Washington Update - AAPP Federal Advocacy in 2022

Laura Hanen, Senior Policy Advisor, Venable LLP

2022 was another busy year for AAPP in terms of outreach and engagement with legislators, regulators, and partner organizations. Throughout the year, AAPP worked to advance the policy priorities outlined in the 2022 Health Policy Agenda. AAPP endorsed five pieces of legislation and supported 20 more in coalition through sign-on letters. As we close out the year, we look back on the many advocacy activities AAPP has been engaged in with the expectation that 2023 will be just as action packed.

Government Affairs Committee Activities

Throughout the year, the Government Affairs Committee (GAC) collaborated and revised our arsenal of advocacy issues briefs. Each issue brief describes the policy challenges and obstacles that members face and describes how psychiatric pharmacists add value in these areas and can help increase access to critical health care services.

Last year, the GAC developed a AAPP Federal Advocacy Toolkit. A video is in production to explain why AAPP members should engage in federal advocacy and how to use the resources in the toolkit. The GAC is also working to finalize a state advocacy toolkit by end of 2022 to guide members on engaging at the state level, including what you should consider when drafting state legislation related to coverage and reimbursement for the services provide by psychiatric pharmacists.

Major Advocacy Milestones

• January: AAPP leadership met with Dr. Rachel Levine, Assistant Secretary for Health, HHS to discuss psychiatric pharmacists as an essential component of the mental health and SUD workforce and ways to relieve the workforce shortages by removing barriers in access and payment.
• January: AAPP provided comments on a DEA advanced notice of proposed rulemaking supporting the use of telemedicine and telepharmacy and urging DEA to continue to allow these services to be provided without imposing barriers that would impede access
• March: Members of AAPP’s Board, Government Affairs Committee, and Public Affairs Committee participated in 15 virtual Congressional visits along with our Venable government affairs consultants. Visits were held with Senators and Representatives who are on the Senate Finance Committee and staff for the Chair and Ranking Member of the House Energy and Commerce Committee. The purpose of the visits was to educate offices that were developing mental health and SUDs legislation on the role of psychiatric pharmacists in providing patient care services and policy options to remove barriers for patients in accessing their services.
• March: Leadership met with Dr. Michael Iadamarco, Deputy Assistant Secretary for Science and Medicine in the Office of the Assistant Secretary of Health (OASH) and team members to discuss developing the evidence base for the value of engaging psychiatric pharmacists on the care team and AAPPs advocacy strategy.
• April: Leadership held meetings with Congressional offices regarding the Collaborate in an Orderly and Cohesive Manner (H.R. 5218) regarding the role of psychiatric pharmacist in collaborative care models and use of sodium nitrite in suicide.
• April: AAPP provided comments to the Centers for Disease Control and Prevention on their Proposed 2022 Clinical Practice Guideline for Prescribing Opioids.
• April: AAPP provided comments to the Agency for Health Research and Quality (AHRQ) on the Patient-Centered Outcomes Research Institute (PCORI) Trust Fund Strategic Framework urging AHRQ to consider non-optimized medication use as a cross-cutting strategy for achieving desired health outcomes and highlighting the importance of CMM.
• May: Leadership met with Dr. Neeraj Gandotra, SAMHSA’s Chief Medical Officer to introduce him to AAPP, the work of psychiatric pharmacists in providing CMM, and barriers in access and payment.
• July: Leadership met with SAMHSA staff, originally slated to be a meeting with Dr. Yngvild Olsen, Director of the Center for Substance Abuse Treatment, to introduce AAPP and the work of psychiatric pharmacists in treating SUDs.
• August: AAPP member, Ben Miskle, participated in a SAMHSA Policy Summit on Buprenorphine Access to provide subject matter expertise.
• August: AAPP submitted comments on the OASH Request For Information (RFI) on the HHS Initiative to Strengthen Primary Health Care. AAPP spoke to successful models of integrated care that provides primary health care with mental health and SUDS highlighting the barriers to participation on the care team for psychiatric pharmacists in providing CMM.
• September: AAPP submitted comments on the CY2023 Physician Fee Schedule proposed rule advocating for:
• Retaining telehealth flexibilities extended during the public health emergency (PHE).
• Parity in reimbursement for service provided by Opioid Treatment Program (OTPs) whether in mobile unites or brick and mortar facilities
• Moving to general supervision for behavioral health services provided “incident to.”
• Inclusion of psychiatric pharmacists as part of the Intensive Outpatient Program care team and to meet with stakeholders to learn more about the scope, intensity and value of IOP services.
• Parity in reimbursement for Opioid Treatment Program services regardless of location and to continue telehealth treatment with buprenorphine beyond the PHE.

• September: AAPP leadership met with contractors for the National Institute of Drug Abuse to provide subject matter expertise on MOUD continuum of care.
• October: AAPP submitted comments to the United States Preventive Services Task Force draft recommendations in support of routine suicide screening for adults in primary care settings.
• October: AAPP submitted comments on the CMS RFI Promoting Efficiency and Equity Within CMS Programs highlighting the role of psychiatric pharmacists and barriers in access to care.
• November: AAPP submitted comments on the AHRQ RFI on Person-Centered Care Planning for Multiple Chronic Conditions highlighting the evidence base for CMM and the role of psychiatric pharmacist.

