Creating A Medical Home is About Improvement, Not Checking Boxes
My medical home has a first name, and it’s not NCQA.
Eight years ago this month, the AAFP joined with the American Academy of Pediatrics (AAP), the American College of Physicians (ACP), and the American Osteopathic Association (AOA) to publish the Joint Principles of the Patient-Centered Medical Home (PCMH). The Joint Principles were grounded in the AAP’s work on children’s medical homes established in 1967 and supported by the AAFP’s 2004 Future of Family Medicine project -- which called for every individual to have a medical home -- and ACP’s work to develop an “advanced medical home,” which started in 2006.
Through a process that originated in 2006, these four organizations developed a set of seven principles that described the characteristics of a PCMH. Those seven principles call for each patient to have an ongoing relationship with a personal physician in a physician-directed medical practice and team. The physician and the team are responsible for providing all the patients’ health care needs, coordinating care across all elements of the health care system, expanding access, and providing patient-centric care. The final principle states that payment should appropriately recognize the added value of PCMH to patients, caregivers and physicians.
The four organizations mentioned above, along with IBM, also founded the Patient-Centered Primary Care Collaborative (PCPCC), and the seven principles continue to serve as the North Star for that organization. The Joint Principles have been cited in numerous academic articles, the Congressional record and functioned as the substance of several state and federal laws and regulations. Furthermore, they are the guiding values of hundreds of PCMH programs run by insurance plans across the nation.
The PCMH, unlike other practice models -- such as managed care -- was created by physicians and not by others for physicians. The Joint Principles embodied an approach to the practice of medicine that many physicians had used throughout their careers. In many ways, the PCMH reflected how physicians wanted to provide care for their patients and not how someone else felt they should do so. It was organic and originated from the physicians who would ultimately practice in the model.
The enthusiasm surrounding the PCMH was palpable in the years following, and many family physicians saw the PCMH and the Joint Principles as the path forward to a better health care system focused on patients and supportive of physicians' sincere desires to “get off the hamster wheel.” The AAFP and our partner organizations were thrilled that the movement was based on a set of achievable characteristics that appealed to physicians in all practice settings.
In recent years, ownership of the medical home has moved from the physicians and physician organizations that created it towards the quasi-government agencies that recognize the practices. As a result, physician enthusiasm for the model has waned -- to put it mildly.
Third-party recognition is important if it is supported by a business case in your practice or local market, meaning there are payment incentives available. The Joint Principles contained a recommendation that “all practices should go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient-centered services consistent with the characteristic of the PCMH as articulated in the Joint Principles.” However, we never thought that this service would be provided only by, let’s say, the National Committee for Quality Assurance (NCQA). We envisioned a recognition process whereby an insurance plan or collection of insurance plans, a quality improvement organization, or a Medicaid program that was offering enhanced payments for PCMH would verify practice capabilities.
The AAFP remains agnostic on PCMH recognition programs. If you think your local market or practice business plan would benefit from recognition, then discuss with your local payers and/or pursue collaboration with any of the organizations that provide PCMH recognition programs such as the Accreditation Association for Ambulatory Health Care (AAAHC), URAC, the Joint Commission, or the National Committee for Quality Assurance (NCQA). The process of becoming a recognized medical home should be collaborative and focused on the characteristics of the Joint Principles. It should not be a collection of chart extractions, screen captures and checklists. It should be focused on practice and performance improvement. It should not be a product you purchase -- or repurchase every two or three years.
In short, don’t consider PCMH practice redesign and NCQA designation as synonymous. This line of thinking has taken a practice redesign and patient care model once celebrated by primary care physicians and turned PCMH into a dreaded phrase in primary care. I encourage every family physician to transform your practice based on the principles of the PCMH. And, you should consider third-party PCMH designation if that is beneficial to your practice, but please free yourself from thinking that NCQA recognition is the only organization that can recognize you as a PCMH because there are others.
The most important activity for family physicians is providing high quality care to your patients, and I believe that practice transformation consistent with the characteristics of the PCMH will help you in this endeavor by focusing your practice on process improvement, quality improvement, team-based and patient-centric care, and reform at a pace that benefits your patients and your practice. The AAFP has a variety of resources to assist you. Our approach is to meet you where you are and assist you in transforming at your own pace. The PCMH Planner is the perfect tool because it has a full complement of resources and allows you and your practice to move at a comfortable pace.
The Backbone of American Health Care: Serving Small Practice Family Physicians
One of the most common questions asked on this blog, and other AAFP mediums is, “what are you doing for small practices?” The answer is “a lot.”
The AAFP is committed to providing services and products to all family physicians, and the Academy strives to be your first and most trusted source for information and resources. Family medicine is a large and diverse discipline, and our goal is to meet your professional and practice needs, regardless of your practice size, type, location or employment status. Our members are all equally important to the AAFP, and we want to assist you in achieving professional success, so you can concentrate on delivering high quality care to the millions of patients you care for collectively.
The solo and small physician practice remains the bedrock of our nation’s health care system. Although much has changed, the presence of a family physician in communities large and small has remained consistent. Today, more than 70 percent of family physicians practice in groups of five or less. Although some of these physicians may be employed or integrated into larger delivery systems, they remain a solo or small group practice, striving to provide the highest quality of care to their patients.
Although change is inevitable, the volume and pace of change can be overwhelming. In the past decade, family physicians have seen the implementation of the Physician Quality Reporting System (PQRS) and numerous quality reporting programs operated by private payers; the establishment of meaningful use criteria that govern the way in which you must use your electronic health records to earn an incentive and avoid a penalty from Medicare;an explosion in prior authorization and appropriate use criteria programs; new requirements on physician authorization for diabetic supplies and durable medical equipment and more.
You have been asked to do this at the same time that you have seen revenue decrease as a result of a flawed Medicare physician payment formula and continued squeezes on payment by Medicaid and insurers. Each of you know the challenges of meeting these demands, suggestions, and mandates better than I. But I think it is important for you to know that we hear you, and the Academy is working hard to help.
Recognizing the importance of solo and small group physicians to our health care system and the numerous challenges these physicians face, the AAFP formed the Independent, Solo, Small Group Practice Member Interest Group. This group is an important voice for solo and small practices, providing insights and feedback to the AAFP on practice and advocacy issues. If you are a solo or small group practice family physician, or simply someone who supports the practice model, I encourage you to participate in this important group. Not only can you provide input to the AAFP but you can also share best practices with your colleagues who share similar issues and concerns.
In addition to the member interest group and our advocacy in Washington, D.C., and state capitols, the AAFP has amassed volumes of resources for solo and small group practices. You can find these resources on the AAFP’s practice management webpage. I also encourage you to utilize resources from Family Practice Management (FPM). These resources provide information and tools related to many of the issues facing your practice.
I would like to highlight resources the Academy has developed in five key areas: PQRS, meaningful use, practice management, ICD-10 and practice transformation.
Physician Quality Reporting System
There are two primary incentive/penalty programs for family physicians participating in Medicare -- PQRS and meaningful use. PQRS includes a bonus payment for eligible professionals who report data on quality measures for covered services provided to Medicare Part B fee-for-service beneficiaries in 2014. However, the program also implements penalties starting in 2015 for performance year 2013; potential penalties related to the 2014 performance year are effective in 2016. Time is running out to report 2014 PQRS data. You have until 5 p.m. EST on Feb. 26 to submit your 2014 data via the PQRSWizard referenced below. Doing so will help you earn a 0.5 percent bonus for 2014 and avoid a 2 percent penalty in 2016.
The Medicare Electronic Health Record (EHR) Incentive Program provides incentive payments to eligible professionals who demonstrate meaningful use of certified EHR technology. The cumulative payment amount depends on the year in which you began participating in the program. However, penalties will start this year for physicians who do not demonstrate meaningful use in 2015. Compliance with this regulation is one of the top concerns raised by solo and small group physicians.
Although the AAFP is working tirelessly to change the regulation to make it more achievable and less onerous, we recognize that you need assistance in meeting the requirements of meaningful use. The AAFP has compiled a menu of services and products aimed at assisting your efforts to avoid the penalties.
The PCMH Planner has an excellent module aimed at achieving meaningful use. For less than $100, you can receive top-shelf guidance on meaningful use 1 and 2, as well as a step-by-step guide to practice transformation.
