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 Everyone I talked with was pleased that the sustainable growth rate (SGR) was repealed and the threat of substantial annual payment cuts were eliminated.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.
No Summer Break for AAFP Advocacy Efforts
"Summer, summer, summertime. Time to sit back and unwind."
-- The Fresh Prince, aka Will Smith
Summer is officially in full swing. The United States recently celebrated its 240th birthday. A new class of family medicine residents started their training, Major League Baseball held its All-Star Game, and last week Congress wrapped up its work for the first half of 2016 before adjourning for a seven-week summer recess.
I know that each of you do not get a seven-week summer vacation, but I do hope your summer is off to a good start. I thought this would be a good time to provide an update on a variety of issues, so let’s get to it.
First, some important updates from the sports world. The Washington Nationals are leading the National League East, the Kansas City Royals are a mere seven games back in the American League Central, we are 40 days from the opening weekend of college football, and the Summer Olympics kick-off in less than 20 days.
Now, on to some more substantive issues.
Kevin J. Burke
I want to start this post by congratulating Mr. Kevin Burke on his upcoming retirement. For the past 15 years, Kevin has served as the AAFP’s Director of Government Relations. During his tenure, he has led the AAFP’s advocacy work with professionalism and distinction. His accomplishments are many, but his leadership on health care reform and tobacco regulations are two that are especially worth recognizing. I also would note that Kevin guided the AAFP through the tumultuous years of the sustainable growth rate and was a key figure in the successful effort to repeal the SGR last year. Kevin will be missed, but his contributions to the AAFP and family medicine will live on.
2016 Presidential Elections
We are 112 days from Election Day. On Nov. 8, we will elect a new president. This week the Republican National Committee has convened in Cleveland to nominate Donald Trump, and the Democratic National Committee will convene next week in Philadelphia to nominate Secretary Hillary Clinton. The presidential race is officially underway and, regardless of your political persuasion, this is going to be an interesting campaign to watch. The first presidential debate will take place on Monday, Sept. 26 at Wright State University (home court of our friend and AAFP Board member Gary LeRoy, M.D.). Subsequent debates will be held Oct. 4 (Vice Presidential candidates), Oct. 9, and Oct. 19.
MACRA and the Comprehensive Primary Care Plus Program
Most of you are familiar with our work on the Medicare Access and CHIP Reauthorization Act (MACRA) and the comprehensive set of comments and recommendations we sent to CMS on its proposed regulation.
I hope you are also aware of the forthcoming Comprehensive Primary Care Plus program, which not only provides new and improved payments to primary care physicians, but it also is recognized as an Advanced Alternative Payment Model (Advanced APM) under MACRA. We anticipate that the CPC+ states and regions will be announced soon, and we are aggressively recruiting family physicians to participate.
To assist you in the preparation and applications process, we have partnered with Caravan Health. The resources available from Caravan Health are a member benefit, and I strongly urge you to take advantage of this opportunity. Even if you do not participate in the CPC+ program, these resources will greatly assist your practice as you prepare for MACRA. I know that I am starting to resemble a carnival barker, but I encourage each of you to take advantage of these resources by engaging with the AAFP at email@example.com.
Prescription Drug Abuse
The issue of prescription drug abuse and diversion has dominated the national health policy debate for the past six months, and the AAFP has been front and center. On Oct. 21, AAFP President Wanda Filer, M.D., M.B.A., joined President Obama and HHS Secretary Sylvia Burwell at a meeting in Charleston, W.Va., where the President called on the nation to address the opioid and prescription drug abuse epidemic stating, "This crisis is taking lives. It's destroying families. It's shattering communities all across the country."
Prior to the West Virginia meeting the AAFP laid out a set of steps we would take to work with our members to address the epidemic. Part of our pledge to the White House was our commitment to creating new and more advanced education and practice resource tools, which we have done through free-to-members CME offerings and the AAFP’s new opioid toolkit.
On May 20, Filer issued a call to action to all family physicians. She outlined the important role family physicians play in treating pain, but also treating addiction. She also called on family physicians to do more, stating that "We all need to do our part to end this epidemic."
Filer also took this message to policy-makers and the public through a similar posting in The Hill.
Both the House and Senate have approved the Comprehensive Addiction and Recovery Act (CARA) (S. 524) and the legislation is pending the President's signature. CARA, while not as comprehensive as the AAFP would have liked, does include numerous important provisions. The AAFP will be working aggressively during the appropriations process to ensure that the programs established by CARA receive funding. Much more to come on this issue, but the passage of CARA is a good step.
For more information on available resources and tools, please visit the AAFP’s pain management and opioid abuse resources page.
The issue of mental health continues to occupy a prominent position in the national health care debate, but it appears that momentum for federal legislation may be slipping. The House of Representatives did pass the Helping Families In Mental Health Crisis Act (H.R. 2646) on July 6 in an overwhelming bipartisan vote of 422-2. Despite this strong showing in the House, Senate politics seem to have the upper hand at the present time. It remains possible for the issue to remerge in the fall, but I predict mental health will slip until the 115th Congress convenes in 2017.
Making MACRA Manageable
On June 24, the AAFP submitted formal comments in response to the "Medicare Program: Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models" proposed rule, which was published by HHS on May 9.
The AAFP’s 107-page response lays out a vision and series of recommendations on how CMS can improve the regulation to better align with the Congressional intent of the Medicare Access and CHIP Reauthorization Act (MACRA) and establish a framework that will allow family physicians to deliver high quality, efficient health care to their patients -- regardless of practice size and location.
A majority of our key recommendations are included in an executive summary and outlined in an excellent AAFP News story.
I am not going to attempt to provide you a complete summary in this posting. Instead, I am going to focus on three areas of our comment letter. I will continue to write on MACRA during the summer and fall, and future posts will focus on other key areas of the proposed regulation.
The AAFP noted in our response that the proposed rule and the general framework for both the MIPS and APM program was complex. In fact, really complex. The AAFP is concerned that family physicians will be challenged to understand the various layers of eligibility standards, reporting requirements, thresholds, weighting, risk-adjustment and evaluation/scoring criteria created by this rule. In fact, we are concerned that anyone outside of CMS will be challenged to understand. The MACRA law was far simpler in construct, and we strongly encouraged CMS to pull the throttle back and make this regulation far less complex.
