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Tuesday May 09, 2017

Patients on high-deductible plans need primary care coverage

Our health care system has experienced many changes in the past three decades, including impactful and consequential changes in insurance design.

Insurance reforms enacted during the past 30 years, including those in the Children's Health Insurance Program, the Medicare Modernization Act (MMA), and the Patient Protection and Affordable Care Act (ACA) have increased access to health care coverage for millions. As a result of these laws, the nation's uninsured rate has reached a historic low. In fact, the uninsured rate decreased from 15.7 percent in 2009 to 9.1 percent in 2015.  

However, despite significant reductions in the number of uninsured, these changes in policy have not adequately relieved the financial pressures on individuals, families and employers. As a result of increasing economic pressures, there has been a proliferation of high-deductible health plans (HDHP). HDHPs are insurance plans with a minimum deductible and maximum out-of-pocket limit as defined by the Internal Revenue Service (IRS). Currently, the deductible threshold is $1,300 for an individual and $2,600 for a family. Under a HDHP, all medical care must be paid for out of pocket until this minimum deductible is met.

Many of the newly insured have secured their health care coverage through a HDHP.  Although the ACA drove higher utilization of HDHPs, the ACA did not create these insurance products. HDHPs were first offered by employers in 2001, but didn't experience large growth until after creation of health savings accounts through the MMA in 2003. During the past decade, the popularity of HDHPs has consistently increased among employers and individuals.  

In 2006, 4 percent of employees enrolled in an employer-sponsored HDHP. By 2015, 24 percent of employees were enrolled in such plans. HDHPs are especially appealing to younger workers. While these plans are gaining popularity in the employer-sponsored insurance market, they also are prevalent in the individual and small group markets. In fact, according to a report in Health Affairs, approximately 90 percent of enrollees in the individual marketplace have a deductible beyond the qualifying threshold for an HDHP.  

HDHPs have been an important component of our efforts to decrease the number of uninsured, but they come with significant challenges -- most notably is the simple fact that HDHPs provide a disincentive for individuals to seek primary and preventive care due to the associated out-of-pocket expenses. Recent academic literature shows that individuals with HDHPs delay or prolong seeking health care services as a result of the out-of-pocket financial obligations that exists with HDHPs.  

Delays in seeking care, lapses in maintenance, or adherence to treatment protocols lead to a worsening of an individual's health. Ultimately, providing needed care will cost the individual, their insurer and the health care system significantly more money. For example, the average cost of a visit to a primary care physician is $160. By comparison, the median charge for outpatient conditions in the emergency room is $1,233 and the average hospital stay is $10,000.

Based on these indicators, you could see your primary care physician 7.7 times for the cost of a single visit to the emergency room and 62.5 times for a single hospital admission. Furthermore, it is estimated that more than $18 billion could be saved annually if patients whose medical problems are considered avoidable or non-urgent took advantage of primary or preventive health care rather than relying on emergency rooms.  

To address this issue, the AAFP has developed a policy proposal that would expand access to primary care physicians for individuals and families who have a HDHP. Our proposal would provide individuals and families with a high-deductible health plan (as defined by the IRS) access to their family physician, or primary care team, without the obligation to meet the cost-sharing requirements (deductibles and co-pays) stipulated by their policy.

The company issuing the HDHP would be required to provide full coverage for designated primary care services for the plan year. Covered services would include Evaluation & Management (E&M) codes for new and existing patients (99201-99215) prevention and wellness codes (99381-99397), chronic care management and transition care management codes. The company issuing the HDHP policy would be responsible for paying the physician according to the contracted rate for these services.  

Patients would be required to designate a primary care physician or a primary care team.  The designated primary care physician or team would be the only site of service eligible for this benefit for the enrollment period. If a patient fails to designate a primary care physician, the insurer would be responsible for assigning a primary care physician to the patient. Our proposal defines primary care as those eligible clinicians enrolled in Medicare via the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) and practicing under one or more of the following Physician Specialty Codes: 01 General Practice; 08 Family Medicine; 11 Internal Medicine; 37 Pediatric Medicine; and 38 Geriatric Medicine.

This is an important component of our efforts to promote primary care as foundational to our nation's health care system. We have started to engage members of Congress and will be working to advance this policy as part of the current health care debate.

Wonk Hard    
On May 4, the House of Representatives narrowly approved the American Health Care Act (AHCA) (H.R. 1628) on a vote of 217-213.  The passage of the AHCA brings to a close a brutal four-month effort on the part of House Republicans to fulfill their promise to repeal and replace the ACA. The legislation now moves to the Senate where its fate is unknown. It is clear from Senators' public statements that they will significantly alter the legislation. The AAFP released a statement shortly after House voted.

Tuesday Apr 25, 2017

I'm Listening: Part II

"The mirror mirror on the wall, sees my smile and it fades again -- give me something to believe in." – Poison

In my previous post I started a conversation  regarding the most common themes captured in your replies to this blog. As noted, during the past four months you have provided comments and feedback on a variety of issues and topics. This feedback, predominately, has fallen into one of three categories:

  • The AAFP does not represent me or my views;
  • administrative burden; or
  • the Patient Protection and Affordable Care Act (ACA) isn't working and should be repealed.

I covered "the AAFP does not represent me or my views" in my previous posting, and I have written extensively on the Affordable Care Act in the past few months, so let's first dive into the second item, which is the negative impact of regulations and administrative functions on family physicians.

Administrative Burden
A 2016 study published in the Annals of Internal Medicine found that during a typical day, primary care physicians spend 27 percent of their time on clinical activities and 49 percent on administrative activities. The authors of this study concluded that for every hour primary care physicians spend in direct patient care, they spend two hours engaged in administrative functions.

This is a startling finding. It demonstrates the imbalance between patient care and administrative functions that has been established in recent years. It also demonstrates that health policy is asking physicians to focus too much time and resources on things that do not contribute to direct patient care and, in fact, detract from patient care.  Administrative burden is one of the leading causes of physician burnout.

Family physicians are frustrated with the growing volume and complexity of regulations. Small independent practices are especially incensed, and they are extremely frustrated with the AAFP and what they perceive as our lack of urgency in addressing this problem. The frustration is understandable and justified.  

The AAFP recently joined with the AMA and more than a dozen other medical groups to create a set of 21 principles related to prior authorizations. The document highlights the fact that prior authorization processes could be improved simply by applying common-sense concepts to issues that affect clinical validity; continuity of care; transparency and fairness; timely access and administrative efficiency; and alternatives and exemptions.

A related AMA survey found that the average physician practice completes 37 prior authorization requirements per physician each week. This means a small group practice of three family physicians would likely complete more than 100 prior authorization requests per week. Compliance with regulations and administrative requirements are not only time consuming as noted above, they are expensive as well.

A March 2016 study published in Health Affairs found that primary care physicians spend 3.9 hours per week on reporting for quality programs. The same study estimated that the average annual cost of compliance with quality programs alone was $40,069 per physician. This study only evaluated quality reporting, so the cost of prior-authorizations and other administrative functions would be in addition to these findings.

The negative impact of compliance with regulations is a subject I have written about several times during the past two years. In my first post on the subject, I discussed the negative impact of "work after clinic" -- or the WAC -- and its negative impact on patient care and physician well-being. My most recent post on this subject outlined a set of administrative functions the AAFP had identified for modification, reform or elimination -- our top 10 list.

Given the negative impact of administrative burden, the AAFP has made this issue one of our highest priorities for the 115th Congress. Here is an accounting of the other actions taken since January:

  • Developed the AAFP's Agenda for Regulatory and Administrative Reforms, a set of regulations and administrative functions that we believe should be revised and/or eliminated.
  • Sent a letter to President Trump in response to his executive order calling for the reduction in regulatory burden on businesses. In our letter we outlined the negative impact regulations are having on the practice of medicine and included our policy recommendations on how the Administration could reduce regulatory burden on family physicians.
  • Sent a letter to HHS Secretary Tom Price, M.D., outlining four immediate steps that should be taken to reduce the administrative burden created by electronic health records (EHRs).  

These actions are expected to be completed by the end of May:

  • Develop a white paper that outlines multiple recommendations aimed at reducing the administrative complexity of the Medicare Access and CHIP Reauthorization Act (MACRA). Our policy recommendations will identify specific steps CMS should take to eliminate certain reporting requirements and reduce the overall burden of participating in the program.
  • Meet with CMS Administrator Seema Verma to outline our recommendations on regulatory reform.
  • Meet with the Office of the National Coordinator for Health Information Technology to discuss reforms to the EHR requirements under MACRA and to increase the certification requirements for vendors.

In closing, let me stress how important reducing your administrative burden is for the AAFP. We hear your frustration, and we are seeking both immediate and long-term reforms. We believe that your time and skills should be devoted to direct patient care -- not "administrivia." We also place a high priority on restoring the joy of practicing medicine. You should continue to push us on this issue, you know where to find me (smartin@aafp.org).

Affordable Care Act

The third issue that has garnered significant communication during the past few months is the ACA, or Obamacare as it is frequently referenced. Although the frequency of comments on the ACA has followed the tempo of the larger national debate, there has been a sustained feeling that the ACA is not working -- especially in rural communities. As noted above, I have written on this subject fairly extensively this year, but I did want to share a few thoughts in this post -- a modest attempt to clear up some confusion about what was and was not "created" by the ACA.

There seems to be some confusion about what was, and what was not, created and/or implemented by the ACA. Meaningful Use, the Physician Quality Reporting System (PQRS), and Value-Based Modifier were not created by the ACA. Meaningful Use was established by the HITECH Act, which was enacted into law in February 2009. PQRS was established through the Tax Relief and Health Care Act (TRHCA), which was enacted into law in 2006. The Value-Based Modifier was first established by the Medicare Improvements for Patients and Providers Act (MIPPA), which was enacted into law in 2008. The Affordable Care Act was enacted in March 2010, several months and years after each of these programs were enacted.

The ACA is challenging to write about. It has been enormously successful in some respects and equally disappointing in others. The law has resulted in millions of previously uninsured individuals gaining health care coverage. However, it has failed to control the cost of health care for individuals or purchasers.  

