“If you’re not at the table, you’re on the menu.” It’s an admonition that reminds the American College of Radiology’s (ACR’s) Government Relations staff of the crucial role they play on Capitol Hill advocating for its members’ interests.
On January 17, government relations staff members hosted an hour-long Grand Rounds webinar that exposed ACR staff to that advocacy world and the tactics the ACR’s government relations staff members uses to advance the College’s legislative agenda.
“The agencies we look at and the policies we develop have tremendous impact on individual practice,” said Cynthia Moran, ACR executive vice president of government relations. “It is not for the faint of heart. You’ve got to be an entity that cares a lot for its beliefs and is willing to spend a lot of money and use a lot of resources to build a Washington (D.C.) advocacy effort.”
With 435 members in the House of Representatives and 100 in the Senate, ACR Director of Congressional Affairs Rebecca Spangler and colleagues focus on House and Senate leaders and the members of Congress who sit on the committees that most often determine the course of legislation of interest to the ACR. The primary committees of jurisdiction in the House are Energy and Commerce Committee and Ways and Means Committee. The Finance Committee and Health, Education, Labor and Pensions (HELP) Committee play that role in the Senate.
A bipartisan approach to relationship-building directed to staff members and legislators is a key to effective lobbying, Moran noted. “Any kind of legislative success we’ve had is associated with the educational work we’ve done with staff members who have passed this information and our policy recommendations on to their members.”
The value of this approach was displayed during the ACR’s four-year campaign to persuade Congress to repeal Medicare’s unjustified professional payment discount from Medicare’ professional component multiple procedure payment reduction (PC MPPR) for advanced imaging procedures. At one point, Spangler realized that an okay from a senior member of the congressional leadership was needed to move a PC MPPR-related bill forward. She had already scheduled several meetings in his office, and he was soon repeating her arguments for the bill to his staff when she dropped by. The merits of her talking points sunk in, and the congressman supported the bill for final passage.
Christopher Sherin, who was serving his final day as ACR’s director of congressional affairs during the Grand Rounds presentation, noted that every initiative the government relations staff pursues in Washington, D.C., is affected by internal and external policy drivers. Internally, they can arise from ACR leaders, members, state chapters, economics staff or quality and safety department or externally from political and policy contacts in Congress, the federal bureaucracy or stakeholders in the larger health care system.
With such input, the ACR government relations staff orchestrated major Congressional victories for the ACR’s three top legislative priorities, not long after Congress was routinely targeting radiologists for Medicare reimbursement rate cuts to reduce the cost and use of diagnostic imaging.
The ACR Government Relations team in their Washington, D.C. offices.
The turnaround began with several years of lobbying effort that led to the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008, Sherin said. It required suppliers of the technical component of advanced imaging to be accredited by an entity recognized by the Centers for Medicare & Medicaid Services (CMS). Before MIPPA, accreditation was largely voluntary, except for mammography services, which were subjected to mandatory accreditation by the 1994 Mammography Quality Standards Act, a federal law the ACR also helped develop and strongly supported
MIPPA raised facility accreditation rates for all imaging modalities, with some accreditation rates doubling. Substandard imaging services closed. Imaging quality and equipment safety improved, and the ACR became the nation’s dominant accreditor of imaging equipment, Sherin said.
The Protecting Access to Medicare Act (PAMA) became law in 2014 but required several years of effort by Congress and CMS, with monitoring by the ACR government relations staff, to work out the details for implementation. PAMA included provisions that requires ordering physicians to consult with – but not necessarily adhere to – medical specialty society-developed appropriateness use criteria before referring Medicare patients for advanced diagnostic imaging. The ACR was a pioneer in developing such expert-based criteria. MIPPA laid the groundwork for its mandatory use beginning on January 1, 2020.
Radiologists questioned CMS’ motives for the application of the professional component of care to its multiple procedure payment reduction policy (PC MPPR) for high tech imaging in 2012. The policy seemed to be more about imposing another Medicare rate cut on radiologists than responding with a reasonable discount for supposed efficiencies from overlapping work when radiologists interpret images from multiple advanced imaging procedures performed on the same patient, on the same day, in a single office visit.
