AAFP Showing Strong Support for DPC
Innovations in primary care continue to flourish in various markets across the country. One such innovation, which is mentioned often in the comment section of this blog, is direct primary care. What once was a novel idea in primary care delivery is rapidly becoming a highly sought after practice design for many family physicians.
The AAFP strongly supports innovations in primary care delivery and payment models that embody the core elements of the patient-centered medical home (PCMH) and place a priority on the patient-physician relationship. We also strongly support the reduction, if not elimination, of the complex administrative burden placed on family physicians through prior authorizations, appropriate use, and other such measures aligned with payment and compliance. We believe that the DPC model is an advanced primary care delivery and payment model that meets these criteria.
The DPC model embodies the core principles of the PCMH and is, at its core, patient centric. The model, through its payment structure, eliminates much of the administrative burden associated with modern primary care practice, which in return allows the physician to focus more time on direct patient care.
It is noteworthy that the DPC model is becoming widely accepted as a primary care delivery model that promotes patient-centered care. Although some suggest that it is a "return to traditional primary care," I would argue otherwise. It is a progressive delivery and payment model, built on the traditional primary care patient-centric model that places the patient as the focal point of the practice, but it also is a model that uses a team-based approach, advanced technology and data to deliver timely and quality care. The DPC community deserves a lot of credit for its efforts to demonstrate to public and private payers that the DPC model drives improvements in quality at a lower per capita cost, and people are starting to notice.
The AAFP has taken some criticism from the DPC community for not being an advocate for the model, but this is not the case. The AAFP first engaged with the DPC community in 2012, during the earliest days of the movement. I will admit that we were not the first person on the dance floor, but we have worked hard behind the scenes to make certain that the band keeps playing.
We have focused our efforts in two places; education and advocacy. Our education efforts feature a content resource page and a comprehensive toolkit that serves as a step-by-step guide on how to open a DPC practice.
We also have conducted a series of educational seminars around the country that have provided interested physicians the tools and resources they need to transition their practices to the DPC model.
Finally, in 2015, we partnered with the American College of Osteopathic Family Physicians and the Family Medicine Education Consortium to host the Direct Primary Care Summit. The 2016 Direct Primary Care Summit will be held July 8-10 in Kansas City, Mo. If you are a DPC practice or simply interested in exploring the opportunity, I would urge you to attend this event. We are confident that you will find this meeting both educational and energizing.
Our DPC advocacy efforts originated during the debate and consideration of the Patient Protection and Affordable Care Act (ACA). The ACA established DPC as a qualified health plan for the purposes of meeting the individual mandate established by the law. Although this was an important first step, which established a path forward for the DPC model, much work remains to ensure that patient contributions to a DPC practice are recognized as qualified medical expenses. The AAFP initiated our advocacy on this objective in 2013 when the AAFP formally recognized DPC as an advanced primary care delivery and payment model.
We accomplished this through the adoption of a position that reads, in part, "The American Academy of Family Physicians supports the physician and patient choice to, respectively, provide and receive health care in any ethical health care delivery system model, including the DPC practice setting."
During the past few years we have worked closely with our state chapters and other interested organizations such as the Direct Primary Care Coalition (DPCC) to advance legislation that would recognize payments made by patients to DPC practices as a qualified medical expense. For the DPC model to flourish, it is important that we ensure such recognition. I am pleased to report to you that there has been progress made. Sixteen states have enacted legislation in the past few years: Arizona, Idaho, Kansas, Louisiana, Michigan, Mississippi, Missouri, Nebraska, Oklahoma, Oregon, Tennessee, Texas, Utah, Washington, West Virginia, and Wyoming. Montana and Virginia passed legislation this year, but pending bills were vetoed by their respective Governors.
The AAFP also is actively supporting the Primary Care Enhancement Act (S. 1989). This legislation clarifies that DPC is a medical service and not a health plan under section 223 (c) of the Internal Revenue Code relating to Health Savings Accounts (HSAs). The legislation correctly defines DPC services as qualified health expenses under section 213 (d) of the tax code. The bill also creates a new payment pathway for DPC as an alternative payment model (APM) in Medicare and with dual eligible. This would allow CMS to pay practices an affordable flat fee for primary care services offered by a DPC medical home. The legislation includes a waiver to allow qualified physicians who have opted out of Medicare to participate in the program at any time. It also allows for Medicare Advantage plans to pair with DPC practices as primary care partners in an ACO-like structure.
To learn more about the DPC model, please consult our DPC FAQ. I also encourage you to join our DPC member interest group, which provides an opportunity for you to connect with other DPC family physicians.
Hi, My Name Is …
Congratulations to David Barbe, M.D., M.H.A., for being elected president-elect of the AMA. Barbe, a family physician from Mountain Grove, Mo., will become president of the AMA in June 2017. Family medicine has strong representation on the AMA Board. In addition to Barbe, there are four other family physicians serving on the AMA Board of Trustees.
A special hat tip to Barbe for quoting the incomparable poet Marshall Bruce Mathers III in his acceptance speech to the AMA House of Delegates: "Anything is possible as long as you keep working at it and don't back down."
AAFP Offering Resources, Support for Small Practices
"There is nothing wrong with staying small. You can do big things with a small team."
-- Jason Fried, software entrepreneur
For decades, medicine -- especially primary care -- was delivered by a cohort of independent physicians who dedicated themselves to their patients and their communities. These physicians delivered their services and compassion through a network of solo and small group practices that were largely isolated from each other and other physicians. There was connectivity to the local hospital because family physicians, not hospitalists, took care of their patients who were admitted. They also worked the emergency room, delivered a few babies along the way, performed school physicals, and made weekly trips to the nursing home. This scenario was the prototypical family medicine practice in countless communities across the nation, large and small.
I know this model well because I grew up with one of these family physicians, and I witnessed first-hand the relationship that he had with his patients and our rural Oklahoma community.
One thing that has long been a concern for the AAFP is ensuring that solo and small group practices are able to sustain their business model and continue providing care to their patients. Yes, many physicians have chosen to pursue other practice settings and financial arrangements. We support these practice choices fully in our education and advocacy activities, but we have added emphasis to the future of the solo and small group independent practice. We are not alone in this work, and several people have begun to invest thought and energy into the importance of maintaining diversity in physician practice types and arrangements. In a May 26 blog posting, David Blumenthal, M.D., and David Squires from the Commonwealth Fund posed an interesting question: "Do Small Practices Have a Future?"
This question has taken on renewed interest and importance as we approach the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) and became highly emotional thanks to the now infamous "Table 64," which CMS published as part of proposed MACRA regulations that inaccurately predicted that more than 80 percent of solo and small practices would take a penalty under the MACRA payment pathways. CMS published a follow up fact sheet explaining how solo and small practices can achieve success under the new payment programs.
The Commonwealth Fund article noted some interesting facts:
- Between 1983 and 2014 the percentage of physicians practicing alone fell from 41 percent to 17 percent.
- During the same time, the percentage of physicians in practices with 25 or more doctors grew from 5 percent to 20 percent.
- Younger doctors are 2.5 times less likely than older doctors to be in a solo practice.
It likely is no surprise to any of you that the solo, independent practice model has been in decline for several decades. There are multiple reasons (population shifts, economics, costs of education) why this shift has occurred, and I am quite confident that the comments associated with this article will provide some colorful clarity on this subject. However, before you throw in the proverbial towel, let me remind you of a few additional facts about the strengths of solo and small practices:
- Four of 10 physicians are in practices with fewer than five physicians. This is especially true in non-urban and rural communities. So, despite all the public commentary about the elimination of the solo and small group practice, they actually still exist and are an essential part of our health care delivery system.
- Solo and small practices often outperform larger practices in many evaluations. In fact, a recent Commonwealth Fund study found that patients of physicians practicing in solo and small practices have lower rates of preventable hospital readmissions. The Robert Graham Center recently published a study that found that "more comprehensive care among family physicians is associated with lower costs and fewer hospitalizations."
These studies and many others demonstrate that there are significant public policy justifications for why the preservation of solo and small practices should be a priority. Setting aside the simple fact that consolidation in health care escalates costs for patients and decreases payments for physicians professional services, the fundamental reason that community-based primary care should be preserved is that it actually benefits patients.
The AAFP is dedicated to ensuring that family physicians, regardless of practice type or location, have the tools and resources needed to be successful. We strive to ensure that each of you can find and maintain a practice that enables you to provide high quality care to your patients and allows you to realize your professional and personal goals. We recognize that many solo and small group practices feel that the current trends in health policy are moving away from them, or as some put it, destroying them. We understand why this anxiety exists and we prioritize the development and distribution of resources that can assist our members in these practice settings. The following is a sampling of the tools and services the AAFP has created for members:
- Solo and small practice resources;
- Independent solo and small group practice member interest group;
- Chronic care management toolkit;
- Family Practice Management's "Four Coding and Payment Opportunities You Might Be Missing."
In addition, the AAFP is working closely with CMS to prepare physicians for value-based payment models through two programs, the Transforming Clinical Practices Initiative (TCPI) and the recently announced Comprehensive Primary Care Plus program.
