Repairing ACA May be More Likely Than Full Repeal
This blog is brought to you by the letter R.
No single letter better describes the first six weeks of the 115th Congress. "R" is, after all, for repeal, replace, reconciliation, repair, reform, restore, reduce, reservations, recording, retract, regulations, and -- most importantly -- reality.
As Congress and President Trump transition from campaign slogans to the hard process of legislating, it has become clear that promises made during the 2016 election to repeal the Patient Protection and Affordable Care Act "lock, stock, and barrel" are running headfirst into the reality of just how difficult such an endeavor is. I discussed the impact of a full repeal in a recent post.
The original plan outlined by Republican leadership after the election was to repeal the ACA prior to Trump's inauguration and then work during the next few years to develop and implement a replacement plan.
Shortly after Congress convened in January, the House and Senate quickly passed a budget resolution that included reconciliation instructions that would accelerate repeal. The resolution instructed five congressional committees to report their recommendations to the House and Senate Budget Committees by Jan. 27 -- a date that came and went with no apparent progress towards the development of repeal legislation.
In my Jan. 27 post, I predicted that the complexities of replacing the ACA would become the primary challenge. "Setting aside how complicated repealing the ACA will be, the complexity of that process pales in comparison to replacing the law," I wrote. This reality became apparent to members of Congress during a Jan. 25-27 meeting in Philadelphia.
After passing the budget resolution, House and Senate Republicans held their annual retreat where a number of members were heard expressing their reservations with the established "repeal and replace" plan. A significant number expressed their preference that a replace plan be drafted and vetted before they proceeded with a vote on repeal. These reservations, which under normal circumstance would have been confidential, were shared with the world via a secret recording of the closed-door session. Shortly after the retreat, Republicans made a noticeable shift from "repeal and replace" to "repair."
Further complicating congressional legislative activities is an inconsistent message from the Trump Administration. Trump has been consistent in his pursuit of full repeal of the ACA since the summer of 2015. However, in an interview that aired on Super Bowl Sunday, he stated that work on the ACA may not occur until 2018.
The Administration still has control over the regulatory process and will, in all likelihood, make significant changes to the law through this process. This process will take time, lots of time, so this may be a contributing factor in the President's recent comments. It is way too early to know if Trump's comments signal a shift in the Administration's priorities, but it certainly represents a change in expectations.
In the coming weeks, the five congressional committees (House: Ways & Means, Energy & Commerce, Education & Workforce; Senate: Finance, Health, Education, Labor, & Pensions) will develop legislative proposals to repeal the ACA. We anticipate that they also will begin work to develop a "skinny replace plan," which will allow them to signal their vision for a replacement policy at the time that they vote on repeal. It is unclear how quickly the House and Senate will move on repealing the ACA.
At this point, we anticipate votes in both Chambers prior to April 1, but timing is largely dependent on our final "R" in this equation, which is for Speaker Paul Ryan. At some point in the near future Ryan will need to identify a path forward and establish a reasonable time frame for legislative action.
The AAFP continues to work closely with Congress and the Administration on health care reform. Our advocacy efforts are aimed at advancing priorities, which we outlined in a Nov. 9 letter to then President-elect Trump and then a Dec. 28 letter to House and Senate leadership.
We also continue to work closely with other physician organizations. On Feb. 2, AAFP President John Meigs, M.D., joined the presidents of the American College of Physicians, American Academy of Pediatrics, American College of Obstetricians & Gynecology, and the American Osteopathic Association in Washington, D.C., to meet with several senators. The five organizations advanced policies and recommendations that would ensure gains made in health care coverage, preserve existing patient-centered insurance reforms, and promote primary care as foundational to our health care system. AAFP News has a great summary of this collaboration and the Feb. 2 meetings.
The next few weeks will be pivotal -- primarily because the legislative clock is ticking. Although the legislative path forward is unknown, we do believe that both the House and Senate will take action on the ACA and health care reform more broadly. Whether they are successful depends on how you define success. I personally anticipate that "repair" will become the dominant "R" word in the coming days.
In the infamous words of Dr. Dre -- "take a seat, I hope you’re ready for the next episode."
Reducing Administrative Burden a Must
"Darling, I'm a nightmare dressed like a daydream."
-- Taylor Swift
The regulatory framework that family physicians are required to comply with on a daily basis is daunting and, according to most of you, crushing and demoralizing.
Further complicating the work environment is a widespread opinion that many (if not most) regulations have limited impact on the quality of care provided to patients and, in some instances, actually slow down or prohibit access to care. Most health care regulations are developed based on a good intent, such as "improves quality," "prevents fraud," or "lowers cost." Others are developed and implemented in an attempt to improve patient access to health care services.
Regardless of a regulation's original aim, it is common for the scope of any given regulation to be expanded to an untenable level. To paraphrase the lyric above, most regulations are presented as items that are a "daydream" -- items that will require "minimal effort" but turn out to be a "nightmare" for family physicians and your practice.
The regulatory framework for physician practices has driven operating costs upward and profits lower. Without question, the administrative and regulatory burden is one of the top reasons independent practices close and is a leading cause of physician burnout.
Due to all of the reasons above, one of the most common questions that appear in the comments of this blog and other AAFP communication mediums is: "What are you doing to reduce the administrative burden for family physicians?" I wrote about this issue in a previous post that discussed how the AAFP was addressing the so-called "work after clinic" or WAC, largely driven by inefficiency of electronic health records (EHRs). Although we have a significant amount of work remaining, I believe our advocacy has resulted in some improvements in the regulations associated with the use of EHRs.
Reducing the administrative and regulatory burden on family medicine practices is a multi-faceted effort. The AAFP is actively advancing reforms with both public and private payers, but we also are advocating for reductions in burdens associated with the licensure and certification processes -- both of which have grown at a healthy pace during the past decade.
We see a renewed interest in this issue, and we have begun to increase our advocacy activity accordingly. In our Nov. 9 letter to then President-elect Donald Trump, the AAFP positioned administrative burden as a priority issue we would be advancing during the next few years: "Reduce the administrative burden by improving the functionality of EMRs, reducing the use of prior authorization and appropriate use programs, reducing needless documentation requirements, and streamlining workflow processes to ensure that patient care remains the top priority for family physicians."
The AAFP soon will be sending a new letter to President Trump, outlining the AAFP's agenda for regulatory and administrative reforms. This proposal identifies 10 administrative functions and regulatory compliance requirements that are crippling family medicine practices. I do not have space to outline each, but I will expand on the top three.
Prior authorizations are without question, the number one administrative burden identified by family physicians, and this is a priority issue for the AAFP. The frequent phone calls, faxes and forms you and your staff must manage to obtain prior authorization for an item or service not only create an uncompensated burden, but it makes patient care more difficult and certainly more frustrating. To address the negative impact of prior authorizations, the AAFP recommends the following:
- Congress and CMS should eliminate the use of prior authorizations in the Medicare program for generic drugs, create a single form that all Medicare Part D plans are required to use, and further limit or reduce the number of products and services requiring prior authorizations.
- All public and private health plans pay physicians for prior authorizations that exceed a specified number of prescriptions or that are not resolved within a set period of time; prohibit repeated prior authorizations for ongoing use of a drug by patients with chronic disease; prohibit prior authorizations for standard and inexpensive drugs; and require that all plans use a standard form.
Documentation Guidelines for E/M Services
The CMS Documentation Guidelines for Evaluation and Management (E/M) Services were written almost 20 years ago and do not reflect the current use and further potential of EHRs to support clinical decision-making and patient-centeredness.
The AAFP believes there should be changes in these outdated guidelines as well as the Medicare Program Integrity Manual. The changes would better ensure that the final entire medical information entered by the team related to a patient's visit would be considered in determining and supporting the submitted code.
To address the negative impact of current guidelines, the AAFP recommends that all documentation guidelines for E/M codes 99211-99215 and 99201-99205 be eliminated for primary care physicians.
Translation Service Costs
Since 2000, physicians have been required to provide translators for Medicare and Medicaid patients with hearing impairments or limited English proficiency, and on Oct. 17, new and costly limited English proficiency policies went into effect. Many family medicine practices operate on slim financial margins. We believe that Congress and HHS must procure the necessary funding to address and offset the estimated financial burden translation service requirements have on physician practices. We have significant concerns that primary care practices are already taking a financial loss for treating patients that require interpretive services because of the historical undervaluation of primary care services in the resource-based relative value scale system.
CMS must fund the increased costs practices will bear to comply with new translation requirements. If additional funding cannot be provided, then we call on CMS to eliminate the new translation service requirement.
One blog post does not allow space for a full description of all 10 recommendations, but I wanted to share items four through 10. These items, like the ones outlined above, also relate to the day-to-day activities that are frustrating each of you.
- quality measure harmonization and alignment;
- electronic health record interoperability;
- electronic care management documentation;
- appropriate use criteria alignment with the Merit-Based Incentive Payment System (unfunded mandate);
- Social Security number removal initiative (unfunded mandate);
- inconsistent claims review; and
- transitional care management services.
I recognize that this is not an exhaustive list of regulations that impact your practice each day, but this top 10 list does capture those regulations that family physicians have indicated to the Academy as the most time consuming and impactful. I will share more information on this effort in future posts, and you can follow our work on our administrative simplification resource page.
Speak Out to Preserve Health Care Coverage
On Friday, Donald Trump will be sworn in as the 45th President of the United States. Pursuant to our country's rich tradition, the transfer of power from the Obama Administration to the Trump Administration will take place in a peaceful manner.