The initial 50 percent discount for PC MPPR was cut to 25 percent after talks between CMS and ACR’s economics and government relations staffs. Pressures to reduce the discount even more arose when a study in the Journal of American College of Radiology found the actual efficiencies were in the three-to-five percent range. While ACR economists attempted to pressure CMS to release data that justified its policy, the government relations staff distributed the study to sympathetic members of Congress, who introduced legislation to repeal the rate reduction.
The issue became a cause célèbre for the ACR after the bill didn’t come to a vote in 2012, despite attracting 259 co-sponsors in the House and 22 in Senate. For several years, it was the focal point of the College’s annual Capitol Hill Day when ACR members visited their elected representatives to discuss radiology’s top legislative priorities.
In 2014, Congress included a provision in PAMA that required CMS to conduct a study to generate data to determine if the rate reduction was justified, Sherin said. Congress was infuriated when CMS was unable to produce the data.
The issue was finally resolved two years later with the Consolidated Appropriations Act of 2016. It cut the discount to five percent and delivered a major victory to the ACR that translated into about a $300 million increase in Medicare payments to radiologists over 10 years.
The government relations staff indirectly gains valuable support from RADPAC, the political arm of the ACR Association. Under the direction of RADPAC Director Ted Burnes, the political action committee collects about $1.2 million annually in contributions from about 10 percent of ACR members. In each two-year election cycle, it spends about $900,000 to mainly to help fund the election campaigns of Congressional leaders and members of Congress serving on congressional committees with jurisdiction on health care issues.
In anticipation of a Democrat takeover of the House last year, RADPAC contributed funds to Rep. Richard Neal, who would become chair of the powerful Ways and Means Committee and Rep. Frank Pallone, who is now chair of the House Energy & Commerce Committee.
Burnes also took interest in Republican Masha Blackburn’s bid to move from the House to the Senate representing Tennessee. To support one of the ACR’s biggest supporters for mammography screening and to the repeal PC MPPR, RADPAC sponsored a $100,000 television ad blitz for Blackburn in eastern Tennessee that turned the election in that region in her favor.
RADPAC also lent “significant” support to Steve Sevigny, MD, for his congressional bid in Florida’s fourth district, despite his late start and though he lost the Democrat primary election.
Running as a Republican, Steve Ferrara, MD’s chances looked good because of his stellar career as an interventional radiologist and Naval officer. RADPAC backed him with over $600,000 including direct mail and social media ads. He easily won the primary easy but fell short in the general election largely because of a huge Democratic voter turnout, Burnes said.
Outside of election seasons, Burnes is often found representing RADPAC at Congressional fund-raising events. He and members of the ACR government relations staff attend about 500 annually. Participation is necessary to show support for elected officials and to educate lawmakers and their staffs about the practice of radiology and its legislative agenda.
With Democrats now controlling the House, Moran expects new legislation that centers on the health care consumer. House Speaker Nancy Pelosi will probably solidify some aspects of the Affordable Care Act, such as cost-sharing reductions and assured insurance coverage for individuals with preexisting conditions.
Proposals for ‘Medicare for all,’ a hot topic during the election, will appear in the legislative arena. Congress is expected to discuss lowering pharmaceutical costs and to consider requiring more health care price transparency from hospitals and physicians.
In addition to legislation in many states, Congress will also possibly debate how to avoid surprise gaps in insurance coverage that lead to big bills for consumers.
But Moran doubts whether the aspirations of the new Democrat House majority will result in new laws. Legislation may be passed by the House, but it will likely die in the Republican-controlled Senate. Bipartisan actions relating to health care are hard to imagine, and actions will be geared to gaining advantages in 2020 presidential election.
“We will be threatened,” Moran said. “Imaging reimbursement will again be in the cross-hairs at some point, but we are prepared to take it on.”