You can learn more about the practice transformation opportunities available through the TCPI program on our resource page. I also encourage you to join our TCPI member interest group.
The AAFP also is actively engaged in identifying and recruiting physicians to participate in the CPC+ program, which will be launched later this summer. While the exact regions are not yet known, we are seeking to identify family physicians who have an interest in participating in this program in advance of the enrollment period, which opens July 15. We are especially interested in identifying solo and small group practices so that we can begin assisting you prior to the open enrollment period. If you are interested in participating in the CPC+ program, please email us at CPCPLUS@aafp.org.
As noted in this posting, the AAFP continues to place an emphasis on solo and small group practices. We see these practice settings as contributory to the betterment of our health care system. However, we fully recognize that much has changed during the past 30 years. We feel it is important to hear directly from our members on how these changes in care delivery and physician payment may impact your practices.
If you practice in a solo or small independent practice and you are interested in learning more about MACRA and its opportunities for solo and small practices, we will be hosting a webinar on Thursday, June 16 at 7:30 pm Eastern. We will be posting registration information on the Solo and Small Group Member Interest Group listserve and directly emailing to our CPC Plus community. To ensure you receive the registration information, please email us at CPCPLUS@aafp.org or join the solo and small practice group member interest group.
Why You Should Apply for CPC+ Program
On April 11, CMS announced the establishment of the Comprehensive Primary Care Plus (CPC+) program. CPC+ is an advanced primary care medical home delivery and payment model that builds on the Comprehensive Primary Care Initiative (CPCi) program, which was launched in 2012 and concludes at the end of this year.
In its announcement, CMS referred to CPC+ as "largest-ever multi-payer initiative to improve primary care in America." The AAFP welcomed the announcement of the new program. Fundamentally restructuring how we pay for primary care is an important step towards our goal of reforming the health care system to one that is foundational in primary care. The underlying policies of the CPC+ program are consistent with the AAFP policies on primary care delivery system and payment reform.
The program, which is a regionally-based and multi-payer, will launch formally in January 2017 and run for five years. CMS plans to identify and enroll 5,000 practices -- up to 20,000 total participants -- practicing in 20 yet-to-be-identified regions to participate in the program. Up to 2,500 practices will be selected to participate in one of two tracks (5,000 total participants).
Additionally, and probably most importantly, the CPC+ has been identified as an advanced alternative payment model (Advanced APM) under the Medicare Access and CHIP Reauthorization Act, meaning that practices participating in the CPC+ program will be eligible to receive a 5 percent bonus payment on their Medicare allowable charges starting in 2019.
CPC+ is designed to reward primary care physicians for the comprehensive, coordinated, and continuous care they provide their patients. By incorporating a multi-payer approach, the CPC+ program promotes alignment in delivery and payment policies across all payers in a physician’s practice. This means that all patients cared for by that primary care physician practice will be participating in the program versus just a physician's Medicare patients.
Participating practices will be asked to transform their practices to focus on the five core principles of advanced primary care, also known as the Comprehensive Primary Care Functions, which were established as part of the original CPCi program. These five functions, when accompanied by the Joint Principles of the Patient-Centered Medical Home, are consistent with the AAFP’s definition of an advanced primary care practice. The five functions are:
- access and continuity;
- care management;
- comprehensiveness and coordination;
- patient and caregiver engagement; and
- planned care and population health
Clearly, practice transformation consistent with these five functions necessitates payment policies that support such activities. The CPC+ program adheres to the AAFP's long-standing policy that advanced primary care practices should receive advanced payments on a per capita basis for both care delivery and care management. In an April 11 JAMA article, Laura Sessums, J.D., M.D., director of the Division of Advanced Primary Care at the Center for Medicare and Medicaid Innovation, expressed similar sentiments.
"To support fundamental change in care delivery, practices require a fundamental change in payment structure," she wrote.
The CPC+ program is designed to accomplish this goal in three ways.
- Care management -- All practices participating in the program will receive, from Medicare, an advanced care management fee for each attributed beneficiary. They also will receive an advanced care management fee from participating private insurers. The care management fee for CPC+ Track 1 will be determined in four risk tiers, but it is expected to average $15 per beneficiary per month or $180 per year. Track 2 payments will be determined in five risk tiers, but are expected to average $27 per beneficiary per month or $324 per year.
- Performance-based incentive payments -- All practices participating in the program will receive an advanced, performance-based incentive payment for each attributed beneficiary. The per beneficiary incentive payment for practices participating in Track 1 will be $2.50 and $4 for those in Track 2. These payments are designed to both facilitate and reward performance on patient experience, clinical quality, and utilization measures. The payments will be made at the beginning of each year, but will be subject to recoupment if the practice fails to meet its thresholds for the quality and utilization performance.
- Payment reform -- Practices participating in Track 1 will continue to receive fee-for-service payments for services provided to Medicare beneficiaries. However, practices participating in Track 2 will receive a blended payment of a global payment for evaluation and management services and fee-for-service. The advanced E&M payment, referred to as the "comprehensive primary care payment," is designed to pay the practice for the costs of a typical office visit, thus creating flexibility in how the physician delivers care to their patients. More explicitly, the comprehensive primary care payment is designed to create parity in delivery modalities -- face-to-face, telemedicine, phone, etc.
The AAFP sees the CPC+ program as a positive step towards creating and implementing a payment model that aligns with the core functions of an advanced primary care practice. Yes, there are likely things that will need to be tweaked or improved, but we should not allow the perfect to become the enemy of the good. It is important that we have robust participation among family physicians in the CPC+ program -- especially those in solo and small practices. To this end, we are urging family physicians to pursue this opportunity. Enrollment for physicians opens July 15 and concludes Sept. 1.
Additional information and a complete timeline are available on our CPC+ resource page.
If you are interested in learning more about how you can participate in this program please send an email to CPCPLUS@aafp.org. We will follow up regarding how the AAFP can help prepare for your practice for the open enrollment period.
MACRA is Coming, the AAFP Has Resources to Help
A little more than a year ago, Congress approved the Medicare Access and CHIP Reauthorization Act (MACRA) by substantial bipartisan votes of 392-37 in the House and 92-8 in the Senate.
To put these votes in context, 91 percent of Congress voted to repeal the flawed sustainable growth rate (SGR) formula and put our nation’s health care system on a new trajectory. On April 16, 2015, President Obama enacted this historic legislation into law. With a single stroke of the pen, the entire construct of how physicians are paid for their services, changed.
During the past 11 months, the AAFP has been diligently reviewing and analyzing MACRA in an effort to better understand the law so that we can prepare and position you for success. In addition, we initiated programs aimed at educating family physicians about the changes that are coming with respect to delivery system and payment reforms.
We launched a resource center and published content designed to assist you in understanding the scope and implications of the law. My colleague Amy Mullins, M.D., wrote a great primer for Family Practice Management entitled "Making Sense of MACRA."
I addressed the two payment pathways established by MACRA -- the Merit Based Incentive Payment System (MIPS) and the Alternative Payment Models (APMS) in previous posts on this blog. These resources were appropriate and adequate for the early stages of our member education campaign, but we promised you we would do more for you, our members.
Last Friday, we took the first step towards fulfilling that promise by ramping up our efforts in a big, big way through the announcement of MACRA Ready, which is a multi-faceted, multi-year campaign aimed at preparing our members for the new delivery reforms and payment pathways created by the law. The campaign features educational content on how the law is structured and functions, timelines for implementation, and tools aimed at helping you and your practice understand and prepare for one of the two payment pathways.
The most common question I am asked these days goes like this, "What should I be doing to prepare myself and my practice for MACRA?" I encourage you to visit the AAFP’s MACRA resources page. Here you will find information, tools and resources that are designed to help you better understand the new law. I have selected a few resources that will provide a good starting point:
- MACRA overview video;
- frequently asked questions;
- implementation timeline;
- MACRA acronyms;
- practice readiness assessment;
- AAFP News resources; and
- Making Sense of MACRA infographic.
The AAFP has also produced a series of MACRA webinars. This four-part series provides you with:
- an overview of MACRA;
- an introduction to MIPS;
- an introduction to APMs; and
- information about your current payment track.
I encourage you to sign up to receive MACRA email updates from the AAFP. These periodic emails will provide you the latest details on the new payment law and access to the latest tools and resources from the AAFP.
During the past year, I have had the opportunity to discuss MACRA with thousands of family physicians across the country. It is fair to say that many are anxious about these changes and eager to learn what the new law will mean to them and their practice. This is completely understandable. I firmly believe that the SGR was one of the worst health care policies every enacted into law and that family physicians and our health care system are far better off since it has been sent to the garbage pile of failed policies. However, I do understand that the SGR and the traditional fee-for-service system were familiar and, no matter how bad they were, you knew and understood them.
I often refer to MACRA as a historic law. Besides the fact that it repealed a severely flawed payment formula, MACRA made a substantive and meaningful shift in the ideology of the Medicare physician payment formula by shifting the concept of payment from payment for episodes of care to payment for the longitudinal quality of care provided to patients. Most importantly, the new law took significant steps to place an expressed emphasis on the importance of primary care.
