Maximizing MACRA for Family Medicine
"The pen is mightier than the sword." – English writer and politician Edward Bulwer-Lytton, 1839
In the past two weeks, the AAFP has submitted more than 60 pages of comments and recommendations on the delivery system and physician payment reforms outlined in the Medicare Access and CHIP Reauthorization Act (MACRA) (Public Law 114-10). Optimistic that the phrase made famous by Bulwer-Lytton 176 years ago still holds true, the Academy is exercising its "pen" to influence the implementation of MACRA in a manner that best benefits family physicians and their patients.
On Nov. 9, the AAFP responded to CMS’ request for information regarding the Merit-Based Incentive Payment System, Promotion of Alternative Payment Models, and Incentive Payments for Participation in Eligible Alternative Payment Models. The AAFP’s 53-page response responds directly to the 126 questions in the RFI.
On Nov. 19, the AAFP responded to the Alternative Payment Model Framework Draft White Paper published by the Health Care Payment Learning and Action Network (HCPLAN), a group assembled by CMS to assist with MACRA implementation .
MACRA was signed into law April 16, bringing to a close the 13-year drama that was the sustainable growth rate (SGR). Repealing the SGR was a significant accomplishment that created an environment whereby we can begin the transition away from episodic and fragmented delivery and payment models towards those that promote continuity, coordination and connectivity. MACRA represents the future -- albeit a somewhat confusing future.
The transition from legislation to regulation is one of the most important processes in government. It also is the arena where the AAFP must perform at the highest level on behalf of our members. We take the regulatory process very seriously. The emphasis we are placing on the implementation of MACRA is driven by our desire to realize the full potential of delivery and payment system reform and our understanding that MACRA refers decisions to the secretary of HHS more than 100 times.
The AAFP response to both documents advance the importance of increasing the overall investment in primary care and not building new delivery and payment models on the biased and inaccurate relative value data used in the fee-for-service system. Our letters strongly recommended that CMS and private payers do more to ensure that Medicare and all other public and private programs pay appropriately for primary care physician services. Appropriate, obviously, means more than current levels.
To achieve this goal, the AAFP urged CMS to use its authority and take administrative actions to increase the values of primary care services in the Medicare program. Additionally, the AAFP outlined a comprehensive payment proposal that would move a larger percentage of payments from the traditional fee-for-service model toward alternative payment models. With respect to primary care, the AAFP proposes that payments for primary care services under this advanced primary care delivery model be made on a per-patient basis through the combination of a global payment for direct patient care services and a global care management fee.
Our letters also raised concerns about several barriers that may prohibit successful participation in the new payment models. The most significant barrier is the poorly designed meaningful use program and its lack of interoperability standards, which prohibit the sharing of patient information. Family physicians continue to face significant challenges with their EHRs and meeting meaningful use standards. Until this program is improved and the EHR issues are resolved, it is difficult to foresee a large percentage of physicians -- particularly physicians in small and independent practices -- being successful in MACRA programs.
We continued our advocacy aimed at encouraging CMS to use the Joint Principles of the Patient-Centered Medical Home and the key functions of the Comprehensive Primary Care (CPC) initiative as criteria for determining what constitutes a medical home. The Joint Principles, when aligned with the five key functions of the CPC initiative, capture the true definition of a PCMH and its performance thresholds. The AAFP clearly states in multiple places that we do not believe a physician should be required to pay a third party to secure the PCMH recognition necessary to participate in a Medicare program.
Finally, we strongly urged CMS to streamline, harmonize and reduce the complexity of quality reporting in the MIPS and APM programs. Out letters outline a vision for quality improvement programs that promote continuous quality improvement and measure patient experiences. The AAFP expresses opposition to any approach that requires physicians to report on a complex set of measures that do not impact or influence the quality of care provided to patients. Instead, we suggest that all measures used must be clinically relevant, harmonized among all public and private payers and be submitted in a manner that is minimally burdensome on physicians.
Our letter offers recommendations on numerous additional topics, but the above information captures the major themes. Clearly, the implementation of MACRA will be a major undertaking, and the AAFP is committed to influencing this process in a manner that benefits family physicians and their patients. This undertaking will not be easy, but our team is capable and ready. I encourage you to follow our work on your behalf on our MACRA resource webpage.
I anticipate that many of you are prepared to utilize your "pen" to communicate your views on MACRA and the choices family physicians face in the next few years. I look forward to your comments, thoughts, and suggestions. More importantly, I look forward to learning from you and your experiences so that we can better serve you and your practice.
The IMS Institute for Healthcare Informatics has released a new report, Global Medicines Use in 2020: Outlook and Implications that project global spending on pharmaceutical products will increase 30 percent by 2020, resulting in a global spend of $1.3 trillion. The report notes that the spending will be driven by expensive new drugs, price hikes for existing drugs, increased use of generic drugs in developing countries and an aging population. IMS projects that, by 2020, annual use of medicine will hit 4.5 trillion doses, up 24 percent from this year. Additionally, the report projects that more than half of the world’s population -- currently 7.6 billion -- will be taking more than one medicine dose per day. Finally, IMS projects that roughly 90 percent of U.S. prescriptions dispensed in 2020 will be for generic products.
Beat the PQRS Deadline, Avoid 2 Percent Medicare Cut
CMS has announced that it is extending the 2014 informal review period for the Physician Quality Reporting System to Nov. 23. The previous deadline had been Nov. 9. All physicians who participate in the Medicare fee-for-service program, the Comprehensive Primary Care Initiative, PQRS group practice reporting option, or an accountable care organization are required to report quality measures through the PQRS program.
Starting in 2016, physicians who did not report quality measures in 2014 face a negative 2 percent payment adjustment on all Medicare services. If you are uncertain about your status with respect to the 2014 PQRS reporting year, the AAFP encourages you to contact CMS and initiate an informal review. All informal review requests must be submitted electronically via the Quality Reporting Communication Support Page (CSP) by 11:59 p.m. Eastern on Nov. 23. According to CMS, all informal review requestors will be contacted via email with a final decision within 90 days of the original request.
The PQRS program, established by the Tax Relief and Health Care Act of 2006 and signed into law by President George W. Bush on Dec. 20, 2006, requires physicians participating in Medicare to submit quality data to CMS. The program initially provided positive payment incentives, but starting this year penalties were implemented. The negative 2 percent payment adjustment being implemented in 2016 will remain in effect until the PQRS program is revised by the Merit-Based Incentive Payment System, established by the Medicare Access and CHIP Reauthorization Act.
The AAFP has extensive PQRS resources that can assist you. Family Practice Management also has information that you may find beneficial. You may also wish to review CMS’s 2014 Physician Quality Reporting System (PQRS): Incentive Eligibility & 2016 Negative Payment Adjustment -- Informal Review Made Simple. Finally, you can contact the CMS QualityNet Help Desk at 1-866-288-8912 (TTY 1-877-715-6222) or Qnetsupport@hcqis.org Monday through Friday from 7 a.m. to 7 p.m. Central.
On Oct. 29, Paul Ryan, R-Wis., was sworn in as the 54th speaker of the House of Representatives. He was elected to the position by the full House following the retirement of Speaker John Boehner, R-Ohio. Ryan, who was the Republican candidate for vice president in 2012, was first elected to the House in 1998 at the age of 28. He is a former chairman of the House Budget Committee and was most recently chairman of the powerful House Ways and Means Committee. He is the co-author of the Bipartisan Budget Act of 2013, better known as the Ryan-Murray. This legislation averted a sustained financial crisis and looming government shutdown -- scenarios he once again faces as the new speaker.
On Nov. 4, the Kevin Brady, R-Texas, was selected to replace Ryan as the chairman of the House Ways and Means Committee. Congressman Brady was previously chairman of the committee’s Subcommittee on Health.
BMJ has published a new report entitled “Physician Spending and Subsequent Risk of Malpractice Claims: Observational Study.” The authors examined the long-standing issue of the relationship between medical liability claims against physicians and defensive medicine. They note that, “Despite widespread agreement that physicians practice defensive medicine to reduce malpractice liability, there are no studies of whether greater resource use by physicians, whether it is defensively motivated or not, is associated with reduced claims for malpractice. This lack of evidence is surprising, given that defensive medicine is premised on greater resource use reducing malpractice liability.”
So what did the researchers find? Well, defensive medicine likely grew due to the simple fact that it may actually work. According to the findings, “in six of seven specialties, we found that greater resource use was associated with statistically significantly lower subsequent rates of alleged malpractice incidents.”
The authors note that this study has limitations, but the findings have important policy implications. In an era where the costs of health care are front of mind for individuals and policy-makers, it may be time to place greater emphasis on medical liability reform as a means of managing escalating costs.
Whack the 'WAC'
How many of you can relate to this statement? "I am self-employed, but I work for the government and insurance companies."
This is a common refrain from physicians in all specialties, but it is an especially frequent complaint among family physicians. The administrative burden on family physicians is mind boggling. A majority of family physicians have contractual relationships with seven or more payers. That means there are seven different prior authorization forms, seven different quality reporting systems, seven different prescribing formularies, seven different appropriate use programs, seven different … Well, you get the idea.