One area where the AAFP is paying close attention is the growing prevalence of high-deductible health plans (HDHP). The trend towards HDHP started in the mid-2000s, but the ACA has accelerated their use in both the employer-sponsored and individual markets. Many of you have suggested that the use of HDHPs is having a negative impact on patients and your practices due to the decreased use of primary care by individuals who face high out-of-pocket cost. We also have observed this trend and share your concern. In the next few weeks we will be introducing a new policy proposal aimed at this specific issue -- more to come.

Wonk Hard

As noted above, the AAFP is placing significant emphasis on reducing the administrative burden on family physicians. Earlier this month, AAFP President John Meigs, M.D., joined AMA President Dave Barbe, M.D., (also a family physician) at a meeting with CMS Administrator Seema Verma to discuss MACRA.  Dr. Meigs shared several recommendations regarding steps CMS should take to reduce the reporting burden created by MACRA -- especially in the MIPS pathway.

Tuesday Apr 11, 2017

Go Ahead, I'm Listening

"In my mind, I'm going to Carolina"
-- JamesTaylor


One of the most important aspects of this blog, as it is with other AAFP communications, is the feedback provided by each of you. Your feedback plays an important role in shaping the advocacy and policy activities of the AAFP. Your comments serve as the "canary in the coal mine," in some respects, which allows us to gauge the mood, sentiment, and overall feeling of our membership on any given issue, at any given point in time. Sometimes the canary doesn't come out, sometimes it does.

I have a colleague who is a master of the PDSA (Plan-Do-Study-Act) Cycle (tip of the hat to AAFP senior vice president of  education Clif Knight, M.D.) and the value of creating a continuous cycle of evaluation, planning and action. My attention span limits me to one of these activities at a time, so I decided to choose "evaluation." As part of this evaluation, I decided to look at the comments provided in response to my postings since the 2016 presidential election -- about four months. During this time period, I have covered a variety of topics that range from purely political topics, such as the elections; to more wonkish topics, such as the Medicare Access and CHIP Reauthorization Act (MACRA) implementation and the Patient Protection and Affordable Care Act (ACA); to practice management topics such as administrative and regulatory reform.

Your comments regarding these issues fell into three large categories:

  • the AAFP does not represent me or my views;
  • administrative burden; and 
  • the ACA isn't working and should be repealed.

There were secondary issues, such as direct primary care, single-payer, graduate medical education, scope of practice, and a few pithy comments on elected officials. But overall these three themes were dominant. In this posting, I am going to take a deep dive into the first of these three. In my next posting on April 25, I will explore the second and third issue.

"The AAFP doesn't represent me or my views," was the most common theme during the past four months. In most cases it was in reference to a single issue (e.g., the AAFP does not represent my view on single-payer or ACA repeal) and not a definitive statement on the full scope of AAFP's member services. However, there were some pointed comments regarding our advocacy efforts with respect to solo and small practices.

The AAFP represents a diverse membership. The diversity of family medicine is its strength, and diversity is also a key to our future. Diversity should be celebrated, but we also must acknowledge that it requires some patience and it forces us to be honest about the fact that there may be issues where our membership disagrees. Maintaining a focus on a common goal is important to balancing these differences.  

The AAFP mission statement directs us to "improve the health of patients, families, and communities by serving the needs of members with professionalism and creativity." Put more frankly, our goal is to support and advance policies that allow each of you to provide the highest quality of care to your patients in a practice environment that provides you professional satisfaction and financial remuneration that reflects your skills and services. This is our common goal.

The most common comment received was, "the AAFP never asks what I think." I recognize that many of you share this sentiment, but I can assure you that we do want to hear what you think. Each year, since 1992, the AAFP has conducted a member satisfaction survey whereby we ask a sample (5,000) of our membership to share their views and opinions on a variety of policy, education and membership issues. This year, we made the survey available to all members. If you haven't yet taken the survey, there is still time through the end of this month.

The survey's findings are collected, dissected and discussed to determine what we can do to better serve our members. I can assure you these reports do not go on the shelf. They drive work (lots of work) on your behalf. The survey has been issued annually for more than 20 years, so it plays a key role in helping us identify trends in the professional and practice challenges facing family physicians. By following "trend lines" we can develop and advance solutions before "trend" transforms into "crisis."

The second most common comment in this category was, "the AAFP does not represent my views on this policy." AAFP policies are established and reaffirmed by the Congress of Delegates  (COD). The COD is a representative body that meets annually to develop and set policy, and to elect your officers and members of the AAFP Board of Directors. Each year, the COD considers resolutions that aim to establish policy on relevant issues. You can read and comment on the 2017 resolutions in advance of the COD and communicate your support, opposition, or concerns. (None have been submitted yet for the Sept. 11-13 event in San Antonio.)

I would encourage you to first communicate with your state's elected COD delegates on policy issues under the purview of the COD. You also should feel free to reach out to your state chapter  on important issues. The elected delegates from your state are your voice at the COD.

If you prefer to communicate with a national representative, then you should feel free to contact any member of the AAFP Board at any time to share your views and opinions.  

The COD represents you and it benefits from engagement and diversity of opinion. If you are interested in participating in the COD, please use these resources.   

These are the mechanisms in place for you to communicate your views and opinions -- through our official representative body, the Congress of Delegates; through our elected leadership, the Board of Directors; and through our annual membership survey. You also should continue to comment on the various AAFP blogs and AAFP News on specific issues. You also can engage with the AAFP via social media at @aafp on Twitter and on Facebook. If these communication channels don't suit you, you can email me. I want to hear from you.

I thought it would be fun to address a few specific comments:

  • "You are not a physician."
    Yes, this continues to be a source of disappointment for my parents.  Despite my lack of medical credentials, I have traveled this road for several years and, in my opinion, have a pretty good understanding of family medicine and the health care system.
  • I have been told, "You are a shill for liberal policies," AND "You are a shill for conservative policies."
    I try to stay fair and balanced.
  • "You just write what CMS tells you to write."
    I do attempt to share information from CMS with our members, but I can assure you CMS doesn't always like what I have to say. They tell me so.
  • "The AAFP forgets who pays its bills."
    I never lose sight of who and what matters.  We might disagree from time to time, but your interests are my interest.
  • "You pick on Texas too much."
    I will never stop (after all I am an Oklahoma fan!)

Thank you for your continued membership and your support of this blog. Most importantly, thank you for what you do for your patients, your community and our country.  

I leave you with Sir Winston Churchill, who said, "A pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty."

I see a lot of opportunity.

Tuesday Mar 28, 2017

Pick-Your-Pace Program Can Help FPs Prepare for 2018

Spring has arrived!  

As I have shared in previous years, this is my favorite time of year -- largely due to the fact that baseball season is here, and baseball season means longer days and warmer temperatures. For those not following closely, Opening Day is less than a week away.   

Opening Day has to be the single most optimistic day of the year. It is the one day that every team has a chance to win the World Series, the crowds are big and loud, and everyone is pulling for the hometown team. On Opening Day, there are 30 teams who all believe that "this is their year," and they will compete for six months to be World Series Champions.  

Reality slowly sets in during the summer, but nothing can beat the enthusiasm of Opening Day.  

Speaking of enthusiasm! (levity my friends), I thought it would be a good time to discuss the Medicare Access and CHIP Reauthorization Act (MACRA) and share some new resources the AAFP has produced to assist you and your practice. As you know from a previous post, 2017 is the initial performance period of the MACRA Quality Payment Programs.  

Remember, if you engage in the QPP program at any level during the 2017 performance period, you will not receive a negative payment adjustment in 2019.  

If you are a Medicare participating family physician, you are an eligible clinician (EC) for the purposes of participation in MACRA. As an EC, you will participate in one of the two MACRA QPP pathways -- the Merit-Based Incentive Payment System (MIPS) or Advanced Alternative Payment Model (Advanced APM). Many family physicians will pursue participation in an Advanced APM, but a large number will initially participate in the MIPS pathway. If you take no action, you will be included in the MIPS cohort for the performance period.

There are three exemptions for Medicare participating physicians:

  • Low Volume Threshold -- If your Medicare Part B allowable charges are less than $30,000 a year or you do not provide care to more than 100 Medicare Part B fee-for-service patients in a year, you are exempt from participation in the QPP. However, if your Medicare allowable charges exceed $30,000 a year and you provide care to more than 100 Medicare fee-for-service patients a year, you are part of MIPS.
  • Initial Medicare Participation Year -- If 2017 is your first year as a Medicare participating physician, then you are exempt from participation in the MIPS program.
  • Advanced APM -- If you are part of an Advanced APM, you are exempt from the MIPS program.

Step 1: Don't Panic
There are more than 900,000 physicians and other health care professionals participating in the Medicare program. Your current capabilities likely are far ahead of many of these ECs. Remember, practice transformation is a journey not a destination, and you should not try to master MIPS or an APM in a weekend. Take your time and be thoughtful, but diligent in your approach. I encourage you to think of the MIPS program as four functions -- not a comprehensive regulation. You likely are already doing these four things in your practice, so you are farther along than you may think. If you are not engaged in these activities, it's OK because you have time.   

In the simplest terms, these are the four functions you need to prepare for:

  • report quality;
  • use an electronic health record (EHR);
  • become a medical home or engage in performance improvement activities; and
  • understand the resource use (cost) of your patients.

The AAFP has two great resources: Making Sense of MACRA and MACRAnyms that can assist you in this step.

Step 2: Reflect
I would encourage you to reflect on your current capabilities and compare that to the four functions outlined above.

  • Do you currently report quality to Medicare, Medicaid, or a private insurer?
  • Do you have a certified EHR?  
  • Have you reviewed your Quality and Resource Use Report (QRUR)? 
  • What skill sets do you currently have in your practice?

After you complete this inventory, itemize and prioritize your strengths, weaknesses, and gaps. Then prepare a plan to prepare for 2018, not 2017. Remember, if you engage at any level in 2017 you will avoid a negative payment adjustment in 2019.  

