Hit the Pause Button on Meaningful Use
Sometimes the best idea gets lost in translation or implementation. I'm sure history is riddled with examples of this, but I can think of no greater example in health policy than the meaningful use program.
What started as a simple idea of developing and implementing an interoperable health information system that would encourage physicians to transition from paper-based medical records to electronic health records (EHRs) has, in reality, turned into a labyrinth of regulations that has actually resulted in discouraging physicians to the point of revolt. How did something so straightforward go so wrong?
There are plenty of reasons why this occurred, but I am going to focus on four.
The regulations regarding the implementation of meaningful use are too complicated. The goal was simple -- transition from paper to computers and share information among physicians and health care settings. The concept of providing financial incentives to lessen the economic impact on the purchase and implementation of EHRs was a good one, but the hoops and hurdles that come with that money are not. Our government has developed a set of regulations that are so confusing, so complex, and so numerous that most physician practices face significant challenges complying.
The sequential implementation of the regulations was misaligned. In retrospect, the regulations governing interoperability should have been put in place prior to ramping up efforts to implement EHRs on a widespread basis at the physician and hospital level. This small, yet meaningful, change in sequence would have prevented many of the challenges we face today. Primarily, it would have prevented the proprietary cannibalism that EHR companies and major health systems have engaged in since 2009.
The sphere of influence at the regulatory development level was too dominated by the vendor community which, not surprisingly, protected its self-interests versus advancing the interest of patients, physicians and the health care system.
Finally, the meaningful use program should have been an on-ramp for physicians, setting them on a path toward a fully functioning and interoperable EHR system that promoted quality care. Instead, the program is a pass/fail puzzle that is followed by the threat of penalties for non-compliance and heavy-handed audits for those who are successful in securing incentive payments. The program is not an on-ramp and, instead, is viewed as a cliff that physicians are afraid of being pushed over.
I am going to pause for a second to state that I unequivocally think our health care system will be better at providing high quality and cost-appropriate health care with an interoperable health information system. Additionally, I think electronic records, if re-designed to better support the work flow of a family physician and operating on a platform that allows for interoperability that facilitates the real-time exchange of relevant patient information, will improve the performance of individual physicians and allow for better care to patients at a more appropriate cost. The key to salvaging the simple goals of the meaningful use program may be as simple as saying, “we need to hit the pause button.”
As noted in my post last month, the AAFP is aggressively pursuing modifications to the meaningful use program. Specifically, we have been working to create changes in regulation that would delay meaningful use stage 3 until regulations implementing the Medicare Access and CHIP Reauthorization Act (MACRA) have been drafted, thus allowing alignment of the meaningful use program with the requirements of MACRA. We also have been pursuing changes to meaningful use stage 2 that would lessen the administrative burden it places on physicians, thus allowing greater participation and a lower percentage of physicians facing penalties for non-compliance. Finally, we are determined to change the pass/fail nature of the program and return to a process that encourages progress towards the ultimate goal of every physician and hospital using an interoperable EHR.
In my July posting I assured you that the AAFP would lead in developing legislation that would reform the meaningful use program and launch a grassroots campaign aimed at enacting those reforms into law. I am pleased to report that, in July, Rep. Renee Ellmers, R-N.C., introduced the Further Flexibility in HIT Reporting and Advancing Interoperability (FLEX-IT 2) Act (HR 3309), that captured reforms promoted by the AAFP and outlined above.
The FLEX-IT 2 Act would:
- Eliminate the current “all or nothing” assessment and replace it with a standard allowing physicians to be evaluated based on the proportion of MU measures they meet.
- Delay meaningful use stage 3 regulations.
- Allow physicians to attest for MU based on a 90-day reporting period instead of a burdensome 365-day reporting period. Physicians reporting at all MU stages would be allowed this 90-day flexibility, and it would remain in place for all subsequent years.
- Expand the allowable conditions for MU hardship exceptions. Under the bill, physicians will be allowed to claim a hardship exception in several scenarios, including a change in technology vendors, unforeseen circumstances (like becoming the victim of a cyber-attack), being at or near retirement or working in certain specialties with limited patient interaction outside the hospital.
- Require that all certified EHRs undergo interoperability testing.
- Harmonize CMS quality reporting standards across all programs.
The AAFP communicated our strong support for this legislation in a July 30 letter to Rep. Ellmers. We also have launched an aggressive Speak Out campaign aimed at building support for the important reforms included in H.R. 3309. I urge each of you to send a letter to your representatives urging them to support this legislation and, more importantly, these much needed reforms to the meaningful use program.
Patients, Physicians, Payer Benefit From Primary Care Investment
"Secret, secret, I've Got a Secret."
Some of you may recognize these lyrics from the 1983 Styx mega-hit "Mr. Roboto," but most of you probably are pondering its application to the AAFP and family medicine. My secret is this: the key to improved quality and reduced health care costs is -- wait for it -- primary care. I realize that few of you are shocked by this statement, but there are plenty of people in health care that are just now waking to this reality.