Although there has long been an academic and conceptual belief that a health care system built on a primary care foundation is beneficial to patients and payers, there had never been a policy manifestation of this ideology -- until now. This law, by design and intent, places a renewed emphasis on primary care delivery models and goes so far as to protect them from financial risk in the APM pathway.
This renewed approach to primary care was set in motion as part of MACRA, but it can only be achieved as a result of the regulations issued by CMS. Therefore, the approach taken by CMS to implement MACRA is key. On May 5, CMS Acting Administrator Andy Slavitt tweeted some information, and I think you will be pleasantly surprised by what he had to say:
- "Must start with a core belief that MDs know best how to take care of patients and allow freedom"
- "Must simplify the practice of medicine: reduce burden, add flexibility, and provide support at every turn"
- "Pay more to PC [primary care] for care coordination, for dialogue, for cost of care outcomes"
I respect that some of you will disagree that MACRA holds any opportunity or value, and I look forward to hearing your thoughts, concerns, and suggestions. I can promise you this, the AAFP will do everything we can to provide you information, resources and tools that will allow you to be successful under one of the two new payment pathways.
Teaching Health Centers Key to Solving FP Shortage
March 18 was Match Day, which is when most fourth-year medical students receive confirmation of where they will conduct and hopefully complete their residency training.
Overall, the 2016 Match continued an encouraging trend for family medicine and primary care. A record 3,105 allopathic medical students chose family medicine residency positions in the National Resident Matching Program. In addition, 2016 marked the seventh consecutive year that the number of medical students choosing careers in family medicine increased.
Meanwhile, the American Osteopathic Association Intern/Resident Registration Program also produced encouraging results for family medicine with nearly one-fourth of participants choosing a family medicine position. The number of osteopathic medical students choosing careers in family medicine has nearly doubled since 2011.
The emphasis and priority placed on primary care by policy-makers and payers is influencing career choices of medical students. Primary care residencies had a fill rate of 96.1 percent, and family medicine increased its fill rate to 95.2 percent. This is a fairly remarkable number when you consider that less than a decade ago the fill rate for family medicine had dipped below 85 percent.
Overall, primary care positions accounted for 14.5 percent of all residency positions offered (4,053 of 27,860). With a primary care shortage knocking at the door, it is clear that more needs to be done to increase the pipeline for primary care specialties, which brings me to one of one of my all-time favorite policy issues -- teaching health centers (THCs).
The concept of teaching health centers is really quite simple. Instead of relying on the legacy graduate medical education system, which is focused on the academic medical center and other hospital settings, THCs use community-based settings such as federally qualified health centers (FQHCs), rural health clinics (RHCs), tribal clinics, and other settings to train residents.
Most primary care services are provided in community-based settings, so this concept aligns quite nicely with the education and training model for family medicine residency programs. Additionally, unlike the legacy GME programs, the money for training flows directly to the practice and training site versus going directly into the overall budget of an academic health center or hospital.
Teaching health centers were established in 2010 under the Patient Protection and Affordable Care Act (ACA) and reauthorized in 2015 as part of the Medicare Access and CHIP Reauthorization Act (MACRA). Today, there are 690 residents being trained in 59 teaching health centers in 27 states and the District of Columbia. Of the 59 programs, an overwhelming majority of the residency positions are in family medicine. Yes, there are a few internal medicine, pediatrics, and obstetrics/gynecology positions, but the clear recipient of the majority of these positions is family medicine. And, these programs produce -- big time.
Besides producing large percentages of family physicians, the graduates of these programs have a strong commitment to providing care to vulnerable populations. The AAFP's Robert Graham Center for Policy Studies in Family Medicine and Primary Care recently published a one-pager that shows a stark difference between graduates of teaching health centers and those who completed their training in a legacy GME program. Specifically, the Graham Center found that 33 percent of THC graduates “planned to practice in a setting primarily associated with underserved populations (e.g. community health centers, rural health clinics, Indian Health Service, US Public Health Service).” By comparison, only 18 percent of graduates from non-THC programs planned to practice in underserved areas.
One of the primary reasons that I love THCs is this -- they are better positioned to address the geographic distribution problems that currently exist in the physician workforce. According to the Agency for Healthcare Research and Quality (AHRQ), 91 percent of all physicians practice in urban areas. This makes perfect sense, if you train in an academic health center or large hospital; it is highly unlikely -- if not improbable -- that you will migrate from Manhattan, New York, to Manhattan, Kansas. Training future physicians near desired practice locations is nothing new or novel. The de-centralization of GME has been a desired policy objective of academic leaders for decades.
There is compelling data to support the de-centralization of physician training, especially in primary care. According to a 2015 Family Medicine study entitled “Family Medicine Graduate Proximity to Their Site of Training,” 54.8 percent of family physicians practice within 100 miles of where they train, and 46 percent practice within 50 miles of their training location. When you look at those who have completed their training since 2000, the numbers are even more significant with 62.5 percent choosing practice locations within 100 miles of their training site.
The challenge historically was the lack of a program that allowed GME training to take place away from the hospital setting – until THCs. I'm not advocating for the elimination of all hospital-based GME because we need primary care programs in all settings. What I am an advocate for are policies that work, are scalable, and most importantly, achievable in our current political environment.
Upon his capture in 1934, FBI agents asked legendary bank robber Willie Sutton why he robbed banks. Sutton, who believed the question to be rhetorical, replied, dryly, "Because that's where the money is."
Why do I support THCs so strongly? Because that’s where the opportunities are. There are more than 9,000 community health centers in the country serving more than 24 million patients annually. Fifty-seven have training programs. THCs are the hidden gem of workforce policy when they should be the Hope Diamond. The AAFP has placed a priority on the continuation and appropriate funding of THCs. During the recent Family Medicine Congressional Conference (FMCC), participants advocated on behalf of THCs with their mnembers of Congress. In addition to this work, the AAFP continues to pursue policies that extend the THC program and create a stable funding stream to ensure the continuation of this successful program.
The Partnership to Fight Chronic Disease has released a new report, “What is the Impact of Chronic Disease on America?” Two key takeaways from the report:
- In 2015, 191 million people in America had at least 1 chronic disease, 75 million had 2 or more chronic diseases.
- Chronic disease could cost the United States $2 trillion in medical costs and an extra $794 billion annually in lost employee productivity per year between now and 2030. The organization also has state-by-state impact analysis that you can review.
Family Medicine's Role in Strengthening Public Health
“I’m a clown, which could be a public health role.” -- Patch Adams, M.D.
Last week was National Public Health Week. Established in 1995, the week draws the nation’s attention to timely and impactful public health issues. In addition, it provides an opportunity to recognize the contributions of physicians, nurses, researchers and others who devote their talents to the betterment of public health.
In this post, I would like to celebrate the family physicians who dedicate their careers to public health, as well as recognize the contributions that each of you make to the betterment of public health in your communities.
My colleague and family physician Julie Wood, M.D., is recognized as a national leader on the integration of public health and primary care. Beyond leading the AAFP’s efforts in this area, she drives the larger public dialogue on many public health issues and the role of primary care in addressing those issues.
In 2015, she assisted in drafting The Practical Playbook: Public Health and Primary Care Together, which was a joint effort of the CDC, the de Beaumont Foundation and the Department of Community and Family Medicine at Duke University. In this text book, Dr. Wood described the relationship as follows. “Primary care and public health have natural links that strengthen each other.”
Public health has its origins in the United States dating back to 1798 when Congress created the Marine Hospitals to care for sick and infirm seamen. In 1870, the nation’s network of Marine Hospitals were reorganized into a centrally controlled Marine Hospital Service and placed under the supervision of the Supervising Surgeon -- a position later renamed Surgeon General. In 1871, John Maynard Woodworth, M.D., was appointed the first Supervising Surgeon/Surgeon General.
In 1889, Congress created the commissioned officer corps as a means of providing physician workforce to the various Marine Hospitals. The commissioned officer corps later became known as the United States Public Health Service Commissioned Corps (PHSCC). The PHSCC is the federal uniformed service of the U.S. Public Health Service (PHS) and is led by the Surgeon General.
The AAFP and family medicine have a long and proud history as a leader on public health issues. The earliest days of public health, outside of the military system, are grounded in primary care and community medicine. Family medicine and the AAFP remain strong contributors to the nation’s public health. Thousands of family physicians have and continue to serve in the Public Health Service Corps and each of you, in your own important ways, contribute to the health of your communities through your day-to-day practice of medicine.
No single topic exemplifies our leadership more than the issues related to smoking and tobacco use. It is indisputable that the AAFP’s advocacy efforts on these issues drove changes in law and have been a major driving force behind national efforts to limit smoking and tobacco use. Clearly there is more work to do, but family medicine should be proud of the changes you have caused through your advocacy on these important public health issues.
Our work on public health issues is far-reaching. Honestly, there are few public health issue that the AAFP is not working on. We are at the forefront of efforts to curb the opioid and heroin epidemic, working closely with Surgeon General Vivek Murthy, M.D., the White House, governors and the CDC to identify and disseminate information that will allow family physicians to better identify abuse and intervene on behalf of patients in their communities.