Step 3: Evaluate and Develop a Plan with a Timeline
As we move towards advanced delivery models and value-based payments, it is important for you to truly understand your patient population. This will assist you in developing a quality and performance improvement strategy, which will better position you for success in MACRA and other value-based payment programs. A few items for you to think about:

  • Who are your patients? 
  • What are the most common health conditions among your patient panel?
  • What are the most common services provided in your practice?
  • Who are your payers?

It may seem trivial, but taking some time to reflect on your patients and the capabilities of your practice will assist you moving forward. The AAFP's Making Sense of MACRA: Understanding Your MACRA Pathway is a good resource to consult.  After you have evaluated your patients, practice capabilities, and the composition of your payers; develop a plan of action with a timeline. Approach your plan and execution timeline from the perspective of, "Where do we want to be on Jan. 1, 2018," not, "Where are we today?"

Step 4: GO!
I know you may not want to, but the best thing you can do is get started. The Pick-Your-Pace program is an excellent opportunity to engage in the QPP program and avoid negative payments in 2019. The AAFP has extensive resources on the Pick-Your-Pace program. CMS also has extensive QPP resources www.qpp.cms.gov for physicians. These are the descriptions from our MACRAReady resources on the four options available under Pick Your Pace:

  • Test -- Submit data for one quality measure, or one improvement activity,  or the four required advancing care information (ACI) measures and avoid a negative payment adjustment. Read a practice scenario for the test option.
  • Partial Participation -- Submit at least 90 days of data for more than one quality measure, OR more than one improvement activity, OR more than the four required ACI measures and avoid a negative payment adjustment. Partial participation also allows ECs to possibly receive a small positive payment adjustment. Read a practice scenario for the partial participation option.   
  • Full Participation -- Submit at least 90 days of data for all required quality measures, and all required improvement activities, and more than the four required ACI measures to avoid a negative payment adjustment. Full participation also allows ECs to possibly receive a moderate positive payment adjustment. Read a practice scenario for the full participation option.
  • Advanced Alternative Payment Model -- Eligible clinicians will receive a 5 percent bonus if they receive 25 percent of Medicare Part B payments, or see 20 percent of patients through an Advanced APM.

Think of 2017 as a dress rehearsal. The Pick-Your-Pace program provides an opportunity to test your capabilities and prepare for 2018 when the payment adjustments become real.

Wonk Hard
In my next post, which will publish on Tuesday, April 11, I will be addressing many of the comments you have submitted in response to this blog during the past few months.  Many of you have submitted thoughtful comments, questions and suggestions on the various issues I have covered during the past three months, and I look forward to answering your questions and addressing your concerns. Your comments inform our thinking and influence our work. I look forward to sharing some perspective with you.

Tuesday Mar 14, 2017

Repeal and Replace? A Look at American Health Care Act

"Every day is a winding road."

The long promised and much anticipated legislative effort to "repeal and replace" the Patient Protection and Affordable Care Act is underway. On March 6, House Republicans introduced the American Health Care Act (AHCA).

After a lengthy process, both the Ways & Means and Energy & Commerce committees approved the legislation on March 8 and 9, respectfully. The two committees considered more than 100 amendments, but no meaningful reforms were made to the proposal.

The next step in the legislative process calls for the House Budget Committee to compile the two committee bills into a single bill, approve it, and then send it for consideration by the full House of Representatives. We anticipate the Budget Committee will conduct its work this week, and the full House will consider it as early as the week of March 20.

The AAFP wrote letters to the Ways & Means  and Energy & Commerce committees on March 7. In our letters, we shared our evaluation of the AHCA based on the health care reform criteria we outlined in a Dec. 28 letter to House and Senate leadership. We laid out several recommendations and summarized our comments as follows:

"The AAFP has significant concerns with the AHCA as drafted and is deeply troubled by the negative impact it would have on individuals, families, and our health care system writ large."

Those concerns were underscored this week when the Congressional Budget Office estimated that the number of uninsured would increase by 24 million people by 2026 as a result of the proposal.

The following is a summary of the proposal divided into two categories, provisions in current law that are maintained and those that are altered or repealed.

PROVISIONS MAINTAINED
Consumer Protections and Insurance Reforms -- The AHCA maintains consumer protections under current law that prohibits insurance companies from discriminating against individuals and families based on age, gender, race and socioeconomic status in their underwriting activities.

Pre-existing Conditions -- The proposal maintains provisions in current law that protect individuals from being discriminated against in coverage and benefit determinations based on their current or historical health status or health conditions.

Essential Health Benefits -- The proposal leaves the essential health benefits in place for all commercial insurance plans.  However, it is anticipated that the Trump Administration will attempt to repeal or modify the EHBs through the regulatory process.

Prevention Services -- The proposal maintains current law that requires all insurers (public and private) to provide preventive services and certain vaccines independent of patient cost-sharing.

Health Insurance Marketplaces -- The proposal maintains the Health Insurance Marketplaces, or exchanges as they are more commonly known. The presence of the exchange infrastructure will allow plans to be sold on the individual market and provide a framework for administering the tax credits created by the proposal.

Center for Medicare & Medicaid Innovation -- The proposal maintains CMMI. We anticipate that the Trump Administration will use its administrative authority to modify the CMMI scope of work, but we are pleased that CMMI will continue to provide a platform for delivery system and payment innovation.

Patient-Centered Outcomes Research Institute -- Similar to CMMI, PCORI survives the repeal effort -- at least for the time being.

CHANGES TO CURRENT LAW
Individual and Employer Mandates
-- The proposal does not repeal the mandates.  Instead, it rolls the penalties to $0, which is essentially the same as repealing them.

Premium and Cost-Sharing Subsidies -- The AHCA repeals ACA premium tax credits, cost-sharing subsidies and small-business tax credits, beginning Jan. 1, 2020. During interim period (2018-19), any excess tax credits will be recaptured, and use of tax credits expanded to some off-exchange coverage.

Tax Credits -- The proposal establishes a new system of advanceable tax credits to help individuals and families purchase health insurance, beginning Jan. 1, 2020. The tax credits will be available to all Americans, including qualified legal aliens, in the individual market. Tax credits range from $2,000 to $4,000 per year based on the age of the individual. Tax credits can be combined up to $14,000 per family. Individuals with incomes of $75,000 or less and families with joint income of $150,000 or less receive the full tax credit. The credits phase down gradually.   

Consumer Protections & Insurance Reforms -- The AHCA provides $100 billion to states to establish "high-risk pools" to assist high-need, high-cost patients with their health coverage costs. The proposal expands the "rating bands" from 3:1 to 5:1, thus allowing older people to be charged more for their insurance and repeals the ACA metal-level plans actuarial value standards, meaning there is no minimal value placed on the benefits that must be offered.

Continuous Coverage -- The AHCA replaces the individual mandate with a continuous coverage provision. Under this proposal, individuals who had a lapse in coverage greater than 63 days would face a 30 percent surcharge penalty on their premium for 12 months.

Medicaid -- The AHCA proposes substantial structural changes to the Medicaid program and its financing. First, it repeals the current option for states to cover adults above 133 percent of the federal poverty level, effective Dec. 31, 2019. Individuals currently enrolled under the Medicaid expansion remain eligible so long as they maintain continuous enrollment. The proposal repeals the enhanced match rate for newly eligible Medicaid beneficiaries on Dec. 31, 2019. The proposal repeals the essential health benefits (EHBs) for state Medicaid plans and requires states to re-determine eligibility for their expansion population every six months. Starting in 2020, Medicaid is transitioned to a per-capita financing model.

The proposal provides $10 billion over 5 years (2018-22) to non-expansion states for safety-net funding and enhanced provider payments and restores some of the previously reduced Medicaid disproportionate share payments to hospitals.

Health Savings Accounts -- The proposal expands the availability and role of Health Savings Accounts (HSA).  Effective Jan. 1, 2018, the proposal increases allowable contribution limits from $2,250 to $6,550 (self-only coverage) and $4,500 to $13,100 (family coverage). This allows HSA enrollees to use HSA dollars for all out-of-pocket expenses up to the limit of a high-deductible plan.

As the Sheryl Crow said, "Every day is a winding road." Please remember this is step one in a long legislative process. There are many miles left to travel. Please be assured that the AAFP will continue to advance recommendations that we believe would improve the proposal and our nation's health care system. I encourage you to engage with your legislators using our Speak Out  tool. Your voice is important.

Tuesday Feb 28, 2017

AAFP to Help FPs With Population Health

I am taking a brief departure from the Patient Protection and Affordable Care Act, the Medicare Access and CHIP Reauthorization Act and politics, to introduce you to some exciting work the AAFP is doing in population health and the emerging field of social determinants of health (SDoH).  

The AAFP is at the leading edge among physician organizations in exploring ways to incorporate both population health and SDoH into family medicine and primary care practices.

Although both population health and SDoH have been prominent in health services research circles for many years, their relevance or contributions to physician delivery and payment models is just now coming into light. Family physicians have long been aware of the demographic, socio-economic, and family issues that impact their patients. This is at the core of family medicine and the meaningful relationships you have with your patients. However, as delivery and payment models move away from episodic-based methodologies and become more intensely focused on longitudinal care and patient outcomes, the need for a more robust evaluation of patients and their environments has become more relevant and desired.  

I like to summarize this transition as follows: family physicians, under advanced delivery and payment models, will care for the individual but manage a population. In order for family physicians to manage a population, they will need new data and new perspective on their patients.

Family medicine is fortunate to have some of the country's leading experts on these issues contributing to our work both directly and indirectly. I asked two of those experts to help frame what is meant by "population health" and "social determinants of health" and how they contribute to better primary care.

Julie Wood, M.D., MPH is the AAFP's Senior Vice President for Health of the Public and Interprofessional Activities. She is a leading national voice on the policy and practice issues that occur at the primary care level due to the intersection of primary care, public health, and population health. I asked Dr. Wood to define population health and the role it plays in family medicine. Here is her response:

"Population health is a term being more frequently used in both healthcare and public health. The population being considered may vary based on an individual's perspective and goals. For the family physician, the most obvious 'population' is their patient panel. This is where most AAFP members focus their energies and where they often have the greatest impact. Population health also includes the health status and outcomes of the larger communities to which the physician and patient belong. It is essential when caring for patients that family physicians consider the factors beyond the walls of their practice that influence their patients' health. The family physician and their team must consider the social and physical environments in which their patients live and work in order to effectively improve health outcomes."