Family physicians not only hate red tape, but there is growing evidence that it contributes to lower quality of care and is a major driver of physician burnout.
Have you ever experienced a sequence of events that crystalizes an issue for you? This happened to me earlier this month through a conversation with a family physician from rural North Carolina, a comment by an AAFP member from California, and a statement by a prominent author -- all driving home the same point -- the administrative burden on physicians is a HUGE problem.
This sequence of events started with a phone conversation I had with a family physician in North Carolina who is in a solo practice in a rural community. "You just have no idea how hard it is to take care of my patients," he told me. The thing that caught my attention was the fact that he wasn't complaining about the time, money, or the hassle on him or his staff; his concern was the red tape preventing him from taking care of his patients.
That conversation was followed by a conversation with a member from California who, during a large meeting, stated that physicians are tired of the "WAC." I was not familiar with that term, so I did what any inquisitive person would do. I shouted out, "What is the WAC?" He responded, "Work after clinic." This physician said that the volumes of administrative activity that require physicians to spend hours working after seeing patients was hurting patient care and destroying the love of practice among family physicians. He said that the AAFP needed to help physicians "whack the WAC."
The third and final event in this sequence was a paragraph in the closing chapter of Steven Brill's latest book, "America's Bitter Pill," which reads as follows:
"We should recognize that the quality of medical care is going to continue to be jeopardized by the broken economics of the marketplace, which provides rich incentives to everyone except those actually treating all of these newly covered patients. As doctors remain bogged down in paperwork and face mounting business pressures, the portion of our best and brightest who want to care for the sick instead of cashing in on the business of healthcare is likely to drop.”
Administrative simplification is something that has been a priority for the AAFP for many years. AAFP resources on administrative simplification say, in part, "The AAFP is determined to help family physicians reduce these roadblocks by identifying and eliminating regulations and processes that add cost while undermining the efficient and effective delivery of quality care."
In addition, we have pursued extensive advocacy initiatives aimed at reducing the administrative burden associated with Medicare and Medicaid. These efforts include establishing a core set of primary care quality measures that would be used by all payers, including Medicare. We also continue to press CMS and commercial insurers to forgo the implementation of complex prior authorization and appropriate use programs that delay access to care for patients and add to the “WAC.”
The most meaningful and important work we are doing to "whack the WAC" is our aggressive efforts to delay and reform the flawed meaningful use program. Last week, CMS and the Office of the National Coordinator for Health Information Technology (ONC) advanced meaningful use (MU) stage three regulations despite widespread criticism from the AAFP and other physician organizations.
In 2009, Congress passed the HITECH Act. This law instructed CMS and ONC to establish a program that would result in the adoption and implementation of electronic health records among physicians, hospitals, and other health care providers. It also instructed ONC to establish a standard for the interoperability of those EHR products. The legislation did not instruct CMS and ONC to create a complex, three-phase regulatory framework that would add layers of administrative complexity on physicians and throw cold water on any enthusiasm that existed among physicians to implement EHRs in their practices, yet this is exactly what has happened.
Only 10 percent of physicians have attested to MU stage two, and 43 percent of physicians face penalties in 2015. It is unacceptable and unreasonable to impose further punishments on physicians when more time and evaluation of the MU program is clearly needed. The AAFP strongly supports Congress' efforts to transition our health care system from paper-based to electronic health records, however, current MU regulations place unnecessary administrative and financial burdens on family physicians, favor software vendors over physicians and patients, and do little to improve the quality of care we provide.
Are you tired of inputting meaningless data into your patient records simply to comply with a regulation and avoid a financial penalty on your practice? Are you tired of your EHR working for vendors and failing to work for you and your patients? It is time to "whack the WAC," and let's start with the meaningful use stage 3 regulations. Use the AAFP's Speak Out resources and tell your representative and senators to pause the implementation of the stage 3 MU regulation.
Support the Primary Care Caucus
A congressional caucus is a group of legislators that meets to pursue common objectives. Formally, caucuses are formed as congressional member organizations (CMOs) through the U.S. House of Representatives and governed under the rules of that chamber.
There are more than 100 Congressional Caucuses, and there already are several pertaining to health care -- including the Arthritis Caucus, the Academic Medicine Caucus, the Rural Health Caucus, the Disability Caucus and the Affordable Medicine Caucus. Then there is the always important Bourbon and Wine Caucuses and -- my favorite -- the Internet of Things Caucus.
Throughout history, however, there has never been a congressional caucus devoted to primary care. On Oct. 8, that changed.
I am pleased to inform you that Rep. David Rouzer (R-N.C.) and Congressman Joe Courtney (D-Conn.) have launched the Bipartisan Congressional Primary Care Caucus. The AAFP was honored to participate in the formal launch, which took place as part of a Congressional briefing entitled “The Impact of Primary Care on Rural and Urban Underserved Communities.” In addition to the events on Oct. 8, Rouzer and Courtney recorded a video message announcing the formation of the Primary Care Caucus and outlining their motivations.
The formation of the Primary Care Caucus is a significant and important development for the AAFP and primary care. The AAFP strongly supports the Primary Care Caucus and applauds Rouzer and Courtney for their leadership. We are excited to partner with the caucus to inform and educate members of Congress and the public on issues of importance to family medicine and primary care.
The AAFP has launched a Speak Out campaign aimed at encouraging other members of Congress to join and support the Caucus. You can learn more about the caucus and send a letter to your representative urging them to join by using Speak Out. Also, follow the activities of the caucus on Twitter using #PrimaryCareCaucus.
On Oct. 1, physicians and other health care providers were required to convert their billing systems from ICD-9 to ICD-10. The AAFP is carefully monitoring the situation and we are eager to learn how your practice is handling the transition and if you are having any challenges. You can submit your feedback through our practice management resource page. Information you provide will assist the AAFP in our advocacy on your behalf
The Commonwealth Fund has released its annual report on health care entitled “U.S. Health Care from a Global Perspective: Spending, Use of Services, Prices, and Health in 13 Countries.” The Commonwealth Fund, using data from the Organization for Economic Cooperation and Development (OECD), analyzed health care spending, supply, utilization, prices and health outcomes from 13 high-income countries: Australia, Canada, Denmark, France, Germany, Japan, Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States. It is important to note that the data used in this report is from 2013, the year prior to the full implementation of the Patient Protection and Affordable Care Act.
So what did the report find?
Well, our trend of higher spending and lower quality continues. On average, the United States spent $9,086 per person on health care in 2013 -- the highest of the 13 countries. The next highest per person spend was Switzerland at $6,325. The lowest was the United Kingdom at $3,364 per person. Although the spending is concerning, what is even more troubling is the fact that despite spending significantly more on health care, the United States has a significantly lower life expectancy as compared to the other countries. In 2013, the life expectancy in the United States was 78.8 years. Switzerland was 82.9 years. The highest life expectancy is found in Japan at 83.4 years.
The authors suggest that higher spending in the United States is largely driven by greater use of technology and higher prices per health care service, rather than an over-utilization of physician services. The report found that the average person in the United States saw a physician four times in the evaluation year, which landed the U.S. in the bottom third of physician utilization of the evaluated countries. The highest number of annual physician visits was 12.9 in Japan. The lowest was 2.9 visits per year in Switzerland.
This report is important because it continues to shed light on what has been a consistent finding over several years -- the U.S. spends significantly more per person but has not improved long-term quality outcomes or life expectancy as a result of such spending. I will suggest that those countries that have lower spending and high life expectancy all have one thing in common as compared to the U.S. They place a much greater emphasis on primary care.
Ready Or Not, ICD-10 is Here
The moment of truth is upon us. ICD-10 is here.
On Oct. 1, all physicians and health care providers must convert their billing systems from ICD-9 to ICD-10. This also will mark the day that all payers -- Medicare, Medicaid, private insurance -- will no longer accept claims for care provided that does not include an ICD-10 code.
I understand that there remains a fading glimmer of hope that Congress will step in and avert the implementation of ICD-10, but as we have stated for much of the past year, Oct. 1 will come and ICD-10 will be implemented. Although I am approaching Oct. 1 with cautious optimism that the conversion will go smoothly, I recognize fully that a conversion of this size will not occur independent of challenges. The AAFP’s top priority is making certain that you have the resources you need to make the transition and deal with any problems that may arise as a result of the conversion.
To this end, I want to call attention to the AAFP’s top ICD-10 resources:
- ICD-10 Referential Flash Cards;
- Frequently Asked Questions;
- Countdown to ICD-10;
- ICD-10 Webinar: Think Outside the Book; and
- Family Practice Management eBook Anthology.
The AAFP will be carefully monitoring this transition and will be communicating all information we receive from family physicians directly to CMS. If you encounter challenges with claims submission or, more importantly, claim rejections please let us know so we can work with you to resolve these issues. The AAFP has created a direct communication link. (Log in required.) I wish each of you luck.