One of the most important objectives for any practice, but especially small practices, is establishing predictable revenue. Although the most important step to achieving this goal is the elimination of the flawed Medicare payment formula and the sustainable growth rate, there are practice management resources that can help. The AAFP has developed the Five Key Financial Metrics online education modules to assist you in evaluating and establishing sound business practices for accounts receivable, accounts receivable greater than 100 days, adjusted collection rate, denial rate and average reimbursement rate. These online tools summarize steps you can take to improve the financial health of your practice.
FPM toolbox also is a tremendous resource for your practice. FPM has articles and tools on a variety of topics, including billing, collections, claims processing, financial management, coding and documentation, staffing and many other important topics.
Compliance with the upcoming ICD-10 requirement is a concern for all physicians, especially solo and small practices. The Academy supported delaying implementation of these codes, but we recognize the need to provide resources because the transition will become mandatory Oct. 1. The AAFP has several resources designed to provide guidance on this important and complex issue. Our ICD-10 resource page features free information and low-cost products and services to assist your practice in the transition to ICD-10. In addition, FPM has published 11 detailed articles about how to code with ICD-10.
Practice transformation and process improvement is another area where small practice physicians often feel overwhelmed. To assist practices, the Academy has developed a variety of services and products to help. Whether you are interested in becoming a patient-centered medical home, joining an accountable care organization, or transforming your practice into a direct primary care practice, the AAFP has resources to assist you in your practice transformation goals. Our objective is to provide you information and tools that allow you to move at a pace that is most suitable for you and your practice.
I want to thank those who remind me and the AAFP of the unique needs of solo and small group practices. Your messages drive innovation and motivate our team to identify, create, and distribute products and services that enable you to be successful in your practice -- no matter how big or small. I hope you now have a better understanding of the products, services, and resources we have that are designed to assist solo and small practices. Our staff has worked hard to make certain that we are meeting your unique needs. However, if there are other resources and tools needed, please let us know. We welcome your insights and appreciate your recommendations.
Finding a Way Forward, Together
I recently had the opportunity to join HHS Secretary Sylvia Burwell for a small event where she outlined the visions, goals and objectives of the department for the final two years of the Obama Administration in a speech entitled, “Common Interests; Common Ground – Finding a Way Forward, Together.” Although these types of speeches are common in Washington, D.C., this time of the year, the subject matter discussed was quite refreshing.
Burwell expressed a desire to identify areas of common interest with Congress and, as is noted in the title of her speech, “find a way forward, together.” She focused on goals that were achievable versus ideological, and she promoted issues that historically have had strong bipartisan support. She is not naive. She understands the political challenges presented by the Patient Protection and Affordable Care Act. However, she also understands that there is capacity for meaningful work to occur on health care issues while the political debate about the ACA continues. She framed her remarks in the form of an invitation or an open call to interested parties inside and outside the federal government to work with the administration on a set of common goals.
I was struck by the level of commitment the AAFP has made to each of the priorities articulated by the secretary. Family medicine remains at the forefront of innovation in science, medicine, quality improvement, patient engagement and health care delivery. We are the physician leaders that advocate for patients and drive change in our health care system. Although the specifics of HHS policy objectives may differ from those of the AAFP, the areas of focus are aligned. These are areas that beckon for policy and advocacy work as a means of improving our health care system and the health of our population. The goals articulated by the secretary focused on six large themes:
- Medicaid expansion;
- A health care system that’s better, smarter and healthier;
- Reducing substance use disorders and overdose deaths;
- Global health security;
- Leadership in science and innovation; and
- Building an innovation economy.
I would like to expand on four of these themes and share how family medicine is leading on each.
Today, roughly 70 percent of family physicians participate in Medicaid. With the exception of pediatricians, that level of participation is not seen by other physician specialties. Twenty-seven states and the District of Columbia have expanded their programs. The AAFP and our state chapters continue to advocate for the expansion of Medicaid in the remaining 23 states as a means of providing health care coverage to low income individuals and families. As I have stated many times in this blog, there are two common indicators of improved health for individuals -- health care coverage and a continuous relationship with a primary care physician, most commonly a family physician. The AAFP believes that there are many pathways to expanding Medicaid that promote greater access and protect the integrity of the program, while being flexible to account for variations in each state's population and health care needs.
The AAFP has numerous policy objectives aimed at improving Medicaid, specifically the need to ensure adequate networks of participating family physicians are available to Medicaid patients and that the program has a payment model that compensates family physicians fairly for services provided. We will continue to pursue these specific policy objectives with Congress and the administration while also continuing our work to expand access.
A Health Care System That’s Better, Smarter and Healthier
The AAFP has a long history of leadership in quality improvement as well as delivery and payment system reform. This commitment to a better health care system is as old as the discipline itself. This past year, the AAFP and the other family medicine organizations announced a major new initiative -- Family Medicine for America’s Health -- that is aligned with the goal of a better, smarter and healthier health care system. The work of the campaign will focus on six strategic objectives: practice transformation, payment reform, workforce development, improved technology, family medicine research and patient/caregiver engagement. We have already initiated conversation with the administration and Congress on this work, and we look forward to working collaboratively with them and state governments on this campaign during the next five years.
Reducing Substance use Disorders and Overdose Deaths
The challenges presented by substance abuse disorders and prescription drug abuse are far too common in our country. Family physicians are on the front lines of this health care and public policy issue. As the percentage of the population using powerful drugs for chronic pain and other conditions rises, so does the incidence of abuse and overdoses. The AAFP is actively engaged in finding solutions to pain management and prescription drug abuse problems. Our strategies can be found in our policy paper, “Pain Management and Opioid Abuse: A Public Health Concern.”
The AAFP also has made this issue a focal point of our advocacy efforts at the federal and state levels. This past November, the Academy hosted a discussion at our State Legislative Conference that brought together national experts to share strategies on how to best approach these challenging issues with legislators. We also have developed resources aimed at educating patients on the dangers of prescription drug abuse and how they can work with their family physicians to prevent or stop prescription drug abuse.
Global Health Security
This past year saw public health crises associated with respiratory virus, influenza, several antibiotic resistant bacteria and Ebola. The Ebola epidemic gripped our national attention and shed light on the importance of a strong primary care and public health system. Family medicine again was a leader for the public, physicians, elected officials and foreign aid agencies. Time magazine named the “Ebola Fighter” their 2014 Person of the Year. Family medicine should be proud that many of those recognized are your colleagues. Their contributions continue to have a positive impact on the lives of millions of people around the world.
Family physicians have always been at the front edge of public health crises, but this past year amplified just how committed family physicians are to this responsibility both domestically and internationally. In December the AAFP published a new position paper on the integration of primary care and public health. The paper recognizes the importance of strengthening community health infrastructure with a call to action to our members along with our public health colleagues.
A New Year, a New Congress and New Opportunities for Family Medicine
Happy New Year! Today marks the start of the 114th Congress. For the first time since 2006, Republicans control both the House of Representatives and the Senate. It also marks the final two years of President Obama’s administration.
If history is any indication, the combination of a divided government and a lame duck president may lead to more productivity than many are predicting as Republicans focus on demonstrating the ability to govern, and the President strives to solidify his legacy.
A lingering question for the AAFP is how will health care policy fit in these two distinct agendas?
It is important to remind ourselves that all activities in Washington during the next two years will be conducted with an eye on Nov. 8, 2016 -- the date of the next presidential election. As we prepare for the upcoming legislative session, I want to outline the Academy's advocacy priorities as a means to inform you about where the AAFP plans to focus its attention during the next two years and as an invitation for you to comment on other areas where you would recommend the AAFP focus resources.
To get us started I have created a top 15 list of priority issues:
- Physician payment (specifically primary care);
- Primary care workforce and graduate medical education reform;
- Delivery system reform and innovation;
- Electronic medical records and meaningful use;
- Health system financing, coverage and insurance reform;
- Medicaid expansion;
- Children’s Health Insurance Program reauthorization;
- Telemedicine, digital health and medical apps;
- ICD-10 implementation;
- National Health Service Corps reauthorization and funding;
- Administrative simplification;
- Network adequacy (Medicare, Medicaid, health insurance marketplaces);
- Social determinants of health and health disparities;
- Health care consolidation and antitrust issues; and
- Professional liability insurance reforms.
In addition to the list of issues, I wanted to expand on three important areas where the AAFP will be focusing significant resources on your behalf. These three items are routinely identified by our members and state chapters as the top advocacy priorities for family physicians. Although the information below is not exhaustive, it is a fair depiction of the top policy issues we have identified for the 114th Congress.