We also called on CMS to issue an interim final rule with a comment period versus a final rule so that the AAFP and others would have an additional opportunity to provide comments on the various provisions implementing MACRA.
A key passage in our letter says, "While our support for MACRA remains strong, we must state that we see a strong and definite need and opportunity for CMS to step back and reconsider the approach to this proposed rule which we view as overly complex and burdensome to our members and indeed for all physicians. Given the significant complexity of the rule, we strongly encourage CMS to issue an interim final rule with comment period rather than to issue a final rule."
MACRA requires that physicians participate in a "performance period" that will determine their payment rate for a future year. Under the proposed rule, CMS establishes the initial performance year as Jan. 1, 2017 to Dec. 31, 2017 and uses a two-year cycle, meaning that physicians' performance in 2017 would determine their payments in 2019. The AAFP is concerned that a Jan. 1, 2017 initiation of the performance period is ambitious both for physicians and CMS.
Furthermore, we strongly disagree with the two-year data cycle that CMS is proposing. We believe that physicians should receive data and performance reports closer to the time care was provided in order to learn and adjust. If CMS officials think that quality and performance data will inform and influence care delivery, then they should place a priority on ensuring that the delta between the performance and payment years is no longer than six months.
Another key passage in our letter says, "the AAFP urgently and strongly recommends that the initial performance period should start no sooner than July 1, 2017."
Solo and Small Practices
The AAFP reserved its most aggressive and constructive comments for those provisions impacting solo and small practices. We see and promote the tremendous value that solo and small practices bring to the health care system. The quality of care provided by small practices has been well documented in literature, and there is broad agreement that preserving this practice model is essential to the success of MACRA and our health care system more broadly.
The AAFP worked aggressively to ensure that MACRA included protections and opportunities for solo and small practices. Some of these were captured in the proposed rule, but many were not. Due to our dissatisfaction with how the proposed rule promoted and protected this practice model, we proposed that CMS create a "safe harbor" for solo and small group practices until such time that policies specifically aimed at helping these practices, such as "virtual groups," are implemented. The lack of virtual groups may result in a "methodology bias" between solo and small practices and larger practices -- something that is unacceptable.
A key passage in our letter says, "Given the fact that a provision, mandated by law, to ensure the viability of solo and small physician practices in the MIPS program will not be available for such physicians and their practices in the initial performance period, we are strongly urging CMS to include an interim pathway to virtual groups, as outlined below, in the final regulation. Physician practices with five or fewer physicians, billing under a single tax identification number who participate in the MIPS program through the submission of quality data, use of a CEHRT electronic medical record, and participation in clinical practice improvement activities should be exempt from any negative payment updates resulting from the MIPS program until such time that virtual groups -- as outlined and mandated by MACRA -- are readily available. These physician practices are, however, eligible for any positive payment updates that they may warrant based upon their performance in any given performance period."
As a frequent reader of other news sources and blogs, I am well aware that many physicians are throwing shade on MACRA and the reforms that it advances. Some have gone so far as to suggest that the SGR was better. I fundamentally disagree that the flawed sustainable growth rate and current penalty performance programs (PQRS, MU, VBM) were better. Under the SGR methodology, the best you could hope for was level funding from year-to-year. There was never a plausible chance to secure positive payment updates. Furthermore, the penalties associated with PQRS, meaningful use, and the value-based modifier -- all currently in place -- are greater than those associated with the MACRA MIPS pathway. Putting a finer point on this, under the previous payment formula the best you could do was prevent reductions in payment, you were never able to pursue increased payments. MACRA creates opportunities to actually increase payments, something that hasn't existed for physicians participating in the Medicare program for more than a decade.
However, I do recognize that MACRA is not easily understood and it has inherent risks for all physicians in all practice models. It is our job to ensure that you have the appropriate information and resources to be successful in your practice. I encourage you to do three things this week.
- Visit our MACRA Ready resource page. This page has numerous resources and tools that will help you better understand the new payment pathways and begin developing a strategy for your practice.
- Prepare for the CPC+ program by emailing firstname.lastname@example.org. We have a new partnership that will provide you direct assistance in preparing an application for participation in this important payment model should your state or region be selected. This service costs you nothing. It's a member benefit. Please use it.
- Connect with a Practice Transformation Network (PTN). The PTN's have resources and tools that are free to physicians, and we encourage you to take advantage of them. To find a PTN in your area, email email@example.com.
The AAFP is committed to ensuring that you are MACRA Ready and we are equally committed to ensuring that this law is implemented in a manner that reflects Congressional intent and allows each of you to provide quality care to your patients, regardless of where and how you practice.
AAFP Showing Strong Support for DPC
Innovations in primary care continue to flourish in various markets across the country. One such innovation, which is mentioned often in the comment section of this blog, is direct primary care. What once was a novel idea in primary care delivery is rapidly becoming a highly sought after practice design for many family physicians.
The AAFP strongly supports innovations in primary care delivery and payment models that embody the core elements of the patient-centered medical home (PCMH) and place a priority on the patient-physician relationship. We also strongly support the reduction, if not elimination, of the complex administrative burden placed on family physicians through prior authorizations, appropriate use, and other such measures aligned with payment and compliance. We believe that the DPC model is an advanced primary care delivery and payment model that meets these criteria.
The DPC model embodies the core principles of the PCMH and is, at its core, patient centric. The model, through its payment structure, eliminates much of the administrative burden associated with modern primary care practice, which in return allows the physician to focus more time on direct patient care.
It is noteworthy that the DPC model is becoming widely accepted as a primary care delivery model that promotes patient-centered care. Although some suggest that it is a "return to traditional primary care," I would argue otherwise. It is a progressive delivery and payment model, built on the traditional primary care patient-centric model that places the patient as the focal point of the practice, but it also is a model that uses a team-based approach, advanced technology and data to deliver timely and quality care. The DPC community deserves a lot of credit for its efforts to demonstrate to public and private payers that the DPC model drives improvements in quality at a lower per capita cost, and people are starting to notice.