Frustrated With Meaningful Use? Speak Out for Reform
The AAFP continues to be extremely concerned about the future of the meaningful use program and the administrative burdens family physicians face in their efforts to comply with these regulations. In July we called for a delay in the implementation of stage 3 and outlined a series of reforms we believe should be implemented to make stage 2 more simple and therefore achievable for physicians. As noted in my Sept. 1 post, the AAFP is actively advancing legislation that would reform the meaningful use program.
On Sept. 17, the AAFP joined a number of physician organizations in sending a letter to Secretary Sylvia Burwell urging a delay in the implementation of meaningful use stage 3.
Although we remain hopeful that the administration will take the necessary actions to both delay the implementation of MU3 and make much needed improvements in MU2, we are not sitting by and hoping for the best. We are actively engaged with the House and Senate on advancing legislation that would require action on the part of the Office of the National Coordinator (ONC) for Health Technology and CMS. Specifically, we are strongly supporting the Further Flexibility in HIT Reporting and Advancing Interoperability (FLEX-IT 2) Act (HR 3309) introduced in July by Rep. Renee Ellmers, R-N.C.
The FLEX-IT 2 Act would:
- Eliminate the “all or nothing” assessment and replace it with a standard allowing physicians to be evaluated based on the proportion of MU measures they meet.
- Delay meaningful use stage 3 regulations.
- Allow physicians to attest for MU based on a 90-day reporting period instead of a burdensome 365-day reporting period. Physicians reporting at all MU stages would be allowed this 90-day flexibility, and it would remain in place for all subsequent years.
- Expand the allowable conditions for MU hardship exceptions. Under the bill, physicians will be allowed to claim a hardship exception in several scenarios, including a change in technology vendors, unforeseen circumstances (like becoming the victim of a cyber-attack), being at or near retirement or working in certain specialties with limited patient interaction outside the hospital.
- Require that all certified electronic health records (EHRs) undergo interoperability testing.
- Harmonize CMS quality reporting standards across all programs.
The AAFP voiced our strong support in a letter to Rep. Ellmers, and we are aggressively lobbying for the passage of this important legislation. I encourage each of you to take a few minutes to lend your voice to our effort and signal the strong support of family physicians for this legislation. Please use our Speak Out campaign and tell your representative to support of the FLEX-IT 2 Act. Your voice matters, and it needs to be heard.
ONC Launches Website for EHR Complaints
ONC has launched a website where physicians can voice complaints about EHRs, including sharing concerns about information blocking, safety concerns and questions regarding the performance of certified EHR products. Deputy National Coordinator Jon White outlined the website in a Sept. 16 blog post. The AAFP has long encouraged ONC to launch a direct communication medium with physicians, and we are pleased that they have followed our recommendation.
You should contact ONC if:
- Your challenge appears to be related to health information blocking.
- You are not able to share or receive health information.
- You are concerned about the usability of your EHR.
- The certified capabilities of your product are not performing as you expected.
- You have concerns about the safety of your product.
AAFP's Annual Meeting Offers Plenty to 'Experience' in Denver
For me, fall is hands down the best of the four seasons. First, the temperature finally drops below unbearable in Washington, D.C. Second, baseball pennant races heat up, and college football season starts. Third, it’s the season when family medicine gathers in a single city for fun, fellowship and education.
Thousands of family physicians will gather Sept. 29-Oct. 3 in Denver -- the Mile High City (insert your own joke here) -- for the AAFP Family Medicine Experience (FMX). The Academy's annual meeting (formerly Assembly) is a collection of high quality education programs and social events that aims to provide you with information that will enhance your knowledge on timely clinical, practice and professional issues. It also is an opportunity for you to interact with your colleagues from across the nation on those issues impacting family medicine.
I look forward to seeing many of you at FMX and will be interested in hearing your latest thoughts on the array of health policy and practice management issues you are grappling with in your practices. You can find me at AAFP Exhibit & Marketplace (Booth 407), inside the Expo Hall.
Physicians can earn up to 35 prescribed credits in four days, and there are 235 CME sessions to choose from. In addition, the event will feature three outstanding plenary speakers. I urge you to review the full menu of FMX education offerings and review the bios of this year’s outstanding faculty.
I am hesitant to highlight one session over the numerous others, but I am going to do so anyway. At 4:30 p.m. on Sept. 29 there will be a panel discussion on “Capitalizing on Team-Based Care to Improve Quality and Office Efficiency.” This panel will feature one of the nation’s premier health policy leaders, Thomas Bodenheimer, M.D., M.P.H. He has impacted health policy at an unprecedented level and is a physician whose writings and opinions matter to me. If you are able, I would urge you to attend this session. It will be repeated at 12:30 p.m. on Sept. 30.
I will focus on three FMX activities -- practice management and practice improvement education programs, member interest groups and FamMedPAC.
Practice Management and Practice Improvement Programs
Each year, the AAFP offers several hours of education on practice management and practice improvement topics, and this year is no exception. We are excited to offer three education tracks on timely practice management and practice improvement topics. These tracks aggregate a series of education programs into a 3.5 hour time period so you can receive comprehensive education on a single topic or closely aligned topics.
The education tracks are on practice management, motivational interviewing and direct primary care. Here are the dates and times:
- Practice management -- 8 a.m.-11:30am on Sept. 30.
- Motivational interviewing -- 8 a.m.-11:30 a.m. on Sept. 30.
- Direct primary care – 8 a.m.-11:30 a.m. on Oct. 1 and Oct. 2.
During the past year, I have shared information on the numerous changes in our health care system and the resources the AAFP makes available to assist you and your practice in adjusting to these changes. An important part of this blog is the interaction it provides. I learn from you, and your comments influence the work of the AAFP. Yes, we're listening.
We also use your feedback as guidance on what education and services we should provide. To this end, we are pleased to offer education programs on topics that are frequently noted by you as priorities. Here are a few examples with times and dates:
- Assessing the Cost of Sustaining a PCMH -- 8 a.m. and 10:30 a.m. on Oct. 3.
- Meaningful Use -- 1:45 p.m. on Sept. 30.
- Negotiating an Employment Contract -- 9:15 a.m. and 1:30 p.m. on Oct. 1.
- Annual Wellness Visit -- 8 a.m. and 10:30 a.m. on Oct. 2.
- Chronic Care Management -- 1 p.m. on Sept. 29; 12:45 p.m. on Sept 30; 9:15 a.m. on Oct. 1; and 10:30 a.m. on Oct. 2.
- Team-Based Care -- 4:30 p.m. on Sept. 29 and 12:30 p.m. on Sept. 30.
- Alternative Payment Models -- 9:15 a.m. on Sept. 30 and 10:30 a.m. on Oct. 3.
Member Interest Groups
In 2014, the AAFP established member interest groups (MIGs) as a way to define, recognize and engage groups of AAFP members who have shared professional interests. These groups are excellent venues to connect with colleagues, share your ideas, conduct peer-to-peer learning and develop recommendations on how the AAFP can better serve its members. There are 11 MIGs (so far). There will be a reception for members currently participating in MIGs and those interested in learning more at 5:30 p.m. on Thursday, Oct. 1. In addition, each MIG will hold business meetings at the date and times listed below. Please consult the official program for locations.
- Emergency Medicine/Urgent Care -- 12:30-2:30 p.m.
- Global Health -- 12:30-2:30 p.m.
- Oral Health -- 6:30-8:30 p.m.
- Rural Health -- 6:30-8:30 p.m.
- Single Payer Health Care -- 7:30-9:30 a.m.
- Adolescent Health -- 9:15-10:30 a.m.
- Hospital Medicine -- 1:30-3:30 p.m.
- Telehealth -- 1:30-3:30 p.m.
- Independent Solo/Small Group Practice -- 7-9 p.m.
- Reproductive Health Care -- 10 a.m.-noon
- Direct Primary Care -- 8-10 a.m.
In a previous post, I introduced you to FamMedPAC, which is the AAFP’s federal political action committee and one of our most important advocacy resources. I am a firm believer that there are three forms of advocacy -- lobbying, grassroots and political. Each is complementary of the other two, and each is less effective if the others do not exist.
FamMedPAC also represents a great way for family medicine advocates to participate in federal elections and influence the larger health policy debate from the political angle.
FamMedPAC will have a major presence at FMX, and I urge you to stop by its booth in the AAFP Exhibit and Marketplace. You can make a contribution and engage our staff on the latest political news and the AAFP’s efforts to influence federal elections. If you are currently, or become, a contributor at the Club George level ($365 per year for active members or $52 for students and residents) or higher, we invite you to join us for the annual FamMedPAC reception, which will be held from 5:30-7 p.m. on Sept. 30.
FMX promises to be an informative and fun event. If you are attending, I urge you to participate in the education programs offered, and please stop by and see us at our booth in the Exhibit Hall.
Hit the Pause Button on Meaningful Use
Sometimes the best idea gets lost in translation or implementation. I'm sure history is riddled with examples of this, but I can think of no greater example in health policy than the meaningful use program.
