Are Family Physicians an Answer to VA's Primary Care Crisis?
In the wake of an escalating scandal involving the Department of Veterans Affairs and the Veterans Health Administration, the AAFP was the first physician organization to make specific recommendations to President Obama and Congressional leaders about how they could facilitate the use of civilian family physicians to enhance access to primary care services for veterans.
Here's a look back at how the situation unfolded and a look ahead at the important work that remains to be done.
In April, news of a “secret” waiting list at an Arizona VA facility emerged in local media reports in that state, where hundreds of sick vets were forced to wait for care. Dozens died while waiting. In May, a Government Accountability Office (GAO) report -- and subsequent media reports -- exposed the profound and systemic deficiencies in care delivery, access and management within the VA, especially regarding primary care and mental health services.
In a matter of days, the Secretary of Veterans Affairs and two senior officials had resigned or retired, and the public, media and Congressional outrage reached a fever pitch.
Staff in the AAFP Division of Government Relations took note of the GAO report and began developing policy options that would allow civilian family physicians to provide care to veterans. During the same time period, several AAFP members raised concerns about the situation during the annual summer meeting of the Academy's commissions.
Through a series of conversations and policy discussions, AAFP leadership determined that we should communicate directly to President Obama and Congress on how America’s family physicians could assist in the short-term to alleviate backlogs in the VA system.
On June 3, the AAFP made specific recommendations to President Obama and Congressional leaders regarding the use of civilian family physicians to enhance veterans' access to primary care services. Those recommendations focused on four major areas:
- permitting veterans to fill prescriptions from civilian physicians at VA pharmacies,
- allowing civilian physicians to order diagnostic tests and therapy services inside the VA,
- permitting for the referral of veterans by civilian physicians to specialist inside the VA, and
- extending federal tort claims act protections to civilian physicians.
Our letter was received positively and led to ongoing communications between the White House and the AAFP.
Simultaneously, Congress moved quickly and developed legislation that would immediately expand access to care for veterans and implement systems changes to prevent similar failures from occurring in the future. The AAFP worked to communicate quickly with legislators of the House and Senate to advance our policy priorities and ensure their inclusion in the legislation.
A few weeks later, the AMA House of Delegates approved a resolution calling on the AMA and the full house of medicine to support policies similar to those advanced previously by the AAFP.
On June 10, the House approved legislation that would invest $50 billion per year during the next decade to improve access and quality within the VA system, including allowing veterans to access the services of civilian physicians. The Senate approved similar legislation a day later.
Given the rapid process, the AAFP determined that it would be advantageous to further define and articulate our policy priorities, which were submitted to the House-Senate Conference Committee June 23, a day before the committee began its work.
In addition to the policy recommendations in the Academy's letters dated June 3 and June 23, we believe that the VA is fertile ground for workforce development, including graduate medical education, and we are advancing these ideas aggressively. Specifically, we are calling on the conference committee to dedicate significant financial resources to the establishment of family medicine, internal medicine and psychiatry training programs inside the VA -- with or without an external academic partner. We believe that the VA has untapped capacity to train family physicians and, at the same time, expand access to primary care services. This is an idea that has support within the conference committee, and we are working hard not only to build support for the concept, but also to make the policy-political arguments for why they should invest money to create this new VA program.
The legislative process slowed significantly during the Fourth of July recess, but the AAFP’s efforts haven’t. The Academy's government relations staff continues to conduct meetings with the legislators and staff of the conference committee to advance the policies outlined in our written communications. We have made this work a priority, and we are pressing to ensure that our policy recommendations are included in the final VA reform legislation.
While nothing is certain in Washington, we are fairly confident that the conference committee will conclude its work, and both the House and Senate will approve a final bill, prior to the congressional recess. Although partisanship is high in this election year, lawmakers from both parties would like to avoid returning home in August and having to explain why this scandal happened in the first place and why they haven’t demonstrated leadership in correcting this national tragedy.
Merritt Hawkins has released its 2014 Review of Physicians and Advanced Practitioner Recruiting Incentives, and for the eighth consecutive year family physicians were No. 1 on the list. The Merritt Hawkins report is illustrative of the rapid changes in our health care system and the dominant role primary care physicians are playing and will play in new delivery and payment models. Of the 3,158 searches conducted between April 1, 2013 and March 31, 2014, 23 percent were for a family physician. Internal medicine was second at 7 percent. Despite strong promotion from the media and policy-makers, nurse practitioners were the focal point of only 4 percent of searches, and physician assistants came in at 1 percent. A majority of searches, 59 percent, were for positions in communities with populations of less than 100,000 people -- just another demonstration of why graduate medical education needs to be diversified away from urban academic health centers.