A couple of weeks ago, I had the opportunity to meet with the president and CEO of CareFirst BlueCross BlueShield, about that organization's patient-centered medical home program. CareFirst, which operates in Maryland, the District of Columbia, and northern Virginia, launched its PCMH program in 2011 with more than 2,000 primary care physicians and providers participating. Today, 80 percent of primary care physicians and providers in this service area participate in the program, and collectively they provide care to more than 1 million patients. Seventy-five percent of participating physician practices are solo, small and medium-sized physician practices.
The design of the CareFirst program is quite simple. Physicians are asked to align themselves with other primary care physicians to form panels that range in size from five to 15. CareFirst provides two forms of upfront financial support -- a 12 percent participation fee and a $250 payment for each care plan developed. In addition, CareFirst provides three types of administrative support -- care managers; data and analytics; and technical assistance via program consultants.
CareFirst does not require that the practices achieve third-party PCMH recognition, nor do they require that the panels form new legal entities to work together towards achieving shared savings. Physicians can partner with others in a virtual or cooperative way rather than through contractual alignment. In return, CareFirst asks each panel to assume responsibility for the total cost of care for their attributed patients by focusing on five key areas:
- cost effectiveness of referral patterns;
- engagement in care coordination programs;
- medication management;
- reducing gaps in care and quality deficits; and
- physician engagement and performance improvement.
If the primary care panels control total costs of care as compared to their benchmark, they get to share in the savings. I know what you are thinking, the benchmark lowers annually, thus making it impossible to achieve continuous savings in the program. Well, that would be wrong. CareFirst does not lower the benchmark to reflect annual or cumulative net savings. It only adjusts the benchmark based upon the risk stratification of the patients attributed to the panel.
So, has it worked? In short, yes.
Since 2011, CareFirst has reduced its expected costs of care and slowed spending growth by an estimated $609 million. Additionally, CareFirst slowed its rate of growth from 7.5 percent in 2011 to 3.5 percent in 2014. In four years, the CareFirst PCMH program has contributed to a 19 percent reduction in hospital admissions, 15 percent fewer hospital days, 20 percent fewer hospital readmissions, and 5 percent fewer outpatient health facility visits. As a result, participating physicians who met quality and savings targets earned, on average, $41,000 in shared savings.
Physician participation and engagement in the program is high and holding. Since 2011, only 13 percent of physicians have left the program. Of that 13 percent, 82 percent retired. The remaining 18 percent were asked to leave due to a lack of participation, but 7 percent of those physicians subsequently returned.
Since 2011, 38 percent of the primary care panels have secured savings in all four years, and 32 percent have secured savings in three of the four years, debunking the so-called process bias theory that suggests savings are not sustainable over long periods. In fact, only eight panels, or 2 percent, have failed to secure savings at some point.
Following my conversation with CareFirst, I came away with five key points about the future of advanced primary care practices and the medical home:
- Empowering primary care should be a central tenant for payers and purchasers, not a passing ambition. The value of primary care has become widely accepted. Now payers and purchasers need to increase their investment in primary care. Primary care accounts for approximately 5 percent of the total spend for any health care payer or purchaser, but primary care has tremendous influence over the remaining 95 percent of spending. Investments in primary care can come in the form of resources (care managers, data dashboards, cost/quality reports on specialists and hospitals), financial (engagement bonuses, care management fees, increased payment for performance), or both. This investment should be upfront, meaningful and independent of undue administrative complexity.
- Independent does not mean isolated. Primary care physicians in any practice type and size need to embrace alignment. This alignment can be virtual or contractual. More than 75 percent of physicians participating in the CareFirst program are not employed by an academic or large health system, and many of these physicians are in solo or small practices.
- Teams matter. Teams come in various shapes and sizes, but they are important to patients and physicians alike. This can be teams of physicians or physicians working with other health care providers in a coordinated manner, but the key is moving away from the concepts of individual, independent and isolated care delivery models. Care managers, who are embedded in a practice, seem to be an important and essential element of highly functioning and successful advanced primary care practices.
- Data is key. If purchasers and payers truly want primary care physicians to accept responsibility for the total cost of care, they must provide the primary care physicians timely and accurate data on the cost and quality of all physicians, hospitals and outpatient care facilities in their community or service area.
- PCMH recognition by a third party may not be necessary. Evaluating performance remains an important component of advanced primary care practices, but securing recognition of your practice as a medical home may not be essential. The more important recognition is a physician’s performance against a set of core functions in his or her practice.
I realize that this posting could facilitate some interesting comments, and I look forward to hearing your thoughts. I also realize that there are likely some shortcomings in the CareFirst program. However, the successes of the CareFirst program and others like it are becoming far more prevalent. This leads me to believe that the core functions of an advanced primary care practice are becoming more identifiable and replicable and are being paid differently and better.
Country in Crisis: Addressing our Addiction Epidemic
In a recent speech to the National Governors Association, HHS Secretary Sylvia Burwell laid out an aggressive strategy to combat our country's growing drug abuse epidemic. This issue is of great interest to the secretary. As a native of West Virginia, a state on the frontline of the issue, she has seen the impact that drug abuse -- both illicit and prescription -- has had on families and the state’s economy.