There are four priorities for the AAFP in this area: sustainable growth rate (SGR) formula reform, the Medicare Primary Care Incentive Payment program, improved Medicaid payment policies for primary care, and the establishment of a new payment formula for primary care.
Under current law, the Medicare physician payment rate will be reduced by 20.1 percent on April 1 unless Congress takes action to prevent this cut. It is highly anticipated that Congress will take the necessary steps to prevent this draconian cut, but it is unclear if legislators will attempt to enact long-term payment reforms prior to the 2016 election. The early line is that Congress will enact a 20- to 24-month extension of current payment rates in March and then make a run at permanent repeal of the SGR in November/December 2016.
The Primary Care Incentive Payment (PCIP) program was established by the Patient Protection and Affordable Care Act and provides a 10 percent add-on to eligible Medicare payments for qualifying physicians. The program is set to expire Dec. 31, 2015. This important policy has benefited thousands of family physicians and increased access to primary care for beneficiaries, and we are making its extension a top priority.
Medicaid parity payments ended Dec. 31, 2014. More than a dozen states have made a commitment to continuing the payment policy in 2015 at their own expense. We are pleased to see these states take such action, but we continue to believe that the establishment of an equitable primary care payment rate for the Medicaid program should be part of the federal mandate for states receiving federal matching funds.
Workforce and Graduate Medical Education
The AAFP has placed a priority on increasing the primary care physician workforce by expanding both the type and number of graduate medical education programs for family physicians. During the 114th Congress, we will actively seek to further establish the AAFP as the leading voice on primary care workforce and graduate medical education.
During a Capitol Hill briefing in September, the AAFP unveiled its GME reform policy proposal “Aligning Resources, Increasing Accountability, and Delivering a Primary Care Physician Workforce for America.” The proposal has garnered much attention and, along with the Institute of Medicine’s GME proposal, “Graduate Medical Education That Meets the Nation's Health Needs,” has challenged conventional wisdom on the issue of GME structure and financing. Since the release of our GME proposal, we have conducted numerous meetings with congressional legislators and staff and thought-leaders inside the administration and academia.
The AAFP will continue to advance policies that challenge the hospital-based GME system and place a greater emphasis on ambulatory training opportunities that are appropriately funded. A critical component of these efforts will be the reauthorization of the Teaching Health Center program, which expires in 2015. In addition to reauthorizing the program, the AAFP will be advancing policies that aim to establish a more predictable and robust funding mechanism for the program in contrast to the current funding formula which has proven inadequate to support it.
Electronic Health Records
The next two years will be critical to our national efforts to create and implement an interoperable electronic health records system. As the meaningful use program enters the penalty phase, more than 250,000 physicians can expect reductions in their Medicare payments due to their non-participation in the program. For those who are participating, the program is not proving to be a walk in the park. The program is fraught with problems and the “one-size-fits-all, check box, pass/fail and then get audited” style of MU phase 2 has most physicians anxious, if not angry. We are having ongoing discussions with the Office of the National Coordinator of HIT and the Congress on these issues. Although a solution isn’t yet available, we are hopeful that the MU program will be improved during the next 12 months.
A national, interoperable health records system should not be unobtainable, yet it remains so. Maybe 2015 will be the year that an industry that has benefited from $29 billion in government-backed purchasing power will reverse its epic failures and assist those who are trying to actually use their products for the betterment of patient care.
One of the unique aspects of our governing structure is that every two years we get to start over. Similar to an Etch A Sketch, we simply shake off the old and create a clean canvass for the next two years. As a new Congress begins, I hope each of you will continue to engage with the AAFP in our advocacy efforts. Share your thoughts and help us better meet your needs and expectations. In the meantime, I wish you a healthy and prosperous 2015.
AAFP's Advocacy Efforts Paved Way for New Care Management Code
Get to know these five digits – 99490 -- because they will be important to you and your practice and have the potential to be transformational to our health care system.
These five numbers are the new CPT code for the chronic care management service, which family physicians participating in Medicare will be entitled to bill for each eligible Medicare patient starting Jan. 1. This policy is a significant change in the Medicare physician fee schedule for family physicians and is reflective of years of advocacy work by the AAFP.
Family physicians have long argued that the most valuable services they provide their patients occur outside of the traditional face-to-face office visit. The variation and volume of these services have increased significantly as patients, especially those with multiple chronic conditions, live longer, more active lives, requiring more consistent interactions with their physicians, many of which do not require a face-to-face encounter with the physician. This increase in patient interactions has been facilitated by advances in technology that allow for asynchronous communication and the rapid transmittal of information between physicians and care sites.
Family physicians and their practices have always been defined by continuous and comprehensive care. In recent years, a third “c” was added to the list -- connected. Today, the delivery of continuous, comprehensive, and connected care is what family medicine is all about.
Through the 1990s and early 2000s, care management fees were viewed negatively by payers at all levels -- including the federal government. The concept of paying physicians for services provided outside of the face-to-face encounter was deemed of limited value. The AAFP ferociously disagreed with this line of thinking and aggressively moved to educate public and private payers on the value of care management services and how these services were essential to improving quality and lowering long-term costs.
As the health care system began to adopt advanced primary care delivery models, such as the patient-centered medical home, the value of care management became more apparent to those that previously viewed them with a degree of skepticism. Today, there is near consensus that care management by family physicians and primary care practices is essential to achieving higher quality care for patients. More importantly, there is consensus that these services must be paid.
In 2013, CMS first proposed paying for chronic care management services under the Medicare physician fee schedule. The inclusion of this new service in the fee schedule was largely a result of AAFP advocacy efforts.
CMS, through rulemaking, has established that the Medicare allowance for the chronic care management (CCM) service provided to an eligible patient will be approximately $42 for a calendar month. The payment is subject to Medicare deductible and co-insurance policies. Physicians will be allowed to bill the CCM code for services provided to Medicare patients with multiple chronic conditions that are expected to last more than 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/decompensations, or functional decline.
CMS is encouraging physicians to acutely focus on patients who have four or more chronic conditions but has established the eligibility criteria at two or more chronic conditions.
The AAFP has an excellent tool to assist with risk-stratified care management that will benefit you with the CCM code.
To receive the CCM payment, a family physician must collect a signed patient agreement, and the practice must provide at least 20 minutes of physician-directed, clinical staff time per month that aligns with eight performance elements:
- access to care management services;
- continuity of care;
- care management for chronic conditions;
- creation of a patient-centered care plan;
- management of care transitions;
- coordination with home and community-based clinical service providers;
- enhanced communication with patients and care givers; and
- electronic capture and sharing of care plan information via a certified electronic health records system.
The AAFP has created a variety of resources aimed at assisting family physicians and their practices. I urge you to read “Chronic Care Management and Other New CPT Codes.” This article will appear in the January/February 2015 edition of Family Practice Management, but it already is available online.
The AAFP also has created a Frequently Asked Questions document about the CCM benefit, a sample patient agreement/contract, a Medicare chronic care management service log, and patient-centered care plan template. These four resources were created to assist family physicians in securing the CCM payments and are available on the AAFP website.
Finally, please join the AAFP for a free webinar, “Getting Paid for Chronic Care Management Under Medicare in 2015,” on Jan. 27 at 1:30 p.m. Eastern.
This is the final In the Trenches for 2014. Thank you for engaging with the AAFP on our advocacy efforts during the past year. Your views, opinions, and suggestions make us better and allow us to focus our advocacy resources on those items that have the greatest impact on you and your patients. The next edition will publish on Tuesday, Jan. 6. I wish you and your families a wonderful holiday season and a prosperous new year.
Analyze This: Graham Center's Work Shows Value of Primary Care
The power of informed debate is something that is often overlooked and undervalued in our current political environment -- especially in health care where emotion can often override sound policy. The ability to evaluate policies, data, and trends is essential to the improvement of our health care system.
The need for such analysis is what led physician researchers such as Kerr L. White, M.D., to establish a field, as he described it, devoted to the “study of the relative benefits, risks, and costs of health interventions for individuals and populations.” Although the field of health services research has existed in some form for hundreds of years, its formal roots in the United States are largely tied to the establishment of the National Center for Health Services in 1968. Today, it is known as the Agency for Health Care Research and Quality (AHRQ) and remains at the forefront of the federal government’s efforts to "produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable."
The AAFP also recognized the importance of producing evidence that demonstrated the value of family medicine and primary care, and, its impact on the health of individuals and our health care system. In 1997, the AAFP Board of Directors approved the development of a Center for Policy Studies in Family Practice and Primary Care. The center, which is located in Washington, D.C., is charged with producing research and analysis that informs deliberations of the AAFP and its public policy work. It also provides the perspective of family medicine to policy debates in Washington and around the nation.