Andrew Bazemore, M.D., is the Director of the Robert Graham Center and is recognized as one of the leading thinkers on SDoH. I asked Dr. Bazemore to frame what SDoH are and why they are important to family medicine. Here is his response:

“Social determinants of health (SDH) are the milieu of social, economic, occupational, and environmental factors that influence the health of the patients and populations we serve. They impact morbidity and mortality more than anything we traditionally address through clinical care, yet most family physicians aren't given the training or tools to incorporate information about patients' SDoH into healthcare decision-making at the point-of-care."

With a richer understanding of population health and SDoH, the AAFP has been aggressively pursuing tools, resources, and education to assist family physicians incorporates both into their practices. To this end, the AAFP recently launched one of the nation's first population health tools, the Community Health Resource Navigator  (CHRN). 

CHRN,  built by HealthLandscape, is designed to provide family physicians and their teams information at the point-of-care on community resources, such as housing and food options for low-income patients, smoking cessation resources, addiction treatment centers, or family and caregiver support organizations to name a few. By having this information at the point-of-care, physicians and their teams are better positioned to provide comprehensive care to their patients that, hopefully, results in better outcomes for the patient. Under new value-based payment models, better outcomes for patients equates to higher payments for family physicians. 

We are excited about CHRN, but HealthLandscape is actively building a next generation tool called Community Vital Signs (CVS) that will allow physicians and practices to incorporate patient-level data using HealthLandscape's innovative, interoperable, HIPAA-compliant tool, the Geoenrichment Application Programing Interface (API), which aims to connect the patient to the broader community where they live.

The Geocoding API appends a core set of community vital signs to any patient with a valid address. Using patients' addresses from an originating data system, the API geocodes each address, assigning longitude and latitude coordinates. Next, it derives geographic identifiers (e.g., county, census tract) for each coordinate. The API then links available community vital signs with the assigned geographic identifiers. Lastly, it returns the geographic identifiers and community vital signs to the originating system. 

Furthermore, since it uses an API, CVS is designed to work with your existing electronic medical record and its built-in registry functions, thus negating the need to purchase an add-on registry component or module. CVS, once implemented, will provide access to an enhanced set of community resources similar to those in CHRN, but it will also allow for the identification and aggregation of patient level data to assist practices in identifying hotspots in their patient population. In a value-based payment model, the ability to identify high-cost, high-need patients is important to the success of the practice.

In addition to our work to build tools and resources, the Graham Center, through a collaboration with the Health Resources & Services Administration (HRSA) and other partners, is developing population health/SDoH curriculum and tutorials that will assist family physicians and the primary care team in incorporating population health and SDoH into their practices.  This curriculum and associated tutorials will greatly assist family physicians interested in using population health/SDoH tools in their practices.

Wonk Hard
While writing this post, I realized that many of you may not be familiar with HealthLandscape, so I thought I would introduce you. HealthLandscape is an interactive, web-based mapping tool that allows health professionals, policy makers, academic researchers and planners to combine, analyze and display information in ways that promote better understanding of health and the forces that affect it. The tool brings together various sources of health, socio-economic and environmental information in a convenient, central location to help answer questions and improve health and health care.

The AAFP, in partnership with the Greater Cincinnati Health Foundation, co-founded HealthLandscape in 2007. In 2014, the AAFP acquired full ownership of HealthLandscape. If you would like more information on HealthLandscape, please participate in one of its introductory webinars or send an email to info@healthlandscape.org.

Tuesday Feb 14, 2017

Repairing ACA May be More Likely Than Full Repeal

This blog is brought to you by the letter R.  

No single letter better describes the first six weeks of the 115th Congress. "R" is, after all, for repeal, replace, reconciliation, repair, reform, restore, reduce, reservations, recording, retract, regulations, and -- most importantly -- reality.

As Congress and President Trump transition from campaign slogans to the hard process of legislating, it has become clear that promises made during the 2016 election to repeal the Patient Protection and Affordable Care Act "lock, stock, and barrel" are running headfirst into the reality of just how difficult such an endeavor is. I discussed the impact of a full repeal in a recent post.

The original plan outlined by Republican leadership after the election was to repeal the ACA prior to Trump's inauguration and then work during the next few years to develop and implement a replacement plan.  

Shortly after Congress convened in January, the House and Senate quickly passed a budget resolution that included
reconciliation instructions that would accelerate repeal. The resolution instructed five congressional committees to report their recommendations to the House and Senate Budget Committees by Jan. 27 -- a date that came and went with no apparent progress towards the development of repeal legislation.

In my Jan. 27 post, I predicted that the complexities of replacing the ACA would become the primary challenge. "Setting aside how complicated repealing the ACA will be, the complexity of that process pales in comparison to replacing the law," I wrote. This reality became apparent to members of Congress during a Jan. 25-27 meeting in Philadelphia.

After passing the budget resolution, House and Senate Republicans held their annual retreat where a number of members were heard expressing their reservations with the established "repeal and replace" plan. A significant number expressed their preference that a replace plan be drafted and vetted before they proceeded with a vote on repeal.  These reservations, which under normal circumstance would have been confidential, were shared with the world via a secret recording of the closed-door session. Shortly after the retreat, Republicans made a noticeable shift from "repeal and replace" to "repair."

Further complicating congressional legislative activities is an inconsistent message from the Trump Administration.  Trump has been consistent in his pursuit of full repeal of the ACA since the summer of 2015.  However, in an interview that aired on Super Bowl Sunday, he stated that work on the ACA may not occur until 2018.

The Administration still has control over the regulatory process and will, in all likelihood, make significant changes to the law through this process. This process will take time, lots of time, so this may be a contributing factor in the President's recent comments. It is way  too early to know if Trump's comments signal a shift in the Administration's priorities, but it certainly represents a change in expectations.

In the coming weeks, the five congressional committees (House: Ways & Means, Energy & Commerce, Education & Workforce; Senate: Finance, Health, Education, Labor, & Pensions) will develop legislative proposals to repeal the ACA. We anticipate that they also will begin work to develop a "skinny replace plan," which will allow them to signal their vision for a replacement policy at the time that they vote on repeal. It is unclear how quickly the House and Senate will move on repealing the ACA.

At this point, we anticipate votes in both Chambers prior to April 1, but timing is largely dependent on our final "R" in this equation, which is for Speaker Paul Ryan. At some point in the near future Ryan will need to identify a path forward and establish a reasonable time frame for legislative action.    

The AAFP continues to work closely with Congress and the Administration on health care reform. Our advocacy efforts are aimed at advancing priorities, which we outlined in a Nov. 9 letter to then President-elect Trump and then a Dec. 28 letter  to House and Senate leadership.  

We also continue to work closely with other physician organizations. On Feb. 2, AAFP President John Meigs, M.D., joined the presidents of the American College of Physicians, American Academy of Pediatrics, American College of Obstetricians & Gynecology, and the American Osteopathic Association in Washington, D.C., to meet with several senators. The five organizations advanced policies and recommendations that would ensure gains made in health care coverage, preserve existing patient-centered insurance reforms, and promote primary care as foundational to our health care system. AAFP News has a great summary of this collaboration and the Feb. 2 meetings.

The next few weeks will be pivotal -- primarily because the legislative clock is ticking. Although the legislative path forward is unknown, we do believe that both the House and Senate will take action on the ACA and health care reform more broadly. Whether they are successful depends on how you define success. I personally anticipate that "repair" will become the dominant "R" word in the coming days. 

In the infamous words of Dr. Dre -- "take a seat, I hope you’re ready for the next episode."

Tuesday Jan 31, 2017

Reducing Administrative Burden a Must

"Darling, I'm a nightmare dressed like a daydream."
-- Taylor Swift


The regulatory framework that family physicians are required to comply with on a daily basis is daunting and, according to most of you, crushing and demoralizing.  

Further complicating the work environment is a widespread opinion that many (if not most) regulations have limited impact on the quality of care provided to patients and, in some instances, actually slow down or prohibit access to care. Most health care regulations are developed based on a good intent, such as "improves quality," "prevents fraud," or "lowers cost." Others are developed and implemented in an attempt to improve patient access to health care services.  

Regardless of a regulation's original aim, it is common for the scope of any given regulation to be expanded to an untenable level. To paraphrase the lyric above, most regulations are presented as items that are a "daydream" -- items that will require "minimal effort" but turn out to be a "nightmare" for family physicians and your practice.  

The regulatory framework for physician practices has driven operating costs upward and profits lower. Without question, the administrative and regulatory burden is one of the top reasons independent practices close and is a leading cause of physician burnout.

Due to all of the reasons above, one of the most common questions that appear in the comments of this blog and other AAFP communication mediums is: "What are you doing to reduce the administrative burden for family physicians?" I wrote about this issue in a previous post that discussed how the AAFP was addressing the so-called "work after clinic" or WAC, largely driven by inefficiency of electronic health records (EHRs). Although we have a significant amount of work remaining, I believe our advocacy has resulted in some improvements in the regulations associated with the use of EHRs.

Reducing the administrative and regulatory burden on family medicine practices is a multi-faceted effort. The AAFP is actively advancing reforms with both public and private payers, but we also are advocating for reductions in burdens associated with the licensure and certification processes -- both of which have grown at a healthy pace during the past decade.

We see a renewed interest in this issue, and we have begun to increase our advocacy activity accordingly. In our Nov. 9 letter to then President-elect Donald Trump, the AAFP positioned administrative burden as a priority issue we would be advancing during the next few years: "Reduce the administrative burden by improving the functionality of EMRs, reducing the use of prior authorization and appropriate use programs, reducing needless documentation requirements, and streamlining workflow processes to ensure that patient care remains the top priority for family physicians."