What started as a simple idea of developing and implementing an interoperable health information system that would encourage physicians to transition from paper-based medical records to electronic health records (EHRs) has, in reality, turned into a labyrinth of regulations that has actually resulted in discouraging physicians to the point of revolt. How did something so straightforward go so wrong?
There are plenty of reasons why this occurred, but I am going to focus on four.
The regulations regarding the implementation of meaningful use are too complicated. The goal was simple -- transition from paper to computers and share information among physicians and health care settings. The concept of providing financial incentives to lessen the economic impact on the purchase and implementation of EHRs was a good one, but the hoops and hurdles that come with that money are not. Our government has developed a set of regulations that are so confusing, so complex, and so numerous that most physician practices face significant challenges complying.
The sequential implementation of the regulations was misaligned. In retrospect, the regulations governing interoperability should have been put in place prior to ramping up efforts to implement EHRs on a widespread basis at the physician and hospital level. This small, yet meaningful, change in sequence would have prevented many of the challenges we face today. Primarily, it would have prevented the proprietary cannibalism that EHR companies and major health systems have engaged in since 2009.
The sphere of influence at the regulatory development level was too dominated by the vendor community which, not surprisingly, protected its self-interests versus advancing the interest of patients, physicians and the health care system.
Finally, the meaningful use program should have been an on-ramp for physicians, setting them on a path toward a fully functioning and interoperable EHR system that promoted quality care. Instead, the program is a pass/fail puzzle that is followed by the threat of penalties for non-compliance and heavy-handed audits for those who are successful in securing incentive payments. The program is not an on-ramp and, instead, is viewed as a cliff that physicians are afraid of being pushed over.
I am going to pause for a second to state that I unequivocally think our health care system will be better at providing high quality and cost-appropriate health care with an interoperable health information system. Additionally, I think electronic records, if re-designed to better support the work flow of a family physician and operating on a platform that allows for interoperability that facilitates the real-time exchange of relevant patient information, will improve the performance of individual physicians and allow for better care to patients at a more appropriate cost. The key to salvaging the simple goals of the meaningful use program may be as simple as saying, “we need to hit the pause button.”
As noted in my post last month, the AAFP is aggressively pursuing modifications to the meaningful use program. Specifically, we have been working to create changes in regulation that would delay meaningful use stage 3 until regulations implementing the Medicare Access and CHIP Reauthorization Act (MACRA) have been drafted, thus allowing alignment of the meaningful use program with the requirements of MACRA. We also have been pursuing changes to meaningful use stage 2 that would lessen the administrative burden it places on physicians, thus allowing greater participation and a lower percentage of physicians facing penalties for non-compliance. Finally, we are determined to change the pass/fail nature of the program and return to a process that encourages progress towards the ultimate goal of every physician and hospital using an interoperable EHR.
In my July posting I assured you that the AAFP would lead in developing legislation that would reform the meaningful use program and launch a grassroots campaign aimed at enacting those reforms into law. I am pleased to report that, in July, Rep. Renee Ellmers, R-N.C., introduced the Further Flexibility in HIT Reporting and Advancing Interoperability (FLEX-IT 2) Act (HR 3309), that captured reforms promoted by the AAFP and outlined above.
The FLEX-IT 2 Act would:
- Eliminate the current “all or nothing” assessment and replace it with a standard allowing physicians to be evaluated based on the proportion of MU measures they meet.
- Delay meaningful use stage 3 regulations.
- Allow physicians to attest for MU based on a 90-day reporting period instead of a burdensome 365-day reporting period. Physicians reporting at all MU stages would be allowed this 90-day flexibility, and it would remain in place for all subsequent years.
- Expand the allowable conditions for MU hardship exceptions. Under the bill, physicians will be allowed to claim a hardship exception in several scenarios, including a change in technology vendors, unforeseen circumstances (like becoming the victim of a cyber-attack), being at or near retirement or working in certain specialties with limited patient interaction outside the hospital.
- Require that all certified EHRs undergo interoperability testing.
- Harmonize CMS quality reporting standards across all programs.
The AAFP communicated our strong support for this legislation in a July 30 letter to Rep. Ellmers. We also have launched an aggressive Speak Out campaign aimed at building support for the important reforms included in H.R. 3309. I urge each of you to send a letter to your representatives urging them to support this legislation and, more importantly, these much needed reforms to the meaningful use program.
Patients, Physicians, Payer Benefit From Primary Care Investment
"Secret, secret, I've Got a Secret."
Some of you may recognize these lyrics from the 1983 Styx mega-hit "Mr. Roboto," but most of you probably are pondering its application to the AAFP and family medicine. My secret is this: the key to improved quality and reduced health care costs is -- wait for it -- primary care. I realize that few of you are shocked by this statement, but there are plenty of people in health care that are just now waking to this reality.
A couple of weeks ago, I had the opportunity to meet with the president and CEO of CareFirst BlueCross BlueShield, about that organization's patient-centered medical home program. CareFirst, which operates in Maryland, the District of Columbia, and northern Virginia, launched its PCMH program in 2011 with more than 2,000 primary care physicians and providers participating. Today, 80 percent of primary care physicians and providers in this service area participate in the program, and collectively they provide care to more than 1 million patients. Seventy-five percent of participating physician practices are solo, small and medium-sized physician practices.
The design of the CareFirst program is quite simple. Physicians are asked to align themselves with other primary care physicians to form panels that range in size from five to 15. CareFirst provides two forms of upfront financial support -- a 12 percent participation fee and a $250 payment for each care plan developed. In addition, CareFirst provides three types of administrative support -- care managers; data and analytics; and technical assistance via program consultants.
CareFirst does not require that the practices achieve third-party PCMH recognition, nor do they require that the panels form new legal entities to work together towards achieving shared savings. Physicians can partner with others in a virtual or cooperative way rather than through contractual alignment. In return, CareFirst asks each panel to assume responsibility for the total cost of care for their attributed patients by focusing on five key areas:
- cost effectiveness of referral patterns;
- engagement in care coordination programs;
- medication management;
- reducing gaps in care and quality deficits; and
- physician engagement and performance improvement.
If the primary care panels control total costs of care as compared to their benchmark, they get to share in the savings. I know what you are thinking, the benchmark lowers annually, thus making it impossible to achieve continuous savings in the program. Well, that would be wrong. CareFirst does not lower the benchmark to reflect annual or cumulative net savings. It only adjusts the benchmark based upon the risk stratification of the patients attributed to the panel.
So, has it worked? In short, yes.
Since 2011, CareFirst has reduced its expected costs of care and slowed spending growth by an estimated $609 million. Additionally, CareFirst slowed its rate of growth from 7.5 percent in 2011 to 3.5 percent in 2014. In four years, the CareFirst PCMH program has contributed to a 19 percent reduction in hospital admissions, 15 percent fewer hospital days, 20 percent fewer hospital readmissions, and 5 percent fewer outpatient health facility visits. As a result, participating physicians who met quality and savings targets earned, on average, $41,000 in shared savings.
Physician participation and engagement in the program is high and holding. Since 2011, only 13 percent of physicians have left the program. Of that 13 percent, 82 percent retired. The remaining 18 percent were asked to leave due to a lack of participation, but 7 percent of those physicians subsequently returned.
Since 2011, 38 percent of the primary care panels have secured savings in all four years, and 32 percent have secured savings in three of the four years, debunking the so-called process bias theory that suggests savings are not sustainable over long periods. In fact, only eight panels, or 2 percent, have failed to secure savings at some point.
Following my conversation with CareFirst, I came away with five key points about the future of advanced primary care practices and the medical home:
- Empowering primary care should be a central tenant for payers and purchasers, not a passing ambition. The value of primary care has become widely accepted. Now payers and purchasers need to increase their investment in primary care. Primary care accounts for approximately 5 percent of the total spend for any health care payer or purchaser, but primary care has tremendous influence over the remaining 95 percent of spending. Investments in primary care can come in the form of resources (care managers, data dashboards, cost/quality reports on specialists and hospitals), financial (engagement bonuses, care management fees, increased payment for performance), or both. This investment should be upfront, meaningful and independent of undue administrative complexity.
- Independent does not mean isolated. Primary care physicians in any practice type and size need to embrace alignment. This alignment can be virtual or contractual. More than 75 percent of physicians participating in the CareFirst program are not employed by an academic or large health system, and many of these physicians are in solo or small practices.
- Teams matter. Teams come in various shapes and sizes, but they are important to patients and physicians alike. This can be teams of physicians or physicians working with other health care providers in a coordinated manner, but the key is moving away from the concepts of individual, independent and isolated care delivery models. Care managers, who are embedded in a practice, seem to be an important and essential element of highly functioning and successful advanced primary care practices.
- Data is key. If purchasers and payers truly want primary care physicians to accept responsibility for the total cost of care, they must provide the primary care physicians timely and accurate data on the cost and quality of all physicians, hospitals and outpatient care facilities in their community or service area.
- PCMH recognition by a third party may not be necessary. Evaluating performance remains an important component of advanced primary care practices, but securing recognition of your practice as a medical home may not be essential. The more important recognition is a physician’s performance against a set of core functions in his or her practice.