The AAFP has taken some criticism from the DPC community for not being an advocate for the model, but this is not the case. The AAFP first engaged with the DPC community in 2012, during the earliest days of the movement. I will admit that we were not the first person on the dance floor, but we have worked hard behind the scenes to make certain that the band keeps playing.
We have focused our efforts in two places; education and advocacy. Our education efforts feature a content resource page and a comprehensive toolkit that serves as a step-by-step guide on how to open a DPC practice.
We also have conducted a series of educational seminars around the country that have provided interested physicians the tools and resources they need to transition their practices to the DPC model.
Finally, in 2015, we partnered with the American College of Osteopathic Family Physicians and the Family Medicine Education Consortium to host the Direct Primary Care Summit. The 2016 Direct Primary Care Summit will be held July 8-10 in Kansas City, Mo. If you are a DPC practice or simply interested in exploring the opportunity, I would urge you to attend this event. We are confident that you will find this meeting both educational and energizing.
Our DPC advocacy efforts originated during the debate and consideration of the Patient Protection and Affordable Care Act (ACA). The ACA established DPC as a qualified health plan for the purposes of meeting the individual mandate established by the law. Although this was an important first step, which established a path forward for the DPC model, much work remains to ensure that patient contributions to a DPC practice are recognized as qualified medical expenses. The AAFP initiated our advocacy on this objective in 2013 when the AAFP formally recognized DPC as an advanced primary care delivery and payment model.
We accomplished this through the adoption of a position that reads, in part, "The American Academy of Family Physicians supports the physician and patient choice to, respectively, provide and receive health care in any ethical health care delivery system model, including the DPC practice setting."
During the past few years we have worked closely with our state chapters and other interested organizations such as the Direct Primary Care Coalition (DPCC) to advance legislation that would recognize payments made by patients to DPC practices as a qualified medical expense. For the DPC model to flourish, it is important that we ensure such recognition. I am pleased to report to you that there has been progress made. Sixteen states have enacted legislation in the past few years: Arizona, Idaho, Kansas, Louisiana, Michigan, Mississippi, Missouri, Nebraska, Oklahoma, Oregon, Tennessee, Texas, Utah, Washington, West Virginia, and Wyoming. Montana and Virginia passed legislation this year, but pending bills were vetoed by their respective Governors.
The AAFP also is actively supporting the Primary Care Enhancement Act (S. 1989). This legislation clarifies that DPC is a medical service and not a health plan under section 223 (c) of the Internal Revenue Code relating to Health Savings Accounts (HSAs). The legislation correctly defines DPC services as qualified health expenses under section 213 (d) of the tax code. The bill also creates a new payment pathway for DPC as an alternative payment model (APM) in Medicare and with dual eligible. This would allow CMS to pay practices an affordable flat fee for primary care services offered by a DPC medical home. The legislation includes a waiver to allow qualified physicians who have opted out of Medicare to participate in the program at any time. It also allows for Medicare Advantage plans to pair with DPC practices as primary care partners in an ACO-like structure.
To learn more about the DPC model, please consult our DPC FAQ. I also encourage you to join our DPC member interest group, which provides an opportunity for you to connect with other DPC family physicians.
Hi, My Name Is …
Congratulations to David Barbe, M.D., M.H.A., for being elected president-elect of the AMA. Barbe, a family physician from Mountain Grove, Mo., will become president of the AMA in June 2017. Family medicine has strong representation on the AMA Board. In addition to Barbe, there are four other family physicians serving on the AMA Board of Trustees.
A special hat tip to Barbe for quoting the incomparable poet Marshall Bruce Mathers III in his acceptance speech to the AMA House of Delegates: "Anything is possible as long as you keep working at it and don't back down."
AAFP Offering Resources, Support for Small Practices
"There is nothing wrong with staying small. You can do big things with a small team."
-- Jason Fried, software entrepreneur
For decades, medicine -- especially primary care -- was delivered by a cohort of independent physicians who dedicated themselves to their patients and their communities. These physicians delivered their services and compassion through a network of solo and small group practices that were largely isolated from each other and other physicians. There was connectivity to the local hospital because family physicians, not hospitalists, took care of their patients who were admitted. They also worked the emergency room, delivered a few babies along the way, performed school physicals, and made weekly trips to the nursing home. This scenario was the prototypical family medicine practice in countless communities across the nation, large and small.
I know this model well because I grew up with one of these family physicians, and I witnessed first-hand the relationship that he had with his patients and our rural Oklahoma community.
One thing that has long been a concern for the AAFP is ensuring that solo and small group practices are able to sustain their business model and continue providing care to their patients. Yes, many physicians have chosen to pursue other practice settings and financial arrangements. We support these practice choices fully in our education and advocacy activities, but we have added emphasis to the future of the solo and small group independent practice. We are not alone in this work, and several people have begun to invest thought and energy into the importance of maintaining diversity in physician practice types and arrangements. In a May 26 blog posting, David Blumenthal, M.D., and David Squires from the Commonwealth Fund posed an interesting question: "Do Small Practices Have a Future?"
This question has taken on renewed interest and importance as we approach the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) and became highly emotional thanks to the now infamous "Table 64," which CMS published as part of proposed MACRA regulations that inaccurately predicted that more than 80 percent of solo and small practices would take a penalty under the MACRA payment pathways. CMS published a follow up fact sheet explaining how solo and small practices can achieve success under the new payment programs.
The Commonwealth Fund article noted some interesting facts:
- Between 1983 and 2014 the percentage of physicians practicing alone fell from 41 percent to 17 percent.
- During the same time, the percentage of physicians in practices with 25 or more doctors grew from 5 percent to 20 percent.
- Younger doctors are 2.5 times less likely than older doctors to be in a solo practice.
It likely is no surprise to any of you that the solo, independent practice model has been in decline for several decades. There are multiple reasons (population shifts, economics, costs of education) why this shift has occurred, and I am quite confident that the comments associated with this article will provide some colorful clarity on this subject. However, before you throw in the proverbial towel, let me remind you of a few additional facts about the strengths of solo and small practices:
- Four of 10 physicians are in practices with fewer than five physicians. This is especially true in non-urban and rural communities. So, despite all the public commentary about the elimination of the solo and small group practice, they actually still exist and are an essential part of our health care delivery system.