The leadership of family medicine is on display each day through the work of AAFP President Wanda Filer, M.D., M.B.A., and countless others who are working tirelessly to educate the public, policy-makers, physicians, and health care providers on this important issue.
In addition, the AAFP is working on Zika, childhood immunizations, antibiotic resistance, obesity and countless other important issues.
The AAFP has a full set of public health and social determinants resources available for you and your practice.
One of the greatest demonstrations of family medicine’s commitment to public health occurred earlier this year (and continues to this day and will for years to come) when our colleagues and friends in Michigan stepped forward and provided demonstrable leadership to the community of Flint. Most of you are aware of the series of tragic events that have come to light with respect to the water supply in Flint. As family physicians you should be proud of the manner in which your colleagues in Michigan have responded to this tragic event. I am especially moved by a quote on the Michigan AFP's website which reads in part, “It is clear that Family Physicians have a large role in screening for lead poisoning and developmental issues in the children and families afflicted by the Flint water crisis. Their expertise, however, goes far beyond the provision of comprehensive medical care. … the heart of Family Medicine is community.”
I think it is important to reflect on the significant and important contributions family medicine makes to public health -- at the policy level, but more importantly at the community level. In 1989, the AAFP established a Public Health Award that recognizes individuals who have made or are making extraordinary contributions to the American public’s health. If you know of a family physician or group of family physicians who are making a difference in the health of the public, please nominate them so we can celebrate their contributions.
Finally, Alignment of Meaningful Quality Measures May be Reality
How many times in your career have you audibly uttered "why can't all insurance companies use the same quality measures and reporting process?" I'm guessing many of you have probably said it today.
A few weeks ago, I wrote about the AAFP’s 2016 advocacy agenda. In that post, I identified reducing "administrative complexity" and "alignment" as Academy priorities. The vast volume of rules, regulations, and guidelines that family physicians must navigate each day is a leading driver of professional dissatisfaction and frustration. A 2013 study of 23 health insurers found that 546 quality measures were used, few of which matched across insurers.
Given that 61 percent of family physicians have contracts with seven or more payers -- each with their own quality reporting, prior authorization, and appropriate use criteria -- it's easy to understand why you are so frustrated with quality reporting and performance improvement programs.
One physician told me, "Unless you reduce the administrative and bureaucratic burden to primary care, family medicine will cease its existence. Time has a care value, care has a time value."
This frustration is expressed by family physicians of all ages and in most practice settings.
Not to deemphasize the negative impact administrative complexity has on physicians' professional satisfaction, but the financial impact on physicians' practices is probably a bigger concern. As noted from the physician above, "time has a care value, care has a time value," and this is greatly out-of-balance. A recent study published in Health Affairs found that physicians individually spend $40,069 per year and, collectively, more than $15.4 billion annually to report quality measures. Startling statistics, but the underlying commentary is what concerns me. It reads, in part, as follows:
"… physicians and their staff spend 15.1 hours per physician per week dealing with external quality measures including the following: tracking quality measure specifications, developing and implementing data collection processes, entering information into the medical record, and collecting and transmitting data. This is equivalent to 785.2 staff and physician hours per physician per year. The average physician spent 2.6 hours per week (enough time to care for approximately nine additional patients) dealing with quality measures."
The AAFP has long recognized and advocated for a reduction in the administrative burden placed on family physicians. In 2014, the AAFP ramped up its efforts when we engaged in a collaborative effort with CMS, America’s Health Insurance Plans (AHIP), and representatives from the patient community to identify and develop a set of core quality measures for primary care physicians. Our collaboration was supported by the National Quality Forum, and the National Committee for Quality Assurance to ensure that our work was adhering to the most recent science and evidence on quality and performance measurement. It's noteworthy that payers (CMS and commercial insurers) who participated in the collaboration represent approximately 70 percent of the combined population of Medicare Advantage enrollees and fee-for-service Medicare beneficiaries in the United States -- not to mention a clear majority of covered lives in the employer-sponsored and individual markets.
The collaborative developed a framework of three aims for our work which were:
- Recognize high-value, high-impact, evidence-based measures that promote better patient health outcomes, and provide useful information for improvement, decision-making and payment.
- Reduce the burden of measurement and volume of measures by eliminating low-value metrics, redundancies, and inconsistencies in measure specifications and quality measure reporting requirements across payers.
- Refine, align and harmonize measures across payers to achieve congruence in the measures being used for payment and other accountability purposes.
These three aims were further articulated through 11 key attributes, one of which states "data collection and reporting burden must be minimized." A second key attribute stated, "measure sets for clinicians should be as parsimonious as possible and should focus on those measures delivering the most value."
I am pleased to report, that after nearly two years of work, our collaboration has produced a meaningful result for family physicians. On Feb. 16, the AAFP joined CMS and (AHIP) in announcing the establishment of a Core Measure Set for Primary Care and the Patient Centered Medical Home. This core measure set is an important step in reducing the administrative burden each of you experience on a daily basis. Furthermore, the adoption of this core set across all payers has real potential to reduce the negative financial impact on practices.
The AAFP is actively advancing the inclusion of this core measure set in the Medicare program and in the forthcoming Medicare Access and CHIP Reauthorization Act regulations. Additionally, we are pressing commercial insurance plans to include the core set in their next round of contracts for family physicians. We urge you to use AAFP resources or the CMS webpage to familiarize yourself with these core measures and insist that the insurance companies you contract with transition your practice towards these measures.
APMs: A Primer on the New Payment Model
Each of you is now familiar, or is hopefully growing more familiar, with the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA).
MACRA was enacted April 16, 2015, and repealed the Medicare sustainable growth rate. It also set in motion the creation and implementation of two payment pathways for physicians participating in the Medicare program. Last month I shared information and insights on the Merit-Based Incentive Payment System (MIPS). In this post, I am providing an overview of the MACRA Alternative Payment Model (APM).
The AAFP views the APM as the best opportunity for family physicians, primarily due to the fact that it promotes new delivery and payment models that migrate away from fee-for-service. Our primary goal for several years has been the establishment of payment policies that promote and finance comprehensive, continuous, and coordinated primary care. We believe that MACRA creates an environment whereby these models can be implemented, and we believe the APM pathway gives these models a place to grow and mature.
Starting in 2019, family physicians participating in a qualified alternative payment model who successfully meet the quality and performance criteria and exceed the established Medicare beneficiary thresholds will be eligible for a 5 percent bonus payment on their total allowed Medicare charges. Furthermore, qualifying physicians participating in a qualifying and eligible APM will be exempt from the MIPS program. APM qualifying physicians also will receive a higher Medicare physician fee schedule update (of 0.75 percent) starting in 2026.
There are three sets of criteria that must be met in order to secure the bonus payment in the APM pathway. Those three criteria are:
Qualifying Alternative Payment Model -- MACRA explicitly outlines which delivery and/or payment models will ultimately qualify as an APM. The law states that qualifying APMs must be established through one of four ways:
- Medicare Shared Savings Program;
- Centers for Medicare and Medicaid Innovation (CMMI) programs expanded by the HHS Secretary;
- Medicare Quality or Acute Care Episode Demonstration projects; and
- demonstrations required by federal law
Eligible Alternative Payment Model -- Any APM that meets one of the four qualifying criteria listed above must also meet the performance and quality thresholds established by the law. There are three performance thresholds:
- APMs must report quality and performance measures comparable to those contained in the MIPS program.
- APMs must use a certified EHR technology.
- APMs must incur nominal financial risk for monetary losses or be a medical home model expanded under CMMI authority.
Qualifying Alternative Payment Model Physician -- The final criterion in determining if an individual physician or a group of physicians qualified for the 5 percent bonus payment is that a qualified physician must demonstrate that the required percentage of his or her payments is received through a qualified and eligible APM.
For 2019 and 2020, qualifying physicians must demonstrate that, at minimum, 25 percent of their total Medicare payments are aligned with a qualifying and eligible APM. Starting in 2021, the minimum threshold increases to 50 percent, but the law allows physicians to use a combination of Medicare and non-Medicare payments, such as those from Medicaid and commercial insurers, to meet that threshold.
A few observations on APMs:
- APMs represent the better of the two pathways, in AAFP’s opinion, for family physicians to move away from the challenges of episodic fee-for-service practice models towards more comprehensive delivery and payment models that allow for and compensate you for comprehensive and coordinated patient care.
- The AAFP is aggressively advocating for the inclusion of an advanced primary care delivery model as a qualifying APM. We view the Comprehensive Primary Care (CPC) initiative as a model that can and should be expanded on a national scale.
- APMs are more inclusive than accountable care organizations (ACO) and do not “require” family physicians to sell their practice to a hospital or health system to qualify for the APM bonus payment.
- The medical home plays an important role in the APM pathway, since medial home APMs are exempt from the “nominal risk” eligibility criteria.
- Pursuit of the APM pathway is valuable even if you fall short of the eligibility and qualification criteria since APM participation is recognized as a Clinical Practice Improvement Activity (CPIA) under the MIPS pathway. This means that those that attempted to participate in an APM will receive favorable scoring for the CPIA performance category in the MIPS program.