I realize that this posting could facilitate some interesting comments, and I look forward to hearing your thoughts. I also realize that there are likely some shortcomings in the CareFirst program. However, the successes of the CareFirst program and others like it are becoming far more prevalent. This leads me to believe that the core functions of an advanced primary care practice are becoming more identifiable and replicable and are being paid differently and better.
Country in Crisis: Addressing our Addiction Epidemic
In a recent speech to the National Governors Association, HHS Secretary Sylvia Burwell laid out an aggressive strategy to combat our country's growing drug abuse epidemic. This issue is of great interest to the secretary. As a native of West Virginia, a state on the frontline of the issue, she has seen the impact that drug abuse -- both illicit and prescription -- has had on families and the state’s economy.
This speech by Secretary Burwell is one of many recent activities that have raised awareness and a created a sense of urgency about drug abuse. The Obama Administration has made the issue a priority for its final two years, and the White House Office of Drug Control Policy released the National Drug Control Strategy: A 21st Century Approach to Drug Policy. This policy outlines the expansive scope of this issue. The report outlines a number of policy proposals, many of which are consistent with AAFP policies. We have communicated our support for the proposal and have identified a series of collaborative activities we plan to pursue.
During the past few years, our nation has seen an increase in the prevalence of abuse of a number of legal and illegal substances, including prescription drugs. According to the CDC, roughly 110 Americans died from drug poisoning every day in 2011. Prescription drugs were involved in more than half of the drug poisoning deaths that year. Sadly, these numbers are four years old, and the problem has grown worse.
The cost of addiction and abuse is startling. Although the majority of our attention is focused on opioid addiction, we should not overlook or underestimate the impact that all addictions have on the health of individuals, the health care system and the national economy.
Since the “war on drugs” campaign, which was a cornerstone of the Reagan Administration, we have viewed the issue of drug abuse as a law enforcement issue. This trend has held consistent for much of the past three decades. To this day, the primary regulatory body that grants physicians prescribing rights for controlled substances is a law enforcement agency -- the DEA. However, we are in the midst of a gradual transition whereby we are beginning to view prescription drug abuse as a public health issue, not simply a law enforcement issue. This transition is important, and it would not have happened without the AAFP’s leadership and collaborative advocacy efforts with patient and public health organizations during the past decade.
The AAFP has been a national leader on the issues of pain management and opioid abuse. The AAFP policy paper “Pain Management and Opioid Abuse: A Public Health Concern” is a document that is widely regarded as instrumental to the current public discourse on this issue.
It is important for us to all fully acknowledge that family physicians, collectively, prescribe a majority of opioids in this country. According to research conducted (pending publication) by the Robert Graham Center, more than 60 percent of all prescriptions for controlled substances provided to Medicare patients are written by family physicians. Researchers at the Graham Center estimate that the percentage in the non-Medicare population is likely higher, between 65 percent and 70 percent. However, it is important to note that family physicians diagnose and treat the majority of acute and chronic pain patients. Like most chronic conditions, family physicians are the primary providers of care to patients with chronic pain.
Striking a balance between treating pain and appropriate prescribing is the primary reason this issue has become so complicated from a policy perspective. Although we should be diligent in our efforts to address what is a real and growing epidemic of prescription drug abuse, we should not underestimate the prevalence of acute and chronic pain and the need to ensure that family physicians are able to care for patients in a manner that is free of unnecessary regulatory compliance burdens.
It is estimated that 60 million Americans have some type of chronic nonmalignant pain, and the annual cost associated with all types of pain is estimated to be greater than $500 million per year. Given our aging population, we should anticipate that these numbers will increase in the next two decades.
The issue of substance and prescription drug abuse is ever-present for state governments and has emerged as a top policy issue for Congress and the Obama Administration. Many states have seen dramatic increases in the number of individuals seeking treatment for substance abuse and, sadly, significant increases in the number of deaths from overdoses of legal and illegal substances. The negative economic impact of abuse on state budgets has become a frontline political issue in almost every state.
In an effort to better monitor prescribing in their respective states, 49 states (Missouri is the hold out) have established prescription drug monitoring programs (PDMPs). Unfortunately, only 24 of the 49 PDMPs communicate with each other, leaving gaps in access to timely data that could assist physicians in making informed decisions.
The AAFP consistently reiterates our commitment to work with federal and state governments to identify and implement a balanced approach to curbing the prevalence of prescription drug abuse while ensuring that physicians can continue to provide appropriate care to patients. A key component of our advocacy efforts is the work we are doing as part of the Task Force to Reduce Opioid Abuse, convened by the AMA.
The task force is compromised of the AAFP, the AMA, the American Dental Association and 25 other national and state physician organizations. The task force’s goal is to “significantly enhance physicians’ education on safe, effective, and evidence-based prescribing.” On July 29, the task force released a series of policy recommendations. The task force organized its recommendations around five main goals:
- Increase physicians’ use of effective PDMPs.
- Enhance physicians’ education on safe, effective and evidence-based prescribing of opioids.
- Reduce the stigma of pain and promote comprehensive assessment and treatment.
- Reduce the stigma of substance use disorder and enhance access to treatment.
- Expand access to naloxone in the community and through co-prescribing.
The AAFP remains dedicated to finding solutions to the crisis of pain management care and opioid abuse. Our policies are reflective of these two goals. Here are some key points from the Academy's policy paper, “Pain Management and Opioid Abuse: A Public Health Concern."
- The AAFP advocates for increased national funding for research into evidence-based strategies for pain management and their incorporation into the patient-centered medical home model.
- The AAFP urges states to obtain physician input when considering pain management regulation and legislation.
- The AAFP urges states to implement PDMPs and the interstate exchange of registry information as called for under the National All Schedules Prescription Electronic Reporting Act of 2005.
- The AAFP opposes mandated CME as a prerequisite to DEA or other licensure due to the limitations on patient access to pain management.
- The AAFP supports development of evidence-based physician education to ensure the safest and most effective use of long-acting and extended-release opioids and to reduce the problem of opioid abuse.
- The AAFP will continue to work with appropriate government agencies to ensure policies are in place to allow effective and safe opioid prescribing by family physicians for patients in their pain management programs.
- The AAFP has a number of resources available related to this issue.
AAFP Advocacy Promotes Compassionate Care
On July 9, CMS released its proposed rule for the 2016 Medicare physician fee schedule. As part of this rule, CMS is proposing to pay physicians for advanced care planning services -- better known as end-of-life counseling -- through two codes.
“CMS proposes to establish separate payment and a payment rate for two advance care planning services provided to Medicare beneficiaries by physicians and other practitioners," the agency said in the proposed rule. "The Medicare statute currently provides coverage for advance care planning under the 'Welcome to Medicare' visit available to all Medicare beneficiaries, but they may not need these services when they first enroll. Establishing separate payment for advance care planning codes provides beneficiaries and practitioners greater opportunity and flexibility to utilize these planning sessions at the most appropriate time for patients and their families.”
Under the proposed rule, CMS is proposing to pay for CPT codes 99497 and 99498. These codes, if implemented, will provide compensation for complex advanced care planning, which involves one or more meeting(s), lasting 30 minutes or more, during which the patient’s values and preferences are discussed and documented, and used to guide decisions regarding future care for serious illnesses. These consultations are voluntary on the part of the patient, and the patient may choose to include family members or caregivers in the meeting.
The AAFP has long advocated for Medicare to pay for advanced care planning services, and we applaud CMS for including this policy in the proposed rule. It is long overdue, and we promptly communicated our support of this policy proposal in a press statement following the release of the proposed rule.
In 1789, Benjamin Franklin stated, “…in this world nothing can be said to be certain, except death and taxes.” The problem is we, as a country, are much more comfortable having a conversation about taxes, than death. Conversations about death are difficult. They are especially difficult at the time that the outcome is imminent. However, as Mr. Franklin stated, death is certain. Our collective reluctance to discuss death doesn’t prevent it from happening; it only makes needed conversations and decisions harder.
This issue has always been wrought with political undercurrents and challenges. In 2009, as part of the health care reform debate, our country was starting to have a serious conversation about the importance of patients, caregivers and physicians engaging in a meaningful conversation about death and, more importantly, how we as a society could begin to openly discuss those difficult decisions that each of us will ultimately face. Sadly, the political discourse of the day reduced these conversations to a ridiculous talking point comparing advanced care planning to “death panels.” Thankfully the mastermind of this dreaded talking point has seen her 15 minutes of fame expire.
The AAFP played a prominent role in this policy being included in the 2016 proposed rule. In the years following health care reform, the AAFP worked closely with other physician and patient organizations to promote advanced care planning policies in the legislative and regulatory environments. We worked closely with Rep. Earl Blumenauer, D-Ore., on his legislation, the Personalize Your Care Act and Sens. Mark Warner, D-Va., and Johnny Isakson, R-Ga., on their Care Planning Act. We also worked closely with the Pew Charitable Trust as part of its Improving End-of-Life Care Initiative to develop and promote advanced care policies.