Upon being sworn-in as president, Trump and his administration will formally start working with the 115th Congress to pursue an ambitious domestic and foreign policy agenda. At the top of the domestic policy agenda is the repeal of the Patient Protection and Affordable Care Act (ACA). During a press conference on Jan. 11, President-elect Trump provided his most concise perspective on the issue since winning the election.
"It will be repeal and replace," he said. "It will be various segments, you understand, but will most likely be on the same day or the same week, but probably the same day. Could be the same hour."
Setting aside how complicated repealing the ACA will be, the complexity of that process pales in comparison to replacing the law. Despite objections from a growing number of governors and congressional Republicans who are calling for a more thoughtful approach to repealing the law, Republican leadership and the Trump Administration are moving forward with repeal at an accelerated pace. The first wounds were inflicted last week.
On Jan. 12, the Senate approved a budget resolution for fiscal year 2017 that includes reconciliation instructions that will allow the Senate to repeal large parts of the ACA with a simple majority (51 votes). The House approved a similar resolution on Jan. 13, setting in motion a legislative process seeking to have a full repeal bill approved by the end of February.
In a Dec. 28 letter, the AAFP laid out its priorities with respect to how Congress and the new administration should proceed with health care reform. In that letter, the AAFP clearly stated that currently insured individuals should not lose their coverage due to any action or inaction by Congress or the administration. We also continue to stress the importance of impactful insurance reforms in current law that provide numerous protections for individuals, regardless of whether they have employer-sponsored insurance or purchase insurance through the individual market.
In addition to our letter, we also joined with the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the American College of Physicians to communicate a set of principles regarding how Congress should approach their work.
I encourage you to lend your voice to this important debate by sharing how important health care coverage and insurance reforms are to your patients. Use the AAFP’s Speak Out to communicate with your members of Congress on this important issue. If you would like to stay closely connected to our ongoing work on this or any other issue, you should follow @AAFP and @rshawnm On Twitter.
The next few months will be quite busy in Washington, D.C. Here are the four items that will dominate the first 100 days of the Trump Administration:
- cabinet nominations;
- Supreme Court;
- Affordable Care Act; and
PQRS, ICD-10 and the Impact of AAFP Advocacy
On Jan. 9, CMS announced that it "will not apply the 2017 or 2018 downward payment adjustments, as applicable, to any individual eligible professional or group practice that fails to satisfactorily report for CY 2016 solely as a result of the impact of ICD-10 code updates on quality data reported for the fourth quarter of CY 2016."
This decision was made following an internal review because CMS determined that updates made to ICD-10 in October 2016 negatively impacted the agency's ability to process data.
This action is consistent with recommendations the AAFP provided to CMS in July 2015 regarding the implementation of ICD-10. At that time, the AAFP called for "additional appeals and agency monitoring for reporting systems that determine appropriate payment for medical services based on quality measures and meaningful use of electronic health records."
CMS is encouraging physicians to refer to the ICD-10 Code Updates message on the PQRS Spotlight webpage or the PQRS ICD-10 Section page for additional information.
AAFP News has an excellent summary about how this may impact your practice. We also have extensive resources on PQRS available for our members.
The issue of drug pricing has emerged as a concern for patients and payers. Although the headlines are dominated by the costs of new-to-market blockbuster drugs, the real impact is the escalating costs of existing products -- including generics -- for millions of patients who rely upon them for their health maintenance. Few things catch Washington, D.C., and Wall Street by surprise, but President-elect Trump did so on Jan. 12.
"(What) we have to do is create new bidding procedures for the drug industry, because they're getting away with murder. Pharma. Pharma has a lot of lobbies, a lot of lobbyists, a lot of power. And there's very little bidding on drugs. We're the largest buyer of drugs in the world. And yet we don't bid properly. We're going to start bidding. We're going to save billions of dollars over a period of time."
Stock values for pharmaceutical companies took an immediate hit, and patient advocacy organizations cheered. There is still plenty of work that will need to be done, but it looks like the Pharmaceutical Research and Manufacturers of America may need that $300 million they stockpiled for a Clinton Administration after all.
AAFP Urges Congress to Uphold Health Care Coverage Expansion
Happy New Year!
I hope each of you had a nice and restful holiday and were able to spend time with family and friends. With the holidays behind us, it's time to turn our attention to Washington, D.C. and what will certainly be a busy first few months of legislative activity.
This week, the 115th Congress will convene and begin consideration of legislation that, if approved, would set in motion a series of events that could undermine the significant improvements that have been made in our health care system during the past decade. Specifically, in danger are the gains we have made in reducing the number of uninsured children and non-Medicare eligible adults, as well as a number of important insurance reforms that protect individuals in all insurance markets from discrimination based on age, race, gender, health condition, and socio-economic status.
The AAFP has long advocated for health care coverage for all Americans. Our policy, which dates back to 1989, clearly states that our goal is, "to provide health care coverage to everyone in the United States through a primary care based system built on the patient-centered medical home."
During the past two decades, the AAFP has worked in a bipartisan manner to identify and implement policies that have moved us closer to this laudable goal. The enactment of the Children's Health Insurance Program (CHIP) in 1997 provided health care coverage to millions of previously uninsured children. The Patient Protection and Affordable Care Act (ACA), enacted in 2010, built on the progress made through CHIP and extended access to affordable health care coverage for millions of previously uninsured, non-Medicare eligible adults and additional children not previously eligible for CHIP coverage. Throughout these reforms, we worked to solidify the important role of primary care and the value of a longitudinal relationship with a family physician. In 2015, our delivery system and payment reform efforts were captured, in part, through the bipartisan policies contained in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
Each of these steps was a result of the AAFP's consistent pursuit of our policies and a never wavering commitment to patients and their family physicians. We still have work to do, but we should recognize that we have made substantial progress towards our goal of providing health care coverage to everyone.
According to Gallup, the number of uninsured is at a historic low of 11 percent. This is an incredible statistic when you consider that less than a decade ago, our uninsured rate was nearing 17 percent with nearly 50 million people uninsured. The greatest gains in health care coverage have occurred among our most vulnerable populations and young adults. The uninsured rate among those making less than $36,000 annually has declined from 30.7 percent to 20.4 percent. The uninsured rates for those between 18 and 25 years of age has decreased from 23.5 percent to 14.9 percent, and the uninsured rates for those between 26 and 34 years of age has decreased from 28.2 percent to 19.4 percent.
These decreases in the number of uninsured are significant and reflect the consequential provisions enacted into law. These accomplishments are now under scrutiny, if not outright attack. Now is the time to accelerate our efforts on reducing the number of uninsured, not roll them back.
The AAFP's policies and advocacy on these issues moving forward are guided by a standard that has been proven accurate and factual the world over: The two primary factors that are most indicative of better health and more efficient spending on health care are continuous health care coverage and a usual source of care, normally through a primary care physician.
In the weeks ahead we will be aggressively defending and advancing our priorities with the House and Senate. There is not room in this space to outline each of the AAFP's policy priorities, but I do want to stress six key objectives:
- Insured individuals should not become uninsured as a result of any legislative or administrative short-term actions or inactions. Individuals who have already secured health care coverage should retain that coverage, including those who obtained coverage as a result of their state's expansion of its Medicaid program. Furthermore, individuals should be protected from loss of coverage that could result from inactions that result in a destabilizing of the individual and small-group market.
- Premium assistance and cost-sharing reduction subsidies aimed at assisting qualifying individuals with the purchase of health care coverage and/or paying their deductibles and co-pays should be preserved.
- There should be a viable and equitable safety net health care program for low-income individuals including those enrolled in Medicaid and CHIP. The basic benefits of the safety net should be universal, meaning beneficiaries are guaranteed health care coverage that is equitable to such coverage in any of the other states. We support continuation of incentives for additional states to expand Medicaid and those that have expanded to keep it.
- Policies prohibiting health insurers from imposing annual and lifetime caps on benefits should be retained and made applicable to all insurers, public and private.
- Insurance reforms that prevent discrimination against individuals in the insurance market must be preserved. Specifically, individuals should not be denied health care coverage, charged higher premiums, or have their coverage canceled based on a current or pre-existing health care condition, color, national origin, sex, age, disability, family history, race, gender, or income. We particularly call for continuation of protections that ensure that women are not charged higher premiums than men because of gender.
- All health insurance products should be required to cover evidence-based essential benefits including coverage, at no out-of-pockets cost to insured persons, to those preventive care and vaccines identified by the U.S. Preventive Services Task Force and other designated evidence-based assessment entities.
Wonk Hard -- The Process
I am not 100 percent certain about the process, but here is how we think things will play out during the next few weeks or months.
- This week, the Senate will consider a budget resolution for fiscal year 2017. The budget resolution will contain so-called "reconciliation instructions" that will request that the Finance and Health, Education, Labor, and Pensions (HELP) Committees identify a set amount of savings in their areas of jurisdiction (in this case, the ACA). The budget resolution requires 50 hours of debate in the Senate, so final passage would occur on or around Jan. 6.
- Upon approval by the Senate, the House will consider the Senate-approved budget resolution. The House version of the legislation will be identical with the exception that it will instruct the Ways and Means, Energy and Commerce, and Education and Workforce Committees to identify savings in their areas of jurisdiction (again, in this case, the ACA).
- Upon approval of the budget resolution by both chambers, the committees will begin drafting legislation aimed at repealing or reforming major portions of the ACA.