This speech by Secretary Burwell is one of many recent activities that have raised awareness and a created a sense of urgency about drug abuse. The Obama Administration has made the issue a priority for its final two years, and the White House Office of Drug Control Policy released the National Drug Control Strategy: A 21st Century Approach to Drug Policy. This policy outlines the expansive scope of this issue. The report outlines a number of policy proposals, many of which are consistent with AAFP policies. We have communicated our support for the proposal and have identified a series of collaborative activities we plan to pursue.
During the past few years, our nation has seen an increase in the prevalence of abuse of a number of legal and illegal substances, including prescription drugs. According to the CDC, roughly 110 Americans died from drug poisoning every day in 2011. Prescription drugs were involved in more than half of the drug poisoning deaths that year. Sadly, these numbers are four years old, and the problem has grown worse.
The cost of addiction and abuse is startling. Although the majority of our attention is focused on opioid addiction, we should not overlook or underestimate the impact that all addictions have on the health of individuals, the health care system and the national economy.
Since the “war on drugs” campaign, which was a cornerstone of the Reagan Administration, we have viewed the issue of drug abuse as a law enforcement issue. This trend has held consistent for much of the past three decades. To this day, the primary regulatory body that grants physicians prescribing rights for controlled substances is a law enforcement agency -- the DEA. However, we are in the midst of a gradual transition whereby we are beginning to view prescription drug abuse as a public health issue, not simply a law enforcement issue. This transition is important, and it would not have happened without the AAFP’s leadership and collaborative advocacy efforts with patient and public health organizations during the past decade.
The AAFP has been a national leader on the issues of pain management and opioid abuse. The AAFP policy paper “Pain Management and Opioid Abuse: A Public Health Concern” is a document that is widely regarded as instrumental to the current public discourse on this issue.
It is important for us to all fully acknowledge that family physicians, collectively, prescribe a majority of opioids in this country. According to research conducted (pending publication) by the Robert Graham Center, more than 60 percent of all prescriptions for controlled substances provided to Medicare patients are written by family physicians. Researchers at the Graham Center estimate that the percentage in the non-Medicare population is likely higher, between 65 percent and 70 percent. However, it is important to note that family physicians diagnose and treat the majority of acute and chronic pain patients. Like most chronic conditions, family physicians are the primary providers of care to patients with chronic pain.
Striking a balance between treating pain and appropriate prescribing is the primary reason this issue has become so complicated from a policy perspective. Although we should be diligent in our efforts to address what is a real and growing epidemic of prescription drug abuse, we should not underestimate the prevalence of acute and chronic pain and the need to ensure that family physicians are able to care for patients in a manner that is free of unnecessary regulatory compliance burdens.
It is estimated that 60 million Americans have some type of chronic nonmalignant pain, and the annual cost associated with all types of pain is estimated to be greater than $500 million per year. Given our aging population, we should anticipate that these numbers will increase in the next two decades.
The issue of substance and prescription drug abuse is ever-present for state governments and has emerged as a top policy issue for Congress and the Obama Administration. Many states have seen dramatic increases in the number of individuals seeking treatment for substance abuse and, sadly, significant increases in the number of deaths from overdoses of legal and illegal substances. The negative economic impact of abuse on state budgets has become a frontline political issue in almost every state.
In an effort to better monitor prescribing in their respective states, 49 states (Missouri is the hold out) have established prescription drug monitoring programs (PDMPs). Unfortunately, only 24 of the 49 PDMPs communicate with each other, leaving gaps in access to timely data that could assist physicians in making informed decisions.
The AAFP consistently reiterates our commitment to work with federal and state governments to identify and implement a balanced approach to curbing the prevalence of prescription drug abuse while ensuring that physicians can continue to provide appropriate care to patients. A key component of our advocacy efforts is the work we are doing as part of the Task Force to Reduce Opioid Abuse, convened by the AMA.
The task force is compromised of the AAFP, the AMA, the American Dental Association and 25 other national and state physician organizations. The task force’s goal is to “significantly enhance physicians’ education on safe, effective, and evidence-based prescribing.” On July 29, the task force released a series of policy recommendations. The task force organized its recommendations around five main goals:
- Increase physicians’ use of effective PDMPs.
- Enhance physicians’ education on safe, effective and evidence-based prescribing of opioids.
- Reduce the stigma of pain and promote comprehensive assessment and treatment.
- Reduce the stigma of substance use disorder and enhance access to treatment.
- Expand access to naloxone in the community and through co-prescribing.
The AAFP remains dedicated to finding solutions to the crisis of pain management care and opioid abuse. Our policies are reflective of these two goals. Here are some key points from the Academy's policy paper, “Pain Management and Opioid Abuse: A Public Health Concern."
- The AAFP advocates for increased national funding for research into evidence-based strategies for pain management and their incorporation into the patient-centered medical home model.
- The AAFP urges states to obtain physician input when considering pain management regulation and legislation.
- The AAFP urges states to implement PDMPs and the interstate exchange of registry information as called for under the National All Schedules Prescription Electronic Reporting Act of 2005.
- The AAFP opposes mandated CME as a prerequisite to DEA or other licensure due to the limitations on patient access to pain management.