In 1999, the center began operations with a research agenda focused on "policy questions related to family physician services and the general domain of primary care." In 2000, the center was renamed, in honor of former AAFP Executive Vice President Robert Graham, M.D. This year the Robert Graham Center for Policy Studies in Family Medicine and Primary Care is celebrating its 15th anniversary, a milestone worth noting. During the past 15 years, the Graham Center has grown into a nationally recognized research center that is at the forefront of health services and economic research. It is a resource unique to family medicine, and we should celebrate its contributions to the advancement of family medicine and the betterment of health care policy.
Today, the Graham Center focuses its research agenda around four themes: the value of primary care; health access and equity; delivery and scope of the medical home; and healthcare quality and safety. Although the center has a broad and impactful research agenda, its contributions to physician workforce research is the cornerstone of its success. The center’s research on physician workforce has directly influenced policies at the federal and state levels and is the foundation for programs such as teaching health centers and rural training tracks. The center has published a state-by-state analysis of workforce projections that influences decisions made by state legislatures and governors and empowers family medicine advocates in all 50 states.
In recent years, the center has expanded its research portfolio to focus on issues that directly and indirectly impact the economic viability of family medicine practices. These research projects range from payment policies to analysis of new and emerging delivery models such as the patient-centered medical home and direct primary care. In the past year, the Center published an analysis on Blended Payment Models and Associated Care Management Fees. This document already is influencing public and private payment policies and is a tremendous resource that I encourage you to familiarize yourself with.
Although the research work of the Graham Center remains its highest priority, it is important to note that it also has emerged as one of the top incubators of the next generation of family medicine and primary care researchers through its visiting scholars and fellows programs. Since the inception of these two programs, more than 120 family medicine researchers have participated. This network of scholars includes individuals who now serve as leaders in academic and government institutions across the nation and around the world. Training future research leaders is an investment that will pay dividends for family medicine for generations to come.
The establishment of the Robert Graham Center was a forward thinking decision by the AAFP and indicative of the manner in which we continue to deploy resources in a manner that benefits patients, our members, the discipline, and our health care system.
Critical Issues at Stake for Primary Care in Lame Duck Session
I start this week’s posting with an urgent request. If you accept Medicaid in your practice and you do not want to see your payments for services provided to Medicaid patients slashed by, on average, 40 percent, I encourage you to take a few minutes today to send a letter to your representative and senators urging them to extend the Medicaid Primary Care Incentive Payment Program.
Unless Congress acts, Medicaid payment rates for primary care services will return to 2012 levels levels on Jan. 1, 2015. Please visit Speak Out and send a letter to your elected officials today. After you send your letters, please encourage your colleagues, friends, and neighbors to do the same.
On Sept. 29, the AAFP sent a letter to House and Senate leadership urging action on this issue. We continue to actively lobby legislators to extend this provision, but we need your help!
With the mid-term elections in the rearview mirror, the 113th Congress has returned to Washington to complete its work in what could be an eventful lame duck session. Although the lame duck session will be relatively short in duration, the days will be jammed with lingering legislative items needing attention. Besides the Medicaid payment policy outlined above, there are several other items on the AAFP’s year-end to-do list for Congress.
One of the most important things Congress must do is fund operations of the federal government. Prior to the elections, Congress approved a continuing resolution funding the government through Dec. 11. Now Congress must develop and pass funding to sustain government operations through the end of the fiscal year, which ends on Sept. 30, 2015. This process is complicated by the need for additional funding to support domestic and foreign efforts to combat the Ebola virus and evolving foreign policy issues.
The AAFP has several priorities in play that will be directly impacted by the appropriations spending bill. At the top of that list is financing for the National Health Service Corps and other primary care programs included in the Health Resources and Services Administration budget. Also, there are some concerns that funding for primary care research at the Agency for Healthcare Research and Quality could be in jeopardy. The AAFP is actively promoting the continuation and responsible funding for each of these programs. On Oct. 28 we joined more than 100 organizations in sending a letter to House and Senate leadership urging them to avoid the “primary care cliff” by preserving funding for these important programs.
For physicians, fall is once again the time of year when we wonder if payments will be slashed by a draconian funding formula that has haunted physicians for more than a decade -- the sustainable growth rate (SGR). In March, Congress enacted a short-term extension of Medicare physician payments, preventing scheduled cuts of more than 20 percent. This short-term reprieve expires on March 31, 2015. At that time, Medicare payments will be slashed by 21.2 percent unless Congress intervenes. I laid out a compelling argument for why Congress should act in the lame duck in a recent column for The Morning Consult.
The AAFP is aggressively lobbying Congress to act in the lame duck session to enact SGR repeal legislation, and this also is an issue that we could use your help with. Your elected officials need to hear directly from you regarding the negative impact the failed SGR formula is having on your practice and the patients you care for. I encourage you to engage with us in this advocacy effort by visiting our Speak Out page.
The Administration recently requested emergency funding for the domestic and foreign Ebola response. Although the amount of spending is still under discussion, it will be significant. The AAFP supports the increased funding which would improve our public health system and expand our capabilities to identify, isolate, and treat patients with infectious diseases such as Ebola. As an organization representing physicians who find themselves at the leading edge of public health, we view this funding as essential.
The next item on the AAFP’s to-do list is the confirmation of Vivek Murthy, M.D., as Surgeon General. The AAFP recently joined with other physician organizations to articulate why the Senate should act immediately to confirm Dr. Murthy. The health of our population is not a partisan issue, and our public health service is deserving of effective leadership, which Dr. Murthy would provide. The AAFP strongly supports his nomination and we are urging the Senate to act prior to adjournment to confirm Dr. Murthy.
On Nov. 1, CMS released the 2015 Medicare Physician Fee Schedule. This regulation establishes physician payment rates for the coming year and outlines several new policy changes within the Medicare program. The final regulation is painfully long, so the Academy has developed a manageable summary for family physicians. There also is a great AAFP News article that summarizes the major provisions of the final rule.
Less Than One Year to ICD-10; Will you be ready?
There are few topics in health policy that I am hesitant to discuss, but today’s topic is one of them. Lucky for me, there is probably an ICD-10 code for “scared to discuss ICD-10 codes, initial encounter.”
The International Classification of Diseases (ICD) coding system has been a part of our national health care system since 1979. Although the implementation of ICD-9 wasn’t without resistance, it was mild compared to the collective negative reaction received to ICD-10. ICD-10 is one of those issues that symbolize what many physicians consider to be the “over-regulation” of the U.S. health care system.
This collection of codes is fascinating to those that study and write about our health care system, but they are costly and of questionable value to those that actually provide patient care. In a world of “paying for value,” ICD-10 seems to miss the mark in the minds of most physicians.
So, how did we get here? The 43rd World Health Assembly endorsed the ICD 10th Revision in 1990, and limited implementation by some WHO countries began in 1994. In response to the WHO, the U.S. National Center for Health Statistics developed the ICD-10-Clinical Modification (ICD-10-CM) to ensure greater accuracy and clinical utility in 1993 and made the code set available in 1995. In 1996, the Health Insurance Portability and Accountability Act (HIPAA) was enacted into law. Included in that law were provisions that allowed for a standard code set to be established under the Administrative Simplification provisions of the law. In 2003, the National Committee for Vital and Health Statistics recommended to the Secretary of HHS that the United States move forward with adoption and implementation of ICD-10-CM and ICD-10-PCS (procedure coding system) under HIPAA standards.
The reaction by physicians and insurers was swift and negative. The sheer costs of implementation would be expensive and, in the minds of many, a complete disaster (not much changed from 2003 to 2014). Remember that, in 2003, the use of electronic health records (EHRs) was nascent, which made the transition to ICD-10 seem, well, impossible. The political pressure to prevent the transition to ICD-10 began to fade following the HITECH Act, which facilitated a broader adoption of EHRs in our health care system. As EHRs became more prevalent, the pressure to transition to ICD-10 intensified. On Jan. 5, 2009, the waiting finally ended when HHS announced that all HIPAA covered entities would be required to comply with ICD-10 on Oct. 1, 2014.
Although an implementation date was set, the opposition to ICD-10 did not subside. In fact, many physicians became even more concerned that the cost of implementing EHRs and ICD-10 would overwhelm their available resources.