- The product produced by the committees will then be assembled by the Budget Committee in the House and prepared for consideration by the full House. The legislation would impact revenues (taxes), so it must originate in the House.
- Assuming the House approves the legislation, it would then be sent to the Senate for consideration. The legislation would be considered under reconciliation, so passage in the Senate only requires 51 votes. Republicans will hold 52 seats in the 115th Congress.
- If the Senate approves the House-passed bill, the legislation would go to the president for enactment into law. If the Senate alters the House-passed bill, it must return to the House for passage prior to being sent to the president.
- It is important to note that this is a long and complicated process. Getting a bill through five committees and two chambers will not be an easy task. Factor in the issue and the impact it will have on millions of people, and the level of complexity increases significantly.
Old Issues, New Year: A Look Back (and Ahead)
"Success is not final, failure is not fatal: it is the courage to continue that counts."
-- Winston Churchill
As we approach the end of the year, I decided to use my final post of 2016 to reflect on the past 12 months and provide some well-deserved thank yous to a group of deserving individuals.
I'll start by recognizing a group of people that dedicate their professional careers to the AAFP -- the incomparable Academy staff. The teams at our offices in Leawood, Kan.; Washington, D.C.; Cincinnati; and Hasbrouck Heights, N.J. -- as well as individuals in Austin, Texas; and Seattle -- are an amazing collection of talented and dedicated individuals. I am impressed by the talent assembled amongst our staff and their dedication to you, our members. Each day the entire AAFP team works to advance the mission of the AAFP, by producing resources and education for family physicians, advocating for our specialty and, most importantly, dedicate themselves and their talents to making the world a better place. I am truly honored to call each of them colleagues.
There is great risk in naming names, but there are a few people that I would like to thank for their contributions and support of this blog. David Mitchell, Min Shepherd, and Sarah Thomas are colleagues that I work with each week, and this blog would not happen without them. I am grateful for their contributions, guidance and collaboration. I am especially appreciative of David's ability to make me sound a little less "Oklahoman" and for his subtle ways of deleting controversial text!
This was quite a year, no doubt about it. Setting aside the elections, 2016 produced significant developments and changes in health policy. As I reflected on the past year, I identified five issues/items that I think symbolize the top health policy issues and those areas where the AAFP was most engaged in 2016.
The opioid epidemic dominated health policy at the federal and state level in 2016. According to the CDC, drug overdose is the leading cause of accidental death in the United States, with 55,403 lethal drug overdoses in 2015 alone. Opioid addiction is driving this epidemic, with 20,101 overdose deaths related to prescription pain relievers, and 12,990 overdose deaths related to heroin in 2015. These numbers are startling and likely to increase in 2016.
The AAFP has worked closely with the Obama Administration and the surgeon general on this issue for the past two years and will continue our efforts with the Trump Administration. We have developed extensive member resources aimed at providing you the timeliest information and a set of tools you can use in your practice as you balance the treatment of pain with the challenges of addiction. This is an important issue that requires family medicine leadership, which we are committed to providing.
The past year saw the promulgation and finalization of regulations implementing Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the historic delivery system and payment reform law. In April, the AAFP launched its MACRA Ready campaign aimed at assisting family physicians in their preparation for the new Quality Payment Programs (QPP) created by the law.
During the summer, the AAFP analyzed the proposed regulations implementing MACRA and then submitted more than 100 pages of comments, which had an impact on the final rule. In September, CMS announced it would implement a Pick Your Pace program that would allow physicians to participate in one of the MACRA QPP pathways at their own pace, thus avoiding negative payment updates in 2019.
In October, CMS published the MACRA QPP final rule and launched a website aimed at assisting physicians. MACRA will continue to be a top priority for the AAFP in the coming year, and we will continue to produce tools and resources that assist you and your practice. I will be devoting future posts to this topic, so please stay tuned.
The nation once again became focused on a public health outbreak in 2016. The AAFP quickly produced information and patient education materials for our members, and we partnered with the CDC and others to inform the public on how to protect themselves from the Zika virus.
The frequency of public health emergencies is concerning to the AAFP and a central reason why we are prioritizing public health and population health in our strategic plan. Family physicians are on the frontline of these public health outbreaks and place a critical role in educating patients and communities on how best to protect themselves against these occurrences. You can find up-to-date information on public health issues on our patient care resource page.
Direct Primary Care
The DPC practice model continues to draw interest among family physicians, and the AAFP remains at the forefront of efforts to assist interested family physicians in their transformation from a traditional, insurance-based practice model to DPC. The AAFP has developed a DPC Toolkit that provides detailed guidance on making such a change. This toolkit has been used by hundreds of physicians during the past few years and continues to be the best single source of information for those interested in DPC.
The Academy continues to support its DPC Member Interest Group, which allows interested family physicians to share ideas and concerns with each other.
The AAFP also continues to play a prominent role in advancing policies and regulations that would make DPC practices more broadly available. In 2016, the AAFP worked closely with members of the House and Senate to introduce legislation that would allow DPC practices to be recognized under federal laws governing health savings accounts. This bill is a priority for the AAFP in the 115th Congress.
Finally, the AAFP is hosting a DPC Workshop in Atlanta on March 11, and the Academy will once again co-host the 2017 DPC Summit in either June or July. We are finalizing details, and an announcement will be made early next year.
You are probably asking yourself how the Cubs qualify as a health care issue, so I am going to tell you. For more than 100 years, our nation's third-largest city (at least the north side) has been paralyzed by an August-induced anxiety, largely associated with its beloved team's historic (and often dramatic) collapses in the fall months. By winning the World Series, the Cubs decreased the anxiety levels (at least temporarily) of nearly 10 million people in the Chicago metropolitan area and millions more around the world. And, because we know anxiety is not good for our health, I am giving the 2016 World Champion Cubs credit for positively impacting the health and wellbeing of millions of people -- a great accomplishment!
I started this blog with a quote from Churchill. This is one of my favorite statements by the former United Kingdom prime minister because it captures the fluidity of the world in which we live and reminds us to set our eyes on the horizon. In closing, thank you for your support of the AAFP, the great service you provide your patients and our country each and every day and for your support of this blog.
I hope you have a wonderful holiday season. May you always find yourself on the north side of the Red River in the New Year.
AAFP to Congress: Hands Off USPSTF
Last week, AAFP President John Meigs, M.D., testified before the House Energy and Commerce Committee Subcommittee on Health in defense of the U.S. Preventive Services Task Force (USPSTF).
The hearing was scheduled to examine the task force and discuss the USPSTF Transparency and Accountability Act (HR 1151), legislation that would alter the composition and scope of work of the task force. Meigs was invited to share the AAFP's views on the USPSTF and the important role it plays in assisting family physicians in their daily interactions with patients.
The AAFP is a strong supporter of the task force and is an active participant in its work. The Academy actively engages with the task force to identify and evaluate clinical guidelines to ensure that family physicians have the most timely and relevant information to assist them in the care of their patients. The AAFP's clinical recommendations typically align with recommendations made by the task force.
In his testimony, Meigs outlined our strong support for the USPSTF and its existing composition.
"My work and that of hundreds of thousands of primary care physicians relies on the integrity of the U.S. Preventive Services Task Force (USPSTF or the task force)," he said. "The task force was designed to be, and has been, a non-partisan, independent body of physicians and other health professionals who make valuable recommendations for primary care. Many recommendations within H.R. 1151, the USPSTF Transparency and Accountability Act, in our opinion, would undermine the work and progress that has been achieved since the task force was established in the early 1980s."
In recent years, the task force and its recommendations have faced increased political scrutiny. Although some of this scrutiny was in response to recommendations made by the task force (specifically related to mammography and prostate cancer screening), the more significant attention came about as a result of Section 1302 of the Patient Protection and Affordable Care Act. Section 1302 of the ACA requires all insurers (public and private) to provide preventive services that receive an A or B grade from the USPSTF and vaccination recommendations from the CDC's Advisory Committee on Immunization Practices independent of patient cost-sharing (co-pay and deductible).
The AAFP has policy supporting this provision, but recognizes that the inclusion of the coverage provisions in the ACA changed the impact of the work for the task force and elevated its significance in the eyes of many in the health care industry.
HR 1151 would make four significant changes:
- alter the composition of the task force to include subspecialists;
- allow representation and participation by the broader health care industry, including pharmaceutical and medical device companies;
- require that the task force to assess how its grades would impact access to a health care service or device; and
- require that the task force publish its research plan, including the analytic framework, key questions and literature search strategy.
Although HR 1151 will not advance in the current Congress, it likely will be re-introduced in the 115th Congress. The AAFP will continue to support the task force, its work and its recommendations. We also will aggressively oppose efforts to diminish the task force's work.
The USPSTF, created in 1984, is a panel of national experts in prevention, epidemiology and evidence-based medicine. These experts include family physicians and other primary care physicians. The task force is charged with making evidence-based recommendations about clinical preventive services such as screening exams and preventive medications. The task force gives each recommendation a grade of A, B, C, or D or an I Statement based on the strength of the evidence considered during the rigorous review of evidence. The recommendations are applicable to individuals who do not demonstrate signs or symptoms of the specific disease or condition under evaluation and only apply to services provided by primary care physicians. The recommendations are not designed to prohibit or restrict patient access to any preventive service.
Presidential Transition Update
In recent days, President-elect Trump has begun announcing nominees for key post in his administration. These nominations have spurred a flurry of reactions -- positive and negative -- from individuals across the nation, including family physicians. In my previous post, I discussed the impact of the elections and the AAFP's approach to working with the Trump Administration and the incoming 115th Congress. I would like to build on my previous post and offer some additional perspective on how the AAFP can best represent our members and advocate on behalf of our patients.