- The AAFP supports development of evidence-based physician education to ensure the safest and most effective use of long-acting and extended-release opioids and to reduce the problem of opioid abuse.
- The AAFP will continue to work with appropriate government agencies to ensure policies are in place to allow effective and safe opioid prescribing by family physicians for patients in their pain management programs.
- The AAFP has a number of resources available related to this issue.
AAFP Advocacy Promotes Compassionate Care
On July 9, CMS released its proposed rule for the 2016 Medicare physician fee schedule. As part of this rule, CMS is proposing to pay physicians for advanced care planning services -- better known as end-of-life counseling -- through two codes.
“CMS proposes to establish separate payment and a payment rate for two advance care planning services provided to Medicare beneficiaries by physicians and other practitioners," the agency said in the proposed rule. "The Medicare statute currently provides coverage for advance care planning under the 'Welcome to Medicare' visit available to all Medicare beneficiaries, but they may not need these services when they first enroll. Establishing separate payment for advance care planning codes provides beneficiaries and practitioners greater opportunity and flexibility to utilize these planning sessions at the most appropriate time for patients and their families.”
Under the proposed rule, CMS is proposing to pay for CPT codes 99497 and 99498. These codes, if implemented, will provide compensation for complex advanced care planning, which involves one or more meeting(s), lasting 30 minutes or more, during which the patient’s values and preferences are discussed and documented, and used to guide decisions regarding future care for serious illnesses. These consultations are voluntary on the part of the patient, and the patient may choose to include family members or caregivers in the meeting.
The AAFP has long advocated for Medicare to pay for advanced care planning services, and we applaud CMS for including this policy in the proposed rule. It is long overdue, and we promptly communicated our support of this policy proposal in a press statement following the release of the proposed rule.
In 1789, Benjamin Franklin stated, “…in this world nothing can be said to be certain, except death and taxes.” The problem is we, as a country, are much more comfortable having a conversation about taxes, than death. Conversations about death are difficult. They are especially difficult at the time that the outcome is imminent. However, as Mr. Franklin stated, death is certain. Our collective reluctance to discuss death doesn’t prevent it from happening; it only makes needed conversations and decisions harder.
This issue has always been wrought with political undercurrents and challenges. In 2009, as part of the health care reform debate, our country was starting to have a serious conversation about the importance of patients, caregivers and physicians engaging in a meaningful conversation about death and, more importantly, how we as a society could begin to openly discuss those difficult decisions that each of us will ultimately face. Sadly, the political discourse of the day reduced these conversations to a ridiculous talking point comparing advanced care planning to “death panels.” Thankfully the mastermind of this dreaded talking point has seen her 15 minutes of fame expire.
The AAFP played a prominent role in this policy being included in the 2016 proposed rule. In the years following health care reform, the AAFP worked closely with other physician and patient organizations to promote advanced care planning policies in the legislative and regulatory environments. We worked closely with Rep. Earl Blumenauer, D-Ore., on his legislation, the Personalize Your Care Act and Sens. Mark Warner, D-Va., and Johnny Isakson, R-Ga., on their Care Planning Act. We also worked closely with the Pew Charitable Trust as part of its Improving End-of-Life Care Initiative to develop and promote advanced care policies.
In 2014, the Institute of Medicine issued a report, “Dying in America,” which cited payment for advanced care planning as one of its five recommendations. The report states that “payers and health care delivery organizations should adopt these standards and their supporting processes, and integrate them into assessments, care plans and the reporting of health care quality.” Building on the recommendations of the IOM, in May of this year, the AAFP joined more than 50 other organizations urging CMS to provide payment for advanced care planning services.
The importance of this policy is well understood. Demographics are rapidly changing, and our population is growing older. The aging of our population is to be celebrated, but it does present challenges. By 2050, the number of people who are 80 and older will triple, and the number of people in their 90s and 100s will quadruple. Roughly 6 percent of Medicare patients die each year, and they consume approximately 30 percent of Medicare resources. As noted earlier, death is certain.
My question is this: How do we want the health care system to treat us or our loved ones in our final days and hours of life? I would suggest that there is not a more appropriate place for this conversation to take place than a family medicine practice. You are the trusted advisers and the facilitators of communication on these difficult issues with patients and their caregivers, and it is time that Medicare paid you for these services.
AAFP policy states, “supporting a patient’s care decisions at the end of life is part of the family physician’s responsibility in his or her partnership with the patient. The American Academy of Family Physicians (AAFP) believes that each individual has the right to decide what medical treatment he or she will receive. This right includes decisions about what life-sustaining treatment should be provided at the end of his or her life.” If this proposed rule is finalized, we will have successfully aligned public policy with AAFP policy, and patient care will be improved.
American Family Physician has volumes of resources on this topic that are well situated to assist you with end-of-life issues.
Moving from Meaningless to Meaningful Use
A decade ago, President George W. Bush created the Office of the National Coordinator of Health Information Technology (ONC) and called for the "widespread adoption of electronic health records in 10 years." This directive set our nation on a path towards the establishment and implementation of a national health IT system.