- The MIPS program is designed to prepare physicians for participation in an APM. For this reason, making an effort to transition towards an APM sooner rather than later is encouraged.
The AAFP is committed to ensuring that you and your practice are ready to take advantage of new payment opportunities presented by MACRA. In the coming weeks we will be launching a comprehensive member education and communications effort designed to simplify the transition and provide the guidance you need to realize the benefits of value-based payment. Please watch for additional information at this blog or on aafp.org.
On March 8, CMS announced a proposed rule to test new models to improve how Medicare Part B pays for prescription drugs and the administration of those drugs by physicians. Although most prescription drugs are paid through Medicare Part D, there is a substantial number of drugs paid for under the Part B program. Primarily, Medicare Part B covers prescription drugs that are administered in a physician’s office or hospital outpatient department, such as cancer medications, injectables like antibiotics, or eye care treatments.
The proposal issued by CMS puts in place a value-based payment model for prescription drugs, but also alters the payment for the administration of such products in a manner that is favorable for family physicians. The proposed rule seeks to test six alternative approaches for Part B drugs. The AAFP issued a statement on the proposal and will be providing CMS with substantive comments on the proposal in the coming weeks. The full proposal is available on the Federal Register.
HHS Program Offers Free Practice Transformation Support
Many of you, like me, may cringe at the sheer volume of acronyms, abbreviations, and initialisms that exists in health care policy these days. There is MACRA, MIPS, APMs, MU, QRUR, CPT, and ICD-10 -- just to name some of the more common examples. Well, let me introduce you to a new term that you should know -- PTN, which stands for the Practice Transformation Networks. If you are an independent solo or small-group practice, you should get to know this program soon.
On Oct. 23, 2014, HHS Secretary Sylvia Burwell stood before the nation’s family physicians during her FMX keynote address and announced that HHS was launching an $840 million effort to assist physicians in transforming their practices and delivery systems. During her speech, Burwell promised family physicians in attendance that HHS was launching the Transforming Clinical Practice Initiative (TCPI), a program designed to assist physicians in their individual journeys towards practice transformation.
"We want to support you in innovation," she said.
One year later, on Sept. 29, 2015, Burwell announced $685 million in TCPI awards to national and regional health care networks to carry out the transformation project she had announced at FMX. The TCPI program aims to assist more than 140,000 physicians and other health care providers in transforming their practices in an effort to improve the quality of care provided, increase patients' access to information, and reduce the total cost of care.
HHS is quick to point out that the TCPI program is "one of the largest federal investments designed to support doctors and other clinicians in all 50 states through collaborative and peer-based learning networks."
In total, there are 29 practice transformation networks that cover all 50 states. The TCPI website describes the PTNs as "peer-based learning networks designed to coach, mentor and assist clinicians in developing core competencies specific to practice transformation. This approach allows clinician practices to become actively engaged in the transformation and ensures collaboration among a broad community of practices that creates, promotes, and sustains learning and improvement across the health care system."
The AAFP has assembled information on each of the 29 PTNs that you can access to determine which may be the most appropriate fit for your practice. You can also access PTN information through the TCPI Health Care Communities.
Practice transformation and the PTN program are important opportunities for each of you, but especially those of you that are in an independent solo or small group practice(s). I know that there will be some pushback to me suggesting that you pursue alignment with a PTN as a means of securing tools and resources that can assist you with practice transformation. However, I am going to do just that. These resources are available to you in your state or region and are largely free, and I urge each of you to reach out to your local or regional PTN. All family physicians -- with the exception of those of you who are participating in the Medicare Shared Savings Program, Pioneer ACO Program, Multi-Payer Advanced Primary Care Practice, or the Comprehensive Primary Care Initiative -- are eligible to receive technical assistance from the TCPI program.
The AAFP is committed to providing you information on the opportunities PTNs may provide for you and your practice. I encourage you to use the resources we have assembled on our TCPI resource web page. In addition to these resources, a member interest group has been formed and we will be offering additional TCPI learning opportunities at FMX in Orlando, Fla. If you have questions on the TCPI program, please email the AAFP.
Last week pitcher and catchers reported to spring training and position players will join them this week. In my opinion, the first day of spring training should be a national holiday. It is a day when every player has a chance to make a roster and every team believes they will play in the World Series. Many of you may know what spring training is, but how many of you know its history? Well I am here to help, so here is the short version.
The first known spring training was held in 1886 when the Chicago White Stockings (now the Cubs) traveled to Hot Springs, Ark., to prepare for the upcoming season. Legend has it that the White Stockings had a good season following their spring in Arkansas, so a tradition was born. Hot Springs remained the center of the spring training universe until the late 1920s when many teams began establishing spring training facilities in Florida and Arizona.
Although spring training has departed its original Arkansas home, Hot Springs has an undeniable impact on the history of baseball. In fact, more than 130 members of the Baseball Hall of Fame participated in spring training at facilities in Hot Springs. The history of Hot Springs spring training was captured in a 2015 documentary called The First Boys of Spring. This documentary is a great way to spend a cold winter day -- enjoy.
Report: PCMH improves quality, reduces cost
"We've been together since way back when,
And sometimes I never want to see you again.
But I want you to know, after all these years,
That you're still the one …"
Nine years ago this month, the American Academy of Family Physicians collaborated with the American College of Physicians, American Academy of Pediatrics, and the American Osteopathic Association to develop and introduce the Joint Principles of the Patient-Centered Medical Home (PCMH). These principles were viewed as the articulation of ideas that would establish a health care system that was focused on the patient, foundational in primary care, and mindful of appropriate use of our limited health care resources.
Since February 2007, the Joint Principles have been foundational in establishing a variety of advanced primary care delivery models in public and private health care systems and remain the most applicable and appropriate roadmap for primary care delivery system reforms. Today, the PCMH, or some variation of the concept, is recognized by every major private insurer, Medicare, Medicaid, the Veterans Health Administration, and the Department of Defense. And, most importantly, it is the only delivery system model mentioned and recognized in the recently enacted and soon to be implemented Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
So after nine years, the question we all should be asking ourselves is: "Do advanced primary care practices built on the principles of the PCMH improve quality and reduce the cost of health care?"
For the answer, I point you to a report recently released by the Patient-Centered Primary Care Collaborative (PCPCC) entitled the "Patient-Centered Medical Home's Impact on Cost & Quality: Annual Review of Evidence 2014-2015." The PCPCC report looked at 30 published studies of advanced primary care or medical home practices and or programs. Seventeen of these studies were peer-reviewed, four were state government evaluations, six were industry reports, and three were independent evaluations of federal initiatives. Based on this report, I would suggest that the answer to the question above is yes, but let's take a look at the key findings from the report's executive summary:
- This year's 30 publications point to a clear trend showing that the medical home drives reductions in health care costs and/or unnecessary utilization, such as emergency department visits, inpatient hospitalizations and hospital readmissions.
- Those with the most impressive cost and utilization outcomes were generally those who participated in multipayer collaboratives with specific incentives or performance measures linked to quality, utilization, patient engagement or cost savings.
- The more mature medical home programs demonstrated stronger improvements.
Each of you has a rich understanding of just how impactful comprehensive, continuous, and connected primary care can be. You live it each day. This report and others that have been published during the past few years are starting to demonstrate, in a quantifiable manner, the true value of primary care.
I had three other important takeaways from the PCPCC report:
- The most glaring demonstration of the value among advanced primary care practices is the decrease in emergency room visits, especially emergency room visits for primary care services. The second is the decrease in hospital admissions. These utilization reductions were noted in the PCPCC report, but they were also key findings in the latest Comprehensive Primary Care Initiative report. It is really quite simple, hospitals and the care provided in hospitals are expensive and when we focus on reducing the frequency of patient visits in those settings we save money.
- Time and experience yield stronger outcomes in quality and cost. The PCPCC report clearly demonstrates that advanced primary care practices need time to develop and mature before they truly produce significant improvements in quality and cost. Think of it this way, PCMH's are like children or good scotch -- they need time and space to mature.
- Payment reform remains both essential and elusive. I was struck by the differences in outcomes among those programs that had made meaningful changes in the payment system for their participating advanced primary care practices versus those that didn't. Each category demonstrated improvement, but the presence of meaningful payment reforms certainly accelerated progress. We have much work to do in this space. Fifty-five percent of all medical office visits are to a primary care physician, yet only 4 percent to 7 percent of our total health care spend is directed to primary care. We can't continue to ask family medicine and primary care to shoulder the responsibility of health delivery system reform on what is essentially the scraps of our overall health care spend.
It has not been an easy ride, but the AAFP remains strongly supportive of the Joint Principles. They remain as needed and applicable today as they did when they were created. There is work to do, of course. However, there is growing evidence that advanced primary care practices, when supported by systemic changes in payments, improve quality and decrease the overall cost of health care. That's why, as the song lyric states, PCMH is "still the one."
Public Health Alert: Zika
Many of you have likely been following the Zika virus issue. The AAFP has as well. My colleagues in the AAFP's Division of Health of the Public and Science have been working diligently to assemble information and resources for you and your practice. I encourage you to use these excellent resources and share them with your colleagues. As a family physician you play an important role in public health outbreaks such as this and we urge you to be prepared to assist your patients and your community.