The AAFP is a professional organization that has the tremendous honor and obligation of representing the nation's family physicians and, more importantly, being an advocate for patients. The AAFP has been and remains a bi-partisan organization. We are an organization grounded in a set of core beliefs that each individual, regardless of their personal or economic situation, deserves access to affordable and quality health care. We are guided by our strategic plan and policies adopted by our Congress of Delegates. Although elections and politicians come and go, the AAFP's steadfast commitment to these fundamental objectives remains constant.
Elections, by design, create disruption. This disruption contributes to a sense of uncertainty about what is to come and what is to be expected of new leaders. This is why it is important to be grounded as an organization. The AAFPs inclusive and comprehensive set of policies allow us to advance our mission and advocate for our members with any individual, regardless of their party affiliation or ideology. These same policies also allow the AAFP to hold elected officials accountable for their decisions and actions.
It would be a disservice to our members and their patients to not engage with an individual or political party simply because they hold or have advanced a point of view contrary to ours. Our job is to advocate on behalf of family medicine and patients, to the best of our ability, with all elected officials. We are a professional organization that feeds on the passion and commitment of our current and future members, while looking to our Board of Directors and professional staff to harness that passion and advance our goals and mission.
There is a professional standard that guides how an organization such as the AAFP should conduct itself. This includes an effort to adhere to respectful dialogue on issues and representing our organization and members in a reputable manner at all times.
Although we all have our personal opinions on the various individuals who serve in government, it is important to remind ourselves that we all share a set of common goals for family medicine and patients. Now is the time to rally around those goals and objectives that unite us. To this end, I urge you to engage with the AAFP to advocate for our profession and our patients. The best way to do this is by joining the Family Physician Action Network.
The 'Change Election' Happened -- Now What?
"Wish we could turn back time, to the good ol' days
when our mama sang us to sleep but now we’re stressed out."
-- Twentyone Pilots
I chose the above verse because it captures so many emotions that have nearly paralyzed our nation for the past 18 months. During the past year, each of us has probably wished at some point that we could just crawl into bed and hide under the covers. AAFP President John Meigs, M.D., wrote an excellent editorial in AAFP News last week in which he captured the wide range of emotions aligned with the election and its outcome.
Nov. 8 brought to a conclusion one of the most aggressive and divisive elections in our nation's history and certainly the most negative campaign of the modern political era. Although the results of the election have spawned mixed reactions, it is now clear who will lead our government for the next four years. There is much work to do, but I would suggest that there already was much work to do on Nov. 7.
In the early morning hours of Nov. 9, after securing more than 270 Electoral College votes, Donald J. Trump became president-elect Donald J. Trump. On Jan. 20, he will be sworn-in as the 45th president of the United States of America.
A few hours after President-elect Trump delivered his speech to the nation, accepting the results of the election, his transition team received a letter from the AAFP congratulating him and outlining our priorities for the next four years. Our advocacy work with the 45th president and his administration started before sunrise on Wednesday, Nov. 9 and will continue for the next four years. In our letter we outlined five policy priorities and pledged our commitment to working with the new administration to develop and implement policies that would achieve those priorities. Here are those five priorities:
- health care for all;
- delivery system and payment reform;
- health care affordability;
- primary care physician workforce; and
- promotion of prevention and wellness.
On Jan. 3, when the 115th Congress convenes, Republicans will have majorities in the Senate and the House. These majorities are smaller than those in the 114th Congress, but they are working majorities. Those margins coupled with Trump's victory mean the federal government will be under unified Republican control for at least the next two years.
We are entering a legislative session that has the potential to fundamentally reshape our nation's health care system and safety-net programs. In addition, we likely will see policies proposed in Congress that will challenge many long-standing AAFP policies related to health care coverage and access, women's health and public health programs.
It is impossible to predict with any accuracy what will happen in this Congress. As I have said many times in the past few days, "campaigning is easy, governing is hard." The process of drafting and enacting policy is much more involved and time consuming than candidates imply during campaigns.
However, we do have a decent understanding of policies that the Trump Administration and the 115th Congress likely will focus on. The following are five issues that we see as items in focus for 2017:
Patient Protection and Affordable Care Act -- The full repeal of Obamacare has been a priority for the Republican Party since 2010. To quote Vice President-elect Mike Pence, "We will repeal Obamacare lock, stock and barrel." This point of view is shared by a majority of House and Senate Republicans. Despite campaigning on the full repeal of the law, Trump has begun to nuance his policy position on the law. In an interview with The Wall Street Journal, he suggested that he would be willing to keep certain parts of the law.
Repealing the ACA outright is, in reality, improbable. Any such action would unravel the insurance market and create a financial crisis for individuals and businesses. Therefore, we will see efforts to replace certain policies and, possibly, create new programs that would extend access to health care coverage -- think health savings accounts and high-risk pools.
Despite the complexity of repealing the ACA, I am confident that the ACA will be altered and damaged in a significant manner on Jan. 20 or shortly thereafter.
MACRA -- The Medicare Access and CHIP Reauthorization Act was approved by overwhelming bipartisan majorities in the House and Senate. In fact, 91 percent of the House and Senate voted for this law. Additionally, reducing the cost of health care remains a priority. Due to the continued focus on costs and the bipartisan support the law secured, MACRA will continue to be implemented.
There may be slight modifications to improve the law, but these changes needed to be made regardless of who won the election. The AAFP continues to make available valuable resources on MACRA, and I encourage you to review the options available to you under the Pick Your Pace program that is available for 2017. Remember, if you participate in the program at any level in 2017 you will not face negative payment updates in 2019. (I discussed these options in my Oct. 25 post.)
Medicaid -- The Medicaid program, like the ACA, has been a priority for Republicans for the past several years. Speaker Paul Ryan, R-Wis., has developed and advanced an alternative to the current federal-state partnership funding formula that would utilize a state-by-state per-capita cap to fund the program. This is different than the more traditional "block grant" proposals advanced by Republicans in the past, but the two proposals would significantly alter the Medicaid program, essentially turning the program over to individual states and eliminating the current role of the federal government in the program.
I anticipate that Medicaid will get significant legislative attention in 2017. I am not confident that Republicans can rollback Medicaid expansion or change the underlying funding formula, but I am confident that they will pursue these changes aggressively.
Administrative simplification -- Trump discussed the negative impact of regulation on businesses throughout the campaign. Although his comments were not specifically focused on health care, we see an opportunity to potentially reduce the administrative burden of participating in the Medicare and Medicaid programs under his administration. A priority for the AAFP will be a reduction in documentation guidelines for physician services under Medicare.
Workforce -- The issue of physician workforce did not come up during the campaign, but we see opportunities. Republican majorities are largely a result of rural and exurban communities, predominately in the south and west of the Mississippi River. These communities are more likely to face physician shortages as compared to urban and suburban communities on the East and West Coasts. I don't see workforce as a top-tier issue, but it is a place where we will be pushing hard.
On Jan. 23, 2009 President Obama stated, "Elections have consequences." This statement was true then, and it is true today. We, as a nation, experience political disruption every few years. The specific consequences of this year's elections are unknown, but the AAFP is not resigned to being a passive participant in the next four years. We see opportunities to shape our specialty's future, and we will be grinding the policy levers daily to ensure that family medicine and patient-centered policies are front and center.
You can drive change in Washington; here's how
Happy Election Day!
I hope each of you have voted today. If you have not, I urge you to do so before the polls close. Engaging in our political process is both a right and privilege, and I hope that each of you will exercise your civic duty of participating in our electoral process. Then, if you are like me, you can spend the rest of the night staring at your television, computer and smart-phone -- all at the same time!
At some point tonight, the United States of America will elect its 45th President. The announcement of a projected winner of the presidential election will set in motion a series of activities aimed at transitioning from the Obama Administration to the administration of the president-elect, which will formally occur on Jan. 20.
The announcement also will set in motion a series of activities at the AAFP as we initiate our transition to the new administration. Tomorrow, the AAFP will send a communication to the president-elect outlining a set of policy priorities that we will advance on behalf of family physicians and patients. It will also state our intentions to work with the new president-elect and his or her administration during the course of the next four years to advance policies that increase access to care and improve our health care system.
Prior to Inauguration Day, the AAFP will meet with professional staff representing the president-elect to share our priorities and explore opportunities for the AAFP to work with the new administration. Additionally, we will be identifying and advancing the names of family physicians interested in serving in various positions within the administration.
Regardless of who wins tonight, the federal government will undergo a change in leadership. Thousands of new staff will occupy positions being vacated by the Obama Administration. This turnover is extraordinary in scope, but I can promise you that the AAFP will be there to advance the interests of family medicine.
Family Physician Action Network
"One person can make a difference, and everyone should try." – John F. Kennedy
This simple, yet impactful statement from President Kennedy is truly the motivating quote that describes the importance of advocacy and being an advocate. Looking forward to 2017, the AAFP will be prioritizing its advocacy efforts with you, our members. We are fortunate to have a membership that is passionate about family medicine and primary care. I continue to be moved by the selfless passion you have for your patients and communities.
Most people believe that you need people who are passionate about your cause or issue -- in our case family medicine and primary care -- to have a successful advocacy network. I do not question that passion is an important attribute of successful advocates, but passion alone is not really sufficient to identify and enact change. I am not alone in this thinking, and I have been influenced by author Simon Sinek. I am a disciple of his first book Start With Why. If you have a few minutes, I encourage you to watch his TedTalks about leadership.