Pharmacists Scope of Practice

Throughout the year, AAPP has been an active participant of the Joint Commission of Pharmacy Practitioners (JCPP) to advocate with federal policymakers to pay for patient care services provided by pharmacists, including during the public health emergency (PHE).

Last year, the Pharmacy and Medically Underserved Areas Enhancement Act (H.R. 2759/S. 1362) was reintroduced with bipartisan support. The legislation adds pharmacists to the list of providers whose patient care services, when delivered to patients in medically underserved communities, are covered by Medicare Part B (i.e., grant them “provider status”). While the House bill has 73 cosponsors and the Senate bill has 15, there has been no movement on the bill in part due to the large cost of the bill.

This year, the Equitable Community Access to Pharmacist Services (ECAPs) Act (H.R. 7213) was introduced and a website promoting the bill was created. The bipartisan bill authorizes pharmacists to provide care and receive reimbursement for pandemic-related services under Medicare Part B. The bill has 56 cosponsors. There has been no movement on the bill but has served as an important vehicle for educating members of Congress on the importance of paying for patient care services provided by pharmacists.

AAPP joined three letters with pharmacy stakeholders to the Administration related to scope of practice. The letters largely focused on COVID medication and MPV vaccine administration as well as future pandemic response with an emphasis on obtaining payment through Medicare Part B.

AAPP has supported all activities that will open the door to payment to pharmacists for patient care services. Unfortunately, CMS continues to maintain that they do not have the authority to do so.

Mental Health and Substance Use Legislation

This year there has been much focus on the need for mental health and substance use services resulting from the COVID pandemic and record rates of suicide among youth. Legislative activities included the following:

• February: Senate Finance Committee Chair Ron Wyden (D-OR) and Ranking Member Mike Crapo (R-ID) announced a bipartisan process to develop legislation in five focus areas (see chart below). Draft legislation has been released for four of the five areas. AAPP has provided comments on the workforce discussion draft urging the inclusion of psychiatric pharmacists as qualified health providers of mental health and SUD services under Medicare. Finance Committee Chairman Ron Wyden (D-OR) is committed to passing mental health legislation whether in this Congress or the next.

• June: the Senate negotiated the Bipartisan Safer Communities Act that signed into law (PL-117-159). The legislation includes pieces from the Senate Finance youth discussion draft that seek to expand access to mental health services for youth and further invests in programs at the Department of Health and Human Services (HHS) that advance behavioral health, including certified community behavior health centers.
• June: The House passed the bipartisan Restoring Hope for Mental Health and Well-Being Act (H.R. 7666). The legislation reauthorizes the Substance Abuse and Mental Health Services Administration (SAMHSA) and Health Resources and Services Administration (HRSA) programs to address mental health. The Senate Health, Education, Labor and Pensions (HELP) Committee has not yet taken up the House bill or released a companion bill of their own.

• AAPP actively supports the Mainstreaming Addiction Treatment (MAT) Act (H.R. 1384/ S. 445) to eliminate the DATA waiver (or X waiver) requirement for prescribing buprenorphine to treat opioid use disorders. The House bill passed as part of the Restoring Hope for Mental Health and Well-Being Act. It’s fate in the Senate is uncertain.

There is a possibility that mental health legislation, including the MAT Act, could be included in an end of year package as there is strong bipartisan support for taking action. However, no mental health legislation has been marked up in either Senate Finance or Senate HELP making it more difficult to include provisions in an omnibus package in December. Regardless, AAPP anticipates legislative activity to address mental health and substance use to continue in 2023.

Telehealth

Maintaining flexibilities telehealth has been a key priority for AAPP this year. AAPP has advocated for these flexibilities in our physician fee schedule comment letter, as noted above, and has endorsed legislation including:

• AAPP supports the Telemental Health Care Access Act (H.R. 4058/S. 2061) to remove the six-month in person visit requirement prior to telemental health services for Medicare beneficiaries as enacted in the Consolidated Appropriations Act, 2021.
• AAPP supports the Advancing Telehealth Beyond COVID-19 Act (H.R. 4040) to extend Medicare telehealth flexibilities for an additional two years, which includes retaining audio-only services, the expanded list of telehealth-eligible providers, and delays the mental health in-person requirement. The House passed the bill in July but the Senate has yet to take it up.
• AAPP supports the DEA finalizing the special registration process for teleprescribing controlled substances under the Ryan Haight Act and implementing short-term solutions until the rules are finalized so that patients don’t lose access to MOUD. AAPP also supports removing the in- person evaluation requirement prior to prescribing MOUD.

Congress may take up legislation to extend the telehealth flexibilities beyond the 151 days post the expiration of the PHE declaration in the end of year legislative package.

Looking to 2023

With a new Congress starting on January 3, it is highly likely that mental health, SUD, and telehealth legislation will continue to be a focus. There are a number of substance use bills that are up for reauthorization and work on mental health legislation will continue. Even if the telehealth provisions are extended, there will be interest in making them permanent. The pharmacy bills will be reintroduced but there continue to be significant barriers to their passage. The bottom line is that AAPP and its members will have may opportunities next year to provide their expertise and weigh-in with their Members of Congress and the Administration on issues of importance to the practice of psychiatric pharmacy.