In 2009, Congress moved us further down this path when it enacted the Health Information Technology for Economic and Clinical Health (HITECH) Act. This law established an implementation framework through the meaningful use program and created an expectation that physicians and hospitals participating in the Medicare and Medicaid programs would use certified electronic health records (EHRs) by 2017.
This is where our story departs from script. To date, federal and state governments collectively have paid more than $28 billion in incentive payments to hospitals, physicians and other health care providers. By surface measures, one could argue that this investment and the meaningful use program have been successful. A 2014 HHS press release touted "significant increases in the use of electronic health records (EHRs) among the nation’s physicians and hospitals."
Although we should not overlook progress, there are some epic challenges (pun intended) that must be overcome if we are to realize the full potential of electronic medical records.
Despite a massive investment by federal and state governments, the quality and functionality of EHRs has not improved, and physician enthusiasm for EHRs have plummeted. Many family physicians, regardless of practice setting, complain about EHRs. The complaints fall in four major themes:
- "My EHR is clunky and disrupts workflow in our office."
- "My EHR cannot communicate with other physician offices or my local hospital."
- "I cannot access data in my EHR without paying a fee or hiring a consultant."
- "I can't afford all the upgrades, and I can't afford to change vendors."
These same themes were captured in a 2014 Medical Economics physician survey regarding EHRs. This survey found that nearly half of physicians think that EHRs are making patient care worse, more than 60 percent think that EHRs are hurting care coordination, and an astonishing 70 percent of physicians said that the implementation of their EHR was not worth the time, resources and cost. Adding insult to injury, a 2013 RAND study showed that EHRs are a leading driver of negative job satisfaction among physicians.
The AAFP has been a leader for more than a decade in assisting ONC, CMS, HHS and Congress on policies aimed at improving the nation's fledgling health IT system. We have conducted dozens of meetings and written numerous letters on this subject. In March, AAFP President Robert Wergin, M.D., testified before the Senate Health, Education, Labor and Pensions Committee (HELP) where he laid out a series of recommendations from the AAFP on how to improve both EHRs and the health information system.
Not only have we failed to meet the directive set forth by President Bush or capitalize on the investments made in the HITECH Act, but we may actually be further from reaching the 2017 goal today than we were five years ago. For the first time, member feedback suggests that a growing percentage of family physicians are simply giving up on meaningful use. Put another way, some physicians would rather pay a penalty than participate in meaningful use.
The decreasing levels of participation in meaningful use is concerning to the AAFP on its own, but with the passage of the Medicare Access and CHIP Reauthorization Act (MACRA), our sense of urgency around failing HIT policies is increasing rapidly. The ability of family physicians to achieve success in advanced delivery and payment models will depend on the availability of data and the ability to transmit and receive medical information in real-time. We cannot call the emailing of an 80-page discharge summary "interoperability." We need a system that can transmit clinically relevant health information in real-time and contributes to true care coordination, and we need EHR vendors to design products that actually fit into the workflow of a physician's office.
The reasons are complex, but one thing is clear -- current meaningful use criteria are not moving us closer to widespread adoption, and it is time for a change in direction. The AAFP advocated for changes in meaningful use stage 2, and we are pleased that ONC and CMS responded positively to reduce the required percentage of interactions through a patient portal and reduced the reporting period from 365 to 90 days. Additionally, we have called for a delay in meaningful use stage 3 to align these requirements with those contained in MACRA.
However, we are convinced that these changes are not sufficient to salvage the meaningful use program and facilitate an interoperable health information system. We need dramatic improvements in the program if we are to achieve the goals contained in the HITECH Act, and the AAFP is prepared to work with Congress and ONC to achieve these improvements. But, in order to accomplish these improvements it is clear that we should operate in a space that is free of financial penalties. This is why, in the coming weeks, the AAFP will be launching an advocacy campaign aimed at delaying the meaningful use stage 2 and 3 penalties.
Wonk Hard: Supreme Court Edition
On June 25, the U.S Supreme Court handed down a 6-3 decision in King v. Burwell in which they upheld that individuals who purchase health insurance though a federally facilitated health insurance marketplace are eligible for subsidies. The majority opinion was written by Chief Justice John Roberts, marking the second occasion that he has written the majority opinion in a case involving the Patient Protection and Affordable Care Act. The dissenting opinion, written by Associate Justice Antonin Scalia, offered a scathing rebuke of what the dissenting judges viewed as judicial activism going so far as suggesting the law be referred to as "SCOTUScare."
The King lawsuit is the last of the major challenges to the law or its provisions. Certainly additional cases will be filed, but the pathway for additional legal challenges to the ACA will be extremely challenging following this decision.
Medicare and Medicaid: 'Doing the Right Thing for Those in Need'
On July 30, 1965, President Lyndon Johnson signed into law the Health Insurance for the Aged Act, or as it is better known, the Medicare & Social Security Amendments of 1965. This established Titles 18 and 19 of the Social Security Act, which are better known to us today as Medicare and Medicaid.
Creation of these programs was not free of political and public resistance. Organized medicine was largely opposed and actively fought to prevent passage of the legislation. Twenty years prior, organized medicine had successfully defeated a similar proposal advanced by President Harry S. Truman.