Sinek has a quote that has always struck me as descriptive and applicable to advocacy and how individuals and organizations view and approach it: "Being driven is not the same as being passionate. Passion is a love for the journey. Drive is a need to reach the destination."
I think this is demonstrative of the AAFP's current thinking about advocacy. How do we take 124,900 passionate individuals and give them the tools and motivation to be driven to accomplish change versus simply calling for change?
In an effort to give members a way to easily and effectively engage in grassroots advocacy, the AAFP has re-launched its advocacy toolkit, which introduces the new Family Physician Action Network. The network is designed to be a forum to educate, coordinate, and engage family physicians around family medicine's priority issues. Network members will have access to issue briefings, tools and the best practices to directly communicate with your legislators on a given topic. Network members also will have access to an online community platform where they can discuss and organize around legislative issues. This will allow for a more efficient coordination of Speak Outs and social media campaigns.
Our goal is to harness your passion for family medicine and give you the tools to join our efforts to drive change. I urge you to join the Family Physician Action Network . As a member you will receive insider information on the progress of health care in Washington, and you will become a driver of change in Washington, D.C.
MACRA 101: What You Need to Know
We are now 14 days from Election Day (assuming you did not participate in early voting). After more than 18 months of campaigning, the end is in sight. Soon, the nation will elect its 45th president, and our favorite television stations will return to a mix of auto insurance and pharmaceutical advertisements in place of the plethora of political ads that have aired for the past six months.
In my previous post, I outlined the two major party candidates' positions on health care issues. I urge each of you to vote on Nov. 8. Our democracy benefits from participation.
Fall also means rule-making, and the folks at CMS have been busy. On Oct. 14, CMS released the final rule implementing the Medicare Access and CHIP Reauthorization Act (MACRA). AAFP News has a good story on the rule and the AAFP's response. CMS finalized all provisions of the law, including eligibility, participation and evaluation requirements for the MACRA Quality Payment Programs (QPP). These criteria become effective Jan. 1.
The following is a high-level summary of the law. I will dig deeper into each of these sections during the next few months, but this post is designed to give you basic information.
First, I must state three things up front:
- This final regulation includes numerous policies that are the direct result of AAFP advocacy. Since submitting our comment letter on the proposed regulation, we have continued to advocate on your behalf to improve the regulation. I am especially proud of the Pick Your Pace program. This is a concept the AAFP provided CMS, and we are pleased that it was incorporated.
- All physicians participating in the Medicare program will receive a 0.5 percent update in payments for services provided in 2017.
- If you participate in the Merit-Based Incentive Payment System (MIPS) program, no matter for how long, you will not be penalized in 2019.
CMS has provided an excellent online resource on the QPP program. Let’s jump into the details.
The MACRA QPP creates two pathways for Medicare participating physicians:
- Advanced Alternative Payment Models (Advanced APM)
If you are one of the following, you are eligible to participate in either of the QPP pathways:
- physician assistant;
- nurse practitioner;
- clinical nurse specialist; and
- certified registered nurse anesthetist.
You are not required, as a condition of participating in the Medicare program, to participate in either of the QPP pathways. You may elect to provide care to Medicare patients and not participate in the QPP. However, if this is your decision, you will face maximum negative payment updates as outlined below.
Exemptions -- If your Medicare allowable charges are less than $30,000 a year or you do not provide care to more than 100 Medicare fee-for-service patients in a year, you are exempt from participation in the QPP. However, if your Medicare allowable charges exceed $30,000 a year and you provide care to more than 100 Medicare fee-for-service patients a year, you are part of MIPS. Additionally, if 2017 is your first year as a Medicare participating physician, then you are exempt from participation in the MIPS program. You may participate in an Advanced APM.
Performance period -- The performance period starts Jan. 1 and concludes on Dec. 31, 2017. Due to the flexibility provided by the Pick Your Pace provisions, physicians may initiate their 2017 performance period at any point between Jan. 1 and Oct. 2.
Data Submission -- Physicians participating in the MIPS pathway must submit quality, advancing care and clinical practice improvement activity data to CMS by March 31, 2018. Physicians participating in an Advanced APM also must submit data by March 31, 2018. If you do not submit 2017 data by the March 31, 2018 deadline, you will receive a negative 4 percent payment adjustment in 2019.
Report as an individual -- If you submit MIPS data as an individual, your payment adjustment will be based on your performance. An individual is defined as a single national provider identifier (NPI) tied to a single Tax Identification Number (TIN).
Report as a group -- If you submit MIPS data as a group, the group will get one payment adjustment based on the group's performance. A group is defined as a set of physicians and other clinicians, identified by their NPIs, sharing a common TIN.
Feedback -- Medicare will provide feedback to individual physicians and physician groups and notify you of your performance score and subsequent payment rate for 2019.
Payment -- Based on your performance in 2017, you will receive a neutral or positive payment update, up to 4 percent, in 2019. If you successfully participate in an Advanced APM, you will receive a 5 percent incentive payment in 2019.
MIPS Payment Adjustments
- 2019 = +/- 4 percent
- 2020 = +/- 5 percent
- 2021 = +/- 7 percent
- 2022 and beyond = +/- 9percent
Advanced Alternative Payment Model
- 2019 to 2024 = +5 percent
Performance Criteria & Weighting -- MIPS
Quality -- 60 percent of total score.
Report up to six quality measures, including an outcome measure, for a minimum of 90 days.
Clinical Practice Improvement Activities -- 15 percent of total score.
Attest that you completed up to four improvement activities for a minimum of 90 days. For solo and small group physicians, or if you practice in a rural or health professions shortage area, attest that you completed up to two activities for a minimum of 90 days. If you are a certified patient-centered medical home or an APM designated as a medical home model, you automatically receive full credit for this category.
Advancing Care Information -- 25 percent of total score.
Fulfill the five required functions which are: security risk analysis, e-prescribing, patient access, summary of care, request/accept summary of care. You may earn additional credit if you submit up to nine measures for a minimum of 90 days. Additionally, you can earn bonus credit for reporting public health and using clinical data registry reporting measures and/or use a certified EHR to complete clinical improvement activities in the performance category.
Cost -- 0 percent of total score.
This category is delayed until 2018 and will not impact payments in 2019. Compliance with the measure does not require data submission on the part of the physician. It is measured using claims data submissions.
Performance Criteria -Advanced APM
APM Model -- You must participate in a selected APM, which includes the following:
- Comprehensive Primary Care Plus (CPC+)
- Next Generation ACO
- Shared Savings Program Track 2 and Track 3.
Risk -- The APM must take on more than nominal risk or be a recognized medical home model as determined by the Center for Medicare and Medicaid Innovation (CMMI) a recognized Medicaid Medical Home Model.
Beneficiary Threshold -- Twenty-five percent of your Medicare Part B payments must be received through the Advanced APM or 20 percent of your Medicare patients are assigned to your Advanced APM.
Data Submission -- Advanced APMs are required to submit data on identified quality measures using a certified EHR.
Pick Your Pace Program
Test -- If you submit a minimum amount of 2017 data to Medicare, you can avoid a downward payment adjustment in 2019. Minimum amount of data can be as de minimis as one quality measure, one improvement activity, or only four advancing care information measures.
Partial Participation -- If you submit 90 days of 2017 data for all three categories (quality, advancing care information and clinical practice improvement activity) to Medicare, you may earn a neutral or small positive payment adjustment in 2019.
Full Participation -- If you submit a full year of 2017 data, in all categories, to Medicare, you may earn moderate positive payment updates in 2019.
Advanced APM -- If you receive 20 percent of Medicare payments or see 20 percent of your Medicare patients through an Advanced APM in 2017, then you earn a 5 percent incentive payment in 2019.
For additional information, check out the following resources:
- AAFP MACRA Ready resources
- AAFP advocacy on MACRA final rule
- AAFP News
- CMS assistance is available by email or by calling 1.866.288.8292.
- Finally, here is my MACRA presentation at the Family Medicine Experience.
Donald or Hillary? How Choice Affects Health Care
In less than 30 days, the United States will elect its 45th president. The upcoming elections also will determine who represents your state and community in the U.S. House of Representative and Senate -- not to mention thousands of state and local offices.
Nov. 8 will bring to a close one of the more memorable presidential campaigns in modern history. If you watch television or read a newspaper you have likely heard that this is the "most important election of our lifetime." Pundits and political operatives tend to say this every four years, so the idea has a bit of a "boy who cried wolf" feel to it. I find such statements a little amusing.
Electing a single individual to lead the most economically and militarily powerful country on earth is a process that should be taken seriously, by each of us, every time. To this end, whether you are "with her," want to "make America great again," or even if you can't stand either of the major parties' candidates, I urge you to participate in our electoral process and cast your ballot on Nov. 8 or through your state's early voting opportunities. To quote the incomparable Winston Churchill, "Democracy is the worst form of government, except for all the others."
Our next president will be responsible for overseeing the federal government for the next four years, including major health insurance programs such as Medicare, Medicaid, and the Veterans Health Administration. To date, the two leading candidates have not featured health care as priority issues for their campaigns. I will note that a former President has made some headlines for his views on health care lately, but the two candidates themselves have stayed focused on other issues -- mainly each other.
