President’s Page – Participation and Advocacy – Part II

by Tilden Childs III, MD

Welcome to the second part of my three-part series on participation in organized medicine with emphasis on advocacy. Participating in organized medicine has benefits for our patients and for our profession, as well as for the individual physician. In my first article, I shared my thoughts on the mechanics of how one gets involved. As I discussed, a particularly important part of participation in organized medicine is advocacy. As many of you are aware, I am a radiologist. I have been involved with my state and national radiology organizations, the Texas Radiological Society (TRS) and the American College of Radiology (ACR), as well as with the TCMS, TMA, and AMA, for many years. In this article, I would like to share some of my experiences in these organizations to highlight how, both individually and collectively, we can participate in advocating for the medical policies formulated by our medical organizations to help see them through to fruition and become law. It might surprise some of you to know that passing scientifically based medical policy can be quite challenging. My description below is somewhat detailed but this is also intentional, to give you a flavor of what it’s really like to participate. 

Some of you are familiar with the 2011 National Lung Screening Trial (NLST), a National Institute of Health funded randomized control trial which showed a 20 percent reduction in lung cancer mortality by low-dose CT scan (LDCT) screening of a specific, high-risk patient population aged 55 to 74. This was a multi-institutional trial involving 33 sites and over 50,000 patients. The evidence from this study was so compelling that the trial was terminated early by the National Cancer Institute’s Data and Safety Monitoring Board. Subsequently, in December 2013, the United States Preventive Services Task Force issued a favorable grade B rating for LDCT screening for lung cancer in high-risk patients aged 55-80, based on empirical data, including the NLST. Under the guidelines of the Patient Protection and Affordable Care Act, coverage for this screening study was mandated to be provided by private carriers by January 2015. However, this mandate did not apply to the Centers for Medicare and Medicaid Services (CMS), thereby excluding patients 65 years and older from this screening benefit.

My involvement with this issue began in April of 2014 at the ACR Annual Meeting and Chapter Leadership Conference (AMCLC) in Washington, DC. The Wednesday of each AMCLC meeting is devoted to advocacy on Capitol Hill by the meeting attendees. That year, our message included a request for representatives and senators to sign letters urging CMS to issue a favorable national coverage determination for LDCT screening for lung cancer. Ironically, on that very Wednesday, April 30, the Medical Evidence Development and Coverage Advisory Committee, which advises CMS, issued an unfavorable recommendation with regard to coverage for LDCT scanning for lung cancer. Ultimately, a bipartisan mix of 45 Senators and 134 Representatives signed these letters.

“Healthcare policy can be affected at the state and national levels, which supports both our patients and our practices, through participation in various medical organizations.“

Two days later, on Friday, May 2, I attended the TMA Annual Meeting (TEXMED) in Fort Worth. Months earlier, I had volunteered to be on a reference committee for the TMA. Reference committees are tasked to take public testimony and to evaluate the evidence and testimony presented concerning committee reports and resolutions. The members then make recommendations for action by the House of Delegates. By chance, I was assigned to the Science and Public Health Reference Committee. One of the resolutions for this committee to consider was adoption of the USPSTF guidelines for LDCT screening for lung cancer. Having attended the ACR AMCLC and participated in the Capitol Hill Advocacy Day, I was familiar with the issues regarding LDCT scanning for lung cancer. Therefore, I was able to give insight to the reference committee and help shepherd the resolution through the committee to the House of Delegates. Additionally, as a TCMS alternate delegate to the TMA, I was able to participate in the Tarrant County caucus at the TMA where I provided further support for this resolution. The TMA House of Delegates subsequently passed the resolution in support of LDCT screening for lung cancer in high-risk patients. On the Monday following TEXMED, I notified the TRS of the TMA’s action on this issue. Subsequently, in the spirit of cooperation with the TRS, the TMA placed an item concerning the TMA support for this issue in the May 16 TMA Action email, thereby helping to bring this issue to the attention of the TMA membership.

Some months earlier, I had been asked to join the ACR delegation to the AMA as an alternate delegate. Consequently, I attended the annual AMA meeting in Chicago on June 7-11. A large part of ACR delegation activities is devoted to identifying and studying the issues pertinent to radiology, attending reference committees, and garnering support for the position of the ACR with respect to these issues. A resolution in support of LDCT screening for patients at high risk for lung cancer was introduced by the Florida delegation and was assigned to Reference Committee A as Resolution 114. Although the majority of the testimony heard during the reference committee was in support of Resolution 114, the reference committee subsequently recommended for referral of the resolution. This was occurring during the 90-day comment period prior to CMS making a national coverage determination in November of that year and the ACR delegation was determined to overcome the reference committee recommendation. The ACR delegation worked very hard to strategize and subsequently garner support for Resolution 114 by communicating and networking with many of the other delegations. One of the important overriding concerns voiced by the ACR delegation was the idea that evidence-based medicine should be accepted and that the NLST was indeed good evidence-based medicine. Subsequently, on the floor of the House of Delegates, a substitute resolution was introduced by the Florida delegation, again supporting LDCT screening for lung cancer. After much positive support was voiced, the resolution that Medicare (as well as Medicaid and private insurance) provide coverage for LDCT screening for patients at high risk for lung cancer was overwhelmingly passed by the AMA House of Delegates by a 73.8 percent majority. Consequently, AMA policy was influenced by the ACR delegation. This was done in a timely manner with the result being that the voice of the AMA would be heard by CMS in support of LDCT scanning during the 90-day comment period prior to the CMS national coverage determination. 

CMS subsequently approved coverage. LDCT screening for lung cancer in the properly selected high-risk patient population is now an accepted screening procedure which has been implemented in our community. As you can see by this example, healthcare policy can be affected at the state and national levels, which supports both our patients and our practices, through participation in various medical organizations.  

Thank you for this opportunity to share some insights with you. More to come, and please join us at the monthly TCMS Board of Advisors meeting at noon on the fourth Wednesday of most months. To find out more information, you can email Melody Briggs at mbriggs@tcms.org.