In addition to the AAFP's resources, you may find Zika related resources at the following sites:
MIPS: A Primer on the New Payment Model
Most of you are well aware that Congress repealed the flawed sustainable growth rate (SGR) in 2015 through the enactment of the Medicare Access and CHIP Reauthorization Act (Public Law 114-10). However, many of you probably have asked the questions, "What now?" and "What does this mean for me and my practice?"
Although we should celebrate the elimination of the flawed SGR, the AAFP recognizes fully that the implementation of the new delivery and payment models outlined in MACRA will require a series of important decisions and actions by family physicians. To assist you and your practices, the AAFP is launching a concerted education effort aimed at providing information and resources on how this new law impacts you and your practice and how you can best position your practice for success under this new payment policy. We will be sharing information and resources on our MACRA resource web page.
MACRA established two distinct payment systems for physicians. Those two systems are the Merit-Based Incentive Payment System (MIPS) and the alternative payment model (APM) program. This post is focused on the MIPS system, but I will be writing about the APM in an upcoming post.
As noted in my previous post, the implementation of the new payment policies is set for 2019. However, the performance year that will determine your payments in 2019 will start as early as 2017. This means we have a lot of ground to cover in the next 12 months.
MIPS Performance Evaluation
The MIPS program, by design, is based on the fee-for-service model. However, the program deviates from current practices whereby all services are paid on the standard Medicare physician fee-schedule. The law incorporates and aligns the three current physician quality and performance improvement programs -- physician quality reporting system (PQRS), value-based modifier (VBM), and meaningful use (MU) -- into a single performance program. This new program will establish a single score on a per physician basis versus continuing the fragmented three-part performance evaluation and penalty programs that exists under current law.
The MIPS program creates a robust quality and performance improvement program that will evaluate and score physician performance in four distinct areas -- quality, resource utilization, meaningful use, and clinical practice improvement activities. Each of these activities is assigned a percentage of the total composite score as follows:
|Clinical Practice Improvement||15%||15%||15%|
A few observations on the valuation of the MIPS performance categories:
- The values for meaningful use and clinical practices improvement activities remain consistent while the value percentages for resource utilization increase during the three-year period.
- The law places an increasing emphasis on resource utilization over time. Note that the values for quality measurement decrease in proportion to the increases in the values for resource utilization.
- The law allows the HHS secretary to decrease the values for meaningful use and shift those values to other categories if it is determined that the proportion of physicians who are meaningful users of electronic health records is 75 percent or greater.
- Any physician who practices in a certified patient-centered medical home will receive the full 15 percent for the clinical practice improvement activity. The law does not define "certified" and the AAFP will be working to influence this definition as the law is implemented.
MIPS Payment Adjustments
The performance threshold is established annually based on the mean or median of the composite performance scores during the performance period. The law prohibits any type of look-back at existing programs as a means of establishing the initial performance threshold and instead defers this authority to the secretary of HHS for the first two performance years.
Once a physicians' composite score is determined, that score will be weighed against the performance threshold and a payment adjustment will be established for the next payment year. Physicians will receive positive, neutral, or negative payment adjustments up to the allowed percentages for the specific program year, which are outlined in the following chart:
|Maximum Positive Adjustment||+4%||+5%||+7%||+9%|
|Maximum Negative Adjustment||-4%||-5%||-7%||-9%|
A few observations on the MIPS payment adjustments:
- We anticipate that CMS will continue to use a two-year look back period to determine payments. This means that payments for 2019 will be based on performance in 2017. Payments in 2020 will be based on performance in 2018 and so on. The AAFP has serious concerns with the two-year look back period and will be advocating that this time frame be shortened significantly.
- MIPS adjustments are budget neutral, meaning that there will be equal numbers of positive and negative payment updates.
- Physicians scoring in the lowest quartile will automatically be adjusted down to the maximum penalty for the performance year. Physicians scoring at the threshold will receive no adjustment. Physicians scoring in the highest quartile are eligible for a potential positive payment adjustments up to the maximum outlined in the chart above. The highest performers will receive proportionally larger incentive payments, up to three times the maximum positive adjustment for the year.
- For years 2019-2024, the law establishes a $500 million bonus pool designed to provide additional incentives of up to 10 percent for "exceptional performers."
- Unfortunately, the law does not provide a definition of an "exceptional performer," so we will be working closely with CMS to establish this definition.
The law established three exemptions from participation in the MIPS program. Those exemptions are:
- The physician is participating in the Medicare program for the first time. Under this scenario, the physician is exempt from MIPS for the first year of Medicare participation.
- The physician is participating in an eligible alternative payment models and qualifies for incentive payments through that program.
- The physician does not see a large enough number of Medicare patients and falls below the established volume threshold for participation.
This is an initial introduction to the MIPS program. I understand that it will likely raise more questions than it answers, but that is a good thing. We need you to raise questions so we can develop materials and resources to assist you and your practice.
2016 Advocacy Agenda: Four Things to Know
Happy New Year! As the calendar turns from 2015 to 2016, it's important to outline priority issues and areas of focus for the AAFP heading into the New Year.
As noted in my last posting, 2016 is an election year. Modern history suggests that opportunities to accomplish major policy objectives in an election year are limited, but we believe this year may be different. We also know that we must approach our work with a greater sense of urgency due to the rapid changes that are coming.
To articulate this, I have decided to borrow a catchy phrase from Sesame Street to describe the AAFP’s advocacy outlook for 2016. So here goes: “The AAFP’s 2016 advocacy agenda is brought to you by the letters M and A.”
MACRA -- On April 16, 2015, President Obama signed into law the Medicare Access and Children’s Health Insurance Program Reauthorization Act (P.L. 114-10). The enactment of MACRA capped a 15-year effort to repeal the flawed sustainable growth rate (SGR) and set in motion reforms that will more appropriately support new delivery systems and establish a path away from fee-for-service. These new delivery and payment models have an opportunity to end decades of de-valuing primary care by appropriately compensating family physicians and financing the functions of an advanced primary care practices.
The major reform provisions of MACRA -- the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Models (APMs) -- will not be fully implemented until 2019. However, the regulatory framework must be developed during the next 12 to 18 months, meaning 2016 is going to be a busy year for CMS and the AAFP. The Academy outlined many of its views on the major issues in our response to a 2015 CMS request for information (RFI) on MACRA implementation.
I encourage you to familiarize yourself with the implementation timeline. It is important that you and your practice start thinking about how you will transition into one of the two payment pathways established by MACRA. The AAFP will be rolling out extensive content and resources during the next few months and will feature extensive education opportunities for family physicians.
You can access AAFP content on our MACRA resource web page. We also anticipate publishing extensive related content through Family Practice Management.
Meaningful Use -- The meaningful use program continues to be the most disliked regulation in existence and for good reasons. Family physicians have implemented electronic medical records at a significantly greater pace than physicians in other specialties. Family physicians also have demonstrated the value of EMRs in enhancing the quality of care provided to patients.
What continues to be a source of frustration is the complex set of regulations that have been developed and implemented through the meaningful use program. As a result of these frustrations, the AAFP has worked to aggressively reform the meaningful use program and eliminate physicians’ exposure to financial penalties that are associated with the program. I am pleased with the progress made in 2015, but more work needs to be done and we are getting some help from a surprising source.
In late December, Congress passed and the President enacted into law, legislation that will provide a hardship exemption from meaningful use stage 2 requirements for qualifying physicians. CMS has, at the time of this posting, not published the guidelines for how physicians can participate in the hardship program. Once this information is available, the AAFP will use multiple communication platforms to share the details with you to ensure that those who wish to seek the hardship exemption have the necessary information to do so.
On Jan. 12, CMS Acting Administrator Andy Slavitt, in a presentation at the JP Morgan Healthcare Conference, pleasantly surprised (totally shocked) the physician community when he publically stated that the meaningful use program may have “met its goals and served its usefulness,” and should be "replaced with something better."
He essentially announced the coming end of the meaningful use program when he said that the "meaningful use program as it has existed will now be effectively over and replaced with something better.”
Obviously the details matter, but the AAFP is pleased that our advocacy efforts have resulted in positive action on the part of Congress and CMS.
On that same day, the AAFP wrote to Slavitt, outlining a set of recommendations on how CMS should pursue revisions to the program. Among those recommendations, we prioritize the need to accelerate robust interoperability to support continuity of care and care coordination, the elimination of burdensome requirements on practices that detract resources away from patient care, and alignment of the numerous regulations governing patient care.
A is for Administrative Complexity and Alignment
Administrative Complexity -- Last year I wrote a posting on “Whacking the WAC.” The time and energy devoted to the administrative functions of a family medicine practice continues to be daunting if not overwhelming. The most frustrating aspect of this issue is few of the administrative functions required of family physicians have any measurable impact on the quality of care received by patients. Multiple surveys and studies have placed the overall time allotted to administrative functions at 15 percent to 17 percent for most physicians.