While health care hasn't emerged as a top-tier issue for the campaigns in the 2016 elections, the economics of health care continues to be important to voters. The September Kaiser Health Tracking Poll includes some interesting insights into voters attitudes towards health care coverage and cost. Sixty percent of respondents said the cost of health insurance premiums is "very important" to their vote for president in 2016. Additionally, 55 percent stated that the cost of health insurance deductibles is "very important" to their vote for president in 2016. Fifty-one percent said that the cost of prescription drugs is "very important" to their vote.
Despite a daily focus on large-scale health care reforms, both candidates have expressed their commitment to addressing the opioid epidemic and their support for greater access to mental health services. The campaigns also have expressed a desire to improve access to care for our nation's veterans. Another interesting area where the candidates have expressed shared concern is the cost of prescription drugs. Interest in this area makes good political sense - it's a kitchen table issue for millions of Americans who are facing escalating bills due to the cost of their prescription drugs. The Kaiser Health Poll mentioned above showed that 77 percent of Americans view the cost of prescription drugs as "unreasonable." More than 35 percent of individuals who take four or more drugs state that it is difficult for them to afford their prescription drugs.
The health policy agenda of the two candidates are difficult to compare due to a lack of comprehensive proposals on the part of the Trump campaign. Kaiser Family Foundation has a side-by-side comparison of the candidates' positions on seven key health care issues. I have found this to be the most comprehensive resource other than the candidates' websites. The following are the top-line policies each candidate is advancing as their "health care agenda."
Donald Trump's health care agenda is outlined in a five-point plan:
- Repeal and replace the Patient Protection and Affordable Care Act with health savings accounts.
- Work with Congress to create a patient-centered health care system that promotes choice, quality and affordability.
- Work with states to establish high-risk pools to ensure access to coverage for individuals who have not maintained continuous coverage.
- Allow people to purchase insurance across state lines, in all 50 states, creating a dynamic market.
- Maximize flexibility for states via block grants so that local leaders can design innovative Medicaid programs that will more appropriately serve their low-income citizens.
- Defend and expand the Affordable Care Act, which covers 20 million people.
- Bring down out-of-pocket costs like copays and deductibles.
- Reduce the cost of prescription drugs.
- Protect consumers from unjustified prescription drug price increases from companies that market long-standing, life-saving treatments and face little or no competition.
- Fight for health insurance for the lowest-income Americans in every state by incentivizing states to expand Medicaid.
- Expand access to affordable health care to families regardless of immigration status.
- Expand access to rural Americans, who often have difficulty finding quality, affordable health care.
- Defend access to reproductive health care.
- Double funding for community health centers, and support the health care workforce.
The most notable difference is the respective positions on the Affordable Care Act. Secretary Clinton supports the law but seeks to improve it. Trump opposes the ACA and pledges to repeal it. The two also split on Medicaid. Trump is promoting the well-established Republican policy of providing states block-grants to operate their Medicaid program. Clinton would expand access to the traditional federal-state partnership model for the Medicaid program.
Regardless of the outcome on Nov. 8, the AAFP will be prepared and positioned to advance policies aimed at improving our health care system for you and your patients. We also will provide information and insight through this blog and AAFP News.
AAFP Advocacy on MACRA Implementation Paying Off
During the past year I have had the opportunity and privilege to listen to, and interact with, family physicians across the country -- including hundreds at the recent AAFP Congress of Delegates and Family Medicine Experience (FMX) meetings -- about the Medicare Access and CHIP Reauthorization Act (MACRA) and how it will impact their practices.
The responses from family physicians are (not surprisingly) mixed. Everyone I talked with was pleased that the sustainable growth rate (SGR) was repealed and the threat of substantial annual payment cuts were eliminated. Everyone was equally pleased with the emphasis and focus being placed on primary care as foundational to our national health care goals. Some see MACRA and the transition to value-based payments as an opportunity that will benefit primary care and patient care. Some, however, see the transition away from fee-for-service as a threat to their business model and their professional viability.
The majority sit between these two positions -- optimistic about the renewed emphasis on primary care focused delivery and payment models that support first contact, continuous, comprehensive and coordinated primary care. Scared about how it will work, what it really means for them, and how soon it will impact their practice. Regardless of whether you are optimistic, scared, or somewhere in between, the AAFP is committed to meeting you where you are and assisting you in your journey.
During my journeys and through my conversations with family physicians I have determined that there are three primary concerns:
- The new law is complex in design and hard to understand.
- Family physicians need flexibility in the early years to determine which of the two payment pathways is best for them and their practices.
- Family physicians, especially those in small practices, should be exempted from financial penalties that may result from their participation in MACRA, especially those penalties that are caused by methodologies that may be biased against them due to their small patient populations.
Earlier this year, the AAFP submitted a 107-page response to the proposed regulation implementing MACRA. I would encourage you to read the executive summary, which is much shorter and includes all the best information from the larger document.
In our letter, we accurately captured and articulated the three concerns mentioned above. Our letter raised significant concerns about the complexity of the proposed regulation, and we called on CMS to re-evaluate its approach to implementing the law. We also called on CMS to implement the law in stages so that all physicians, regardless of practice size and location, could have a positive experience with the new law in the initial years. We also urged CMS to identify a process whereby physicians could participate in the new quality payment program (QPP) in a manner that challenges their current capabilities but is within the realm of achievable for all family physicians in all practice settings. We requested that CMS identify and implement a primary care advanced alternative payment model for all primary care physicians, not just those fortunate enough to be in the CPC+ program. Finally, we suggested CMS create an opportunity for solo and small group family physicians to participate but be protected from financial penalties.
We have continued to press CMS on these items since submitting our letter and, I am pleased to report, CMS has been listening. On Sept. 8, the agency announced its intentions to provide physicians flexibility in the initial performance year of MACRA through a blog posting by CMS Acting Administrator Andy Slavitt. In the post, CMS announced the "Pick Your Pace" program that would provide greater flexibility for physicians in the first performance year of MACRA, which is 2017.
I have been telling you how engaged the AAFP has been during the past 18 months on MACRA implementation and how we continue to pursue regulations that ensure that the law is implemented in a manner that is in the best interest of our members. Obviously, we have not and will not achieve every goal, but the Pick Your Pace announcement is a big one. The CMS announcement reflects the AAFP's recommendations, and we are pleased that CMS listened and acted based on our recommendations.
The Pick Your Pace approach provides four options for physicians:
- Option 1 -- Test the Quality Payment Program. If you submit some data to the Quality Payment Program, including data for services provided after Jan. 1, 2017, you will avoid a negative payment adjustment in 2019.
- Option 2 -- Participate for part of the calendar year. You may choose to submit Quality Payment Program information for a reduced number of days. This means your first performance period could begin later than Jan. 1, 2017, and your practice could still qualify, potentially, for a small positive payment adjustment. Like option 1, if you submit data, you avoid penalties in 2019.
- Option 3 -- Participate for the full calendar year. For practices that are ready to participate Jan. 1, 2017, you may choose to submit Quality Payment Program information for a full calendar year. This means your first performance period would begin on Jan. 1. Practices selecting this option would be eligible for full positive payment updates in 2019, but they also could face potential penalties depending upon performance.
- Option 4 -- Participate in an advanced alternative payment model (APM). Instead of reporting quality data and other information through the Merit-Based Incentive Payment System (MIPS), the law allows physicians to participate in the Quality Payment Program by joining an Advanced Alternative Payment Model (APM), such as the CPC+ program. If your practice receives enough of your Medicare payments or see enough of your Medicare patients through the Advanced Alternative Payment Model in 2017, then you would qualify for a 5 percent incentive payment in 2019.
The changes included in the Pick Your Pace program do not address all of our concerns, but they do create an opportunity for all physicians, regardless of practice size and location, to engage with the QPP program and avoid payment penalties in 2019. The AAFP continues to add resources and tools to our MACRA Ready campaign that can assist you in your journey towards the value-based delivery and payment programs.
Last week, the AAFP Congress of Delegates met in Orlando, Fla. The COD considered, debated, and approved numerous policies that will guide the policy and advocacy work of the AAFP. The hottest debate of the week focused on reducing the administrative burden facing family physicians, largely due to electronic medical records and prior authorization requirements. Delegates also had serious conversations about the escalating costs of prescription drugs, single-payer health systems and maintenance of certification. You can review the COD’s actions and read the resolutions debated at the AAFP Congress of Delegates site.
Looking for a little more information on the COD meeting? AAFP News is your best source of summaries and analysis of the work done by the COD.
Crunch Time for Congress: Key Health Issues Unresolved
On Sept. 6, Congress returned to Washington, D.C., from a seven-week summer recess. With less than 60 days until Election Day, the opportunities to pass major legislation are fading.
Given the limited number of legislative days remaining, Congress will focus its attention on a small set of priority or "must-pass" legislation prior to adjourning for the elections. At the top of that priority list is legislation to fund the federal government for the upcoming fiscal year and emergency spending to address the Zika outbreak.
Congress must pass legislation prior to midnight Sept. 30, to fund the federal government from Oct. 1 through Sept. 30, 2017. Congress will once again use a short-term continuing resolution, or CR, to fund the government until mid-December. At that time, they will attempt to pass legislation to fund the government through September 2017.
The current continuing resolution has a handful of provisions that the AAFP is monitoring. Specifically, we are closely advocating for full funding for the National Health Service Corps, the Agency for Healthcare Research and Quality (AHRQ) and several education and grant programs funded through the Health Resource and Services Administration (HRSA). We also are concerned with provisions that would eliminate funding for certain provisions of the Patient Protection and Affordable Care Act and, more concerning, attempts to cut operational funds at CMS. The AAFP is keeping a close eye on the House and Senate negotiations and is communicating our priorities to members of Congress and congressional staff.