- Solo and small practices often outperform larger practices in many evaluations. In fact, a recent Commonwealth Fund study found that patients of physicians practicing in solo and small practices have lower rates of preventable hospital readmissions. The Robert Graham Center recently published a study that found that "more comprehensive care among family physicians is associated with lower costs and fewer hospitalizations."
These studies and many others demonstrate that there are significant public policy justifications for why the preservation of solo and small practices should be a priority. Setting aside the simple fact that consolidation in health care escalates costs for patients and decreases payments for physicians professional services, the fundamental reason that community-based primary care should be preserved is that it actually benefits patients.
The AAFP is dedicated to ensuring that family physicians, regardless of practice type or location, have the tools and resources needed to be successful. We strive to ensure that each of you can find and maintain a practice that enables you to provide high quality care to your patients and allows you to realize your professional and personal goals. We recognize that many solo and small group practices feel that the current trends in health policy are moving away from them, or as some put it, destroying them. We understand why this anxiety exists and we prioritize the development and distribution of resources that can assist our members in these practice settings. The following is a sampling of the tools and services the AAFP has created for members:
- Solo and small practice resources;
- Independent solo and small group practice member interest group;
- Chronic care management toolkit;
- Family Practice Management's "Four Coding and Payment Opportunities You Might Be Missing."
In addition, the AAFP is working closely with CMS to prepare physicians for value-based payment models through two programs, the Transforming Clinical Practices Initiative (TCPI) and the recently announced Comprehensive Primary Care Plus program.
You can learn more about the practice transformation opportunities available through the TCPI program on our resource page. I also encourage you to join our TCPI member interest group.
The AAFP also is actively engaged in identifying and recruiting physicians to participate in the CPC+ program, which will be launched later this summer. While the exact regions are not yet known, we are seeking to identify family physicians who have an interest in participating in this program in advance of the enrollment period, which opens July 15. We are especially interested in identifying solo and small group practices so that we can begin assisting you prior to the open enrollment period. If you are interested in participating in the CPC+ program, please email us at CPCPLUS@aafp.org.
As noted in this posting, the AAFP continues to place an emphasis on solo and small group practices. We see these practice settings as contributory to the betterment of our health care system. However, we fully recognize that much has changed during the past 30 years. We feel it is important to hear directly from our members on how these changes in care delivery and physician payment may impact your practices.
If you practice in a solo or small independent practice and you are interested in learning more about MACRA and its opportunities for solo and small practices, we will be hosting a webinar on Thursday, June 16 at 7:30 pm Eastern. We will be posting registration information on the Solo and Small Group Member Interest Group listserve and directly emailing to our CPC Plus community. To ensure you receive the registration information, please email us at CPCPLUS@aafp.org or join the solo and small practice group member interest group.
Why You Should Apply for CPC+ Program
On April 11, CMS announced the establishment of the Comprehensive Primary Care Plus (CPC+) program. CPC+ is an advanced primary care medical home delivery and payment model that builds on the Comprehensive Primary Care Initiative (CPCi) program, which was launched in 2012 and concludes at the end of this year.
In its announcement, CMS referred to CPC+ as "largest-ever multi-payer initiative to improve primary care in America." The AAFP welcomed the announcement of the new program. Fundamentally restructuring how we pay for primary care is an important step towards our goal of reforming the health care system to one that is foundational in primary care. The underlying policies of the CPC+ program are consistent with the AAFP policies on primary care delivery system and payment reform.
The program, which is a regionally-based and multi-payer, will launch formally in January 2017 and run for five years. CMS plans to identify and enroll 5,000 practices -- up to 20,000 total participants -- practicing in 20 yet-to-be-identified regions to participate in the program. Up to 2,500 practices will be selected to participate in one of two tracks (5,000 total participants).
Additionally, and probably most importantly, the CPC+ has been identified as an advanced alternative payment model (Advanced APM) under the Medicare Access and CHIP Reauthorization Act, meaning that practices participating in the CPC+ program will be eligible to receive a 5 percent bonus payment on their Medicare allowable charges starting in 2019.
CPC+ is designed to reward primary care physicians for the comprehensive, coordinated, and continuous care they provide their patients. By incorporating a multi-payer approach, the CPC+ program promotes alignment in delivery and payment policies across all payers in a physician’s practice. This means that all patients cared for by that primary care physician practice will be participating in the program versus just a physician's Medicare patients.
Participating practices will be asked to transform their practices to focus on the five core principles of advanced primary care, also known as the Comprehensive Primary Care Functions, which were established as part of the original CPCi program. These five functions, when accompanied by the Joint Principles of the Patient-Centered Medical Home, are consistent with the AAFP’s definition of an advanced primary care practice. The five functions are:
- access and continuity;
- care management;
- comprehensiveness and coordination;
- patient and caregiver engagement; and
- planned care and population health
Clearly, practice transformation consistent with these five functions necessitates payment policies that support such activities. The CPC+ program adheres to the AAFP's long-standing policy that advanced primary care practices should receive advanced payments on a per capita basis for both care delivery and care management. In an April 11 JAMA article, Laura Sessums, J.D., M.D., director of the Division of Advanced Primary Care at the Center for Medicare and Medicaid Innovation, expressed similar sentiments.
"To support fundamental change in care delivery, practices require a fundamental change in payment structure," she wrote.
The CPC+ program is designed to accomplish this goal in three ways.
- Care management -- All practices participating in the program will receive, from Medicare, an advanced care management fee for each attributed beneficiary. They also will receive an advanced care management fee from participating private insurers. The care management fee for CPC+ Track 1 will be determined in four risk tiers, but it is expected to average $15 per beneficiary per month or $180 per year. Track 2 payments will be determined in five risk tiers, but are expected to average $27 per beneficiary per month or $324 per year.