In 2014, the Institute of Medicine issued a report, “Dying in America,” which cited payment for advanced care planning as one of its five recommendations. The report states that “payers and health care delivery organizations should adopt these standards and their supporting processes, and integrate them into assessments, care plans and the reporting of health care quality.” Building on the recommendations of the IOM, in May of this year, the AAFP joined more than 50 other organizations urging CMS to provide payment for advanced care planning services.
The importance of this policy is well understood. Demographics are rapidly changing, and our population is growing older. The aging of our population is to be celebrated, but it does present challenges. By 2050, the number of people who are 80 and older will triple, and the number of people in their 90s and 100s will quadruple. Roughly 6 percent of Medicare patients die each year, and they consume approximately 30 percent of Medicare resources. As noted earlier, death is certain.
My question is this: How do we want the health care system to treat us or our loved ones in our final days and hours of life? I would suggest that there is not a more appropriate place for this conversation to take place than a family medicine practice. You are the trusted advisers and the facilitators of communication on these difficult issues with patients and their caregivers, and it is time that Medicare paid you for these services.
AAFP policy states, “supporting a patient’s care decisions at the end of life is part of the family physician’s responsibility in his or her partnership with the patient. The American Academy of Family Physicians (AAFP) believes that each individual has the right to decide what medical treatment he or she will receive. This right includes decisions about what life-sustaining treatment should be provided at the end of his or her life.” If this proposed rule is finalized, we will have successfully aligned public policy with AAFP policy, and patient care will be improved.
American Family Physician has volumes of resources on this topic that are well situated to assist you with end-of-life issues.
Moving from Meaningless to Meaningful Use
A decade ago, President George W. Bush created the Office of the National Coordinator of Health Information Technology (ONC) and called for the "widespread adoption of electronic health records in 10 years." This directive set our nation on a path towards the establishment and implementation of a national health IT system.
In 2009, Congress moved us further down this path when it enacted the Health Information Technology for Economic and Clinical Health (HITECH) Act. This law established an implementation framework through the meaningful use program and created an expectation that physicians and hospitals participating in the Medicare and Medicaid programs would use certified electronic health records (EHRs) by 2017.
This is where our story departs from script. To date, federal and state governments collectively have paid more than $28 billion in incentive payments to hospitals, physicians and other health care providers. By surface measures, one could argue that this investment and the meaningful use program have been successful. A 2014 HHS press release touted "significant increases in the use of electronic health records (EHRs) among the nation’s physicians and hospitals."
Although we should not overlook progress, there are some epic challenges (pun intended) that must be overcome if we are to realize the full potential of electronic medical records.
Despite a massive investment by federal and state governments, the quality and functionality of EHRs has not improved, and physician enthusiasm for EHRs have plummeted. Many family physicians, regardless of practice setting, complain about EHRs. The complaints fall in four major themes:
- "My EHR is clunky and disrupts workflow in our office."
- "My EHR cannot communicate with other physician offices or my local hospital."
- "I cannot access data in my EHR without paying a fee or hiring a consultant."
- "I can't afford all the upgrades, and I can't afford to change vendors."
These same themes were captured in a 2014 Medical Economics physician survey regarding EHRs. This survey found that nearly half of physicians think that EHRs are making patient care worse, more than 60 percent think that EHRs are hurting care coordination, and an astonishing 70 percent of physicians said that the implementation of their EHR was not worth the time, resources and cost. Adding insult to injury, a 2013 RAND study showed that EHRs are a leading driver of negative job satisfaction among physicians.
The AAFP has been a leader for more than a decade in assisting ONC, CMS, HHS and Congress on policies aimed at improving the nation's fledgling health IT system. We have conducted dozens of meetings and written numerous letters on this subject. In March, AAFP President Robert Wergin, M.D., testified before the Senate Health, Education, Labor and Pensions Committee (HELP) where he laid out a series of recommendations from the AAFP on how to improve both EHRs and the health information system.
Not only have we failed to meet the directive set forth by President Bush or capitalize on the investments made in the HITECH Act, but we may actually be further from reaching the 2017 goal today than we were five years ago. For the first time, member feedback suggests that a growing percentage of family physicians are simply giving up on meaningful use. Put another way, some physicians would rather pay a penalty than participate in meaningful use.
The decreasing levels of participation in meaningful use is concerning to the AAFP on its own, but with the passage of the Medicare Access and CHIP Reauthorization Act (MACRA), our sense of urgency around failing HIT policies is increasing rapidly. The ability of family physicians to achieve success in advanced delivery and payment models will depend on the availability of data and the ability to transmit and receive medical information in real-time. We cannot call the emailing of an 80-page discharge summary "interoperability." We need a system that can transmit clinically relevant health information in real-time and contributes to true care coordination, and we need EHR vendors to design products that actually fit into the workflow of a physician's office.
The reasons are complex, but one thing is clear -- current meaningful use criteria are not moving us closer to widespread adoption, and it is time for a change in direction. The AAFP advocated for changes in meaningful use stage 2, and we are pleased that ONC and CMS responded positively to reduce the required percentage of interactions through a patient portal and reduced the reporting period from 365 to 90 days. Additionally, we have called for a delay in meaningful use stage 3 to align these requirements with those contained in MACRA.
However, we are convinced that these changes are not sufficient to salvage the meaningful use program and facilitate an interoperable health information system. We need dramatic improvements in the program if we are to achieve the goals contained in the HITECH Act, and the AAFP is prepared to work with Congress and ONC to achieve these improvements. But, in order to accomplish these improvements it is clear that we should operate in a space that is free of financial penalties. This is why, in the coming weeks, the AAFP will be launching an advocacy campaign aimed at delaying the meaningful use stage 2 and 3 penalties.
Wonk Hard: Supreme Court Edition
On June 25, the U.S Supreme Court handed down a 6-3 decision in King v. Burwell in which they upheld that individuals who purchase health insurance though a federally facilitated health insurance marketplace are eligible for subsidies. The majority opinion was written by Chief Justice John Roberts, marking the second occasion that he has written the majority opinion in a case involving the Patient Protection and Affordable Care Act. The dissenting opinion, written by Associate Justice Antonin Scalia, offered a scathing rebuke of what the dissenting judges viewed as judicial activism going so far as suggesting the law be referred to as "SCOTUScare."
The King lawsuit is the last of the major challenges to the law or its provisions. Certainly additional cases will be filed, but the pathway for additional legal challenges to the ACA will be extremely challenging following this decision.
Medicare and Medicaid: 'Doing the Right Thing for Those in Need'
On July 30, 1965, President Lyndon Johnson signed into law the Health Insurance for the Aged Act, or as it is better known, the Medicare & Social Security Amendments of 1965. This established Titles 18 and 19 of the Social Security Act, which are better known to us today as Medicare and Medicaid.
Creation of these programs was not free of political and public resistance. Organized medicine was largely opposed and actively fought to prevent passage of the legislation. Twenty years prior, organized medicine had successfully defeated a similar proposal advanced by President Harry S. Truman.
The establishment of Medicare and Medicaid has its roots in the closing years of World War II. In 1943, Sen. Robert Wagner, Sen. James Murray, and Rep. John Dingell introduced the Wagner, Murray, Dingell bill -- better known as the WMD bill-- which would have expanded the Social Security Act to include a national health insurance system. The bill faltered in committee and never developed momentum. However, in 1944, President Franklin Roosevelt revived the WMD bill. After Roosevelt died, Truman continued the push for a national health care system as outlined in the legislation.
During the next five years, Truman fought a tireless campaign against Congress, the public and organized medicine. This public debate is captured in Monte M. Poen's book “Harry S. Truman Versus the Medical Lobby: The Genesis of Medicare.”
Despite his best efforts, Truman’s vision for the creation of a national health care system failed, largely due to the public outcry generated by organized medicine. The AMA spent more than $1.5 million on a national advertising campaign urging defeat of “socialized medicine.” The ads featured the catch phrase “guard your health, guard your pocketbook; socialized medicine would rob both.” In 1950, Truman gave up pursuit of his legislation.
The nation’s attention between 1950 and 1965 was largely focused on rebuilding the economy and the cold war. Health care, however, remained a prominent issue because more, and older, citizens faced daunting economic losses due to their health. In 1965, Johnson decided to refocus the nation’s attention on the issue. On Jan. 7 of that year, Johnson delivered a speech to the 89th Congress entitled “Advancing the Nation’s Health” in which he called for the establishment of an insurance program for the aged and needy children. During the course of seven months, Congress developed and approved the Social Security Amendments of 1965 (H.R. 6675).
The purpose of the legislation, as written by its authors, was "to provide a hospital insurance program for the aged under the Social Security Act, with a supplementary health benefits program and an expanded program of medical assistance, to increase benefits under the old-age, survivors, and disability insurance system, to improve the federal-state public assistance program, and for other purposes.”