The AAFP soon will be sending a new letter to President Trump, outlining the AAFP's agenda for regulatory and administrative reforms. This proposal identifies 10 administrative functions and regulatory compliance requirements that are crippling family medicine practices. I do not have space to outline each, but I will expand on the top three.

Prior Authorizations

Prior authorizations are without question, the number one administrative burden identified by family physicians, and this is a priority issue for the AAFP. The frequent phone calls, faxes and forms you and your staff must manage to obtain prior authorization for an item or service not only create an uncompensated burden, but it makes patient care more difficult and certainly more frustrating. To address the negative impact of prior authorizations, the AAFP recommends the following:

  • Congress and CMS should eliminate the use of prior authorizations in the Medicare program for generic drugs, create a single form that all Medicare Part D plans are required to use, and further limit or reduce the number of products and services requiring prior authorizations. 
  • All public and private health plans pay physicians for prior authorizations that exceed a specified number of prescriptions or that are not resolved within a set period of time; prohibit repeated prior authorizations for ongoing use of a drug by patients with chronic disease; prohibit prior authorizations for standard and inexpensive drugs; and require that all plans use a standard form.

Documentation Guidelines for E/M Services
The CMS Documentation Guidelines for Evaluation and Management (E/M) Services were written almost 20 years ago and do not reflect the current use and further potential of EHRs to support clinical decision-making and patient-centeredness.

The AAFP believes there should be changes in these outdated guidelines as well as the Medicare Program Integrity Manual. The changes would better ensure that the final entire medical information entered by the team related to a patient's visit would be considered in determining and supporting the submitted code.

To address the negative impact of current guidelines, the AAFP recommends that all documentation guidelines for E/M codes 99211-99215 and 99201-99205 be eliminated for primary care physicians.

Translation Service Costs
Since 2000, physicians have been required to provide translators for Medicare and Medicaid patients with hearing impairments or limited English proficiency, and on Oct. 17, new and costly limited English proficiency policies went into effect. Many family medicine practices operate on slim financial margins. We believe that Congress and HHS must procure the necessary funding to address and offset the estimated financial burden translation service requirements have on physician practices. We have significant concerns that primary care practices are already taking a financial loss for treating patients that require interpretive services because of the historical undervaluation of primary care services in the resource-based relative value scale system.

CMS must fund the increased costs practices will bear to comply with new translation requirements. If additional funding cannot be provided, then we call on CMS to eliminate the new translation service requirement.

One blog post does not allow space for a full description of all 10 recommendations, but I wanted to share items four through 10. These items, like the ones outlined above, also relate to the day-to-day activities that are frustrating each of you.

  • quality measure harmonization and alignment;
  • electronic health record interoperability;
  • electronic care management documentation;
  • appropriate use criteria alignment with the Merit-Based Incentive Payment System (unfunded mandate);
  • Social Security number removal initiative (unfunded mandate);
  • inconsistent claims review; and  
  • transitional care management services.

I recognize that this is not an exhaustive list of regulations that impact your practice each day, but this top 10 list does capture those regulations that family physicians have indicated to the Academy as the most time consuming and impactful. I will share more information on this effort in future posts, and you can follow our work on our administrative simplification resource page.

Tuesday Jan 17, 2017

Speak Out to Preserve Health Care Coverage

On Friday, Donald Trump will be sworn in as the 45th President of the United States. Pursuant to our country's rich tradition, the transfer of power from the Obama Administration to the Trump Administration will take place in a peaceful manner.  

Upon being sworn-in as president, Trump and his administration will formally start working with the 115th Congress to pursue an ambitious domestic and foreign policy agenda. At the top of the domestic policy agenda is the repeal of the Patient Protection and Affordable Care Act (ACA).  During a press conference on Jan. 11, President-elect Trump provided his most concise perspective on the issue since winning the election.

"It will be repeal and replace," he said. "It will be various segments, you understand, but will most likely be on the same day or the same week, but probably the same day. Could be the same hour."

Setting aside how complicated repealing the ACA will be, the complexity of that process pales in comparison to replacing the law. Despite objections from a growing number of governors and congressional Republicans who are calling for a more thoughtful approach to repealing the law, Republican leadership and the Trump Administration are moving forward with repeal at an accelerated pace. The first wounds were inflicted last week.

On Jan. 12, the Senate approved a budget resolution for fiscal year 2017 that includes reconciliation instructions that will allow the Senate to repeal large parts of the ACA with a simple majority (51 votes). The House approved a similar resolution on Jan. 13, setting in motion a legislative process seeking to have a full repeal bill approved by the end of February.

In a Dec. 28 letter, the AAFP laid out its priorities with respect to how Congress and the new administration should proceed with health care reform. In that letter, the AAFP clearly stated that currently insured individuals should not lose their coverage due to any action or inaction by Congress or the administration. We also continue to stress the importance of impactful insurance reforms in current law that provide numerous protections for individuals, regardless of whether they have employer-sponsored insurance or purchase insurance through the individual market.  

In addition to our letter, we also joined with the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the American College of Physicians to communicate a set of principles regarding how Congress should approach their work.

I encourage you to lend your voice to this important debate by sharing how important health care coverage and insurance reforms are to your patients. Use the AAFP’s Speak Out to communicate with your members of Congress on this important issue. If you would like to stay closely connected to our ongoing work on this or any other issue, you should follow @AAFP and @rshawnm On Twitter.

The next few months will be quite busy in Washington, D.C. Here are the four items that will dominate the first 100 days of the Trump Administration:

  • cabinet nominations;
  • Supreme Court;
  • Affordable Care Act; and
  • Russia.

PQRS, ICD-10 and the Impact of AAFP Advocacy
On Jan. 9, CMS announced that it "will not apply the 2017 or 2018 downward payment adjustments, as applicable, to any individual eligible professional or group practice that fails to satisfactorily report for CY 2016 solely as a result of the impact of ICD-10 code updates on quality data reported for the fourth quarter of CY 2016."

This decision was made following an internal review because CMS determined that updates made to ICD-10 in October 2016 negatively impacted the agency's ability to process data.

This action is consistent with recommendations the AAFP provided to CMS in July 2015 regarding the implementation of ICD-10. At that time, the AAFP called for "additional appeals and agency monitoring for reporting systems that determine appropriate payment for medical services based on quality measures and meaningful use of electronic health records."

CMS is encouraging physicians to refer to the ICD-10 Code Updates message on the PQRS Spotlight webpage or the PQRS ICD-10 Section page for additional information.

AAFP News has an excellent summary about how this may impact your practice. We also have extensive resources on PQRS available for our members.

Wonk Hard
The issue of drug pricing has emerged as a concern for patients and payers. Although the headlines are dominated by the costs of new-to-market blockbuster drugs, the real impact is the escalating costs of existing products -- including generics -- for millions of patients who rely upon them for their health maintenance. Few things catch Washington, D.C., and Wall Street by surprise, but President-elect Trump did so on Jan. 12.

"(What) we have to do is create new bidding procedures for the drug industry, because they're getting away with murder. Pharma. Pharma has a lot of lobbies, a lot of lobbyists, a lot of power. And there's very little bidding on drugs. We're the largest buyer of drugs in the world. And yet we don't bid properly. We're going to start bidding. We're going to save billions of dollars over a period of time."

Stock values for pharmaceutical companies took an immediate hit, and patient advocacy organizations cheered. There is still plenty of work that will need to be done, but it looks like the Pharmaceutical Research and Manufacturers of America may need that $300 million they stockpiled for a Clinton Administration after all.

Tuesday Jan 03, 2017

AAFP Urges Congress to Uphold Health Care Coverage Expansion

Happy New Year!  

I hope each of you had a nice and restful holiday and were able to spend time with family and friends. With the holidays behind us, it's time to turn our attention to Washington, D.C. and what will certainly be a busy first few months of legislative activity.

This week, the 115th Congress will convene and begin consideration of legislation that, if approved, would set in motion a series of events that could undermine the significant improvements that have been made in our health care system during the past decade. Specifically, in danger are the gains we have made in reducing the number of uninsured children and non-Medicare eligible adults, as well as a number of important insurance reforms that protect individuals in all insurance markets from discrimination based on age, race, gender, health condition, and socio-economic status.

The AAFP has long advocated for health care coverage for all Americans. Our policy, which dates back to 1989, clearly states that our goal is, "to provide health care coverage to everyone in the United States through a primary care based system built on the patient-centered medical home."

During the past two decades, the AAFP has worked in a bipartisan manner to identify and implement policies that have moved us closer to this laudable goal. The enactment of the Children's Health Insurance Program (CHIP) in 1997 provided health care coverage to millions of previously uninsured children. The Patient Protection and Affordable Care Act (ACA), enacted in 2010, built on the progress made through CHIP and extended access to affordable health care coverage for millions of previously uninsured, non-Medicare eligible adults and additional children not previously eligible for CHIP coverage. Throughout these reforms, we worked to solidify the important role of primary care and the value of a longitudinal relationship with a family physician. In 2015, our delivery system and payment reform efforts were captured, in part, through the bipartisan policies contained in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

Each of these steps was a result of the AAFP's consistent pursuit of our policies and a never wavering commitment to patients and their family physicians. We still have work to do, but we should recognize that we have made substantial progress towards our goal of providing health care coverage to everyone.

According to Gallup, the number of uninsured is at a historic low of 11 percent. This is an incredible statistic when you consider that less than a decade ago, our uninsured rate was nearing 17 percent with nearly 50 million people uninsured. The greatest gains in health care coverage have occurred among our most vulnerable populations and young adults. The uninsured rate among those making less than $36,000 annually has declined from 30.7 percent to 20.4 percent. The uninsured rates for those between 18 and 25 years of age has decreased from 23.5 percent to 14.9 percent, and the uninsured rates for those between 26 and 34 years of age has decreased from 28.2 percent to 19.4 percent. 

These decreases in the number of uninsured are significant and reflect the consequential provisions enacted into law. These accomplishments are now under scrutiny, if not outright attack. Now is the time to accelerate our efforts on reducing the number of uninsured, not roll them back. 