The establishment of Medicare and Medicaid has its roots in the closing years of World War II. In 1943, Sen. Robert Wagner, Sen. James Murray, and Rep. John Dingell introduced the Wagner, Murray, Dingell bill -- better known as the WMD bill-- which would have expanded the Social Security Act to include a national health insurance system. The bill faltered in committee and never developed momentum. However, in 1944, President Franklin Roosevelt revived the WMD bill. After Roosevelt died, Truman continued the push for a national health care system as outlined in the legislation.
During the next five years, Truman fought a tireless campaign against Congress, the public and organized medicine. This public debate is captured in Monte M. Poen's book “Harry S. Truman Versus the Medical Lobby: The Genesis of Medicare.”
Despite his best efforts, Truman’s vision for the creation of a national health care system failed, largely due to the public outcry generated by organized medicine. The AMA spent more than $1.5 million on a national advertising campaign urging defeat of “socialized medicine.” The ads featured the catch phrase “guard your health, guard your pocketbook; socialized medicine would rob both.” In 1950, Truman gave up pursuit of his legislation.
The nation’s attention between 1950 and 1965 was largely focused on rebuilding the economy and the cold war. Health care, however, remained a prominent issue because more, and older, citizens faced daunting economic losses due to their health. In 1965, Johnson decided to refocus the nation’s attention on the issue. On Jan. 7 of that year, Johnson delivered a speech to the 89th Congress entitled “Advancing the Nation’s Health” in which he called for the establishment of an insurance program for the aged and needy children. During the course of seven months, Congress developed and approved the Social Security Amendments of 1965 (H.R. 6675).
The purpose of the legislation, as written by its authors, was "to provide a hospital insurance program for the aged under the Social Security Act, with a supplementary health benefits program and an expanded program of medical assistance, to increase benefits under the old-age, survivors, and disability insurance system, to improve the federal-state public assistance program, and for other purposes.”
Despite strident opposition from many, including organized medicine, the legislation was approved 307-116 in the House of Representatives and 70-24 in the Senate. Johnson signed the legislation on July 30th in Independence, Mo., at the Truman Library, in the presence of Truman. President Truman, following World War II, had devoted his presidency to the creation of a national health insurance program, but his most sought-after goal was to create a medical and economic safety-net for older Americans. At the signing ceremony, Truman stated, “Mr. President, I am glad to have lived this long and to witness today the signing of the Medicare bill which puts this Nation right where it needs to be, to be right.”
In his comments on that historic day Johnson stated, “No longer will older Americans be denied the healing miracle of modern medicine. No longer will illness crush and destroy the savings that they have so carefully put away over a lifetime so that they might enjoy dignity in their later years. No longer will young families see their own incomes, and their own hopes, eaten away simply because they are carrying out their deep moral obligations to their parents, and to their uncles and their aunts.”
Eighteen million people were eligible for Medicare in Aug. 1965. By March 31, 1966, 17 million had enrolled. A majority of the remaining 1 million were enrolled by the end of May. On July 1, 1966, the programs began covering medical services for eligible and enrolled individuals.
Next month, these two programs will celebrate their 50th anniversaries. Now, five decades removed from the heated political debate of the times, the programs are widely accepted as important components of our health care system and the social contract between our nation and its citizens. Today, more than 120 million people are enrolled in the Medicare and Medicaid programs. Enrollment in Medicare will continue to increase by 10,000 beneficiaries per day for the next decade as baby boomers become eligible.
By 2030, total enrollment in Medicare will exceed 80 million. Similarly, enrollment in Medicaid continues to increase as a result of the Patient Protection and Affordable Care Act, which extended eligibility to a larger portion of the population.
Both programs have undergone changes during their first 50 years. The most notable are the addition of the Children’s Health Insurance Program to Medicaid in 1997 and the Medicare Prescription Drug Benefit established in 2003. An overwhelming portion of the AAFP’s advocacy agenda for the past 50 years has been associated with these two programs. Looking forward, we see a continuation of this trend -- especially in Medicaid, which is now the largest health insurance plan in the nation.
I have spent my professional career arguing for and against policies that would reform and repair these two programs. The AAFP, through our advocacy efforts, has made significant improvements to care delivery, quality, and payment in both Medicare and Medicaid. Yet, we have so many lingering concerns and recommendations on what should be done to improve the programs for the millions of people who rely upon them. Normally, I would provide a series of resources for you to support the issue outlined in the blog, but this week I am leaving you with a quote from Johnson’s 1965 speech. I hope it reinforces why the voice of the concerned and compassionate physician is so important to our national debates and demonstrates all that can be achieved when we focus on doing the right thing for those in need.
“Few can see past the speeches and the political battles to the doctor over there that is tending the infirm, and to the hospital that is receiving those in anguish, or feel in their heart painful wrath at the injustice which denies the miracle of healing to the old and to the poor. And fewer still have the courage to stake reputation, and position, and the effort of a lifetime upon such a cause when there are so few that share it.”