Despite strident opposition from many, including organized medicine, the legislation was approved 307-116 in the House of Representatives and 70-24 in the Senate. Johnson signed the legislation on July 30th in Independence, Mo., at the Truman Library, in the presence of Truman. President Truman, following World War II, had devoted his presidency to the creation of a national health insurance program, but his most sought-after goal was to create a medical and economic safety-net for older Americans. At the signing ceremony, Truman stated, “Mr. President, I am glad to have lived this long and to witness today the signing of the Medicare bill which puts this Nation right where it needs to be, to be right.”
In his comments on that historic day Johnson stated, “No longer will older Americans be denied the healing miracle of modern medicine. No longer will illness crush and destroy the savings that they have so carefully put away over a lifetime so that they might enjoy dignity in their later years. No longer will young families see their own incomes, and their own hopes, eaten away simply because they are carrying out their deep moral obligations to their parents, and to their uncles and their aunts.”
Eighteen million people were eligible for Medicare in Aug. 1965. By March 31, 1966, 17 million had enrolled. A majority of the remaining 1 million were enrolled by the end of May. On July 1, 1966, the programs began covering medical services for eligible and enrolled individuals.
Next month, these two programs will celebrate their 50th anniversaries. Now, five decades removed from the heated political debate of the times, the programs are widely accepted as important components of our health care system and the social contract between our nation and its citizens. Today, more than 120 million people are enrolled in the Medicare and Medicaid programs. Enrollment in Medicare will continue to increase by 10,000 beneficiaries per day for the next decade as baby boomers become eligible.
By 2030, total enrollment in Medicare will exceed 80 million. Similarly, enrollment in Medicaid continues to increase as a result of the Patient Protection and Affordable Care Act, which extended eligibility to a larger portion of the population.
Both programs have undergone changes during their first 50 years. The most notable are the addition of the Children’s Health Insurance Program to Medicaid in 1997 and the Medicare Prescription Drug Benefit established in 2003. An overwhelming portion of the AAFP’s advocacy agenda for the past 50 years has been associated with these two programs. Looking forward, we see a continuation of this trend -- especially in Medicaid, which is now the largest health insurance plan in the nation.
I have spent my professional career arguing for and against policies that would reform and repair these two programs. The AAFP, through our advocacy efforts, has made significant improvements to care delivery, quality, and payment in both Medicare and Medicaid. Yet, we have so many lingering concerns and recommendations on what should be done to improve the programs for the millions of people who rely upon them. Normally, I would provide a series of resources for you to support the issue outlined in the blog, but this week I am leaving you with a quote from Johnson’s 1965 speech. I hope it reinforces why the voice of the concerned and compassionate physician is so important to our national debates and demonstrates all that can be achieved when we focus on doing the right thing for those in need.
“Few can see past the speeches and the political battles to the doctor over there that is tending the infirm, and to the hospital that is receiving those in anguish, or feel in their heart painful wrath at the injustice which denies the miracle of healing to the old and to the poor. And fewer still have the courage to stake reputation, and position, and the effort of a lifetime upon such a cause when there are so few that share it.”
Not So Fast: AAFP Urging FTC Scrutiny of Health Industry Mergers
Mergers and acquisitions aren’t two words that usually find their way into the lexicon of the AAFP’s advocacy agenda, but that is rapidly changing. Last week, the AAFP once again demonstrated bold leadership on behalf of our members and the patients you serve by publicly expressing concern about potential mergers in the health insurance industry. In a June 4 letter to the Federal Trade Commission (FTC), the AAFP expressed concern about speculation that two or more of the nation’s largest health insurers were exploring a merger.
“The American Academy of Family Physicians (AAFP) is deeply concerned about the potential merger of any of the nation’s largest health insurance companies and the impact such actions would have on access and affordability of health care for consumers across the nation," the letter said. "We urge the Federal Trade Commission (FTC) to carefully evaluate and scrutinize any potential merger(s) in the health insurance industry, specifically those involving two companies that are among the 10 largest national insurers.”
Health care, like many industries, is experiencing a new round of mergers and acquisitions that is reshaping local and national markets, as well as impacting the availability and affordability of health care services for millions of patients. According to many industry and Wall Street experts, we are on the front edge of the most robust merger and acquisition activity in the health care sector since the 1990s. One Wall Street analyst stated that mergers in the health insurance industry were “overdue.” (I believe this was the same attitude of railroad and oil barons of the 1920s, and we are all familiar with how that era ended.)
I am acutely mindful of Wall Street’s insatiable desire to win. Recent events and popular culture clearly demonstrate this -- see "Too Big To Fail," "Wolf of Wall Street," or the 1980s classic "Wall Street." I realize that challenging the desire of Wall Street isn’t always a safe bet, but I think these are issues where the AAFP should lead.
The Academy has been monitoring merger and acquisition activity closely for several years. Although some level of mergers is expected in a growing global economy, we have grown increasingly concerned about the pace and types of mergers occurring in the health care industry. In 2014, our concerns reached a tipping point, and we decided to open direct communications with the FTC on the issue of hospital and health insurer mergers. In a March 2014 letter to the FTC, the AAFP outlined our concerns with mergers in the insurance industry as follows:
“We have witnessed this trend for several years, but are more concerned today as health insurers expand into the Health Insurance Marketplaces and rollout Medicaid managed care products. In many markets, a single insurance company may be the dominant market force for the employer, individual, Health Insurance Marketplace, Medicare Advantage, and Medicaid populations. This situation allows insurers to control, if not manipulate, the physician workforce in those marketplaces. This is anticompetitive in our opinion and we encourage the FTC to use its resources to both examine and prevent such actions by the insurers.”
In that same letter, we expressed similar concerns with hospital and health system consolidation, stating, “The AAFP continues to urge the FTC to focus efforts on exposing the troubling increase in mergers between hospitals and health systems that increase costs, decrease competition, and fuel an uncoordinated race to provide expensive advanced medical technology and high-cost procedures. Patient access in these markets appears destabilized because hospitals and large health systems use unfair market powers and disparate site of service payment policies to buy out small physician practices or undermine them financially.”
In April of 2014, we again communicated with the FTC on these two issues, but added a specific emphasis on the anticompetitive behaviors of electronic medical record vendors. In that letter, we voiced our concerns with what has become known as “vendor lock” in the EMR industry:
“The AAFP is concerned with the utilization of health information technology to create competitive barriers against physicians and patients. The lack of interoperability makes it practically infeasible for a physician practice to switch electronic health records should the vendor or health care community use anticompetitive methods to limit a practice’s access to needed health information on their patients. This hoarding of data negatively impacts care and distorts market forces trying to decrease health care costs and improve quality. It is critical that health data flow to where patients wish to be treated. The current market forces for EHR vendors and large (quasi-monopoly) health systems limit interoperability in order to retain customers and patients and to elevate prices artificially.”
To their credit, the FTC and Department of Justice Antitrust Division have been aggressive in monitoring and challenging mergers in the health care sector. The FTC has successfully challenged several hospital and health system mergers on the grounds that they decreased or eliminated competition in local or regional markets. We also are pleased that the Office of the National Coordinator has voiced concern about EMR “vendor lock” through a report to Congress on information blocking.
Since the enactment of the Patient Protection and Affordable Care Act we have witnessed rapid and troubling mergers in the hospital industry. We are now in the early stages of similar activities in the health insurance industry. A 2014 report from the American Medical Association, “Competition in Health Insurance: A Comprehensive Study of U.S. Markets,” found that a single health insurer had a commercial market share of 50 percent or more in 17 states. Furthermore, the report found that in 45 states, two health insurers had a combined commercial market share of 50 percent or more.
These numbers demonstrate that a lack of competition clearly exists, which is why the AAFP has called on the FTC and Department of Justice to cast a wary eye on potential mergers in the health insurance industry. As we stated in our June 4 letter, “A delicate balance between competition and efficiency needs to be struck to benefit all consumers, physicians, and insurers -- especially during a time of high volatility.”
ICD-10 is inevitable. Be ready.
As we approach the official start of summer, I’d like to provide updates on some important issues that I believe are likely of interest to each of you. On a personal note, I’m encouraged to see -- with the baseball season entering its third month -- the Washington Nationals are starting to play as well as the “experts” predicted. The long, hot days of summer are where pennants are won and lost to be sure, but I’m encouraged that our nation’s baseball team is currently performing better than Congress, although that is a pretty low bar.
As always, I appreciate your feedback, thoughts, suggestions and occasional criticism of our advocacy work. We here at the AAFP want to make sure that we are representing you in the most effective manner possible, and I believe the interaction generated through this blog, as well as other AAFP vehicles, is critical to our ability to do so. So, keep those comments coming.
As of today, you have 127 days to prepare your practice and staff for ICD-10. With the Oct. 1 compliance date rapidly approaching, I thought it advisable to remind you about the AAFP resources available to assist you and your practice with the transition from ICD-9 to ICD-10. These resources include education materials, tutorials and coding flashcards that cross-walk the top 100 ICD-9 frequently used codes in family medicine practices to the more than 800 corresponding ICD-10 codes that will replace them.
We also continue to encourage all members to conduct end-to-end testing to ensure that you are prepared to make the transition. We are emphasizing testing with your billing clearinghouses, as well as with your payers. These clearinghouses created a tremendous bottleneck during the Form 5010 transition, so to avoid this problem; everyone needs to do their part to ensure this will not reoccur during the ICD-10 transition.