The AAFP also was concerned with the impact such a transition would place on family physicians, but we were equally concerned about the ability of our nation’s health care system to shift to a new system. Our health care system isn’t exactly adept at large scale reforms, and ICD-10 is reform on an unprecedented scale.
On Feb. 25, 2014, the AAFP wrote a letter to then HHS Secretary Kathleen Sebelius outlining these concerns and calling for “end-to-end” testing of ICD-10 with an emphasis on solo and small group practices. As more time passed, the AAFP’s concerns grew more profound, and we called on Congress to delay implementation for one year to provide family physicians additional time to successfully make the transition. In April 2014, Congress agreed to delay implementation one additional year as part of the Protecting Access to Medicare Act of 2014, a larger physician payment bill.
Today, we have less than a year until the new, most dreaded, date of Oct. 1, 2015, arrives. Although the AAFP’s concerns remain, we realize there will be no more delays, and family physicians will be required to comply with ICD-10. Recognizing that our members need resources and assistance, the AAFP developed a number of valuable tools aimed at assisting you and your practice in the transition to ICD-10:
- Frequently Asked Questions on ICD-10
- ICD-10 Timeline, which is designed to assist you with budgeting, planning, communicating, training, implementing, and monitoring your transition to ICD-10.
- ICD-10 Cost Calculator to provide you a cost estimate on implementing ICD-10 in your practice.
- ICD-10 Flashcards, which provide a crosswalk between ICD-9 and ICD-10 codes for the 823 most common primary care diagnoses. They are color-coded for quick recognition and contain coding tips to assist in accuracy in coding. Purchasing these flashcards will be the best $79 you spend this year.
- ICD-10 Educational Series. This set of tools consists of 11 family medicine-specific modules developed by coding experts to assist you and your practice. The modules focus on the top-50 diagnosis codes in primary care. Each module is 10 to 20 minutes and can be viewed individually or with your practice team on your schedule.
In addition to these resources, Family Practice Management has compiled a collection of journal articles regarding ICD-10.
We continue to advocate for greater resources and testing from CMS. To its credit, CMS is listening and working with the AAFP to increase the availability of such resources. CMS has published “The Road to 10” toolkit, which is designed to assist small practices with the transition. In addition, they have announced three additional weeks of testing:
- Nov. 17-21, 2014,
- March 2-6, 2015, and
- June 1-5, 2015.
For more information on how you can participate, visit the CMS ICD-10 Provider Resource page.
It is incumbent on the AAFP to tell you that ICD-10 is going to happen, and we urge you to prepare your practice. We have numerous resources that can assist you and your staff, and we urge you to use them. In the end, we all can only hope that there is an ICD-10 code for “trauma caused by regulation, reoccurring event."
Physicians Are Directly Impacted by Government, so You Should Directly Influence Government
On Nov. 4, Americans will go to the polls to elect national, state and local officials. At stake are 435 seats in the House of Representatives, 33 in the U.S. Senate and governorships in 36 states. Clearly, these elections will have a profound impact on our country.
Politics and participation in the political process is probably best described as an uncomfortable necessity. The advancement of sound public policy is often dependent on successfully navigating the political process, and navigating the political process often allows for the advancement of sound public policy. Physicians, during the past two decades, have begun to see the value of active participation in the political process at both the state and federal levels.
In 2005, the AAFP established the Family Medicine Political Action Committee, better known as FamMedPAC. The AAFP realized that the absence of a collective voice for family medicine in the political process was hindering our ability to successfully advocate on behalf of patients and our members. This decision, while not easy, was the right one. The most successful advocacy organizations, regardless of industry, use a four-prong approach to their work -- lobbying, member advocacy, policy development/research and political advocacy. Each of these is important and complementary to the other three.
FamMedPAC is the AAFP’s political advocacy arm. It is the voice of family medicine and patients in the political process. FamMedPAC contributed nearly $400,000 to 100 congressional candidates: 58 Democrats and 42 Republicans in 2013. The PAC is nonpartisan, working to elect -- and re-elect -- legislators who are willing to work with us on issues that are important to family medicine. Many state chapters provide the same advocacy through state political action committees that represent your interests in state capitols.
Randy Wexler, M.D., M.P.H., Chair of the FamMedPAC Board, often says, “if you are involved in medicine, you are involved in politics.” I tend to agree -- with a twist. My version goes like this, “Your profession is directly impacted by government, so you should directly influence government.” An important way that you can directly influence government is through a collective voice of family physicians, best represented by FamMedPAC.
This important organization has been supported by nearly 7,000 family physicians since its establishment. During the 2013-2014 election cycle, FamMedPAC has engaged 128 members of Congress and senators on behalf of family medicine. I encourage each of you to consider participating in our political advocacy activities by supporting FamMedPAC.
Each of us, as individuals, decides who we vote for based on a variety of issues, personal beliefs, and desires for our country. Although I would never attempt to prioritize the criteria by which you should cast your vote, I do encourage you to include the viability of our health care system, your patients and your profession among the factors you consider when determining who to vote for next month. It is important that family physicians, as advocates for patients, voice our opinions through the electoral process. The ability to participate in our representative government is a hallmark of our democracy. I urge each of you to exercise this right and vote.
Remember this famous William E. Simon quote, “Bad politicians are sent to Washington by good people who don’t vote.”
Welcome to Washington, D.C.!
For those of you joining us this week for Congress of Delegates and/or AAFP Assembly, welcome! Washington -- which is home to the Academy's government relations office and the Robert Graham Center for Policy Studies in Family Medicine and Primary Care -- is one of the world’s most important and historic cities.
Washington often gets described in pejorative terms. Although the descriptions may apply to the work that takes place in D.C., they do not apply to the city as a historical destination. Washington is home to the U.S. Capitol, the White House, some of the world’s finest museums, the beautiful National Mall, and a number of monuments, statues and memorials that recognize our history. It also is home to a surprisingly vibrant food scene -- at all prices.
Here are 10 recommendations on how best to enjoy your experience in our nation’s capital:
- Don’t rent a car. The city is difficult to navigate, traffic is infuriating and parking will cost you $40 to $50 per day.
- Do walk. D.C. is one of those rare cities that can be easily navigated on foot. Bring comfortable shoes, discover a great city and burn some calories while you are at it.
- Do run or bike on the Mall. A morning run on the Mall will give you great views of the Capitol and monuments. You can rent bikes from a variety of places in the city. Ask your hotel where the closest spot is for you.
- Do ride the Metro. The Metro system is one of the nicest, cleanest public transportation systems in the world. You can take it anywhere in the city and surrounding counties and find yourself within a few blocks of almost any destination.
- Don't stand on the left side of the Metro escalators. Just remember, “walk left, stand right.”
- Don't try to hold the Metro doors open. They are not like elevator or other electronic doors, and they do not open when you stick your hand, arm, handbag, etc. between them. In fact, they will simply close on that item. Be safe, and wait for the next train.
- Do visit a museum. Washington is home to most of the Smithsonian Institute Museums. They are free and have generous hours. D.C. also is home to a number of private museums. I highly recommend the Newseum. Assembly Celebration on Friday will take us to four of the city's finest museums.
- Do visit the National Zoo. Besides being free, the zoo is a great place to go for a walk and see the animals.
- Don't eat every meal at the hotel. D.C. has amazing food options at all price points. Get out and enjoy some new culinary experiences. For the best ethnic food, drift towards the neighborhoods versus downtown. If you are up for a true D.C. experience, head to U Street, NW and Ben’s Chili Bowl. Take cash because they do not take credit or debit cards.
- Do walk by the White House at night. I recommend that you start at the corner of 15th and Pennsylvania streets and head west. You can circle the entire property in less than 30 minutes.
Put the Baseball Bat Down: What the AAFP is Doing to Address EHR Issues
There are few terms in the English language that solicit vitriol among physicians quite like “electronic health record.” Listening to physicians discuss their EHRs conjures up visions of the infamous scene in Office Space where a printer meets its doom at the hands of three employees who have endured its incompetence. Although it may not be practical for a physician to take a Louisville Slugger to his or her EHR, it does not stop them from fantasizing about it.
How we got to this point is complicated. I am old enough to remember the massive file cabinets in a physician's office containing thousands of paper medical records. I also am old enough to remember writing paper checks to pay my bills. These two industries -- medicine and banking -- have had completely different levels of success with implementing information technology and data sharing during the past 20 years. The banking industry moved to accelerate the use of information technology and data sharing technologies, rendering paper checks (and many a bank teller) obsolete. Transactions can be made electronically in real time. As a result, many of us have not written a check in years.