- Performance-based incentive payments -- All practices participating in the program will receive an advanced, performance-based incentive payment for each attributed beneficiary. The per beneficiary incentive payment for practices participating in Track 1 will be $2.50 and $4 for those in Track 2. These payments are designed to both facilitate and reward performance on patient experience, clinical quality, and utilization measures. The payments will be made at the beginning of each year, but will be subject to recoupment if the practice fails to meet its thresholds for the quality and utilization performance.
- Payment reform -- Practices participating in Track 1 will continue to receive fee-for-service payments for services provided to Medicare beneficiaries. However, practices participating in Track 2 will receive a blended payment of a global payment for evaluation and management services and fee-for-service. The advanced E&M payment, referred to as the "comprehensive primary care payment," is designed to pay the practice for the costs of a typical office visit, thus creating flexibility in how the physician delivers care to their patients. More explicitly, the comprehensive primary care payment is designed to create parity in delivery modalities -- face-to-face, telemedicine, phone, etc.
The AAFP sees the CPC+ program as a positive step towards creating and implementing a payment model that aligns with the core functions of an advanced primary care practice. Yes, there are likely things that will need to be tweaked or improved, but we should not allow the perfect to become the enemy of the good. It is important that we have robust participation among family physicians in the CPC+ program -- especially those in solo and small practices. To this end, we are urging family physicians to pursue this opportunity. Enrollment for physicians opens July 15 and concludes Sept. 1.
Additional information and a complete timeline are available on our CPC+ resource page.
If you are interested in learning more about how you can participate in this program please send an email to CPCPLUS@aafp.org. We will follow up regarding how the AAFP can help prepare for your practice for the open enrollment period.
MACRA is Coming, the AAFP Has Resources to Help
A little more than a year ago, Congress approved the Medicare Access and CHIP Reauthorization Act (MACRA) by substantial bipartisan votes of 392-37 in the House and 92-8 in the Senate.
To put these votes in context, 91 percent of Congress voted to repeal the flawed sustainable growth rate (SGR) formula and put our nation’s health care system on a new trajectory. On April 16, 2015, President Obama enacted this historic legislation into law. With a single stroke of the pen, the entire construct of how physicians are paid for their services, changed.
During the past 11 months, the AAFP has been diligently reviewing and analyzing MACRA in an effort to better understand the law so that we can prepare and position you for success. In addition, we initiated programs aimed at educating family physicians about the changes that are coming with respect to delivery system and payment reforms.
We launched a resource center and published content designed to assist you in understanding the scope and implications of the law. My colleague Amy Mullins, M.D., wrote a great primer for Family Practice Management entitled "Making Sense of MACRA."
I addressed the two payment pathways established by MACRA -- the Merit Based Incentive Payment System (MIPS) and the Alternative Payment Models (APMS) in previous posts on this blog. These resources were appropriate and adequate for the early stages of our member education campaign, but we promised you we would do more for you, our members.
Last Friday, we took the first step towards fulfilling that promise by ramping up our efforts in a big, big way through the announcement of MACRA Ready, which is a multi-faceted, multi-year campaign aimed at preparing our members for the new delivery reforms and payment pathways created by the law. The campaign features educational content on how the law is structured and functions, timelines for implementation, and tools aimed at helping you and your practice understand and prepare for one of the two payment pathways.
The most common question I am asked these days goes like this, "What should I be doing to prepare myself and my practice for MACRA?" I encourage you to visit the AAFP’s MACRA resources page. Here you will find information, tools and resources that are designed to help you better understand the new law. I have selected a few resources that will provide a good starting point:
- MACRA overview video;
- frequently asked questions;
- implementation timeline;
- MACRA acronyms;
- practice readiness assessment;
- AAFP News resources; and
- Making Sense of MACRA infographic.
The AAFP has also produced a series of MACRA webinars. This four-part series provides you with:
- an overview of MACRA;
- an introduction to MIPS;
- an introduction to APMs; and
- information about your current payment track.
I encourage you to sign up to receive MACRA email updates from the AAFP. These periodic emails will provide you the latest details on the new payment law and access to the latest tools and resources from the AAFP.
During the past year, I have had the opportunity to discuss MACRA with thousands of family physicians across the country. It is fair to say that many are anxious about these changes and eager to learn what the new law will mean to them and their practice. This is completely understandable. I firmly believe that the SGR was one of the worst health care policies every enacted into law and that family physicians and our health care system are far better off since it has been sent to the garbage pile of failed policies. However, I do understand that the SGR and the traditional fee-for-service system were familiar and, no matter how bad they were, you knew and understood them.
I often refer to MACRA as a historic law. Besides the fact that it repealed a severely flawed payment formula, MACRA made a substantive and meaningful shift in the ideology of the Medicare physician payment formula by shifting the concept of payment from payment for episodes of care to payment for the longitudinal quality of care provided to patients. Most importantly, the new law took significant steps to place an expressed emphasis on the importance of primary care.
Although there has long been an academic and conceptual belief that a health care system built on a primary care foundation is beneficial to patients and payers, there had never been a policy manifestation of this ideology -- until now. This law, by design and intent, places a renewed emphasis on primary care delivery models and goes so far as to protect them from financial risk in the APM pathway.
This renewed approach to primary care was set in motion as part of MACRA, but it can only be achieved as a result of the regulations issued by CMS. Therefore, the approach taken by CMS to implement MACRA is key. On May 5, CMS Acting Administrator Andy Slavitt tweeted some information, and I think you will be pleasantly surprised by what he had to say:
- "Must start with a core belief that MDs know best how to take care of patients and allow freedom"
- "Must simplify the practice of medicine: reduce burden, add flexibility, and provide support at every turn"
- "Pay more to PC [primary care] for care coordination, for dialogue, for cost of care outcomes"
I respect that some of you will disagree that MACRA holds any opportunity or value, and I look forward to hearing your thoughts, concerns, and suggestions. I can promise you this, the AAFP will do everything we can to provide you information, resources and tools that will allow you to be successful under one of the two new payment pathways.
Teaching Health Centers Key to Solving FP Shortage
March 18 was Match Day, which is when most fourth-year medical students receive confirmation of where they will conduct and hopefully complete their residency training.