Not So Fast: AAFP Urging FTC Scrutiny of Health Industry Mergers
Mergers and acquisitions aren’t two words that usually find their way into the lexicon of the AAFP’s advocacy agenda, but that is rapidly changing. Last week, the AAFP once again demonstrated bold leadership on behalf of our members and the patients you serve by publicly expressing concern about potential mergers in the health insurance industry. In a June 4 letter to the Federal Trade Commission (FTC), the AAFP expressed concern about speculation that two or more of the nation’s largest health insurers were exploring a merger.
“The American Academy of Family Physicians (AAFP) is deeply concerned about the potential merger of any of the nation’s largest health insurance companies and the impact such actions would have on access and affordability of health care for consumers across the nation," the letter said. "We urge the Federal Trade Commission (FTC) to carefully evaluate and scrutinize any potential merger(s) in the health insurance industry, specifically those involving two companies that are among the 10 largest national insurers.”
Health care, like many industries, is experiencing a new round of mergers and acquisitions that is reshaping local and national markets, as well as impacting the availability and affordability of health care services for millions of patients. According to many industry and Wall Street experts, we are on the front edge of the most robust merger and acquisition activity in the health care sector since the 1990s. One Wall Street analyst stated that mergers in the health insurance industry were “overdue.” (I believe this was the same attitude of railroad and oil barons of the 1920s, and we are all familiar with how that era ended.)
I am acutely mindful of Wall Street’s insatiable desire to win. Recent events and popular culture clearly demonstrate this -- see "Too Big To Fail," "Wolf of Wall Street," or the 1980s classic "Wall Street." I realize that challenging the desire of Wall Street isn’t always a safe bet, but I think these are issues where the AAFP should lead.
The Academy has been monitoring merger and acquisition activity closely for several years. Although some level of mergers is expected in a growing global economy, we have grown increasingly concerned about the pace and types of mergers occurring in the health care industry. In 2014, our concerns reached a tipping point, and we decided to open direct communications with the FTC on the issue of hospital and health insurer mergers. In a March 2014 letter to the FTC, the AAFP outlined our concerns with mergers in the insurance industry as follows:
“We have witnessed this trend for several years, but are more concerned today as health insurers expand into the Health Insurance Marketplaces and rollout Medicaid managed care products. In many markets, a single insurance company may be the dominant market force for the employer, individual, Health Insurance Marketplace, Medicare Advantage, and Medicaid populations. This situation allows insurers to control, if not manipulate, the physician workforce in those marketplaces. This is anticompetitive in our opinion and we encourage the FTC to use its resources to both examine and prevent such actions by the insurers.”
In that same letter, we expressed similar concerns with hospital and health system consolidation, stating, “The AAFP continues to urge the FTC to focus efforts on exposing the troubling increase in mergers between hospitals and health systems that increase costs, decrease competition, and fuel an uncoordinated race to provide expensive advanced medical technology and high-cost procedures. Patient access in these markets appears destabilized because hospitals and large health systems use unfair market powers and disparate site of service payment policies to buy out small physician practices or undermine them financially.”
In April of 2014, we again communicated with the FTC on these two issues, but added a specific emphasis on the anticompetitive behaviors of electronic medical record vendors. In that letter, we voiced our concerns with what has become known as “vendor lock” in the EMR industry:
“The AAFP is concerned with the utilization of health information technology to create competitive barriers against physicians and patients. The lack of interoperability makes it practically infeasible for a physician practice to switch electronic health records should the vendor or health care community use anticompetitive methods to limit a practice’s access to needed health information on their patients. This hoarding of data negatively impacts care and distorts market forces trying to decrease health care costs and improve quality. It is critical that health data flow to where patients wish to be treated. The current market forces for EHR vendors and large (quasi-monopoly) health systems limit interoperability in order to retain customers and patients and to elevate prices artificially.”
To their credit, the FTC and Department of Justice Antitrust Division have been aggressive in monitoring and challenging mergers in the health care sector. The FTC has successfully challenged several hospital and health system mergers on the grounds that they decreased or eliminated competition in local or regional markets. We also are pleased that the Office of the National Coordinator has voiced concern about EMR “vendor lock” through a report to Congress on information blocking.
Since the enactment of the Patient Protection and Affordable Care Act we have witnessed rapid and troubling mergers in the hospital industry. We are now in the early stages of similar activities in the health insurance industry. A 2014 report from the American Medical Association, “Competition in Health Insurance: A Comprehensive Study of U.S. Markets,” found that a single health insurer had a commercial market share of 50 percent or more in 17 states. Furthermore, the report found that in 45 states, two health insurers had a combined commercial market share of 50 percent or more.
These numbers demonstrate that a lack of competition clearly exists, which is why the AAFP has called on the FTC and Department of Justice to cast a wary eye on potential mergers in the health insurance industry. As we stated in our June 4 letter, “A delicate balance between competition and efficiency needs to be struck to benefit all consumers, physicians, and insurers -- especially during a time of high volatility.”
ICD-10 is inevitable. Be ready.
As we approach the official start of summer, I’d like to provide updates on some important issues that I believe are likely of interest to each of you. On a personal note, I’m encouraged to see -- with the baseball season entering its third month -- the Washington Nationals are starting to play as well as the “experts” predicted. The long, hot days of summer are where pennants are won and lost to be sure, but I’m encouraged that our nation’s baseball team is currently performing better than Congress, although that is a pretty low bar.