Primary Care: 'A Matter of Priorities'
Tucked away inside the Patient Protection and Affordable Care Act (ACA) is a provision that is one of the law's more important policies aimed at improving the quality of care for individual patients and controlling the overall costs of health care for the government. Section 1202 of the ACA requires that Medicaid compensate primary care physicians at 100 percent of Medicare payment rates for a defined set of primary care services in 2013 and 2014. This provision is set to expire on Dec. 31, and all family physicians participating in the Medicaid program will see cuts -- dramatic cuts in many cases -- in their Medicaid payments.
Why is this provision so important? Because it takes the necessary steps to ensure that health care coverage is met with access to primary care physician services. In other words, it makes health insurance a tangible item for millions of Medicaid beneficiaries and not health care coverage in name only.
It's no secret that patients who have health care coverage and a usual source of care have better outcomes than those who lack one or both. It also is no secret that Medicaid, historically, has been an extremely poor payer.
For decades, states have decreased payments to physicians and other health care professionals as a means, in part, to finance more expansive benefit packages for beneficiaries. Physician participation rates reflect the low payment rates, and access to care for Medicaid patients has been challenging (or non-existent) in many areas of the country.
In the good news category, the ACA provision that increased Medicaid payment for primary care services has, apparently, single-handedly solved our nation's primary care shortage. It is amazing how many physicians are providing “primary care” to Medicaid patients and claim to deserve this bonus payment. If you listen to other physician organizations tell it, there are about 800,000 physicians providing primary care in the United States.
The AAFP agrees that a number of physician specialties provide some primary care services just as a large percentage of family physicians provide some cardiology services. The difference is family physicians don’t clamor to be called cardiologists. Just because a physician provides some “primary care services” does not mean that they provide continuous and comprehensive primary care – especially if their discipline ends in “ologist.”
According to Merriam Webster, “ologist” means “specialist.”
Mark Miller, Ph.D., executive director of the Medicare Payment Advisory Commission (MedPAC), was asked during a recent House Ways and Means Committee hearing about the inclusion of physicians who provide primary care services in incentive payment programs. His answer was aimed at the Medicare program, but it is completely applicable to the Medicaid payments and closely aligns with the AAFP’s views on the issue.
“There is great concern that the procedural side of the fee schedule is overvalued," he said. "If you go to the cognitive side there is concern that that is undervalued. … But if you have to pick priorities, and there’s limited amounts of dollars, then the commission’s point is: The first concern is the primary care sets of services. … So it’s not that the commission completely disagrees; it’s more a matter of priorities.”
Well stated, Dr. Miller. The AAFP shares these priorities, and we are working hard to ensure that this policy regarding Medicaid parity continues and allows millions of people to realize the goal articulated in the beginning of this article -- making sure that their health care coverage is met with access to care.
Since 2012, the AAFP has been working to build support for the extension of this important policy. This policy was a focal point of AAFP’s annual Family Medicine Congressional Congress, at which Academy members met with more than 115 Members of Congress and Senators to urge extension of the payment policy for at least two years. Additionally, we have partnered with other physician and patient advocacy organizations to form a coalition aimed at developing legislation that would extend the program and better define eligibility and covered services. In recent weeks, the AAFP has engaged with congressional staff to assist in the drafting of legislation that would extend Medicaid parity payments for at least two years. This process is far from complete, and there is much work to do, but we are pleased that there is movement.
Here is what needs to happen to successfully extend this program. First, we have to articulate to legislators and congressional staff why this program should be limited to true primary care physicians trained in comprehensive primary care. AAFP staff and leaders will handle this task. Second, we need to demonstrate the impact this policy is having on patients and physicians, and this is an area where family physicians can make a big difference in our advocacy efforts. We need your assistance. The AAFP is collecting information on how increased Medicaid payments are improving patient access to primary care services. Your stories can enhance the Academy's advocacy efforts. Please visit our Speak Out page and submit your story by Aug. 1.
We are No. 11! The Commonwealth Fund has released “Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally.”
So, how did we do? According to the report, “Among the 11 nations studied in this report -- Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States -- the U.S. ranks last, as it did in the 2010, 2007, 2006 and 2004 editions of Mirror, Mirror.” It is worth noting that countries that prioritize primary care tend to be at the top of this list.
Is Direct Primary Care Right for You?
I want to welcome you to In the Trenches, a blog devoted to providing family physicians timely information on health policy matters, the work being done on your behalf by the AAFP and insights into the advocacy and political activities that drive our national health care debate.