The AAFP's policies and advocacy on these issues moving forward are guided by a standard that has been proven accurate and factual the world over: The two primary factors that are most indicative of better health and more efficient spending on health care are continuous health care coverage and a usual source of care, normally through a primary care physician.

In the weeks ahead we will be aggressively  defending and advancing our priorities with the House and Senate. There is not room in this space to outline each of the AAFP's policy priorities, but I do want to stress six key objectives:

  • Insured individuals should not become uninsured as a result of any legislative or administrative short-term actions or inactions. Individuals who have already secured health care coverage should retain that coverage, including those who obtained coverage as a result of their state's expansion of its Medicaid program. Furthermore, individuals should be protected from loss of coverage that could result from inactions that result in a destabilizing of the individual and small-group market.
  • Premium assistance and cost-sharing reduction subsidies aimed at assisting qualifying individuals with the purchase of health care coverage and/or paying their deductibles and co-pays should be preserved.
  • There should be a viable and equitable safety net health care program for low-income individuals including those enrolled in Medicaid and CHIP. The basic benefits of the safety net should be universal, meaning beneficiaries are guaranteed health care coverage that is equitable to such coverage in any of the other states. We support continuation of incentives for additional states to expand Medicaid and those that have expanded to keep it.
  • Policies prohibiting health insurers from imposing annual and lifetime caps on benefits should be retained and made applicable to all insurers, public and private.
  • Insurance reforms that prevent discrimination against individuals in the insurance market must be preserved. Specifically, individuals should not be denied health care coverage, charged higher premiums, or have their coverage canceled based on a current or pre-existing health care condition, color, national origin, sex, age, disability, family history, race, gender, or income. We particularly call for continuation of protections that ensure that women are not charged higher premiums than men because of gender.
  • All health insurance products should be required to cover evidence-based essential benefits including coverage, at no out-of-pockets cost to insured persons, to those preventive care and vaccines identified by the U.S. Preventive Services Task Force and other designated evidence-based assessment entities.

Wonk Hard -- The Process
I am not 100 percent certain about the process, but here is how we think things will play out during the next few weeks or months.

  • This week, the Senate will consider a budget resolution for fiscal year 2017. The budget resolution will contain so-called "reconciliation instructions" that will request that the Finance and Health, Education, Labor, and Pensions (HELP) Committees identify a set amount of savings in their areas of jurisdiction (in this case, the ACA). The budget resolution requires 50 hours of debate in the Senate, so final passage would occur on or around Jan. 6.
  • Upon approval by the Senate, the House will consider the Senate-approved budget resolution. The House version of the legislation will be identical with the exception that it will instruct the Ways and Means, Energy and Commerce, and Education and Workforce Committees to identify savings in their areas of jurisdiction (again, in this case, the ACA).
  • Upon approval of the budget resolution by both chambers, the committees will begin drafting legislation aimed at repealing or reforming major portions of the ACA.
  • The product produced by the committees will then be assembled by the Budget Committee in the House and prepared for consideration by the full House. The legislation would impact revenues (taxes), so it must originate in the House.
  • Assuming the House approves the legislation, it would then be sent to the Senate for consideration. The legislation would be considered under reconciliation, so passage in the Senate only requires 51 votes. Republicans will hold 52 seats in the 115th Congress.
  • If the Senate approves the House-passed bill, the legislation would go to the president for enactment into law. If the Senate alters the House-passed bill, it must return to the House for passage prior to being sent to the president.
  • It is important to note that this is a long and complicated process. Getting a bill through five committees and two chambers will not be an easy task. Factor in the issue and the impact it will have on millions of people, and the level of complexity increases significantly.

Tuesday Dec 20, 2016

Old Issues, New Year: A Look Back (and Ahead)

"Success is not final, failure is not fatal: it is the courage to continue that counts."
 -- Winston Churchill


As we approach the end of the year, I decided to use my final post of 2016 to reflect on the past 12 months and provide some well-deserved thank yous to a group of deserving individuals.

I'll start by recognizing a group of people that dedicate their professional careers to the AAFP -- the incomparable Academy staff. The teams at our offices in Leawood, Kan.; Washington, D.C.; Cincinnati; and Hasbrouck Heights, N.J. -- as well as individuals in Austin, Texas; and Seattle -- are an amazing collection of talented and dedicated individuals. I am impressed by the talent assembled amongst our staff and their dedication to you, our members. Each day the entire AAFP team works to advance the mission of the AAFP, by producing resources and education for family physicians, advocating for our specialty and, most importantly, dedicate themselves and their talents to making the world a better place. I am truly honored to call each of them colleagues.  

There is great risk in naming names, but there are a few people that I would like to thank for their contributions and support of this blog. David Mitchell, Min Shepherd, and Sarah Thomas are colleagues that I work with each week, and this blog would not happen without them. I am grateful for their contributions, guidance and collaboration. I am especially appreciative of David's ability to make me sound a little less "Oklahoman" and for his subtle ways of deleting controversial text!  

This was quite a year, no doubt about it. Setting aside the elections, 2016 produced significant developments and changes in health policy. As I reflected on the past year, I identified five issues/items that I think symbolize the top health policy issues and those areas where the AAFP was most engaged in 2016.

Opioids
The opioid epidemic dominated health policy at the federal and state level in 2016.  According to the CDC, drug overdose is the leading cause of accidental death in the United States, with 55,403 lethal drug overdoses in 2015 alone. Opioid addiction is driving this epidemic, with 20,101 overdose deaths related to prescription pain relievers, and 12,990 overdose deaths related to heroin in 2015. These numbers are startling and likely to increase in 2016.

The AAFP has worked closely with the Obama Administration and the surgeon general on this issue for the past two years and will continue our efforts with the Trump Administration. We have developed extensive member resources aimed at providing you the timeliest information and a set of tools you can use in your practice as you balance the treatment of pain with the challenges of addiction. This is an important issue that requires family medicine leadership, which we are committed to providing.

MACRA
The past year saw the promulgation and finalization of regulations implementing Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the historic delivery system and payment reform law. In April, the AAFP launched its MACRA Ready campaign aimed at assisting family physicians in their preparation for the new Quality Payment Programs (QPP) created by the law.

During the summer, the AAFP analyzed the proposed regulations implementing MACRA and then submitted more than 100 pages of comments, which had an impact on the final rule. In September, CMS announced it would implement a Pick Your Pace program that would allow physicians to participate in one of the MACRA QPP pathways at their own pace, thus avoiding negative payment updates in 2019.

In October, CMS published the MACRA QPP final rule and launched a website aimed at assisting physicians. MACRA will continue to be a top priority for the AAFP in the coming year, and we will continue to produce tools and resources that assist you and your practice. I will be devoting future posts to this topic, so please stay tuned.

Zika
The nation once again became focused on a public health outbreak in 2016. The AAFP quickly produced information and patient education materials for our members, and we partnered with the CDC and others to inform the public on how to protect themselves from the Zika virus.

The frequency of public health emergencies is concerning to the AAFP and a central reason why we are prioritizing public health and population health in our strategic plan.  Family physicians are on the frontline of these public health outbreaks and place a critical role in educating patients and communities on how best to protect themselves against these occurrences. You can find up-to-date information on public health issues on our patient care resource page.

Direct Primary Care
The DPC practice model continues to draw interest among family physicians, and the AAFP remains at the forefront of efforts to assist interested family physicians in their transformation from a traditional, insurance-based practice model to DPC. The AAFP has developed a DPC Toolkit that provides detailed guidance on making such a change. This toolkit has been used by hundreds of physicians during the past few years and continues to be the best single source of information for those interested in DPC.  

The Academy continues to support its DPC Member Interest Group, which allows interested family physicians to share ideas and concerns with each other.

The AAFP also continues to play a prominent role in advancing policies and regulations that would make DPC practices more broadly available. In 2016, the AAFP worked closely with members of the House and Senate to introduce legislation that would allow DPC practices to be recognized under federal laws governing health savings accounts. This bill is a priority for the AAFP in the 115th Congress.

Finally, the AAFP is hosting a DPC Workshop in Atlanta on March 11, and the Academy will once again co-host the 2017 DPC Summit in either June or July. We are finalizing details, and an announcement will be made early next year.

Chicago Cubs?
You are probably asking yourself how the Cubs qualify as a health care issue, so I am going to tell you. For more than 100 years, our nation's third-largest city (at least the north side) has been paralyzed by an August-induced anxiety, largely associated with its beloved team's historic (and often dramatic) collapses in the fall months. By winning the World Series, the Cubs decreased the anxiety levels (at least temporarily) of nearly 10 million people in the Chicago metropolitan area and millions more around the world. And, because we know anxiety is not good for our health, I am giving the 2016 World Champion Cubs credit for positively impacting the health and wellbeing of millions of people -- a great accomplishment!

I started this blog with a quote from Churchill. This is one of my favorite statements by the former United Kingdom prime minister because it captures the fluidity of the world in which we live and reminds us to set our eyes on the horizon. In closing, thank you for your support of the AAFP, the great service you provide your patients and our country each and every day and for your support of this blog.

I hope you have a wonderful holiday season. May you always find yourself on the north side of the Red River in the New Year.

Tuesday Dec 06, 2016

AAFP to Congress: Hands Off USPSTF

Last week, AAFP President John Meigs, M.D., testified before the House Energy and Commerce Committee Subcommittee on Health in defense of the U.S. Preventive Services Task Force (USPSTF). 

The hearing was scheduled to examine the task force and discuss the USPSTF Transparency and Accountability Act (HR 1151), legislation that would alter the composition and scope of work of the task force. Meigs was invited to share the AAFP's views on the USPSTF and the important role it plays in assisting family physicians in their daily interactions with patients. 

The AAFP is a strong supporter of the task force and is an active participant in its work. The Academy actively engages with the task force to identify and evaluate clinical guidelines to ensure that family physicians have the most timely and relevant information to assist them in the care of their patients. The AAFP's clinical recommendations typically align with recommendations made by the task force.

In his testimony, Meigs outlined our strong support for the USPSTF and its existing composition.