Overall, the 2016 Match continued an encouraging trend for family medicine and primary care. A record 3,105 allopathic medical students chose family medicine residency positions in the National Resident Matching Program. In addition, 2016 marked the seventh consecutive year that the number of medical students choosing careers in family medicine increased.
Meanwhile, the American Osteopathic Association Intern/Resident Registration Program also produced encouraging results for family medicine with nearly one-fourth of participants choosing a family medicine position. The number of osteopathic medical students choosing careers in family medicine has nearly doubled since 2011.
The emphasis and priority placed on primary care by policy-makers and payers is influencing career choices of medical students. Primary care residencies had a fill rate of 96.1 percent, and family medicine increased its fill rate to 95.2 percent. This is a fairly remarkable number when you consider that less than a decade ago the fill rate for family medicine had dipped below 85 percent.
Overall, primary care positions accounted for 14.5 percent of all residency positions offered (4,053 of 27,860). With a primary care shortage knocking at the door, it is clear that more needs to be done to increase the pipeline for primary care specialties, which brings me to one of one of my all-time favorite policy issues -- teaching health centers (THCs).
The concept of teaching health centers is really quite simple. Instead of relying on the legacy graduate medical education system, which is focused on the academic medical center and other hospital settings, THCs use community-based settings such as federally qualified health centers (FQHCs), rural health clinics (RHCs), tribal clinics, and other settings to train residents.
Most primary care services are provided in community-based settings, so this concept aligns quite nicely with the education and training model for family medicine residency programs. Additionally, unlike the legacy GME programs, the money for training flows directly to the practice and training site versus going directly into the overall budget of an academic health center or hospital.
Teaching health centers were established in 2010 under the Patient Protection and Affordable Care Act (ACA) and reauthorized in 2015 as part of the Medicare Access and CHIP Reauthorization Act (MACRA). Today, there are 690 residents being trained in 59 teaching health centers in 27 states and the District of Columbia. Of the 59 programs, an overwhelming majority of the residency positions are in family medicine. Yes, there are a few internal medicine, pediatrics, and obstetrics/gynecology positions, but the clear recipient of the majority of these positions is family medicine. And, these programs produce -- big time.
Besides producing large percentages of family physicians, the graduates of these programs have a strong commitment to providing care to vulnerable populations. The AAFP's Robert Graham Center for Policy Studies in Family Medicine and Primary Care recently published a one-pager that shows a stark difference between graduates of teaching health centers and those who completed their training in a legacy GME program. Specifically, the Graham Center found that 33 percent of THC graduates “planned to practice in a setting primarily associated with underserved populations (e.g. community health centers, rural health clinics, Indian Health Service, US Public Health Service).” By comparison, only 18 percent of graduates from non-THC programs planned to practice in underserved areas.
One of the primary reasons that I love THCs is this -- they are better positioned to address the geographic distribution problems that currently exist in the physician workforce. According to the Agency for Healthcare Research and Quality (AHRQ), 91 percent of all physicians practice in urban areas. This makes perfect sense, if you train in an academic health center or large hospital; it is highly unlikely -- if not improbable -- that you will migrate from Manhattan, New York, to Manhattan, Kansas. Training future physicians near desired practice locations is nothing new or novel. The de-centralization of GME has been a desired policy objective of academic leaders for decades.
There is compelling data to support the de-centralization of physician training, especially in primary care. According to a 2015 Family Medicine study entitled “Family Medicine Graduate Proximity to Their Site of Training,” 54.8 percent of family physicians practice within 100 miles of where they train, and 46 percent practice within 50 miles of their training location. When you look at those who have completed their training since 2000, the numbers are even more significant with 62.5 percent choosing practice locations within 100 miles of their training site.
The challenge historically was the lack of a program that allowed GME training to take place away from the hospital setting – until THCs. I'm not advocating for the elimination of all hospital-based GME because we need primary care programs in all settings. What I am an advocate for are policies that work, are scalable, and most importantly, achievable in our current political environment.
Upon his capture in 1934, FBI agents asked legendary bank robber Willie Sutton why he robbed banks. Sutton, who believed the question to be rhetorical, replied, dryly, "Because that's where the money is."
Why do I support THCs so strongly? Because that’s where the opportunities are. There are more than 9,000 community health centers in the country serving more than 24 million patients annually. Fifty-seven have training programs. THCs are the hidden gem of workforce policy when they should be the Hope Diamond. The AAFP has placed a priority on the continuation and appropriate funding of THCs. During the recent Family Medicine Congressional Conference (FMCC), participants advocated on behalf of THCs with their mnembers of Congress. In addition to this work, the AAFP continues to pursue policies that extend the THC program and create a stable funding stream to ensure the continuation of this successful program.
The Partnership to Fight Chronic Disease has released a new report, “What is the Impact of Chronic Disease on America?” Two key takeaways from the report:
- In 2015, 191 million people in America had at least 1 chronic disease, 75 million had 2 or more chronic diseases.
- Chronic disease could cost the United States $2 trillion in medical costs and an extra $794 billion annually in lost employee productivity per year between now and 2030. The organization also has state-by-state impact analysis that you can review.
Family Medicine's Role in Strengthening Public Health
“I’m a clown, which could be a public health role.” -- Patch Adams, M.D.
Last week was National Public Health Week. Established in 1995, the week draws the nation’s attention to timely and impactful public health issues. In addition, it provides an opportunity to recognize the contributions of physicians, nurses, researchers and others who devote their talents to the betterment of public health.
In this post, I would like to celebrate the family physicians who dedicate their careers to public health, as well as recognize the contributions that each of you make to the betterment of public health in your communities.
My colleague and family physician Julie Wood, M.D., is recognized as a national leader on the integration of public health and primary care. Beyond leading the AAFP’s efforts in this area, she drives the larger public dialogue on many public health issues and the role of primary care in addressing those issues.
In 2015, she assisted in drafting The Practical Playbook: Public Health and Primary Care Together, which was a joint effort of the CDC, the de Beaumont Foundation and the Department of Community and Family Medicine at Duke University. In this text book, Dr. Wood described the relationship as follows. “Primary care and public health have natural links that strengthen each other.”