The second priority for September is providing resources to combat the Zika outbreak. Congress continues to seek a compromise on a public health funding request for Zika, even though these negotiations become more mired in politics by the day. Last week the Senate attempted to break a logjam and approve legislation that would provide more than $1 billion in funding to states facing the Zika outbreak.
As of Aug. 31, the CDC had reported 2,687 laboratory-confirmed cases of Zika in the United States, including more than 500 in Florida.
The CDC also reported more than 1,500 cases involving pregnant women in the United States and its territories. The known risk to pregnant women and children has been driving an outcry from the public health community and for good reason. Researchers at Yale University’s Center for Infectious Disease Modeling and Analysis estimate that the lifetime health care costs for children infected with Zika are $4.1 million. The CDC estimates the total costs between $1 million and $10 million per child.
FamMedPAC Emerges as Top Political Action Committee
As noted above, the 2016 elections are 56 days away. On Nov. 8, the country will elect a new president, 435 members of the House and 34 Senators. In addition, thousands of state and community officials will be elected. I am quick to admit that the presidential election may not be the most admirable process we as a nation have engaged in, but our open election process remains a beacon of democracy.
I have shared my views previously that to be an effective advocacy organization we must engage on four levels -- direct lobbying, grassroots advocacy, media relations and political advocacy. Each of these supports the other and each is less effective if one of the others is missing or under-represented. This is why it is important that family medicine has a robust and well-funded political action committee. FamMedPAC continues to experience record-breaking growth. Since 2006, FamMedPAC has received more than $4.7 million in donations from more than 8,000 AAFP members. That money has resulted in FamMedPAC making more than 1,300 contributions totaling more than $3.9 million to federal candidates.
In this election cycle (2015-2016), FamMedPAC is poised to raise more than $1 million and join a prestigious group of political action committees that have eclipsed the $1 million milestone in an election cycle. If you are a FamMedPAC supporter, thank you! If you have not supported FamMedPAC previously, I urge you to make a contribution. Your contribution is important to our efforts and, in the end, contributes to a better health care system for your patients and your practice. If you are attending the Family Medicine Experience (FMX) this month in Orlando, Fla., please look for the FamMedPAC booth in the AAFP Marketplace.
The percentage of the U.S. population that is uninsured has fallen to historic lows. The CDC stated in a new report that the uninsured rate was 8.6 percent for the first quarter of 2016. The agency report also noted that the uninsured rate, since the enactment of the Affordable Care Act, has fallen from 14.4 percent in 2013. The previous low was 9.1 percent last year.
Also of note, is a recent study published in JAMA Internal Medicine that shows the positive impact of health insurance on health outcomes. Researchers at the Harvard School of Public Health compared the health outcomes for low-income adults in Arkansas and Kentucky (Medicaid expansion states) to Texas (non-Medicaid expansion state). Two quick findings stand out. Low-income adults in Arkansas and Kentucky were more likely to be insured than their counterparts in Texas, and they were more likely to receive basic preventive care and care for chronic conditions. These findings continue to advance the importance of health coverage as an indicator of health and well-being.
Academy Offering Tools for Chronic Care Management
Most of you are aware that there is a large-scale and coordinated effort underway to change how care is provided and, just as importantly, how care is reimbursed. This effort was set in motion more than a decade ago through policy changes such as the establishment of the physician quality reporting initiative -- which is now known as the physician quality reporting system -- the push for electronic health records, and the failure of commercial disease management programs; among others.
The AAFP, through sound leadership, read the tea leaves appropriately and began to promote delivery and payment models that would place a greater emphasis on the critical role primary care plays in our health care system. Through the Future of Family Medicine project, the AAFP and six other national family medicine organizations promoted a vision for a health care system in which each patient would have an ongoing relationship with a primary care physician. In return, primary care physicians would provide care that was built on five Cs -- first contact, comprehensive, continuous, coordinated and connected. These fundamental elements of primary care were promoted by Barbara Starfield, M.D., but they also were the cornerstone of high-functioning health care systems around the world that exceeded the United States' performance on quality and costs.
To accomplish this goal, the AAFP began identifying, developing and promoting new delivery models, such as the patient centered medical home (PCMH), advanced functions such as electronic health records, and, most importantly, we began to promote the need for primary care physicians to be paid differently and better.
A key aspect of the AAFP's payment policy was the implementation of a blended payment model whereby family physicians would be paid for direct patient care, but also for those services that are provided outside of the traditional face-to-face office visit. This payment would ultimately become known as the care management fee.
Although the Patient Protection and Affordable Care Act contributed to the so-called value-over-volume movement, it was really two events that happened in the first quarter of 2015 that accelerated the pursuit of value-based payments. The first was an announcement by the Obama Administration that it would push to tie 30 percent of traditional fee-for-service Medicare payments to value-based payments by 2016 and 50 percent by 2018. The administration challenged commercial insurers and Medicaid programs to do the same. The second event was the enactment of the Medicare Access and CHIP Reauthorization Act (MACRA), which codified value-based payment designs and put in motion a concerted effort to move away from the traditional fee-for-service construct as a means of compensating physicians for the care they provide. A central part of the MACRA reforms was placing a greater emphasis on the coordination of care across the health care spectrum.
The ability to manage the care of individual patients and populations of patients, especially those with one or more chronic health condition, has been identified as one of the most promising aspects of advanced primary care delivery models such as medical homes. Furthermore, effective care management by family physicians has proven to improve the quality of care for patients and reduce the per capita cost of health care. This has been proven in both public and private health care systems, as noted in the Patient Centered Primary Care Collaborative’s annual evidence report.
About five years ago, the AAFP started studying the concept of care management. What was it? What should it be? How much does it cost to provide care management services? How much should family physicians be paid for care management? How should these payments be risk-adjusted?
We initially asked the Robert Graham Center to study care management programs and fees. Its report -- Blended Payment Models and Associated Care Management Fees -- identified some common care management functions across public and private health care systems and provided a solid foundation for our next project, a partnership with Discern Health which aimed to further examine care management and identify three key findings:
- What is care management?
- What are the benefits of care management?
- What is the value of care management to patients, physicians, and payers?
Discern Health recently provided the AAFP its findings in an issue brief titled Valuation of Care Management Performed by Primary Care Physicians. Here is what Discern Health found with respect to the three questions above:
- Numerous studies have identified reductions in total cost of care associated with patients who have received care management services organized by primary care physicians in a PCMH model. Research has found reductions, ranging from 4.4 percent to 11.2 percent for a particularly high-cost, frail, and elderly population.
- When people receive high-quality care from primary care physicians, particularly for chronic conditions, they are less likely to experience rapid declines in their health that require costly treatment in a hospital.
- A benefit of care management is an increase in the proportion of patients receiving high-quality, appropriate care.
- Care management demonstrated a benefit for patient and staff experience of care, and staff reported lower emotional exhaustion scores on the Maslach Burnout Inventory Scale.
A final finding about per member per month (PMPM) fees is key, so I have included the full paragraph. It reads: "Studies have shown primary care physicians who invest in care management are creating significant value for the health care system through higher quality care at a lower total cost. On the whole, care management payments do not fully compensate physicians for the value they create. One of the best studies of the reduction in total costs of care (a benefit to health insurers) created by effective care management in a commercial population found a $16.73 PPPM reduction. This is considerably more than what insurers are paying for care management, which is $4.90 PPPM."
The AAFP sees care management as an important function of advanced primary care practices, so the Academy has developed an extensive set of resources to help you implement care management in your practices. We have prioritized the resources into the following categories:
- care management;
- risk-stratified care management; and
- population health management.
In addition to these resources, the AAFP, as part of our collaboration with Discern Health, created a care management calculator (member log in required). This tool is designed to assess various factors that might influence care management costs and to provide an estimate of care management costs and savings based on: staffing hours, overhead, the chronic disease burden of the patient panel, the state where the practice is located, and revenue from care management billing or program funds. The calculator is Excel-based and organized in a stepwise process.
You can read more about the brief and the cost calculator in AAFP News.
Family Practice Management also has a number of good resources on care management, specifically the Medicare chronic care code.
AAFP Welcomes New Director of Government Relations
On Sept. 12, Robert Hall, J.D., will join the AAFP as director of government relations. Hall, who most recently worked for the American Academy of Pediatrics, brings more than 20 years of experience to the AAFP. He will oversee the AAFP's vast government relations, advocacy, and political operations. In addition, he will work closely with the AAFP's Commission on Governmental Advocacy and will advise senior management and the Board of Directors on legislative and regulatory matters.
CPC+ Holds Plenty of Potential for FPs
“Even after expenses, this will mean a six-figure boost in income for each of us and the delivery of care will be significantly better.”
This is a portion of an email we received from a family physician in Michigan who wanted to share the impact that the Comprehensive Primary Care Plus (CPC+) program would have on the writer's six-physician practice. This physician estimates that not only will the program allow everyone in the practice to better serve their patients, especially those with complex health conditions, but it will generate significant revenue for each of them, as well as for the practice.
The AAFP shares this excitement about CPC+, but we recognize that to realize the full potential of the program we need to ensure that a high number of family physicians apply and participate in it.
On Aug. 1, CMS announced the 14 states and regions that will participate in CPC+ and opened the application process. Interested and eligible physicians who practice in one of the selected states/regions may apply by Sept. 15.