The AAFP continues to communicate with CMS on this issue, and we are expressing our desire to see CMS establish some form of a contingency plan -- especially for solo and small practices -- to ensure claims are paid in a timely manner in the event the conversion from ICD-9 to ICD-10 does not go as predicted.
Annual Wellness Visit
On April 30, the AAFP wrote to CMS expressing concerns with the emerging prevalence of commercial entities offering annual wellness visits (AWVs) to Medicare beneficiaries. In the letter, the AAFP asserted that “the AWV is a tool designed to encourage Medicare patients to engage with their primary care physicians on an annual basis for prevention and detection of illness and we are concerned that there are commercial entities that are subverting that benefit and may be misleading patients.”
The AWV was established as part of the Patient Protection and Affordable Care Act (ACA) and became part of the Medicare benefit package on Jan. 1, 2011. The AAFP actively supported the AWV as part of the ACA, and while we’ve expressed some serious concerns with the complexity of the documentation associated with the service, we continue to see this as a high-value service that connects family physicians with their patients. In the past year we’ve become increasingly concerned that commercial entities that have no desire or intention of providing continuous or comprehensive care have begun promoting their services directly to Medicare beneficiaries.
Unfortunately, it’s come to the AAFP’s attention that patients may be precluded from the benefits of the AWV provided by their family physicians due to services provided by a commercial entity. We see no commitment on the part of these companies to establish a relationship with the patient and it’s clear that they have no intention of caring for the patient after the AWV is provided. This practice has also drawn the attention of the Federal Trade Commission, which shares our concerns that the direct-to-consumer marketing of these commercial entities may contain false or misleading representations or intentional omission of key facts.
The AAFP met with CMS on this issue earlier this month, and we are working closely with key federal decision makers on a solution to this issue. We will keep you posted on our progress.
Give Me More Family Medicine
The Annals of Family Medicine recently published an article highlighting research done by the Robert Graham Center and building on previous research demonstrating the relationship* between primary care, better health outcomes, and lower overall per capita spending on health care.
The authors conclude that, “Increasing family physician comprehensiveness of care, especially as measured by claims measures, is associated with decreasing Medicare costs and hospitalizations. Payment and practice policies that enhance primary care comprehensiveness may help ‘bend the cost curve.’”
This article makes an important contribution to the growing body of literature and demonstrates the value proposition of primary care broadly and family medicine specifically. To view other work produced by the Graham Center please visit their newly redesigned webpage.
* I would have gone with a correlation/causation argument here, but my good friend and co-worker Julie Wood, M.D., would have a field day with my novice mistake.
The AAFP recently joined more than 60 organizations in urging CMS to value, and start paying for, Advanced Care Planning services through two previously established codes. In a May 12 letter, the AAFP and others urged the inclusion of CPT codes 99497 and 99498 in the 2016 Medicare Physician Fee Schedule.
In addition, the AAFP has recently partnered with the Pew Charitable Trust as a collaborator in its Improving End-of-Life Care initiative. This activity brings together several groups who share a common interest in advancing public policy that promotes access to advanced care planning and palliative care.
I anticipate that this issue will become a more prominent part of our national health policy dialogue in the months and years to come. If you are interested in this topic, American Family Physician offers a great collection of resources.
Family Medicine Congressional Conference
The AAFP recently hosted the Family Medicine Congressional Conference (FMCC) in Washington, D.C. This event brings together family physicians, residents and medical students to advocate on behalf of family medicine. This year, more than 200 participants heard presentations from three members of Congress, a senior administration official, six Congressional staffers, and national experts on issues of importance to family medicine. Additionally, participants visited the offices of 160 representatives and 83 Senators to advocate for reforms to our nation’s graduate medical education system.
This event is informative, fun and important to the Academy's success in Washington. I urge you to join us at the 2016 FMCC, which will be held April 18-19 in D.C.
It’s Time to Revolutionize GME -- Not Simply Reform It
“Social entrepreneurs are not content just to give a fish or teach how to fish. They will not rest until they have revolutionized the fishing industry.”
-- Bill Drayton, founder and chair of Ashoka: Innovators for the Public, a nonprofit organization dedicated to fostering social entrepreneurs worldwide
This post isn’t about fishing or the fishing industry. It's about the ability of each of us, individually and collectively, to drive change or, as the author above stated, “revolutionize” an industry.
Physicians aren’t necessarily the first group that people outside of health care think of when pondering professions that drive innovation, but physicians actually are among the most accomplished drivers of change in the world. And family physicians are at the front of that group. Throughout history, physicians have driven innovation in scientific research, revolutionized the practice of medicine, emphasized public health and dramatically improved the quality of life for millions of people worldwide.
As I examined the impact family medicine has had on revolutionizing the health of our nation, I was struck by just how much change our specialty has made. The AAFP has led the charge against smoking and tobacco, we are at the forefront of the obesity crisis, we were one of the first physician organizations to call for universal access to health care coverage -- recognizing that health insurance was a key indicator of health and wellness -- and we led the national effort to maximize vaccination rates.
Today, we continue this leadership through our efforts to modernize the care delivery system; the promotion of payment models that facilitate comprehensive, continuous and connected patient-centered care; and our efforts to place a higher value on the appropriate use of medical services through our work on the Choosing Wisely campaign. These are just a few examples of our efforts and accomplishments, but they demonstrate the positive impact family physicians and the AAFP can have on the health care system and the health of individuals when we organize our voice and speak loudly for change.
Now it is time for the AAFP to harness our energy and drive change in our graduate medical education system.
Today, family physicians from across the nation are gathering in Washington, D.C., for the AAFP’s 2015 Family Medicine Congressional Conference (FMCC). This event features presentations from notable health policy experts, researchers, a senior member of the Obama Administration, and two members of Congress. However, the most important opportunity FMCC provides is a chance for a group of family physicians to join together to drive change and innovation in health care. This year, we will focus our combined energy on revolutionizing our nation’s graduate medical education system.
Although Medicaid, the Veterans Health Administration and some private sources contribute to the training of our physician workforce, the majority of funding comes from Medicare. We spend more than $16 billion annually to train an estimated 120,000 physicians. The challenge for the country as a whole, and our elected officials, is to determine the return we are getting on this investment.
During the past year, there has been an increased awareness that we, as a nation, need to develop a comprehensive strategy on physician workforce. Our national GME policy was developed in the 1960s and continues to rely primarily on a hospital-based model that places a greater emphasis on training a workforce that reflects the needs of a teaching hospital rather than meeting the needs of its community or state. I am not one to diminish the important role teaching hospitals play and the value they add to our health care system. But we need academic health centers and teaching hospitals to play a role in our GME system rather than playing the leading role.
There are two talking points I use repeatedly to drive home the impact of the legacy hospital-based system. First, since 1965 there has been an increase in the number of recognized medical specialties from 10 to 145. Many of these are subspecialties of internal medicine, pediatrics and surgery, but some are new first-certificate disciplines. Second, 71 percent of all medical residents and fellows train east of the Mississippi River, and 60 percent of all residents and fellows are trained in just 10 states. These statistics demonstrate the economic power of GME and how GME finances have been consolidated to a handful of cities and communities.
To put it kindly, the AAFP believes the GME system is in desperate need of change, so we developed and put forth recommendations. In 2014, the AAFP released a report entitled “Aligning Resources, Increasing Accountability, and Delivering a Primary Care Physician Workforce for America.” This policy is thought-provoking by design, but we felt it was time to revolutionize GME -- not simply reform it around the edges.
Our policy proposal calls for limiting GME finances to first-certificate training -- meaning no more federal funding for fellowship training -- and establishes two levels of primary care accountability that hospitals must meet in order the secure their federal GME financing. Additionally, we create a pathway for more federal GME investment in community settings outside the traditional hospital-based system.
This policy remains the foundation of the AAFP’s advocacy efforts regarding comprehensive GME reform and will be the focal point of FMCC. This will not be an easy journey. GME finances are part of the economic fabric of many hospitals, cities and states, and they will not welcome the reforms we have proposed. We, as family medicine, must also recognize that we have a responsibility to change the GME system for the entire physician workforce, not just family medicine. I hope you will join your colleagues who are attending FMCC and lend your voice to driving innovation. Our country needs family medicine to once again be the catalyst of change.
This week, Atul Gawande, M.D., wrote a compelling article titled “Overkill” for The New Yorker about the changes that have occurred in McAllen, Texas, since his July 2009 article entitled “The Cost Conundrum.” Besides being one of the premier medical writers in the world (in my opinion), Dr. Gawande draws some interesting and encouraging conclusions on what has allowed McAllen to go from a high-cost, low-quality health care community to one that is high quality, low-cost. We should be proud of the answer, which is primary care.
I won’t ruin the article for you, but I will tell you my favorite line: “McAllen, in large part because of changes led by primary-care doctors, has gone from a cautionary tale to something more hopeful.”
That's just one more illustration of family medicine as a driver of change.
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