Public health has its origins in the United States dating back to 1798 when Congress created the Marine Hospitals to care for sick and infirm seamen. In 1870, the nation’s network of Marine Hospitals were reorganized into a centrally controlled Marine Hospital Service and placed under the supervision of the Supervising Surgeon -- a position later renamed Surgeon General. In 1871, John Maynard Woodworth, M.D., was appointed the first Supervising Surgeon/Surgeon General.
In 1889, Congress created the commissioned officer corps as a means of providing physician workforce to the various Marine Hospitals. The commissioned officer corps later became known as the United States Public Health Service Commissioned Corps (PHSCC). The PHSCC is the federal uniformed service of the U.S. Public Health Service (PHS) and is led by the Surgeon General.
The AAFP and family medicine have a long and proud history as a leader on public health issues. The earliest days of public health, outside of the military system, are grounded in primary care and community medicine. Family medicine and the AAFP remain strong contributors to the nation’s public health. Thousands of family physicians have and continue to serve in the Public Health Service Corps and each of you, in your own important ways, contribute to the health of your communities through your day-to-day practice of medicine.
No single topic exemplifies our leadership more than the issues related to smoking and tobacco use. It is indisputable that the AAFP’s advocacy efforts on these issues drove changes in law and have been a major driving force behind national efforts to limit smoking and tobacco use. Clearly there is more work to do, but family medicine should be proud of the changes you have caused through your advocacy on these important public health issues.
Our work on public health issues is far-reaching. Honestly, there are few public health issue that the AAFP is not working on. We are at the forefront of efforts to curb the opioid and heroin epidemic, working closely with Surgeon General Vivek Murthy, M.D., the White House, governors and the CDC to identify and disseminate information that will allow family physicians to better identify abuse and intervene on behalf of patients in their communities.
The leadership of family medicine is on display each day through the work of AAFP President Wanda Filer, M.D., M.B.A., and countless others who are working tirelessly to educate the public, policy-makers, physicians, and health care providers on this important issue.
In addition, the AAFP is working on Zika, childhood immunizations, antibiotic resistance, obesity and countless other important issues.
The AAFP has a full set of public health and social determinants resources available for you and your practice.
One of the greatest demonstrations of family medicine’s commitment to public health occurred earlier this year (and continues to this day and will for years to come) when our colleagues and friends in Michigan stepped forward and provided demonstrable leadership to the community of Flint. Most of you are aware of the series of tragic events that have come to light with respect to the water supply in Flint. As family physicians you should be proud of the manner in which your colleagues in Michigan have responded to this tragic event. I am especially moved by a quote on the Michigan AFP's website which reads in part, “It is clear that Family Physicians have a large role in screening for lead poisoning and developmental issues in the children and families afflicted by the Flint water crisis. Their expertise, however, goes far beyond the provision of comprehensive medical care. … the heart of Family Medicine is community.”
I think it is important to reflect on the significant and important contributions family medicine makes to public health -- at the policy level, but more importantly at the community level. In 1989, the AAFP established a Public Health Award that recognizes individuals who have made or are making extraordinary contributions to the American public’s health. If you know of a family physician or group of family physicians who are making a difference in the health of the public, please nominate them so we can celebrate their contributions.
Finally, Alignment of Meaningful Quality Measures May be Reality
How many times in your career have you audibly uttered "why can't all insurance companies use the same quality measures and reporting process?" I'm guessing many of you have probably said it today.
A few weeks ago, I wrote about the AAFP’s 2016 advocacy agenda. In that post, I identified reducing "administrative complexity" and "alignment" as Academy priorities. The vast volume of rules, regulations, and guidelines that family physicians must navigate each day is a leading driver of professional dissatisfaction and frustration. A 2013 study of 23 health insurers found that 546 quality measures were used, few of which matched across insurers.
Given that 61 percent of family physicians have contracts with seven or more payers -- each with their own quality reporting, prior authorization, and appropriate use criteria -- it's easy to understand why you are so frustrated with quality reporting and performance improvement programs.
One physician told me, "Unless you reduce the administrative and bureaucratic burden to primary care, family medicine will cease its existence. Time has a care value, care has a time value."
This frustration is expressed by family physicians of all ages and in most practice settings.
Not to deemphasize the negative impact administrative complexity has on physicians' professional satisfaction, but the financial impact on physicians' practices is probably a bigger concern. As noted from the physician above, "time has a care value, care has a time value," and this is greatly out-of-balance. A recent study published in Health Affairs found that physicians individually spend $40,069 per year and, collectively, more than $15.4 billion annually to report quality measures. Startling statistics, but the underlying commentary is what concerns me. It reads, in part, as follows:
"… physicians and their staff spend 15.1 hours per physician per week dealing with external quality measures including the following: tracking quality measure specifications, developing and implementing data collection processes, entering information into the medical record, and collecting and transmitting data. This is equivalent to 785.2 staff and physician hours per physician per year. The average physician spent 2.6 hours per week (enough time to care for approximately nine additional patients) dealing with quality measures."
The AAFP has long recognized and advocated for a reduction in the administrative burden placed on family physicians. In 2014, the AAFP ramped up its efforts when we engaged in a collaborative effort with CMS, America’s Health Insurance Plans (AHIP), and representatives from the patient community to identify and develop a set of core quality measures for primary care physicians. Our collaboration was supported by the National Quality Forum, and the National Committee for Quality Assurance to ensure that our work was adhering to the most recent science and evidence on quality and performance measurement. It's noteworthy that payers (CMS and commercial insurers) who participated in the collaboration represent approximately 70 percent of the combined population of Medicare Advantage enrollees and fee-for-service Medicare beneficiaries in the United States -- not to mention a clear majority of covered lives in the employer-sponsored and individual markets.
The collaborative developed a framework of three aims for our work which were:
- Recognize high-value, high-impact, evidence-based measures that promote better patient health outcomes, and provide useful information for improvement, decision-making and payment.
- Reduce the burden of measurement and volume of measures by eliminating low-value metrics, redundancies, and inconsistencies in measure specifications and quality measure reporting requirements across payers.