This is an astonishing allocation of time both from the perspective of meeting administrative requirements, but also the loss of patient care time that results from these administrative requirements.
The so-called “work after clinic” is a major contributor to physician burnout and, unfortunately, leads many physicians to make career decisions that may not be aligned with their personal and professional goals.
It also contributes to the belief that the intensity of work in primary care is not appropriately compensated by payers. To be blunt, the 15-minute office visit is really a 20-minute visit that is compensated at 15 minutes. This is what is inherently unfair about the system and why we are dedicated to reducing administrative complexity.
Alignment -- One of the greatest frustrations expressed by family physicians is the variation in quality and performance measures used by public and private health care payers. Physicians also express frustrations about the lack of congruency in the definitions and execution of delivery system programs such as the medical home or chronic care management programs. This frustration is completely understandable given that family physicians have such a diverse set of payers.
According to research conducted by the AAFP, 61 percent of family physicians have contractual relationships with seven or more payers, and 38 percent have relationships with 10 or more.
The AAFP places a high priority on this work. We continue efforts to educate and influence the commercial insurance plans through meetings and continuous communications with the leadership of these companies.
We also have a meaningful working relationship with America’s Health Insurance Plans (AHIP), which has allowed us to advance policy recommendations that would achieve some level of alignment between payers. We are optimistic that this work with AHIP will be rewarded through the adoption and implementation of a “core (quality) measure set” for primary care. If this comes to fruition, then family physicians would have a single set of quality measures that would be reported to Medicare and all commercial insurers.
I can assure you that this isn’t a comprehensive list of issues that we will be working on this year. This list does not include many priority issues. However, this is a solid summary of the major opportunities and challenges we see in family medicine. Nothing, and I mean nothing, is more pressing than these four issues. I look forward to engaging with you during the next year, and I remind you that your comments and feedback make our work better and more impactful for you and your practice. So, keep them coming.
2016 Election: Dates to Remember
"In this country people don’t vote for, they vote against.” -- Will Rogers
Happy New Year! As a good Oklahoman, I always feel it is appropriate to frame any conversation about elections and politics with a quote from the most famous Oklahoman, Will Rogers. Rogers, who was a newspaper columnist and social commentator as well as a cowboy, vaudeville performer and actor, had a deep respect for our democracy and a healthy skepticism for those that were elected to serve it. He also viewed the responsibility of voting as one of the most important rights granted to any citizen.
This year, you will have an opportunity to exercise this right on at least two occasions -- during your state's primary elections or caucus and on Election Day.
On Nov. 8, we, as a country, will elect a new president and vice president, 435 U.S. Representatives, 34 U.S. Senators, and 12 governors. In addition, the occupants of hundreds of state and local elected positions will be determined.
Unless you live a life free of communication with the outside world, you are probably well aware that the 2016 presidential election process is already well underway. There are 13 Republicans and three Democrats seeking their parties’ nominations. The two nominees will be determined through a series of primary elections and caucuses that begin on Feb. 1 with the Iowa caucuses.
While Iowa has the distinction of being the first in the nation, to vote, the state has an up-and-down record when it comes to picking the ultimate nominee so don’t rush out and buy your bumper stickers on Feb. 2.
And don’t tell Iowa, New Hampshire, or South Carolina, but there are really two key dates on the primary calendar that don't involve those early voting states -- March 1 and March 15. March 1 is Super Tuesday, a date when 13 states hold their primary elections, the largest number of states on any single day in the election cycle. This year Super Tuesday’s importance is amplified because it includes Texas, a state that will have tremendous influence over the Republican nomination process.
March 15 is probably the most significant day because it features elections in Florida, Illinois, Missouri, North Carolina, and Ohio. It is difficult to be elected president if you do not win Florida and Ohio. Those swing states represent 29 and 18 electoral votes, respectively.
A complete listing of the primary schedule is below for your reference.
Once the two parties have completed the primary process, they will convene for the nominating conventions. The Republican National Convention will be held July 18-21 in Cleveland, followed by the Democratic National Convention July 25-28 in Philadelphia. At the conclusion of the conventions, the real fun starts with the general election.
The general election is a 100-day sprint to the finish line featuring four debates, hundreds of millions in campaign advertisements, and more political commentary than any person should be asked to endure.
The presidential debates are always important opportunities to measure the candidates against each other, so I would encourage you to watch. To assist you with your scheduling or DVR programming, the debates will be Sept. 26, Oct. 9, and Oct. 19. The vice presidential debate will be Oct. 4.
While the AAFP and FamMedPAC do not participate in presidential politics, we do participate in House and Senate races. Our involvement in the election and re-election of members of Congress is an important component of our multi-faceted advocacy program. Advocacy takes three forms: grassroots advocacy, professional lobbying, and political advocacy. Seldom do I ask things of you in this blog, but I do encourage you to support FamMedPAC. Your support allows family medicine to be better represented and therefore more impactful in our political advocacy efforts.
FamMedPac is nonpartisan in its support. We look at where candidates stand on issues that affect family medicine rather than at party affiliations. We work to elect -- and re-elect -- legislators who are willing to work with the Academy on those issues.
2016 Primary Schedule
- Feb. 1 -- Iowa caucuses
- Feb. 9 -- New Hampshire
- Feb. 20 -- Nevada Democratic Caucus, South Carolina Republican Primary, Washington Republican Caucus
- Feb. 23 -- Nevada Republican Caucus
- Feb. 27 -- South Carolina Democratic Primary
- March 1 -- Super Tuesday (Alabama, Arkansas, Colorado, Georgia, Massachusetts, Minnesota Caucus, North Dakota Republican Caucus, Oklahoma, Tennessee, Texas, Vermont, Virginia, Wyoming Republican Caucus)
- March 5 -- Kansas, Kentucky Republican Caucus, Louisiana, Maine Republican Caucus, Nebraska Democratic Caucus
- March 6 -- Maine Democratic Caucus
- March 8 -- Hawaii Republican Caucus, Idaho Republican Primary, Michigan, Mississippi
- March 15 -- Florida, Illinois, Missouri, North Carolina, Ohio
- March 22 -- Arizona, Idaho Democratic Caucus, Utah
- March 26 -- Alaska Democratic Caucus, Hawaii Democratic Caucus, Washington Democratic Caucus
- April 5 -- Wisconsin
- April 9 -- Wyoming Democratic Caucus
- April 19 -- New York
- April 26 -- Connecticut, Delaware, Maryland, Pennsylvania, Rhode Island
- May 3 -- Indiana
- May 10 -- Nebraska Republican Primary, West Virginia
- May 17 -- Kentucky Democratic Primary, Oregon
- May 24 -- Washington Republican Primary
- June 7 -- California, Montana, New Jersey, New Mexico, North Dakota Democratic Caucus, South Dakota
- June 14 -- District of Columbia
- Aug. 16 -- Alaska
Meaningful Use Hardship Extended
On Dec. 18, the House and Senate approved the “Patient Access and Medicare Protection Act” (S. 2425). This legislation included a provision granting CMS the authority to expedite applications for hardship exemptions from meaningful use stage 2 requirements for the 2015 calendar year.
Under current law, physicians were required to attest that they met the requirements for MU stage 2 for 90 consecutive days or face financial penalties. However, CMS failed to publish the modifications rule for stage until October 16, which failed to provide adequate time for all physicians to comply with the modified attestation requirement.
CMS has previously stated that it will grant hardship exemptions for 2015 if eligible providers are unable to attest due to the lateness of the rule. However, under current law, CMS can only grant such exemptions on a case-by-case basis. This case-by-case requirement would essentially prevent hundreds of physicians from gaining the hardship exemption.
A provision of S. 2425 grants CMS the authority to process requests for hardship exemptions to physicians through a more streamlined process, alleviating burdensome administrative issues for both providers and the agency. Physicians seeking a hardship exemption must apply prior to March 15. The AAFP will be working closely with CMS on the hardship process and will distribute information as soon as it is available.
Poll: Drug Costs Top List of Public's Health Care Concerns
Prescription drugs have emerged as one of the leading health policy issues for the 2016 election. Regardless of party affiliation, polling shows growing concerns about the costs and availability of pharmaceutical and biologic treatments.
An October Kaiser Family Foundation Health Tracking Poll found that the public's top two health care priorities for the president and Congress were:
- making sure that high-cost drugs for chronic conditions, such as HIV, hepatitis, mental illness and cancer, are affordable to those who need them; and
- government action to lower prescription drug prices.
Concern about medications for chronic conditions was mentioned by 77 percent of respondents (85 percent of Democrats, 75 percent of independents and 73 percent of Republicans), while the need for government action was cited by 64 percent (74 percent of Democrats, 60 percent of independents and 56 percent of Republicans).
It is interesting that 56 percent of Republicans think that the government -- yes, the government -- should take action to lower prescription drug prices. The bipartisan concerns demonstrate why the issue of prescription drug access and pricing has emerged as such a dominant political issue.
