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This COVID-19 Practice: AAN Takes Leading Role in Virtual Advocacy During COVID-19 Pandemic—And It Pays Off

As the COVID-19 pandemic grew in the United States in mid-March, with a national emergency declared, schools closing to in-person learning, and state after state issuing stay-at-home orders, the AAN's advocacy staff quickly realized that the practice of neurology was about to change as well—and with it, their legislative and regulatory efforts on behalf of neurologists and their patients.

Almost overnight, neurology went from a hands-on, in-person specialty to one in which 95 percent of patient visits are conducted by telemedicine. That shift, along with massive relief efforts such as the Coronavirus Aid, Relief, and Economic Security (CARES) Act, dramatically reorganized the AAN's legislative and regulatory priorities. At the same time, all of the Academy's advocacy efforts also had to move from in-person to virtual. 

"Our legislative and regulatory branches of the federal government have never been busier," said Nicholas E. Johnson, MD, FAAN, vice chair of research and associate professor of neurology at Virginia Commonwealth University. "Congress has allotted almost $3 trillion on financial relief, rulemaking and other protections regarding the public health emergency, and in turn regulatory agencies have really stepped forward and moved telehealth far beyond where any of us would have anticipated even six months ago.

"There's been an incredible amount of work and effort that the US government has put forward in terms of protections and financial relief for those affected by COVID-19. But the challenge is that we are no longer able to do in-person visits, either on the Hill or among regulatory agencies."

"We had to be very creative about switching to virtual meetings, both by telephone and video conference, and electronic letters," said Daniel Spirn, JD, MA, the AAN's senior regulatory counsel.


The Regulatory Side

The reinvented approach has clearly been effective. AAN repeatedly took pro-active action to seek regulatory relief during the public health emergency—all through virtual meetings and electronic communications—and each time, often within a few days, the Department of Health and Human Services (HHS) or the Centers for Medicare and Medicaid Services (CMS) issued new policies incorporating the Academy's recommendations.

For example, on March 18, the AAN held a virtual meeting with COVID-19 response staff from HHS to discuss the challenges facing neurologists during the public health emergency. Less than a week later, Academy representatives, including telehealth expert Neil A. Busis, MD, FAAN, clinical professor of neurology and associate chair for technology and innovation at NYU Langone Health, were invited to virtually present Academy telehealth implementation resources to an HHS-CMS workgroup.  

On March 18, the AAN sent an electronic  letter to HHS Secretary Azar requesting regulatory relief, including reduced restrictions on telehealth and relief from reporting requirements related to the Quality Payment Program (QPP). The following week, HHS granted both requests, relieving providers from QPP reporting requirements and pushing states to ease requirements that restricted access to telehealth services.

"We followed that success by taking our message directly to the White House," said Spirn. "We wrote Vice President Pence, chair of the White House Coronavirus Task Force, with recommendations that primarily focused on telehealth implementation, financial support for physicians, the need for greater access to personal protective equipment and testing, and the need to reduce regulatory burdens during the public health epidemic."

Within days after the letter was received, CMS announced its program to offer advanced payments to address physician cash flow issues and also allowed physicians to provide certain services by telephone using the 99441-99443 codes. HHS further released guidance relieving providers from fraud and abuse regulations related to telehealth technology and services.

On March 30, the AAN electronically submitted comments to CMS asking the agency to reduce regulatory burdens for providers in Medicare Advantage and Part D plans, particularly related to telehealth services, during the public health emergency. On May 22, CMS finalized  Medicare Advantage and Part D proposals, which will promote telehealth during the COVID emergency and beyond.

The AAN also joined 43 other specialty societies and stakeholders in an April 8 electronic letter to CMS administrator Seema Verma,  urging the agency to pay for telephone visits at parity with analogous office visits during the public health emergency, and on April 30, CMS announced that it would do so. "As a result, payment for these services increased from a range of about $14-$41 to about $46-$110," Spirn said.

Regulatory advocacy has also extended beyond telehealth payments and restrictions. The AAN also continues to press CMS for relief from prior authorization burdens during the pandemic. After sending CMS a letter on this topic, the AAN held a virtual meeting directly with CMS on May 29 to make the case.

"We have already seen victories from our continuous efforts, as  CMS updated its guidance to Medicare Advantage plans and Part D sponsors on April 20, encouraging them to consider waiving or relaxing prior authorization requirements at any time in order to facilitate access to services with fewer burdens on providers and their patients," Spirn said.

The Legislative Side

In Congress, "Our issues have pivoted," said Derek Brandt, JD, the AAN's director of congressional affairs. "For two months, it was all COVID-related advocacy, all the time; now, while it is still mostly COVID, other priorities are starting to re-emerge in terms of reimbursement, payment and access, and regulatory burdens and relief. As the year goes on, we will likely continue to shift more of our attention to a primary focus on those other issues, as well as other secondary priorities, with COVID remaining in the forefront as well."

During the early phase of the public health emergency, the AAN focused primarily on the series of emergency relief bills that have been passed aimed at limiting the economic fallout from the pandemic.

"So far, four bills have been passed encompassing around $3 trillion in federal funding," said Brandt. "That's two years of discretionary spending in a month. The whirlwind cannot be emphasized enough. We are often working on bills that, while complex and detailed, focus on one or two issues. These bills span everything from the Indian Health Service to water infrastructure to tax relief, and our policy experts have spent an enormous amount of time digging into them."

