drug Administration, Government Accountability Office, National Institutes of Health, and more.

ACMS Issue Fact Sheets

In conjunction with the Annual ACMS Advocacy Conference Fly-In to Washington, D.C., the College provides fact sheets on key issues for attending members to inform their conversations with legislators and Capitol Hill staff. General fact sheets were created for the 2017 Fly-In, as well as additional documents on specific issues:

Let us know if you’re seeking fact sheets on other issues; we may be able to supply them.

Health Policy Briefings

Every Monday, Hart Health Strategies provides a comprehensive policy briefing that recaps the previous week and previews the week ahead. It alerts clients to upcoming congressional hearings, newly introduced bills, regulatory announcements, and implementation activity related to the Affordable Care Act and other health laws. You may also access the weekly newsletter through the Hart Health Strategies podcast, Health on the Hill. To receive new episodes as they are published, subscribe to the podcast in iTunes by visiting here. If you have an Android device without iTunes, you can listen to episodes on SoundCloud by visiting here.

Partners

The American College of Mohs Surgery is committed to excellence in training, education and research and is actively engaged in scholarship and innovation at the national level. To support its mission of promoting and advancing the highest standards of patient care with respect to Mohs surgery and cutaneous oncology, the ACMS is a member of several national organizations. Click here for more about these organizations.

Grassroots Advocacy

Now more than ever, Mohs surgeons must exercise their constitutional right to petition the government on issues that impact our specialty and the skin cancer patients we serve. Download this helpful guide (PDF) on how to work with legislators and effect change:

The Mohs Surgeon’s Guide to Grassroots Advocacy

ACMS Responses

The following were crafted by ACMS leadership in response to issues affecting Mohs surgeons and/or the Mohs surgery specialty. Topics are noted and responses are dated where possible.

ACMS position on Nov. 2017 New York Times skin cancer treatment story

A Nov. 20, 2017 New York Times story, “Skin Cancers Rise – Along With Questionable Treatments,” discusses the treatment of suspected skin cancers by physician assistants without the presence of a dermatologist.

The ACMS affirms the positions of The American Academy of Dermatology in its Letter to the Editor, posted on the AAD website, which states in part:

“The American Academy of Dermatology recommends a board-certified physician dermatologist provide direct supervision of any non-physician (PA/ARNP) for optimum dermatologic care… Board certified dermatologists have extensive specialized training in all skin conditions in addition to their medical training, which makes them uniquely qualified to diagnose and treat skin cancers… Dermatologists take very seriously our obligation to provide the highest standard of care by using appropriate, cost-effective treatment. Decisions of how and when to treat all forms of skin cancer should rest with the patient in consultation with their dermatologist.”

Texas members: Update on Novitas LCD for Mohs Surgery

Novitas recently made a decision to discontinue coverage of Mohs Micrographic Surgery (MMS) in the outpatient hospital setting (Place of Service code 22). Upon review of Novitas’ recently revised local coverage decision for MMS, LCD L34961, dated January 1, 2016, the ACMS notes that Novitas has described the site-of-service as an outpatient or office-based surgery suite (Place of Service codes 11 and 24, respectively). While the physician’s office is the most common site of service for the majority of MMS, this should not preclude MMS from being provided in the outpatient hospital setting. The ACMS responseto Debra Patterson, MD, Medical Director, urges Novitas to reconsider its stance:

ACMS Response

Revisions to General Chapter <797> Pharmaceutical Compounding – Sterile Preparations
as published in Pharmacopeial Forum 41(6) November/December 2015

United States Pharmacopeia sought comment regarding proposed revisions to General Chapter <797> Pharmaceutical Compounding – Sterile Preparations. This ruling would eliminate the low-risk category that allows for Mohs surgeons to prepare local anesthesia by diluting and buffering lidocaine in our office setting. The ACMS strongly opposes this policy shift, and our comment letters can be viewed here:

Mohs Surgery LCD for Florida/Puerto Rico

On August 22, 2014, the Medicare carrier for Florida, Puerto Rico and the Virgin Islands released a new Local Coverage Determination (LCD) that became effective October 6, 2014. The ACMS had monitored the draft LCDs released by First Coast Service Options (FCSO) and provided comment letters and recommendations, which were mostly ignored. The letter below from the Florida Society of Dermatology & Dermatologic Surgery highlighted a number of troubling aspects of the LCD, and requested a reconsideration. The ACMS, along with the AAD, ASDS and ASMS supported this request. Read more:

January 2015 Update on Mohs Surgery LCD for Florida/Puerto Rico
First Coast Service Options (FCSO) has issued a revised Mohs LCD effective for dates of service on or after January 1, 2015. We are pleased that FCSO has modified the LCD and revised the most problematic portions of the original LCD. The ACMS is grateful to Dr. Cliff Lober of the Florida Society of Dermatology and Dermatologic Surgery for working with the carrier medical director, Dr. James Corcoran. We are especially appreciative that Dr. Corcoran altered the provisions most concerning to the ACMS and the skin cancer patients we serve. Even if you do not practice in FL, PR or the USVI, please review this policy and consider some refinement to your Mohs documentation. It is possible that LCDs for Mohs surgery for other Medicare carriers and private payers will be altered in the near future. Understanding the current requirements of the FCSO Mohs LCD will ensure that you can easily be in compliance with the parts of this policy that other medical directors may replicate. Read the revised LCD and a full review of changes and requirements at the links below:

New York Times story: “Patients’ Costs Skyrocket; Specialists’ Incomes Soar”

On January 18, 2014, the New York Times published a story that focused on costs associated with some medical specialties, calling out dermatologists and Mohs surgeons in particular.