The contributions of the pharmaceutical industry to our country and the world are countless and indisputable. As a result of pharmaceutical and biologics we have eradicated diseases, turned what were once fatal diagnosis into chronic conditions, improved the quality of life for millions, and provided hope to those who face the most daunting challenges of their life. At this time of year, millions of people will be able to gather with their families for the holidays because of a pharmaceutical intervention. We cannot and should not overlook the value pharmaceuticals and biologics play in the delivery of health care.
We also should not overlook the simple fact that many pharmaceutical treatments are out-of-reach for a growing portion of the population -- even if they have insurance. Family physician Kyle Jones, M.D., recently wrote a blog on this specific issue and how costs of pharmaceuticals are hindering his patient population. We also should not overlook the impact escalating pharmaceutical costs are having on purchasers of health care, whether they are individuals, employers or governments.
The true costs of pharmaceuticals to individuals, employers, and government programs are honestly impossible to determine due to the variation in deductibles, co-pays, formularies, and other policies that influence the negotiated price of some products. However, it is possible to determine how much of the overall health care spend is devoted to pharmaceuticals and, not surprising, it is sky-rocketing. The CMS Office of the Actuary, in its recent report on health care spending, determined that increased costs associated with prescription drugs were a major driver of the overall increase in health care costs from 2013 to 2014. This impact was also outlined in a recent Wall Street Journal article, which showed spending on pharmaceuticals represents 10 percent of total health care costs.
The same article showed that pharmaceutical costs represent 19 percent of the costs for employers in their health insurance programs. To put this in perspective, the article notes that in-patient hospital care represents 23 percent of total costs for employers.
Finally, the impact on government health care programs is alarming. According to the Medicaid and CHIP Payment and Access Commission, (MACPAC) spending on pharmaceuticals in the Medicaid program increased 14.1 percent between 2013 and 2014 in non-expansion states and an alarming 24.6 percent in expansion states. MACPAC also found that significant increases in the costs of generic drugs.
The factors that determine the costs of pharmaceutical products are numerous and complicated. It is irresponsible to think that the costs are a simple factor of corporate executives maximizing return-on-investment. Well, for one executive that is exactly what they are doing (see Shkreli, Martin) but for the rest of the industry there are many factors that influence price with profit being one of those factors. Pharmaceutical companies may not always be pure of heart in the minds of some, but they do have to operate inside a complex and intertwined set of regulations and manufacturing standards -- which increase costs of production. They also must generate capital that can be invested in the next generation of pharmaceutical and biologic products. Without some level of profit, the ability to conduct research and development is limited, which results in a decrease in new discovery and new products.
One of the leading "cost-drivers" that continues to draw criticism is direct-to-consumer (DTC) advertising. DTC has always drawn the ire of some physicians, and it is rapidly becoming a policy issue that is drawing increased scrutiny from consumer advocates, physicians, and policymakers. According to Kantar Media, the industry spent $4.5 billion on DTC in the past year and has increased its DTC spend by more than 30 percent in the past two years.
The AAFP policy on DTC reflects the complexity of the issue. Our policy states that, "The AAFP supports efforts by manufacturers … to provide general health information to the public. At the same time, the AAFP urges that any direct-to-consumer advertising of prescription drugs … be based on disease state only, without mention of a specific drug by name." In other words, we see value in raising awareness, but we see detriment in traditional advertising tactics that drive consumer consumption.
Despite a high level of scrutiny, most legal experts believe that legal precedent has determined that such advertisements are protected speech and any such ban would violate the First Amendment. However, at the recent AMA Interim Meeting, a resolution calling for an outright ban on DTC passed with overwhelming support. The AAFP delegation, during reference committee deliberations, discussed the value of DTC in raising awareness among patients and caregivers, but in the end agreed with the intent of the resolution and supported its passage.
Although it may not be legal to ban DTC outright, there are examples of how DTC advertising is regulated in a manner that is adherent to the First Amendment, yet mindful of social responsibility. The most prominent examples are tobacco, firearms and alcohol. Each of these industries is allowed to advertise their products, but they all face restrictions on how, when and where they are allowed to do so. I would suggest that this model of regulation may have some applicability to the pharmaceutical industry.
Policymakers have proposed a variety of solutions to this issue ranging from allowing the federal government to negotiate prices in the Medicare program -- as it does in the VA and DOD programs -- to allowing the importation of drugs from Canada and other countries. There also is an increased focus on the appropriateness of one treatment versus the others, largely being driven by comparative-effectiveness research. Each of these solutions has merit, and they all face political challenges. The one thing that seems certain is that people are paying attention to the issue and are eager to identify ways to lessen the economic impact on individuals and payers. How remains unclear.
This is my last posting of 2015. As we conclude the year, I wanted to acknowledge the talented and hardworking staff at the AAFP. They work tirelessly and selflessly to make the health care system a better place for patients and for you, our members. I am proud to be their colleague and to have the opportunity to share with each of you their amazing work. So on behalf of the entire AAFP team, I wish each of you a happy holiday season and a healthy and prosperous New Year. 2016 will be a busy year! Rumor has it we get to elect a president!
Barriers Hindering Use of Telemedicine
The Jan. 17, 1960 edition of the comic strip Our New Age by Athelstan Spilhaus provided a glimpse into the future of technology in health care -- at least as envisioned by the scientist.
Although the comic strip did not coin the term "telemedicine," it did portray a future where a patient might have an encounter with a physician who was not physically present in the room with the patient. The comic strip reflects the country's fascination with science that existed in the 1960s, but interestingly, it does accurately capture a scenario where a patient receives a diagnosis and treatment plan from a physician without actually being physically seen by the physician. Today, we refer to this type of patient-physician interaction as telemedicine.
Historically, telemedicine has been viewed as a modality that could extend health care services to rural and frontier communities. This led to telemedicine primarily being used in one of three ways: remote monitoring, store-and-forward digital imaging evaluation, and consultation with specialty physicians. During the past decade, as technology has become more readily available and inexpensive, interest in expanding the use of telemedicine and other digital health platforms has grown among both patients and physicians. This increase in interest has led to corresponding increased interest among policymakers, payers, and regulatory agencies about how to regulate and compensate telemedicine in an evolving health care system.
The AAFP first established policy on telemedicine in 1994. This policy was modified and reaffirmed by the Congress of Delegates in 2010 and 2015. It reflects the value of telemedicine as a means of extending timely access to physicians, especially for those in underserved or rural communities. The policy also reflects concerns about the appropriate and ethical use of telemedicine and ensuring that telemedicine does not supplant a continuous relationship with a family physician.
The policy also expresses our strong support for adequate payment.
Sensing the growing interest in telemedicine, the AAFP's Robert Graham Center for Policy Studies in Family Medicine and Primary Care opened a research portfolio on the issue. During the past two years, the Graham Center has engaged in a comprehensive analysis of the views and opinions of family physicians about telehealth and telemedicine. The project, conducted through a funding partnership with Anthem, produced a report entitled: “Family Physicians and Telehealth: Findings from a National Survey.”
Here are the key findings of the report:
- Fifteen percent of family physicians have used telehealth in the past 12 months. The most frequent users were isolated rural practices (29 percent as compared to 11 percent in urban settings).
- Family physicians that use telehealth are more likely to practice in a rural location, be younger, have practiced for 10 or fewer years, and employ an electronic health record.
- Among users, the most common clinical uses were for diagnosis and treatment (55 percent), chronic disease management (26 percent) and follow-up with patients (21 percent).
- Barriers to using telehealth include the cost of equipment, lack of training, and the lack of payment for such services.
- There were some differences in opinions among users and non-users of telehealth. Specifically, 89 percent of users agreed that telehealth improves access for patients while 77 percent of non-users felt this was true. The most substantive differences between users and non-users were associated with patient preferences. When asked if patients prefer to see a physician in person, 94 percent of non-users said yes, while only 82 percent of users agreed with this statement.
- More than 85 percent of all respondents (users and non-users) agreed that they would use telehealth if they were adequately paid for such services.
The report summarizes the analysis as follows: "Overall, the findings of this survey confirm that family physicians see promise in the ability of telehealth to improve access to primary care services. The findings also suggest that telehealth is on the cusp of advancing from a tool used occasionally to a tool implemented on a routine basis. However, use of telehealth services will not become widely adopted until health systems are reformed to address barriers."
The Graham Center and Anthem recently received a Robert Wood Johnson Foundation grant to extend their collaboration and research on telemedicine. Results from this second study will be published in spring 2017 .
On Dec. 2, CMS released the 2014 National Health Expenditure Accounts. According to this report, in 2014, health care spending increased 5.3 percent breaking a five-year trend of lower than expected spending growth. Total spending on health care now exceeds $3 trillion and represents 17.5 percent of the gross domestic product. Per capita spending increased 4.5 percent to $9,523. Pharmaceutical spending increased 12.2 percent in 2014 accounting for $297.7 billion in total spend. Hospital spending increased 4.1 percent accounting for 971.8 billion in 2014, and physician and clinical services increased 4.6 percent accounting for $603.7 billion in total spends.
Although the spending numbers will garner the most attention, we should not overlook the fact that the number of uninsured individuals fell by 8.7 million, a decline of 19.5 percent. The percentage of the population that is insured now sits at 88.8 percent, the highest percentage since 1987.
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