I promise this will not be your typical advocacy newsletter. I will focus on providing inside information on what the AAFP is doing to advance family medicine in public and private health care systems. This blog will be informative, deliver a perspective not found in other mediums and will include a healthy dose of commentary on those things that drive debate behind the scenes. Additionally, we will tap the inner health policy wonk in each of you by providing analysis and perspective on emerging issues that will drive the next generation of health policy.
Disruptive Innovation in Family Medicine
The AAFP has a distinguished history of driving innovation in health care. We are, as you recall, the organization that started a national discussion around “advanced primary care” and the need to transform our nation’s health care system and make primary care its foundation. Although this effort manifested itself through the patient-centered medical home (PCMH) during the past decade, the PCMH is not the only innovative delivery and/or payment model supported by the AAFP.
If you aren't already familiar, let me introduce you to a concept gaining strong interest among family physicians, policy-makers, business and -- most importantly -- patients: direct primary care (DPC). The AAFP views the DPC model as a significant and positive contributor to expanding access to primary care for millions of patients, improving the quality of care provided by family physicians, and increasing patient and physician satisfaction. In 2013, the AAFP Congress of Delegates approved an official policy on DPC.
In recent months, the AAFP has amped up its advocacy efforts with respect to DPC. We have met with numerous insurance companies to convey our support for this model and demonstrate the cost-saving potential it presents by reducing downstream health care costs. The Academy also has reached out to policy-makers to educate them on this promising model of care.
For example, the AAFP will host a briefing for Senate health care staff this week to educate them on DPC. Additionally, the Robert Graham Center will host a primary care forum focusing on Disruptive Innovations in Primary Care. DPC will be prominently featured at this event.
Also this week, the AAFP will participate in the Direct Primary Care Summit, a program we are proudly sponsoring. Physicians from across the nation will gather in Washington, D.C., to discuss DPC and share information on this emerging practice model.
One of the driving factors in our interest in this innovative practice model is the shifting framework of health insurance. Since the enactment of the Patient Protection and Affordable Care Act, there has been an increase in the number of individuals who have high-deductible health insurance products -- many with deductibles greater than $4,000. This trend means more primary care, outside of the mandatory preventive services, will be provided on a cash basis. Therefore, patients will have responsibility for the cost of their health care, up to the deductible of their insurance plan, and physicians will have responsibility for collection.
DPC is well positioned to ensure that these patients have access to affordable primary care, while maintaining comprehensive insurance coverage through their high-deductible insurance plan. In addition, by creating a more direct relationship between physicians and patients, both parties are no longer obligated to deal with the complexities associated with insurance companies.
Before you label this as concierge care, please let me tell you why this is superior to concierge practices and why so many people are taking a hard look at this model as a contributor to improving access to primary care. Concierge care practices charge patients a monthly or annual fee for enhanced access to a physician or practice. Physicians participating in this delivery model have, in response, limited their panel to a select set of patients -- thus decreasing the overall capacity and effectiveness of the primary care system. Additionally, physicians in a concierge practice continue to bill their patients' insurance for services provided.
In comparison, DPC practices use a membership model where patients pay a reasonable, monthly fee for all their primary care services. Patients save on insurance premiums with a low-cost, wraparound policy to only cover subspecialists, hospitalization and catastrophic care.
The defining characteristic of a DPC practice is that it offers patients the full range of comprehensive primary services, including routine care, regular checkups, preventive care and care coordination in exchange for a flat, recurring fee. The most compelling case for DPC is it allows family physicians to do what they do best, care for their patients. Since physicians are no longer generating revenue solely on the basis of how many patients they see per day, many physicians in DPC practices report that they have significantly more time to spend with patients in face-to-face visits. To put it bluntly, this model is patient centered and genuinely affordable.
The AAFP has DPC resources available. Additionally, we are developing a comprehensive practice development program that will launch at AAFP Assembly in October in Washington to assist family physicians who are interested in this model. This resource will include toolkits and in-person education programs that will provide what you need to know as you evaluate this promising practice model.
Again, this model isn’t for everyone, and it does not replace the need for the PCMH and other advanced primary care practice models. It is, however, a model of care that is consistent with AAFP policies on advancing continuous and comprehensive primary care as the foundation of our health care system.
Castlight Health, a San Francisco-based company that works with employers on controlling health care costs, has released a new analysis on price variations in health care. Using claims data, Castlight found wide variations in what patients pay for a variety of health care services -- including primary care. For example, the cost of a routine primary care visit ranged from $95 in Miami to $251 in San Francisco. Price transparency is an emerging policy issue, and reducing the wide variations in health care prices is seen as a means of controlling overall costs. You can read the report online.
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