New York Times story: “As Hospital Prices Soar, a Stitch Tops $500”

On December 2, 2013, the New York Times published part five of a multi-part series called “Paying Til It Hurts,” about health care costs.

Texas Medical Board Rules for Definition and Provision of Office-Based Anesthesia

ACMS response to proposed amendments
Reference cited in above letter: Safety of peak serum lidocaine concentration after Mohs micrographic surgery: A prospective cohort study, Alam et. al.

Promoting Integrity in Medicare Act of 2013 (PIMA)

When introduced in mid-2013, the Promoting Integrity in Medicare Act of 2013 would limit patient access to in-office services provided under the physician self-referral or Stark law. The ACMS urged Congrassional opposition to the Act and asked members to contact elected officials to advocate for the right to provide office-based pathology services.

Humana “Efficiency of Care” profile

ACMS response

Alliance of Specialty Medicine News

The Alliance of Specialty Medicine is a coalition of national medical societies representing specialty physicians in the United States. This non-partisan group, of which the ACMS is a member, is dedicated to the development of sound federal health care policy that fosters patient access to the highest quality specialty care.

News and Updates listing

On Call: The Alliance Newsletter Fall 2019
Specialty Spotlight:
Mohs Surgeon Testifies in Congress on Prior Authorization

Member Alerts

News and updates related to ACMS member interests

Provider Relief Fund PRF Portal Reopened (April 18, 2022)
Due to provider community advocacy, the Health Resources and Services Administration (HRSA) has reopened the PRF Portal, allowing physicians to submit a late Reporting Period 1 report request. The portal will close on Friday, April 22, 2022 at 11:59 PM ET. Physicians should receive an email from HRSA on how to submit a request, or they may contact HRSA directly through the provider support line: 1-866-569-3522 for technical assistance or with any questions.

Frequently Asked Questions (FAQs) about Consolidated Appropriations Act, 2021 Implementation (December 22, 2021)

Physician-Focused Payment Model Technical Advisory Committee (PTAC) was held on September 27. Use the link to see the summary of the meeting. PTAC has released a Request for Input on information about optimizing social determinants of health (SDOH) and health equity under APMs and PFPMs. Public input is requested by October 18, 2021.

Episode Based Cost Measure Field Testing (August 4, 2020)

Coronavirus Disease (COVID-19)

Mohs Surgery Ambulatory Protocol During COVID Pandemic (version 6-3-20)

The ACMS encourages members to monitor the CDC, WHO, JAMA Network , NCCN and AMA for updates related to the COVID-19 pandemic, and to continue to practice and enforce PPE best practices.

HHS COVID-19 Resources

H.R. 1 and Your Taxes: Primer for Health Professionals

Please view a recently created summary of the recently enacted tax bill. The document highlights provisions which may be of interest to health care professionals — new pass-through provisions, changes to the state and local tax (SALT) deduction, section 179 changes, and changes related to college endowments. Of course, these are preliminary observations and calculations based on the newly enacted legislation. The Internal Revenue Service (IRS) will need to fully interpret and implement the new tax code to provide further clarity. Therefore, for your own personal situation, please consult your accountant or tax professional.

AMA Updates

House of Delegates Dermatology Section Council

The AMA’s House of Delegates (AMA HOD) is the AMA’s primary organizational and health care policy deliberative body, meeting twice a year to review hundreds of proposed reports and resolutions that, if approved, become official AMA policy. The American Academy of Dermatology, the American Society of Dermatologic Surgery Association, the American College of Mohs Surgery and the Society for Investigative Dermatology are all officially represented in the AMA HOD, giving dermatology seven votes on the floor of the House of Delegates.

MedPAC Resources

The Medicare Payment Advisory Commission (MedPAC) is an independent congressional agency established by the Balanced Budget Act of 1997 to advise Congress on issues affecting the Medicare program. The Commission’s statutory mandate is quite broad: In addition to advising the Congress on payments to private health plans participating in Medicare and providers in Medicare’s traditional fee-for-service program, MedPAC is also tasked with analyzing access to care, quality of care, and other issues affecting Medicare. Please visit medpac.gov to access Congressional Reports in their entirety.

Meeting Summaries

Congressional Reports

Annual Data Book

The MedPAC annual data book, “Health Care Spending and the Medicare Program,” is a chart book that provides tables and graphs describing the Medicare program, Medicare beneficiaries and their utilization of health care services, and Medicare’s payment systems. MedPAC also produces occasional data books on selected topics. Note: Only the most recent version of “Health Care Spending and the Medicare Program” is available here. Click here to view a menu of data book options.

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