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Should physicians be compensated for administering vaccines to Medicare recipients? Should the government offer a public option for health insurance? These were among the more lively debates Sunday during the American Medical Association (AMA) House of Delegates interim meeting.

Attending virtually and in person in Honolulu, AMA members who took to the mic at the advocacy on medical service and practice committee also called for a more assertive posture to persuade the Centers for Medicare & Medicaid Services (CMS) to get tough on less-than-forthcoming Medicare Advantage plans, and to push for reimbursement to meet guidelines on earlier colon cancer screening and CT coronary artery calcium scoring.

Medicare Vaccination Reimbursement

Members expressed frustration over how Medicare payment policy prevents many physicians from being compensated for vaccinating patients at their practices under Part B, which covers outpatient care services. Instead, patients are required to get vaccinations from a pharmacy through their drug plan, Part D.

The AMA's Senior Physician Section proposed that the AMA advocate for moving money into Part B to correct that situation and, as resolution author Doug DeLong, MD, said, "get vaccinations back where they belong, into the doctor's office."

However, a prevailing concern expressed by several speakers was the impact on payments for other Part B services, since Medicare policy dictates that all Part B payments must be budget neutral; if physician practices get reimbursed for vaccinating patients, that money would be subtracted from some other Part B service.

It would reduce "available resources for all physician services when we add something in there, and would therefore further divide the pie, just as many physicians are trying to recover financially from the pandemic," said Daniel Gold, MD, of the New York delegation.

"Many family physicians have expressed concern and frustration over the fact that they are not paid to administer vaccines -- such as shingles and Tdap [tetanus, diphtheria and pertussis] -- in their offices because they're only covered under Part D. Sending patients to the pharmacy disrupts care continuity and decreases vaccine uptake," said Alex McDonald, MD, a delegate from the American Academy of Family Physicians.

"This is not a resolution to be arguing about budget neutrality," said Carolyn Francavilla, MD, speaking on behalf of the Private Practice Physicians Section, which supports submitting claims for vaccinating patients through Part B. "Our Medicare patients cannot get their Tdap and their shingles vaccines in our clinic settings, so they get referred to the pharmacy," she said. "That, of course does not always happen."

Francavilla, chair-elect for the Private Practice Physicians Section, added that this basic preventive care "is not an esoteric procedure.... If we save a case of shingles, we're probably saving a lot of money."

"It really pains me and frustrates me that I cannot provide this very important care to my patients," said William Fox, MD, an American College of Physicians delegate. Regarding concerns that a policy change would subtract needed funds from other services, Fox said the AMA shouldn't be "scared of adding new codes" to the Physician Fee Schedule. "This is how we advance medicine."

The AMA's position "should be that we don't believe in budget neutrality, and that is the stated position of this house," said Fox.

Robert Gilchick, MD, of the American College of Preventive Medicine, noted the huge amount of disinformation regarding vaccines currently circulating. "Immunization is a bit under fire lately, and we need to remove every single obstacle we can."

Public Option Redux

Debate over a resolution that, if passed, would propel the AMA to advocate for a public option to expand health coverage was particularly lengthy and polarized, as it has been at many previous AMA meetings.

While the ACA reduced the numbers of uninsured individuals, the costs of marketplace plans are out of reach for many and "too expensive to actually be used" due to high premiums, deductibles, and other out-of-pocket costs, according to the resolution. In addition, many plans have "narrow provider networks, which reduces access to care."

Sarah Marsicek, MD, delegate from the American Academy of Pediatrics, noted that before the pandemic, 29 million people in the U.S. lacked health insurance, with another 5.4 million losing coverage during the pandemic because of job loss. Another 15 million will lose Medicaid when the pandemic is over.

"Creating a public option will provide Americans who fall in coverage gaps to seek and obtain the healthcare they need and deserve," said Marsicek.

"We know that our patients are suffering and access to healthcare in this country is woefully inadequate," said Alain Chaoui, MD, of the New England delegation, who spoke in support of the resolution. "It's wrong for us to sit around and wait for someone else to serve up an idea of how healthcare should be run in this country."

But many in the room were adamantly against the resolution, fearing a public option would result in Medicare, or even lower, payment rates for physician services.

Shawn Baca, MD, of the Florida delegation, called the resolution a "sneaky way of basically changing AMA policy when you're directly advocating for the public option, and essentially on the road to a single-payer system," he said.

"I get it, we don't like insurance companies. They're not doing a good job. They're putting profits in front of patients," Baca said. "The problem is, the government puts spending in front of patients and does the same exact thing."

A public option, Baca said, would "make the situation worse."

Greg Fuller, MD, of the Texas delegation, said he worried that the resolution included no language to improve federal payment, and historically, physicians have kept their practices viable by having patients covered by multiple payers, since Medicare typically pays lower rates than commercial coverage. "Medicare rates are not market-based and have not kept up with inflation," he said.

A public option would "lead to predatory pricing and would starve out the other market, and would paradoxically then reduce access," added Asa Lockhart, MD, of the Texas Medical Association delegation.

Action on Medicare Advantage Plans

Another hot topic was a resolution calling on CMS to take action on Medicare Advantage plans by requiring "an accurate, up-to-date list of physicians." The resolution also said all plans should disclose whether physicians are taking new patients, something often not provided.

"Many beneficiaries under these plans have been met with unclear benefits, hidden costs, and delays in care in comparison to traditional Medicare," said Nikita Changlani, a regional medical student delegate from Mississippi. The plans are structured around overly narrow coverage networks, she said, adding that "the AMA should continue to strongly support efforts to hold these entities accountable, and to protect the physician-patient relationship and promote access to care."

Michael Butera, MD, a delegate from the Infectious Diseases Society of America, also weighed in. "We really believe that new enrollees in Medicare need to have a transparent comparison of the traditional Medicare and Medigap options versus a Medicare HMO Advantage plan," he said, adding that knowing which physicians are in which networks is important to maintain the physician-patient relationship.

Enrollees must understand, Butera continued, "that there may be inadequate networks with prior authorization that may deny coverage for needed diagnostic procedures, access to medications, and other services," including rehabilitation and access to specialty care.

But Dale Mandel, MD, an alternate delegate from Pennsylvania, urged that the AMA step back and study the issue. He said that not only does Medicare's plan comparison tool show what services are covered and provides some of what the resolution would attempt to accomplish, it's "impractical to try and maintain such a list. It is an immense task."

Some other resolutions discussed during the Sunday meeting would, if passed by the House of Delegates this week, propel the AMA to advocate:

• For first-dollar coverage of CT coronary artery calcium scoring, roughly $49 to $1,209, for patients who meet American College of Cardiology/American Heart Association guidelines
• For payers, health systems, and clinicians to adopt updated U.S. Preventive Services Task Force recommendations for routine colorectal cancer screening starting at age 45
• Against the practice of suing patients with medical debt, considering "the detrimental cost to a patient's well-being"
• For immediate, timely, and transparent negotiations for how Medicare drug prices are incorporated into law, the elimination of loopholes such as "patent evergreening," and for a ban on direct-to-consumer advertising for prescription drugs within 5 years

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