In comparison, the health care industry was caught flat-footed and resisted the technology wave of the 1990s and early 2000s until practices and health care systems were forced by law and regulation to change. Many practices still use paper-based charts or non-interoperable electronic health records that are, in reality, an electronic equivalent of paper charts.
Recognizing the emerging role of information technology in health care and the potential benefits to patient care, the AAFP established the Center for Health Information Technology (CHIT) in 2003. CHIT was a commitment by the AAFP and family medicine to the transformation of our health care system to one that was better aligned to deliver high quality and continuous care. CHIT provided a platform to achieve true care coordination and population health management in the average family physician office and not just in the large integrated systems. The Academy was easily the first physician organization to establish a team of individuals charged with EHR policy and advocacy, and our leadership role continues to this day.
In 2004, President George W. Bush created the Office of the National Coordinator of Health Information Technology and called for the “widespread adoption of electronic health records in 10 years.” Despite investing more than $100 million in federal funds in demonstration projects, little progress was made. In 2009, Congress intervened and forced health care into the technology era when it enacted the Health Information Technology for Economic and Clinical Health (HITECH) Act. This six-year, three-phase program set aside $19 billion in federal money to facilitate the adoption and implementation of EHR systems in hospitals and physician offices by 2017 through the so-called meaningful use program.
To date, federal and state governments collectively have paid more than $24 billion in incentive payments to hospitals, physicians and other health care providers.
We are now at the 10-year mark established by President Bush, so what is the current state of play? Sadly, the state of EHRs and HIT in general is, well, not positive. Some would call it an epic failure (pun intended). How we move forward is critical to the success of our health care system, the quality of care delivered to patients, and the AAFP remains at the forefront of these efforts.
Today, more than 68 percent of family physicians use an EHR -- a participation percentage that dwarfs other physician specialties. However, as previously stated, most physicians have a hate-hate relationship with their EHR and view the systems as a burden on their practice of medicine. The AAFP, like most of you, is concerned about the lack of intuition and interoperability in the current EHR systems. We also are concerned that EHRs have become a financial drain on practices, the root-cause of frustration for physicians, and a contributor to decreasing productivity in practices of all sizes. We are especially frustrated that EHR vendors, insurers and governments have not addressed these concerns in a meaningful way, so we are ramping up our advocacy efforts to create change.
The following is a few of the many resources and advocacy activities the AAFP has pursued to assist our members:
- We have a webpage devoted to assisting you in the evaluation, purchase, and implementation of an EHR system. We have partnered with other medical societies to create additional resources through www.americanehr.com.
- We have re-constituted the CHIT into the Alliance for eHealth Innovation. The Alliance will continue its work to influence EHR and HIT policies, and it will also work more aggressively with vendors to create EHR systems that are congruent with a physicians’ workflow and practice processes.
- We are investing staff resources into workflow and EHR design to better align technology solutions with a physician's practice. This is a priority for the AAFP, and you will be hearing more on our efforts in this area over the next few months.
- We have written numerous letters to CMS calling for improvements to the meaningful use program to ensure that family physicians can qualify and thus avoid the penalties associated with non-compliance.
- We have called for a delay in the implementation date of meaningful use stage three until 2017.
- In April, the AAFP wrote a letter to the Federal Trade Commission on a number of issues impacting the health care marketplace, one of which is our growing concern with the anticompetitive behavior of health information technology vendors that reduce access to patient health information and create silos in care delivery.
We recognize that many of you continue to struggle with your EHR systems. And although the kind of retaliation so artfully visualized in Office Space is fun to think about, we urge you to be patient and work with us to improve our nation’s information technology system. Health care must follow the banking industry and the rest of our economy into the technology era. It won't be easy, but we continue to believe that an interoperable health information system will be beneficial for patient care, population health, and, ultimately, physician productivity.
GME: IOM Report Shines a Light on a Flawed System
It has been well documented that our nation faces a shortage of physicians, especially primary care physicians. Although there is agreement that our nation needs more physicians, there is disagreement on how to best educate and train a physician workforce capable of meeting the health care needs of the nation. What is clear, in the opinion of the AAFP, is that any attempt to simply expand our current system of graduate medical education (GME), will only produce more of the same and do little to meet the health care needs of our citizens.
Our nation has long recognized the value of supporting GME, and the first federal investment came in 1944 as part of the G.I. Bill. The most important step, however, occurred in 1965 when the United States committed to a stable source of funding for GME through Medicare. During the next 49 years, there have been legislative adjustments to our GME system, but until recently there had never been a comprehensive analysis of the program’s purpose and effectiveness. The good news is that this is starting to change as a result of efforts from the AAFP and like-minded organizations.
During the past three to five years, a national discussion about the current and future physician workforce and the process by which we train physicians began. The AAFP has been at the center of these discussions, which have led to an increased effort to research, analyze and ask some thought-provoking questions about the structure, governance and financing of our GME system. These activities have come from the AAFP, the U.S. Congress, foundations, think tanks, health services researchers and government advisory bodies such as the Medicare Payment Advisory Commission, the Council on Graduate Medical Education, and most recently, the Institute of Medicine (IOM).
On July 29, the IOM released its long-awaited report “Graduate Medical Education That Meets the Nation’s Health Needs.” This report was encouraged by several academic organizations, but a 2011 letter from seven senators requesting a study of GME and its financing was the catalyst to the IOM taking on this important issue.
The IOM report focused much of its attention on the relationship between GME financing and hospitals' priorities in physician training. The report notes that “giving funds directly to teaching hospitals, the payment system discourages physician training in the clinical settings outside the hospital where most people seek care. Primary care residency programs are at a distinct disadvantage because of their emphasis on training in ambulatory settings. Hospitals’ control over the allocation of GME funds may also encourage the overproduction of specialists in disciplines that generate financial benefits for an individual institution rather than for the health care system overall.”
The report also questions the validity of proposed policies that would expand the overall number of funded GME positions by stating that “the available evidence suggests that increasing the production of physicians is not dependent on additional federal funding.”
Finally, the IOM report discusses the inherent inequities in the geographic distribution of GME positions and funding. Today, 65 percent of the nation’s residents and fellows (74,195) are trained in 12 states, and 78 percent of all residents and fellows (88,736) are trained in a state east of the Mississippi River.
The IOM report includes five recommendations on how to improve the GME system:
- Maintain Medicare GME support at the current aggregate amount while taking essential steps to modernize GME payment methods based on performance, to ensure program oversight and accountability, and to incentivize innovation in the content and financing of GME. The current Medicare GME payment system should be phased out.
- Build a GME policy and financing infrastructure.
- Create one Medicare GME fund with two subsidiary funds.
- Modernize Medicare GME payment methodology.
- Medicaid GME funding should remain at a state’s discretion. However, Congress should mandate the same level of transparency and accountability in Medicaid GME as it will require under the changes in Medicare GME herein proposed.
The report has been met with mixed reactions in the health care community. Many of the nation’s academic health centers, colleges of medicine and hospitals issued negative statements, essentially stating that the recommendations of the IOM would destroy our nation’s GME system. Of course, we must be mindful that most of those expressing the strongest opposition are the ones that benefit most from the status quo. Overall, the AAFP is pleased with the content and direction of the report. Although we would prefer more immediate actions, the IOM report closely aligns with the AAFP's view of what comprehensive GME reform should accomplish.
As noted, the IOM report has opened communication channels, and a robust discussion on GME reform is occurring in Washington, D.C. The AAFP is seizing this opportunity, and on Sept. 15 we released “Aligning Resources, Increasing Accountability and Delivering a Primary Care Physician Workforce for America." You can read more about the Academy's proposal in a recent AAFP Leaders Voices Blog post by AAFP Board Chair Jeff Cain, M.D., and in AAFP News.
Although recent activities are encouraging and support the AAFP’s policy and advocacy objectives, change will not come independent of resistance. The American Hospital Association, in response to the IOM recommendations, stated that “cuts to GME funding would jeopardize the ability of teaching hospitals to train the next generation of physicians. They would limit the ability of teaching hospitals to offer state-of-the-art clinical and educational experiences.” The association went on to state that “reductions in the IME adjustment would directly threaten the financial stability of teaching hospitals.”
At least they are honest. The key words in these sentences are “state-of-the-art” and “financial stability.” GME has been and continues to be a revenue stream for hospitals, not an education mission. We must shine a light on the shortcomings of our GME financing and governance structure, and the AAFP is just warming up its spotlight.