- Refine, align and harmonize measures across payers to achieve congruence in the measures being used for payment and other accountability purposes.
These three aims were further articulated through 11 key attributes, one of which states "data collection and reporting burden must be minimized." A second key attribute stated, "measure sets for clinicians should be as parsimonious as possible and should focus on those measures delivering the most value."
I am pleased to report, that after nearly two years of work, our collaboration has produced a meaningful result for family physicians. On Feb. 16, the AAFP joined CMS and (AHIP) in announcing the establishment of a Core Measure Set for Primary Care and the Patient Centered Medical Home. This core measure set is an important step in reducing the administrative burden each of you experience on a daily basis. Furthermore, the adoption of this core set across all payers has real potential to reduce the negative financial impact on practices.
The AAFP is actively advancing the inclusion of this core measure set in the Medicare program and in the forthcoming Medicare Access and CHIP Reauthorization Act regulations. Additionally, we are pressing commercial insurance plans to include the core set in their next round of contracts for family physicians. We urge you to use AAFP resources or the CMS webpage to familiarize yourself with these core measures and insist that the insurance companies you contract with transition your practice towards these measures.
APMs: A Primer on the New Payment Model
Each of you is now familiar, or is hopefully growing more familiar, with the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA).
MACRA was enacted April 16, 2015, and repealed the Medicare sustainable growth rate. It also set in motion the creation and implementation of two payment pathways for physicians participating in the Medicare program. Last month I shared information and insights on the Merit-Based Incentive Payment System (MIPS). In this post, I am providing an overview of the MACRA Alternative Payment Model (APM).
The AAFP views the APM as the best opportunity for family physicians, primarily due to the fact that it promotes new delivery and payment models that migrate away from fee-for-service. Our primary goal for several years has been the establishment of payment policies that promote and finance comprehensive, continuous, and coordinated primary care. We believe that MACRA creates an environment whereby these models can be implemented, and we believe the APM pathway gives these models a place to grow and mature.
Starting in 2019, family physicians participating in a qualified alternative payment model who successfully meet the quality and performance criteria and exceed the established Medicare beneficiary thresholds will be eligible for a 5 percent bonus payment on their total allowed Medicare charges. Furthermore, qualifying physicians participating in a qualifying and eligible APM will be exempt from the MIPS program. APM qualifying physicians also will receive a higher Medicare physician fee schedule update (of 0.75 percent) starting in 2026.
There are three sets of criteria that must be met in order to secure the bonus payment in the APM pathway. Those three criteria are:
Qualifying Alternative Payment Model -- MACRA explicitly outlines which delivery and/or payment models will ultimately qualify as an APM. The law states that qualifying APMs must be established through one of four ways:
- Medicare Shared Savings Program;
- Centers for Medicare and Medicaid Innovation (CMMI) programs expanded by the HHS Secretary;
- Medicare Quality or Acute Care Episode Demonstration projects; and
- demonstrations required by federal law
Eligible Alternative Payment Model -- Any APM that meets one of the four qualifying criteria listed above must also meet the performance and quality thresholds established by the law. There are three performance thresholds:
- APMs must report quality and performance measures comparable to those contained in the MIPS program.
- APMs must use a certified EHR technology.
- APMs must incur nominal financial risk for monetary losses or be a medical home model expanded under CMMI authority.
Qualifying Alternative Payment Model Physician -- The final criterion in determining if an individual physician or a group of physicians qualified for the 5 percent bonus payment is that a qualified physician must demonstrate that the required percentage of his or her payments is received through a qualified and eligible APM.
For 2019 and 2020, qualifying physicians must demonstrate that, at minimum, 25 percent of their total Medicare payments are aligned with a qualifying and eligible APM. Starting in 2021, the minimum threshold increases to 50 percent, but the law allows physicians to use a combination of Medicare and non-Medicare payments, such as those from Medicaid and commercial insurers, to meet that threshold.
A few observations on APMs:
- APMs represent the better of the two pathways, in AAFP’s opinion, for family physicians to move away from the challenges of episodic fee-for-service practice models towards more comprehensive delivery and payment models that allow for and compensate you for comprehensive and coordinated patient care.
- The AAFP is aggressively advocating for the inclusion of an advanced primary care delivery model as a qualifying APM. We view the Comprehensive Primary Care (CPC) initiative as a model that can and should be expanded on a national scale.
- APMs are more inclusive than accountable care organizations (ACO) and do not “require” family physicians to sell their practice to a hospital or health system to qualify for the APM bonus payment.
- The medical home plays an important role in the APM pathway, since medial home APMs are exempt from the “nominal risk” eligibility criteria.
- Pursuit of the APM pathway is valuable even if you fall short of the eligibility and qualification criteria since APM participation is recognized as a Clinical Practice Improvement Activity (CPIA) under the MIPS pathway. This means that those that attempted to participate in an APM will receive favorable scoring for the CPIA performance category in the MIPS program.
- The MIPS program is designed to prepare physicians for participation in an APM. For this reason, making an effort to transition towards an APM sooner rather than later is encouraged.
The AAFP is committed to ensuring that you and your practice are ready to take advantage of new payment opportunities presented by MACRA. In the coming weeks we will be launching a comprehensive member education and communications effort designed to simplify the transition and provide the guidance you need to realize the benefits of value-based payment. Please watch for additional information at this blog or on aafp.org.
On March 8, CMS announced a proposed rule to test new models to improve how Medicare Part B pays for prescription drugs and the administration of those drugs by physicians. Although most prescription drugs are paid through Medicare Part D, there is a substantial number of drugs paid for under the Part B program. Primarily, Medicare Part B covers prescription drugs that are administered in a physician’s office or hospital outpatient department, such as cancer medications, injectables like antibiotics, or eye care treatments.
The proposal issued by CMS puts in place a value-based payment model for prescription drugs, but also alters the payment for the administration of such products in a manner that is favorable for family physicians. The proposed rule seeks to test six alternative approaches for Part B drugs. The AAFP issued a statement on the proposal and will be providing CMS with substantive comments on the proposal in the coming weeks. The full proposal is available on the Federal Register.
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