"My work and that of hundreds of thousands of primary care physicians relies on the integrity of the U.S. Preventive Services Task Force (USPSTF or the task force)," he said. "The task force was designed to be, and has been, a non-partisan, independent body of physicians and other health professionals who make valuable recommendations for primary care. Many recommendations within H.R. 1151, the USPSTF Transparency and Accountability Act, in our opinion, would undermine the work and progress that has been achieved since the task force was established in the early 1980s."

In recent years, the task force and its recommendations have faced increased political scrutiny. Although some of this scrutiny was in response to recommendations made by the task force (specifically related to mammography and prostate cancer screening), the more significant attention came about as a result of Section 1302 of the Patient Protection and Affordable Care Act. Section 1302 of the ACA requires all insurers (public and private) to provide preventive services that receive an A or B grade from the USPSTF and vaccination recommendations from the CDC's Advisory Committee on Immunization Practices independent of patient cost-sharing (co-pay and deductible).

The AAFP has policy supporting this provision, but recognizes that the inclusion of the coverage provisions in the ACA changed the impact of the work for the task force and elevated its significance in the eyes of many in the health care industry.

HR 1151 would make four significant changes:

  • alter the composition of the task force to include subspecialists;
  • allow representation and participation by the broader health care industry, including pharmaceutical and medical device companies;
  • require that the task force to assess how its grades would impact access to a health care service or device; and
  • require that the task force publish its research plan, including the analytic framework, key questions and literature search strategy.

Although HR 1151 will not advance in the current Congress, it likely will be re-introduced in the 115th Congress. The AAFP will continue to support the task force, its work and its recommendations. We also will aggressively oppose efforts to diminish the task force's work. 

The USPSTF, created in 1984, is a panel of national experts in prevention, epidemiology and evidence-based medicine. These experts include family physicians and other primary care physicians. The task force is charged with making evidence-based recommendations about clinical preventive services such as screening exams and preventive medications. The task force gives each recommendation a grade of A, B, C, or D or an I Statement based on the strength of the evidence considered during the rigorous review of evidence.  The recommendations are applicable to individuals who do not demonstrate signs or symptoms of the specific disease or condition under evaluation and only apply to services provided by primary care physicians. The recommendations are not designed to prohibit or restrict patient access to any preventive service.

Presidential Transition Update
In recent days, President-elect Trump has begun announcing nominees for key post in his administration. These nominations have spurred a flurry of reactions -- positive and negative -- from individuals across the nation, including family physicians. In my previous post, I discussed the impact of the elections and the AAFP's approach to working with the Trump Administration and the incoming 115th Congress. I would like to build on my previous post and offer some additional perspective on how the AAFP can best represent our members and advocate on behalf of our patients.

The AAFP is a professional organization that has the tremendous honor and obligation of representing the nation's family physicians and, more importantly, being an advocate for patients. The AAFP has been and remains a bi-partisan organization. We are an organization grounded in a set of core beliefs that each individual, regardless of their personal or economic situation, deserves access to affordable and quality health care. We are guided by our strategic plan and policies adopted by our Congress of Delegates. Although elections and politicians come and go, the AAFP's steadfast commitment to these fundamental objectives remains constant. 

Elections, by design, create disruption. This disruption contributes to a sense of uncertainty about what is to come and what is to be expected of new leaders. This is why it is important to be grounded as an organization. The AAFPs inclusive and comprehensive set of policies allow us to advance our mission and advocate for our members with any individual, regardless of their party affiliation or ideology. These same policies also allow the AAFP to hold elected officials accountable for their decisions and actions.

It would be a disservice to our members and their patients to not engage with an individual or political party simply because they hold or have advanced a point of view contrary to ours. Our job is to advocate on behalf of family medicine and patients, to the best of our ability, with all elected officials. We are a professional organization that feeds on the passion and commitment of our current and future members, while looking to our Board of Directors and professional staff to harness that passion and advance our goals and mission. 

There is a professional standard that guides how an organization such as the AAFP should conduct itself. This includes an effort to adhere to respectful dialogue on issues and representing our organization and members in a reputable manner at all times.

Although we all have our personal opinions on the various individuals who serve in government, it is important to remind ourselves that we all share a set of common goals for family medicine and patients. Now is the time to rally around those goals and objectives that unite us.  To this end, I urge you to engage with the AAFP to advocate for our profession and our patients. The best way to do this is by joining the Family Physician Action Network.  

Tuesday Nov 22, 2016

The 'Change Election' Happened -- Now What?

"Wish we could turn back time, to the good ol' days
when our mama sang us to sleep but now we’re stressed out."  
-- Twentyone Pilots


I chose the above verse because it captures so many emotions that have nearly paralyzed our nation for the past 18 months. During the past year, each of us has probably wished at some point that we could just crawl into bed and hide under the covers. AAFP President John Meigs, M.D., wrote an excellent editorial in AAFP News last week in which he captured the wide range of emotions aligned with the election and its outcome.  

Nov. 8 brought to a conclusion one of the most aggressive and divisive elections in our nation's history and certainly the most negative campaign of the modern political era. Although the results of the election have spawned mixed reactions, it is now clear who will lead our government for the next four years. There is much work to do, but I would suggest that there already was much work to do on Nov. 7.

In the early morning hours of Nov. 9, after securing more than 270 Electoral College votes, Donald J. Trump became president-elect Donald J. Trump. On Jan. 20, he will be sworn-in as the 45th president of the United States of America.

A few hours after President-elect Trump delivered his speech to the nation, accepting the results of the election, his transition team received a letter from the AAFP congratulating him and outlining our priorities for the next four years. Our advocacy work with the 45th president and his administration started before sunrise on Wednesday, Nov. 9 and will continue for the next four years. In our letter we outlined five policy priorities and pledged our commitment to working with the new administration to develop and implement policies that would achieve those priorities. Here are those five priorities:

  • health care for all;
  • delivery system and payment reform;
  • health care affordability;
  • primary care physician workforce; and
  • promotion of prevention and wellness.

On Jan. 3, when the 115th Congress convenes, Republicans will have majorities in the Senate and the House. These majorities are smaller than those in the 114th Congress, but they are working majorities. Those margins coupled with Trump's victory mean the federal government will be under unified Republican control for at least the next two years.

We are entering a legislative session that has the potential to fundamentally reshape our nation's health care system and safety-net programs. In addition, we likely will see policies proposed in Congress that will challenge many long-standing AAFP policies related to health care coverage and access, women's health and public health programs.

It is impossible to predict with any accuracy what will happen in this Congress. As I have said many times in the past few days, "campaigning is easy, governing is hard." The process of drafting and enacting policy is much more involved and time consuming than candidates imply during campaigns.  

However, we do have a decent understanding of policies that the Trump Administration and the 115th Congress likely will focus on. The following are five issues that we see as items in focus for 2017:

Patient Protection and Affordable Care Act -- The full repeal of Obamacare has been a priority for the Republican Party since 2010. To quote Vice President-elect Mike Pence, "We will repeal Obamacare lock, stock and barrel." This point of view is shared by a majority of House and Senate Republicans. Despite campaigning on the full repeal of the law, Trump has begun to nuance his policy position on the law. In an interview with The Wall Street Journal, he suggested that he would be willing to keep certain parts of the law.

Repealing the ACA outright is, in reality, improbable. Any such action would unravel the insurance market and create a financial crisis for individuals and businesses. Therefore, we will see efforts to replace certain policies and, possibly, create new programs that would extend access to health care coverage -- think health savings accounts and high-risk pools.

Despite the complexity of repealing the ACA, I am confident that the ACA will be altered and damaged in a significant manner on Jan. 20 or shortly thereafter.

MACRA -- The Medicare Access and CHIP Reauthorization Act was approved by overwhelming bipartisan majorities in the House and Senate. In fact, 91 percent of the House and Senate voted for this law. Additionally, reducing the cost of health care remains a priority. Due to the continued focus on costs and the bipartisan support the law secured, MACRA will continue to be implemented.

There may be slight modifications to improve the law, but these changes needed to be made regardless of who won the election. The AAFP continues to make available valuable resources on MACRA,  and I encourage you to review the options available to you under the Pick Your Pace program that is available for 2017. Remember, if you participate in the program at any level in 2017 you will not face negative payment updates in 2019. (I discussed these options in my Oct. 25 post.)

Medicaid -- The Medicaid program, like the ACA, has been a priority for Republicans for the past several years. Speaker Paul Ryan, R-Wis., has developed and advanced an alternative to the current federal-state partnership funding formula that would utilize a state-by-state per-capita cap to fund the program. This is different than the more traditional "block grant" proposals advanced by Republicans in the past, but the two proposals would significantly alter the Medicaid program, essentially turning the program over to individual states and eliminating the current role of the federal government in the program.

I anticipate that Medicaid will get significant legislative attention in 2017. I am not confident that Republicans can rollback Medicaid expansion or change the underlying funding formula, but I am confident that they will pursue these changes aggressively.

Administrative simplification -- Trump discussed the negative impact of regulation on businesses throughout the campaign. Although his comments were not specifically focused on health care, we see an opportunity to potentially reduce the administrative burden of participating in the Medicare and Medicaid programs under his administration. A priority for the AAFP will be a reduction in documentation guidelines for physician services under Medicare.

Workforce -- The issue of physician workforce did not come up during the campaign, but we see opportunities. Republican majorities are largely a result of rural and exurban communities, predominately in the south and west of the Mississippi River. These communities are more likely to face physician shortages as compared to urban and suburban communities on the East and West Coasts. I don't see workforce as a top-tier issue, but it is a place where we will be pushing hard.

On Jan. 23, 2009 President Obama stated, "Elections have consequences." This statement was true then, and it is true today. We, as a nation, experience political disruption every few years. The specific consequences of this year's elections are unknown, but the AAFP is not resigned to being a passive participant in the next four years. We see opportunities to shape our specialty's future, and we will be grinding the policy levers daily to ensure that family medicine and patient-centered policies are front and center.

Tuesday Nov 08, 2016

You can drive change in Washington; here's how

Happy Election Day!  