Changing Times, Changing Relationships?
One of the most important jobs the AAFP has is to analyze innovations in an effort to influence the future of health care delivery and its financing structure. Currently, there is not an issue more difficult to analyze than retail-based clinics.
The emergence of retail clinics can easily be viewed as innovative and responsive to consumer demand and, simultaneously, disruptive to a well-established health care market and the high quality of care that comes from longitudinal care models.
During the past few years, the AAFP has been engaged in meaningful conversations with the large companies that offer retail clinics about how family physicians and such clinics can, potentially, work together to improve access to health care for individuals in their communities.
To be clear, not all retail clinics are the same, and the AAFP does not view them as a homogenous industry. There are clear differences between the various business models. The challenge for each of us is to ensure we do not view every retail-based clinic through the same prism. The AAFP’s policy on retail clinics makes it clear that we do not support retail clinics providing continuous care to patients with chronic conditions. The policy also expresses, rightfully so, concerns that retail clinics may further fragment care delivery. However, our policy also expresses some belief that there is a potential role for retail clinics in the health care team or neighborhood, and this is what needs greater analysis.
Again, not all retail clinics are the same. There are clinics that are solely attempting to create a disruption in the marketplace and sell consumer products, but there also are companies that are serious about partnering with family physicians to create community delivery models. We need to identify the latter for collaboration and communicate with the former to better influence their business models.
Our motivations are multiple, but here are three primary reasons we are seeking potential collaborations:
- It is time that we acknowledge the existence, contributions and even the potential benefits of retail clinics to patients and family physicians. We can't pretend that retail clinics do not exist, nor can we legislate or regulate them out of business. According to the Convenient Care Association there are 1,500 retail clinics operating in 40 states and Washington, D.C. The impact of these clinics on the primary care system is unknown, but our observations are that the clinics are having a minimal impact on the family physicians in the communities where retail clinics are co-located. Additionally, there are several examples of collaboration that have expanded access for patients.
- Retail clinics may be complementary to family physicians through expanding community delivery partnerships that will enhance a practice's service to their patients and align retail clinics more closely with family physicians in their communities. The use of retail clinics as a part of the patient-centered medical home neighborhood holds great potential for patients and physicians. According to a 2012 RAND Special Feature: "Retail Clinics Play Growing Role in Health Care Marketplace," 44 percent of care provided in a retail clinic takes place at a time when physician offices are typically closed (nights and weekends). Furthermore, RAND notes that 43 percent of individuals seeking care at a retail clinic are between the ages of 18 and 44 (young/healthy). These two data points alone clearly define the demographic factors driving expansion of retail clinics -- young people seeking expanded access that is convenient to them and their family’s personal and professional schedules.
- As fee-for-service becomes a less dominant payment model, the economic pressures of “who provides” will be replaced by “is provided.” An Accenture report entitled "Retail Medical Clinics: From Foe to Friend?" notes the potential benefit of retails clinics to primary care physicians: “As the shortage of PCPs (primary care physicians) relative to demand continues to grow, one option for physicians will be to refer lower acuity cases to retail clinics. In addition to providing additional supply, the clinics would also leave PCPs free to deal with more complex cases, with correspondingly higher reimbursement.”
Although we can’t say with certainty that this scenario is achievable in all occasions, we do agree with Accenture that retail clinics, working with family physicians, can improve care delivery models in communities where they collaborate.
Since the concept first emerged onto the national scene in the late 1990s and early 2000s, retail clinics have been a source of controversy in many communities and a source of improved access and quality in others. Physician organizations were slow to acknowledge and analyze the economic and demographic drivers fueling the expansion of retail clinics. From a market perspective, retail clinics identified a gap in service and created a product to fill that gap. In blunt terms, they noticed that the delivery system was not always patient-centric and, in many cases, was unavailable to certain individuals.
The resistance to retail clinics expressed by the AAFP and other physician organizations during the past 15 years was appropriate. However, it has not impacted their rapid expansion. Is it time for a change? Can retail clinics contribute to the continuum of care for patients? These are important questions, and the AAFP is pursuing answers.
Bringing You Up To Date: New Information on Previous Posts
It's been a little more than two months since the AAFP launched this blog to provide members with timely information on health policy matters and what the Academy is doing on your behalf to address those issues. This edition of In the Trenches will take a look back at our initial posts and provide updates on the work we have conducted, relevant new tools and resources that are available, the advocacy wins we have secured and ways that we can collaborate to improve our ailing health care system.
Direct Primary Care
In our first blog, we introduced you to the AAFP’s work on direct primary care. This work continues, and the AAFP will offer three practice development programs on DPC this fall and winter. The first program will be held Nov. 8 in Tempe, Ariz.; followed by programs on Jan. 10 in New Castle, Del.; and Feb. 25 in Atlanta. You can learn more about these programs and register on the AAFP website.
Medicaid Parity Payment
On July 1, we discussed the work AAFP is doing to extend the Medicaid parity payment policy established by Section 1202 of the Patient Protection and Affordable Care Act. Those efforts are producing results. On July 30, Sens. Sherrod Brown, D-Ohio, and Patty Murray, D-Wash., introduced the Ensuring Access to Primary Care for Women and Children Act (S. 2694), legislation that would extend the payment policy for two years.
The AAFP supports this legislation and has communicated our support in a letter. We are engaged in an active grassroots campaign to build support for this legislation, and we could use your help. During the Labor Day weekend, please take a few minutes to Speak Out and send a letter to your senators urging them to support S. 2694. Ask your colleagues to do the same.
In our July 15 posting, we discussed the vast challenges at the Veterans Health Administration and our work to provide expanded access to veterans. As noted in that blog, the AAFP was the first physician organization to call on the Obama Administration and Congress to make fundamental changes that would allow civilian family physicians to provide care to veterans. As a result of our letters and lobbying efforts, Congress included provisions allowing expanded use of civilian primary care physicians in the VA health care system.
On August 7, President Obama signed into law the Veterans’ Access to Care Through Choice, Accountability, and Transparency Act. On August 13, the Veterans Administration announced that is expanding the Patient-Centered Community Care contracts as a means of expanding access to primary care services and reduce wait times. You can learn more about the PC3 program and how you can participate through the Department of Veterans Affairs. This law authorizes the Secretary of Veterans Affairs to create 1,500 new graduate medical education positions and instructs the Secretary of Veteran Affairs to place a priority on creating new primary care and mental health residency positions. The AAFP actively lobbied for these new positions, and we are pleased that Congress responded.
Home Sweet Medical Home
In my previous post, I shared with you the advocacy work the AAFP was doing with respect to patient-centered medical home (PCMH) recognition programs. Now I want to share with you information on the work we are doing to assist physicians with the transformation process and what tools and resources we have created for you and your practices.
The AAFP has long recognized that the PCMH transformation process may be more difficult for solo and small practices. These practices face challenges on at least two levels -- time and money. Solo and small practices often lack the staffing necessary to aggressively transform their practices and implement the full cadre of services outlined in the Joint Principles of the Patient-Centered Medical Home. They also lack the financial capital to make investments in staff and technology that would facilitate this transformation more rapidly. This is not meant to suggest that a solo or small practice cannot become a PCMH -- many have done so -- only an acknowledgement that it can be more difficult for them.
To assist these practices, we developed the PCMH Planner, an online, “do-it-yourself” tool that allows a practice to conduct a self-evaluation of its capabilities and start, or continue, progressing in its transformation to a PCMH. The Planner was researched and written by PCMH subject matter experts and provides practices with easy-to-follow, step-by-step work plans and links to downloadable tools and resources. This resource is available to AAFP members at a rock-bottom price and allows for multiple users from the same practice. No matter where you are in your journey -- evaluating the merits of practice transformation, just getting started, or well on your way -- I strongly encourage you to purchase the PCMH Planner. I am confident that you will find it valuable to your efforts.
For those practices that require additional assistance, you can contact TransforMED,the Academy's wholly owned subsidiary. TransforMED has a distinguished record of helping practices with transformation and is widely recognized as a national leader in this area. TransforMED’s services will require a financial investment on your part, but the outcomes should produce an appropriate return on your investment.
Home Sweet Medical Home
Since the creation of the Patient-Centered Primary Care Collaborative and the Joint Principles of the Patient-Centered Medical Home, in 2006 and 2007, respectively, we have seen a steady growth in the implementation of the PCMH in primary care practices. According to the 2013 AAFP Practice Profile Survey, 26 percent of family physicians report being in a recognized PCMH and 10 percent report that they have an application for PCMH recognition submitted and pending.