CPC+ is a five-year primary care medical home program that will begin in 2017 and conclude in 2021. It is a multi-payer model, which means that Medicare, Medicaid and commercial insurance programs will all be participating in the selected states/regions. The multi-payer approach is essential to creating alignment across a practice. Fifty-seven payers have signed up to participate in the program.
CMS plans to select 5,000 practices for participation in the CPC+ program from the selected states and regions. The participating states are Arkansas, Colorado, Hawaii, Michigan, Montana, New Jersey, Ohio (including northern Kentucky), Oklahoma, Oregon, Rhode Island and Tennessee. In addition to the 11 states, three regions were selected: Kansas City metro (Kansas and Missouri), Philadelphia metro and New York Hudson Valley. Many of the selected states/regions also participated in the Comprehensive Primary Care Initiative (CPCI), which concludes at the end of this year.
The CPC+ program aims to build on the experiences gained from CPCI or, as it is now known, the CPC Classic program.
CPC+ will have two tracks. Track 1 aims to support practices in building key comprehensive primary care capabilities. Track 2 targets practices that have more experience delivering advanced primary care and aims to support delivery of enhanced care through IT, targeting patients with complex needs and helping to meet patients' psychosocial needs. Participating practices in both tracks must develop, implement and execute against five key primary care functions. Those five functions are:
- access and continuity;
- care management;
- comprehensiveness and coordination;
- patient and caregiver engagement; and
- planned care and population health.
In addition, participating practices must prove that they have support from multiple payers, use a certified electronic health record technology and report electronic clinical quality measures at the practice level. Practices participating in Track 2 must also demonstrate a commitment to using enhanced health IT functions in their practice and a commitment to caring for complex patients. Track 2 practices are required to have a letter of support from their IT vendor(s) when applying. All IT vendors for Track 2 practices will be required to enter into a memorandum of understanding with CMS.
Participating practices will receive prospective payments in three forms: comprehensive primary care payments, care management fees and performance-based incentive payments. Unlike other pay-for-performance programs, payments under the CPC+ Performance-based Incentive Payment (PBIP) system will be made to practices at the beginning -- not the conclusion -- of the performance year. Practices will be retroactively evaluated on their performance on patient experience, clinical quality and utilization. Practices that fail to meet quality and utilization thresholds must repay some of PBIP.
Track 1 practices will continue to receive Medicare fee-for-service (FFS) payments along with a prospective per-beneficiary-per-month care management fee. The practices also will receive prospective PBIP payments of $2.50 per beneficiary per month.
Track 2 practices will receive a blended payment made up of Medicare FFS and a prospective percentage of expected Medicare reimbursement for evaluation and management claims, along with a prospective per-beneficiary-per-month care management fee. The practices also will receive prospective PBIP payments of $4 per beneficiary per month.
Care Management Fee
Participating practices in both tracks will receive prospective monthly care management fees (CMF) on a per-beneficiary basis. The amount of the monthly payment will be based on the health care condition (HCC) of the beneficiary. CMS estimates that the average CMF will be $15 per beneficiary for Track 1 practices and $28 per beneficiary for Track 2 practices. Additionally, Track 2 practices will receive a CMF of $100 per beneficiary for their most complex patients. The CMF structure is as follows:
|Risk Tier||Attribution Criteria||Track 1||Track 2|
|Tier 1||First quartile HCC||$6||$9|
|Tier 2||Second quartile HCC||$8||$11|
|Tier 3||Third quartile HCC||$16||$19|
|Tier 4|| Fourth quartile HCC for Track 1
75% to 89% for Track 2
|Tier 5||Top 10% HCC||Not available||$100|
Family physicians who meet the eligibility criteria and practice in one of the selected 14 states/regions may apply to participate in the CPC+ program by Sept. 15. Practices applying to Track 2 will need to submit a letter of support from their health IT vendor(s) that outlines the vendors' commitment to supporting the practice with advanced health IT capabilities.
The AAFP has numerous resources that can assist you in evaluating your eligibility and completing the application process. We also have partnered with Caravan Health to provide assistance in the practice evaluation and application process. If you are interested in partnering with the AAFP and using the resources available from Caravan Health, please email firstname.lastname@example.org.
- CMS CPC+ Fact Sheet
- CMS CPC+ Practice Open Door Forum schedule
- CPC+ Application Checklist
- CPC+ Frequently Asked Questions
- CPC+ Request for Application
Fee schedule reflects CMS efforts to support primary care
On July 7, CMS released its proposed rule for the 2017 Medicare physician fee schedule (PFS). The proposed rule updates payment policies, payment rates and quality provisions for services furnished under the Medicare PFS starting Jan. 1. The AAFP is in the process of reviewing and analyzing the proposed rule and will be submitting comments and recommendations prior to the Sept. 6 deadline.
We have prepared a summary of the proposed rule to assist members in evaluating the new payment policies. You can also access additional resources on our physician payment advocacy web page.
The proposed rule continues a multi-year effort on the part of the Administration to both prioritize and promote primary care as foundational to the Medicare program. The AAFP continues to assert with CMS and the Administration that to truly realize the value of family medicine and primary care they cannot simply rely on delivery system reforms and alternative payment models. Instead, CMS must make new investments in primary care to truly capture and realize the value proposition of family medicine and primary care. Building new delivery system or payment models on the foundation of a payment system that has methodically undervalued primary care for a generation would be disingenuous to the goals espoused by CMS, private insurers and health policy experts.
CMS has made a commitment to improving payments for family medicine. The 2017 Medicare PFS, according to CMS, results in a 3 percent increase for family physicians compared to other medical specialties. CMS estimates that the changes made in the 2017 Medicare PFS would result in approximately $900 million in additional funding to primary care physicians. In a blog post that coincided with the release of the proposed rule, CMS Administrator Andy Slavitt and Acting Principal Deputy Administrator and Chief Medical Officer Patrick Conway articulated their commitment to improving the investment in primary care.
In the blog, they said that CMS, through the proposed rule, is attempting to: "reinvest in what we value -- primary care -- as a practice, as a profession, and as an abundant resource for patients. In recent years, we have begun taking a number of meaningful steps to begin this reinvestment process. Today, we are proposing significant actions to improve how we pay primary care physicians, mental health specialists, geriatricians, and other clinicians. By better valuing primary care and care coordination, we help beneficiaries access the services they need to stay well. In addition to keeping people healthy, health care costs are lower when people have a primary care provider and a team of doctors and clinicians overseeing and coordinating their care."
Improving payment for family physicians and primary care physicians is a top priority for the AAFP, and we applaud CMS for its commitment to this cause -- even though we remain convinced that CMS can and should do much more.
The following highlights a few key areas of the proposed rule.
- The proposed conversion factor for 2017 would be $35.77.
- The proposed rule would add an advanced care planning code to the eligible code set for telemedicine services.
- The proposed rule would implement appropriate use criteria for advanced imaging services created by the Protecting Access to Medicare Act. This policy requires physicians ordering certain imaging services -- magnetic resonance, computed tomography, nuclear medicine, and positron emission tomography imaging -- for Medicare beneficiaries to consult AUC applicable to the imaging modality. The implementation of this policy was delayed due to AAFP advocacy and we will once again encourage CMS to delay the implementation of the program so that AUC would be aligned with the forthcoming MIPS program versus being introduced as a stand-alone program.
Furthermore, the proposed rule makes significant changes to how CMS pays for several care management services. Specifically, the regulation would make separate payments under Medicare for:
- certain existing CPT codes describing non-face-to-face prolonged evaluation and management services;new codes to describe the comprehensive assessment and care planning for patients with cognitive impairment (e.g., dementia);
- new codes to pay primary care practices that use interprofessional care management resources to treat patients with behavioral health conditions;
- new codes to recognize the increased resource costs of furnishing visits to patients with mobility-related impairments; and
- codes describing CCM for patients with greater complexity.
In addition, the program makes several changes aimed at reducing the administrative burden associated with the CCM codes and revalues existing CPT codes describing face-to-face prolonged services. Both changes are positive for primary care.
Finally, the AAFP has long advocated that CMS should be more assertive in identifying both over and undervalued codes in the PFS. Research has shown that, historically, payments for primary care services provided by primary care physicians are grossly undervalued. We continue to press CMS to use its administrative authority to increase the relative value of primary care codes and, ideally, create new codes explicitly for primary care.
This policy began to be implemented through the Patient Protection and Affordable Care Act, which required the secretary to identify and adjust payments for misvalued codes through adjustments to the relative values of those services. This provision was strengthened through the Achieving a Better Life Experience Act of 2014, which set a specific target for downward adjustments of misvalued codes of 1 percent in 2016 and 0.5 percent for 2017 and 2018. In 2016, CMS was unable to identify the full 1 percent required by law, thus resulting in a cut to all services to account for the difference. In 2017, CMS has proposed reductions equaling 0.51 percent. This means primary care physicians won't see any reductions in payments.
On July 21, the Department of Justice sued to block Anthem’s $48 billion takeover of Cigna Corp and Aetna’s $37 billion takeover of Humana. In both the United States v. Anthem Inc. and Cigna Corp. and the United States v. Aetna and Humana Inc. the Justice Department argues that the mergers would raise health care costs and reduce choices for patients. Attorney General Loretta Lynch, when making the announcement, stated: “If the big five were to become the big three, not only would the bank accounts of American people suffer, but the American people themselves.
Shortly after the announcement, both Anthem and Aetna offered their responses to the Justice Department’s decision. Both have vowed to fight the decision in court.
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