I hope each of you have voted today. If you have not, I urge you to do so before the polls close. Engaging in our political process is both a right and privilege, and I hope that each of you will exercise your civic duty of participating in our electoral process. Then, if you are like me, you can spend the rest of the night staring at your television, computer and smart-phone -- all at the same time!

At some point tonight, the United States of America will elect its 45th President. The announcement of a projected winner of the presidential election will set in motion a series of activities aimed at transitioning from the Obama Administration to the administration of the president-elect, which will formally occur on Jan. 20.

The announcement also will set in motion a series of activities at the AAFP as we initiate our transition to the new administration. Tomorrow, the AAFP will send a communication to the president-elect outlining a set of policy priorities that we will advance on behalf of family physicians and patients. It will also state our intentions to work with the new president-elect and his or her administration during the course of the next four years to advance policies that increase access to care and improve our health care system.  

Prior to Inauguration Day, the AAFP will meet with professional staff representing the president-elect to share our priorities and explore opportunities for the AAFP to work with the new administration. Additionally, we will be identifying and advancing the names of family physicians interested in serving in various positions within the administration.  

Regardless of who wins tonight, the federal government will undergo a change in leadership. Thousands of new staff will occupy positions being vacated by the Obama Administration. This turnover is extraordinary in scope, but I can promise you that the AAFP will be there to advance the interests of family medicine.

Family Physician Action Network
"One person can make a difference, and everyone should try." – John F. Kennedy

This simple, yet impactful statement from President Kennedy is truly the motivating quote that describes the importance of advocacy and being an advocate. Looking forward to 2017, the AAFP will be prioritizing its advocacy efforts with you, our members. We are fortunate to have a membership that is passionate about family medicine and primary care. I continue to be moved by the selfless passion you have for your patients and communities.  

Most people believe that you need people who are passionate about your cause or issue -- in our case family medicine and primary care -- to have a successful advocacy network. I do not question that passion is an important attribute of successful advocates, but passion alone is not really sufficient to identify and enact change. I am not alone in this thinking, and I have been influenced by author Simon Sinek. I am a disciple of his first book Start With Why. If you have a few minutes, I encourage you to watch his TedTalks about leadership.

Sinek has a quote that has always struck me as descriptive and applicable to advocacy and how individuals and organizations view and approach it: "Being driven is not the same as being passionate. Passion is a love for the journey. Drive is a need to reach the destination."

I think this is demonstrative of the AAFP's current thinking about advocacy. How do we take 124,900 passionate individuals and give them the tools and motivation to be driven to accomplish change versus simply calling for change?

In an effort to give members a way to easily and effectively engage in grassroots advocacy, the AAFP has re-launched its advocacy toolkit, which introduces the new Family Physician Action Network. The network is designed to be a forum to educate, coordinate, and engage family physicians around family medicine's priority issues. Network members will have access to issue briefings, tools and the best practices to directly communicate with your legislators on a given topic. Network members also will have access to an online community platform where they can discuss and organize around legislative issues. This will allow for a more efficient coordination of Speak Outs and social media campaigns.

Our goal is to harness your passion for family medicine and give you the tools to join our efforts to drive change. I urge you to join the Family Physician Action Network . As a member you will receive insider information on the progress of health care in Washington, and you will become a driver of change in Washington, D.C.

Tuesday Oct 25, 2016

MACRA 101: What You Need to Know

We are now 14 days from Election Day (assuming you did not participate in early voting). After more than 18 months of campaigning, the end is in sight. Soon, the nation will elect its 45th president, and our favorite television stations will return to a mix of auto insurance and pharmaceutical advertisements in place of the plethora of political ads that have aired for the past six months.  

In my previous post, I outlined the two major party candidates' positions on health care issues. I urge each of you to vote on Nov. 8. Our democracy benefits from participation.

Fall also means rule-making, and the folks at CMS have been busy. On Oct. 14, CMS released the final rule implementing the Medicare Access and CHIP Reauthorization Act (MACRA). AAFP News has a good story on the rule and the AAFP's response. CMS finalized all provisions of the law, including eligibility, participation and evaluation requirements for the MACRA Quality Payment Programs (QPP). These criteria become effective Jan. 1.  

The following is a high-level summary of the law. I will dig deeper into each of these sections during the next few months, but this post is designed to give you basic information.  

First, I must state three things up front:

  • This final regulation includes numerous policies that are the direct result of AAFP advocacy. Since submitting our comment letter on the proposed regulation, we have continued to advocate on your behalf to improve the regulation. I am especially proud of the Pick Your Pace program. This is a concept the AAFP provided CMS, and we are pleased that it was incorporated.
  • All physicians participating in the Medicare program will receive a 0.5 percent update in payments for services provided in 2017.
  • If you participate in the Merit-Based Incentive Payment System (MIPS) program, no matter for how long, you will not be penalized in 2019.

CMS has provided an excellent online resource on the QPP program.  Let’s jump into the details.

Eligibility Criteria
The MACRA QPP creates two pathways for Medicare participating physicians:

  • MIPS
  • Advanced Alternative Payment Models (Advanced APM)

If you are one of the following, you are eligible to participate in either of the QPP pathways:

  • physicians;
  • physician assistant;
  • nurse practitioner;
  • clinical nurse specialist; and
  • certified registered nurse anesthetist.

You are not required, as a condition of participating in the Medicare program, to participate in either of the QPP pathways. You may elect to provide care to Medicare patients and not participate in the QPP. However, if this is your decision, you will face maximum negative payment updates as outlined below.  

Exemptions -- If your Medicare allowable charges are less than $30,000 a year or you do not provide care to more than 100 Medicare fee-for-service patients in a year, you are exempt from participation in the QPP. However, if your Medicare allowable charges exceed $30,000 a year and you provide care to more than 100 Medicare fee-for-service patients a year, you are part of MIPS. Additionally, if 2017 is your first year as a Medicare participating physician, then you are exempt from participation in the MIPS program. You may participate in an Advanced APM.

Performance period -- The performance period starts Jan. 1 and concludes on Dec. 31, 2017. Due to the flexibility provided by the Pick Your Pace provisions, physicians may initiate their 2017 performance period at any point between Jan. 1 and Oct. 2.

Data Submission -- Physicians participating in the MIPS pathway must submit quality, advancing care and clinical practice improvement activity data to CMS by March 31, 2018. Physicians participating in an Advanced APM also must submit data by March 31, 2018. If you do not submit 2017 data by the March 31, 2018 deadline, you will receive a negative 4 percent payment adjustment in 2019.

Report as an individual -- If you submit MIPS data as an individual, your payment adjustment will be based on your performance. An individual is defined as a single national provider identifier (NPI) tied to a single Tax Identification Number (TIN).

Report as a group -- If you submit MIPS data as a group, the group will get one payment adjustment based on the group's performance. A group is defined as a set of physicians and other clinicians, identified by their NPIs, sharing a common TIN.

Feedback -- Medicare will provide feedback to individual physicians and physician groups and notify you of your performance score and subsequent payment rate for 2019.

Payment -- Based on your performance in 2017, you will receive a neutral or positive payment update, up to 4 percent, in 2019. If you successfully participate in an Advanced APM, you will receive a 5 percent incentive payment in 2019.

MIPS Payment Adjustments

  • 2019 = +/- 4 percent
  • 2020 = +/- 5 percent
  • 2021 = +/- 7 percent
  • 2022 and beyond = +/- 9percent

Advanced Alternative Payment Model

  • 2019 to 2024 = +5 percent

Performance Criteria & Weighting -- MIPS

Quality -- 60 percent of total score.
Report up to six quality measures, including an outcome measure, for a minimum of 90 days.

Clinical Practice Improvement Activities -- 15 percent of total score.
Attest that you completed up to four improvement activities for a minimum of 90 days.  For solo and small group physicians, or if you practice in a rural or health professions shortage area, attest that you completed up to two activities for a minimum of 90 days. If you are a certified patient-centered medical home or an APM designated as a medical home model, you automatically receive full credit for this category.

Advancing Care Information -- 25 percent of total score.
Fulfill the five required functions which are: security risk analysis, e-prescribing, patient access, summary of care, request/accept summary of care. You may earn additional credit if you submit up to nine measures for a minimum of 90 days. Additionally, you can earn bonus credit for reporting public health and using clinical data registry reporting measures and/or use a certified EHR to complete clinical improvement activities in the performance category.

Cost -- 0 percent of total score.
This category is delayed until 2018 and will not impact payments in 2019. Compliance with the measure does not require data submission on the part of the physician. It is measured using claims data submissions. 

Performance Criteria -Advanced APM

APM Model -- You must participate in a selected APM, which includes the following:

  • Comprehensive Primary Care Plus (CPC+)
  • Next Generation ACO
  • Shared Savings Program Track 2 and Track 3.

Risk -- The APM must take on more than nominal risk or be a recognized medical home model as determined by the Center for Medicare and Medicaid Innovation (CMMI) a recognized Medicaid Medical Home Model.

Beneficiary Threshold -- Twenty-five percent of your Medicare Part B payments must be received through the Advanced APM or 20 percent of your Medicare patients are assigned to your Advanced APM.

Data Submission -- Advanced APMs are required to submit data on identified quality measures using a certified EHR.

Pick Your Pace Program

Test -- If you submit a minimum amount of 2017 data to Medicare, you can avoid a downward payment adjustment in 2019. Minimum amount of data can be as de minimis as one quality measure, one improvement activity, or only four advancing care information measures.

Partial Participation -- If you submit 90 days of 2017 data for all three categories (quality, advancing care information and clinical practice improvement activity) to Medicare, you may earn a neutral or small positive payment adjustment in 2019.

Full Participation -- If you submit a full year of 2017 data, in all categories, to Medicare, you may earn moderate positive payment updates in 2019.

Advanced APM -- If you receive 20 percent of Medicare payments or see 20 percent of your Medicare patients through an Advanced APM in 2017, then you earn a 5 percent incentive payment in 2019.

For additional information, check out the following resources:

About the Author



Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.