We also have seen an explosion of PCMH programs in health care systems, both public, and private. Today, most major insurance companies have implemented the PCMH at some level. The PCMH was included in the Affordable Care Act, and as of June 2014, 47 states that have adopted policies and programs to advance medical homes in their Medicaid programs, and 30 states are making advanced payments to medical homes within their programs. The growth is something to be proud of, but we also recognize that many challenges must be overcome if we are to realize the full potential of the PCMH.
One complaint that we hear frequently is the difficulty and complexity of the recognition process. There are several organizations that have PCMH recognition programs -- NCQA, URAC, AAAHC, Joint Commission -- and there also are many state and insurance company-sponsored recognition programs. Although the AAFP is agnostic on these programs, we do recognize that NCQA is the dominant player in this market, and a majority of our members have chosen to participate in the NCQA PCMH recognition process. We continue to advocate among all of the recognition programs for standards that meaningfully represent the most important and effective principles of the PCMH and for application processes that are less cumbersome for family physicians.
The Academy recognizes that there is value in PCMH recognition, and such validation of practice capabilities is central to our advocacy efforts for increased payment for PCMH practices. Simply put, practices need to demonstrate transformation and the resulting improvements in processes and outcomes, not simply declare that they are doing so. However (and this is a big however) these recognition programs need to add value to patient care, be measurable, and most importantly be meaningful. This is where the AAFP is working hard on your behalf.
The AAFP met recently with representatives of NCQA to discuss its PCMH recognition program. We expressed several concerns along three major themes:
- Cost -- The AAFP continues to be concerned that recognition programs are placing undue financial strain on practices. According to the 2013 AAFP Practice Profile Survey, 22 percent of family physicians found the expense of the PCMH recognition programs to be a substantial barrier. The costs are both the actual fee for the service, and the financial costs to the practice in the form of human resource allocations and lost revenue due to time spent away from patient care while completing the application. We also continue to express concerns that new forms of the recognition products are solely aimed at securing additional business and fees with little to no meaningful impact on the practice or patient care.
- Complexity -- The AAFP thinks that all recognition programs are overly complex. The Joint Principles included seven items, yet the NCQA process has more than 100 metrics -- this is a disconnect to put it kindly. According to the 2013 AAFP Practice Profile Survey, 54 percent of family physicians’ found the data and documentation requirements for PCMH recognition to be a substantial barrier, and 46 percent said the staffing demands to complete the application presented a substantial barrier. The AAFP continues to advocate for changes in the recognition process that place a greater focus on those key elements that have are demonstrable to improved patient care.
- Efficacy -- The early results on the efficacy of the PCMH are positive, but there are several studies that have raised some meaningful questions, particularly about the efficacy of the NCQA process. The PCPCC published a comprehensive analysis of PCMH programs nationwide. The Medical Home's Impact on Cost & Quality: An Annual Update of the Evidence, 2012-2013 clearly shows that the PCMH has been effective in reducing the overall costs of health care in some key areas and is improving the quality of care – especially for those patients with multiple chronic conditions. The AAFP continues to believe that the PCMH is impactful and will improve quality and lower the overall costs of health care as demonstrated in the PCPCC study, but there are areas that lend themselves to improvement in the PCMH transformation and recognition processes.
We will continue to work with the NCQA and others on refining and improving their recognition programs, especially in those areas outlined above. To their credit, the NCQA and others have been receptive to our concerns and open to our recommendations.
PCMH transformation is challenging and takes time (up to two or three years for some practices) and the benefits take even longer to realize. This is a work in progress and we applaud those practices that have taken on the hard work of transformation and continuous quality improvement. Today there are more than 500 PCMH initiatives or incentive programs nationally. This movement is growing and the foundation for both ACOs and future opportunities for value-based payment. The Academy wants family physicians to be positioned for success in the future health care environment.
We're Not Gonna Take It: Network Optimization Disrupts Continuity of Care
Hundreds of family physicians recently have been informed that they are no longer eligible to provide care to patients covered by certain insurance policies. Sadly, most of these physicians were not notified directly by insurers. Instead, patients told the affected physicians that they received a letter stating that their family physician is no longer covered by their insurance plan. These patients and their family physicians were not given any justification why these actions are being taken. They were only given a date on which their relationship would be terminated. These patients are rightfully upset, their family physicians are mad, and the AAFP is taking aggressive action.
To quote the 1980’s rock band Twisted Sister, “We’re not gonna take it.” Last week, the AAFP wrote letters to America’s Health Insurance Plans (AHIP) and United Healthcare notifying them of our concerns and urging them to take a more responsible approach to the formation of their provider networks – especially with respect to primary care physicians.
We also wrote a letter to CMS Administrator Marilyn Tavenner, M.A., expressing concern with actions taken in Tennessee with respect to TennCare, the state’s Medicaid program. TennCare, operated by UnitedHealthcare Community Plan, recently informed hundreds of individuals that they would need to change primary care physicians or face higher out-of-pocket expenses for their health care.
In addition to these letters, we are meeting with representatives from the insurance industry as well as individual plans to identify ways to curb the negative impact of these decisions. We also are working closely with state chapters to draft letters to governors and state insurance commissioners questioning the legality and purpose of such actions.
Our recent actions are in addition to the "friend of the court" brief the AAFP joined, along with several other medical societies, in support of two Connecticut medical associations that sued United Healthcare in 2013, challenging its actions to summarily “dump” more than 2,000 physicians from its Medicare Advantage network in the state of Connecticut.
Although the practice of “network optimization” is not new, the disruptive manner in which it is being executed is troubling to the patients, their family physicians and the AAFP. Fearing that insurance companies may tighten networks -- similar to health maintenance organizations in the 1980s and 1990s -- Congress included in the Affordable Care Act provisions that require insurance plans participating in the Health Insurance Marketplaces to provide an “adequate” network of physicians and hospitals. The compelling criteria are that insurance plans include a “choice of providers” and that networks include “essential community providers.” The National Association of Insurance Commissioners (NAIC) has a great paper on network adequacy that provides an excellent overview of the issue.
The AAFP is deeply concerned with actions being taken by insurance companies. Decades of peer-reviewed studies have shown that there are two factors that contribute to better health outcomes for individuals – health care coverage and a usual source of care. We also know from research that patients that have a continuous and longitudinal relationship with a primary care physician have better health care outcomes at lower costs than those who do not have a continuous relationship with a primary care physician.
The AAFP has evidence that thousands of patients, in multiple states, are being told that they must identify a new family physician in the next few months as a result of their family physicians being dropped from certain insurance products as a result of insurers optimizing their provider networks to better align resources. Many of these patients will have years' long relationships with their family physicians terminated in the name of efficiency. These actions are tremendously disruptive to a physician practice, but we are most concerned with the disruption patients face as they are told to change primary care physicians without any input in the decision – not to mention the lack of an appeals process in many cases. These patients face intrusive disruptions in their care and an uncertain future as a result of these actions.
We recognize that insurers have a responsibility to align networks of physicians and hospitals to maintain affordable premiums while ensuring quality and efficiency, but we feel that disruptions to the patient-physician relationship at the primary care level are contrary to both of these goals. Primary care is relatively inexpensive as compared to specialty or hospital care. It also benefits from continuity and trusting relationships. We are baffled by the language used by insurers who say they support patients having a continuous relationship with a primary care physician and then act in a way that make this impossible. In short, we are no longer flattered by insurers’ language that speaks to our policy goals but are demanding action that aligns their public comments with their actions in the health care market place.
If you have received a letter from an insurance company notifying you that you or your practice is being dumped -- oh, excuse me, “optimized out of network” -- please notify your AAFP chapter. We are in close contact with the chapters on this issue, and it benefits our efforts to organize actions by states and regions.
The Congressional Budget Office (CBO) has released its 2014 Long-Term Budget Outlook and predicts that the Independent Payment Advisory Board (or IPAB) created under the Affordable Care Act will not go into effect for the next 10 years due to a slowing in overall Medicare spending. IPAB, in concept, is a 15-member panel tasked with achieving specified savings in Medicare if spending growth exceeds a set target. They are not allowed to negatively impact benefits, coverage or quality – meaning they can only cut payments. The controversial panel has yet to have any members appointed to it, and its funding was cut by $10 million in the most recently enacted spending bill.
Jonathan Easley at Morning Consult wrote a great explanation on the politics of IPAB.
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