The CARES Act, signed into law on March 27, contains a number of provisions that will help neurologists continue to care for their patients, practices and families, including greater access to personal protective equipment (PPE), ventilators, and medical supplies for federal and state response efforts; insurance coverage for COVID-19 testing; increased payments of 30 percent to hospitals treating patients with COVID-19; and increased support to the National Institutes of Health ($900 million), CMS ($200 million), public health data surveillance ($500 million), the Center for Disease Control and Prevention ($4.3 billion), hospital preparedness ($250 million), and vaccines/therapeutics/diagnostics preparedness ($11 billion).

It also boosts payments to physicians and health care providers by temporarily lifting the Medicare sequester, makes $100 billion in grants available to reimburse health care providers for COVID-19 related expenses and lost revenue, and provides $200 million for the Federal Communications Commission to support health care providers to address coronavirus by providing telecommunications services and devices necessary to enable telehealth services.

And on April 13, the AAN sent a letter to Congress outlining requests for provisions to include in the next COVID-19 legislative package highlighting support for physician practices, telemedicine, medication access, provider workforce, medical liability, research, and more. The AAN also signed onto a letter led by the American Medical Association on simiar topics. On May 18, the AAN also led a letter co-signed by 28 patient and provider organizations to congressional leadership focused on ensuring patient access to care.

It has been important for the AAN to work closely with allied organizations in these efforts. "Telemedicine is essential in the COVID-19 era to ensure our patients are able to safely access the care they need, particularly in fields that will see surges in demand, like psychiatry and neurology," said American Psychiatric Association (APA) CEO and Medical Director Saul Levin, MD, MPA. "The APA and AAN have joined together to ask Congress and the Administration that the easing of regulations that stopped or slowed us from using telehealth, and restricted care pre-COVID, needs to continue post-COVID. The combined advocacy in tandem is powerful and it is indeed critical as this pandemic continues to ensure care for our patients."

How's the New World Working?

There definitely are limitations to virtual advocacy. "Building relationships with the people who represent you is harder to do by phone or by videoconference than when you're in the same room face to face," says Lyell K. Jones Jr., MD, FAAN, professor of neurology at the Mayo Clinic in Rochester, MN. "There's something intangible about that interpersonal connection, and nothing can probably ever take the place of that."

But on the other hand, an all-virtual environment "levels the playing field" for neurologists who want to participate in advocacy, said Spirn. "As long as you have internet or telephone access, you can contribute to our communications with legislators and regulators, and that has proven very effective."

Constantine Moschonas, MD, FAAN, medical director of Four Peaks Neurology in Scottsdale, AZ, experienced that firsthand when he was asked by the AAN to participate in a virtual town hall with his representative, Congressman David Schweikert.

"Unfortunately, because of an emergency on my schedule, I couldn't participate in the original teleconference [with Congressman Schweikert]," Dr. Moschonas said. "But he said that he wanted to talk to me individually, so two days later we had a personal half-hour conversation, just the two of us. Even though he is our representative, I did not realize that he has a great passion for telemedicine. We talked about easing the regulatory burden on telemedicine even beyond the pandemic, as well as about the importance of ongoing funding for neurologic research, and reimbursement parity for cognitive specialties. He got the message loud and clear. We really connected and we exchanged phone numbers. It was even more personal than face-to-face meetings we've had in the past through Neurology on the Hill."

"The ease with which you can set up a video or a phone conference with a legislator, instead of traveling to DC for two to three days just to participate in one or two 30-minute meetings, is fantastic," Dr. Jones agreed. "And fortunately, the AAN's staff and volunteers in DC have done a very good job over the past few years reinforcing our reputation for thoughtful policy analysis and advocacy, so when COVID-19 hit, having a reputational advantage in the policy world in DC was very helpful for the AAN."

With health care on the front of everyone's mind during the pandemic, this is an ideal time for neurologists to be talking with legislators and regulators, said Sarah Benish, MD, FAAN, the division head for general neurology at the University of Minnesota, who along with Dr. Jones recently participated in  conference calls with health care staffers for Senators Tina Smith and Amy Klobuchar.

"They are really receptive to hearing what are the hurdles and barriers to providing care for patients right now," she observed. "I found them to be very attentive, and they asked very good questions. In the past, it has sometimes felt like our advocacy interactions were more about us asking for help and trying to fit into the day to day schedule of the legislators with so many other things competing for their attention, and now it seems like it's been switched a bit. They're trying to step up quickly and decisively with actions that will have an impact for their constituents at home, both providers and patients, and we can give them the information about how the pandemic is impacting their own communities, such as why it is so important to get appropriate funding for telemedicine and eliminate things like state-line barriers."

Dr. Moschonas predicts that these virtual meetings will remain an important part of the AAN's advocacy even after the public health emergency stage of the COVID-19 pandemic has passed. "While it will absolutely be important to resume Neurology on the Hill and our in-person meetings once Washington opens back up, this direct contact between neurologists and our representatives, the ability to do small town halls and talk more individually with legislators and regulators allows us to expand our advocacy even more."

For neurologists in the community who have considered becoming more involved in governmental affairs, Dr. Benish said that now is the perfect time.

"It's always more impactful if legislators are talking to folks from their home districts, so we want the whole country to be involved. And you don't have to miss work or travel!" she said.

"You don't have to be an expert on policy; you will always have support of AAN staffers who can meet with you beforehand and give you the Cliff Notes version of the active bills being discussed. Your role is to give that story of what's happening in the legislator's home district. You know what's going on in your practice setting, and that's really all you need to know. The AAN can help you with the rest!"