As always, I appreciate your feedback, thoughts, suggestions and occasional criticism of our advocacy work. We here at the AAFP want to make sure that we are representing you in the most effective manner possible, and I believe the interaction generated through this blog, as well as other AAFP vehicles, is critical to our ability to do so. So, keep those comments coming.
As of today, you have 127 days to prepare your practice and staff for ICD-10. With the Oct. 1 compliance date rapidly approaching, I thought it advisable to remind you about the AAFP resources available to assist you and your practice with the transition from ICD-9 to ICD-10. These resources include education materials, tutorials and coding flashcards that cross-walk the top 100 ICD-9 frequently used codes in family medicine practices to the more than 800 corresponding ICD-10 codes that will replace them.
We also continue to encourage all members to conduct end-to-end testing to ensure that you are prepared to make the transition. We are emphasizing testing with your billing clearinghouses, as well as with your payers. These clearinghouses created a tremendous bottleneck during the Form 5010 transition, so to avoid this problem; everyone needs to do their part to ensure this will not reoccur during the ICD-10 transition.
The AAFP continues to communicate with CMS on this issue, and we are expressing our desire to see CMS establish some form of a contingency plan -- especially for solo and small practices -- to ensure claims are paid in a timely manner in the event the conversion from ICD-9 to ICD-10 does not go as predicted.
Annual Wellness Visit
On April 30, the AAFP wrote to CMS expressing concerns with the emerging prevalence of commercial entities offering annual wellness visits (AWVs) to Medicare beneficiaries. In the letter, the AAFP asserted that “the AWV is a tool designed to encourage Medicare patients to engage with their primary care physicians on an annual basis for prevention and detection of illness and we are concerned that there are commercial entities that are subverting that benefit and may be misleading patients.”
The AWV was established as part of the Patient Protection and Affordable Care Act (ACA) and became part of the Medicare benefit package on Jan. 1, 2011. The AAFP actively supported the AWV as part of the ACA, and while we’ve expressed some serious concerns with the complexity of the documentation associated with the service, we continue to see this as a high-value service that connects family physicians with their patients. In the past year we’ve become increasingly concerned that commercial entities that have no desire or intention of providing continuous or comprehensive care have begun promoting their services directly to Medicare beneficiaries.
Unfortunately, it’s come to the AAFP’s attention that patients may be precluded from the benefits of the AWV provided by their family physicians due to services provided by a commercial entity. We see no commitment on the part of these companies to establish a relationship with the patient and it’s clear that they have no intention of caring for the patient after the AWV is provided. This practice has also drawn the attention of the Federal Trade Commission, which shares our concerns that the direct-to-consumer marketing of these commercial entities may contain false or misleading representations or intentional omission of key facts.
The AAFP met with CMS on this issue earlier this month, and we are working closely with key federal decision makers on a solution to this issue. We will keep you posted on our progress.
Give Me More Family Medicine
The Annals of Family Medicine recently published an article highlighting research done by the Robert Graham Center and building on previous research demonstrating the relationship* between primary care, better health outcomes, and lower overall per capita spending on health care.
The authors conclude that, “Increasing family physician comprehensiveness of care, especially as measured by claims measures, is associated with decreasing Medicare costs and hospitalizations. Payment and practice policies that enhance primary care comprehensiveness may help ‘bend the cost curve.’”
This article makes an important contribution to the growing body of literature and demonstrates the value proposition of primary care broadly and family medicine specifically. To view other work produced by the Graham Center please visit their newly redesigned webpage.
* I would have gone with a correlation/causation argument here, but my good friend and co-worker Julie Wood, M.D., would have a field day with my novice mistake.
The AAFP recently joined more than 60 organizations in urging CMS to value, and start paying for, Advanced Care Planning services through two previously established codes. In a May 12 letter, the AAFP and others urged the inclusion of CPT codes 99497 and 99498 in the 2016 Medicare Physician Fee Schedule.
In addition, the AAFP has recently partnered with the Pew Charitable Trust as a collaborator in its Improving End-of-Life Care initiative. This activity brings together several groups who share a common interest in advancing public policy that promotes access to advanced care planning and palliative care.
I anticipate that this issue will become a more prominent part of our national health policy dialogue in the months and years to come. If you are interested in this topic, American Family Physician offers a great collection of resources.
Family Medicine Congressional Conference
The AAFP recently hosted the Family Medicine Congressional Conference (FMCC) in Washington, D.C. This event brings together family physicians, residents and medical students to advocate on behalf of family medicine. This year, more than 200 participants heard presentations from three members of Congress, a senior administration official, six Congressional staffers, and national experts on issues of importance to family medicine. Additionally, participants visited the offices of 160 representatives and 83 Senators to advocate for reforms to our nation’s graduate medical education system.
This event is informative, fun and important to the Academy's success in Washington. I urge you to join us at the 2016 FMCC, which will be held April 18-19 in D.C.
It’s Time to Revolutionize GME -- Not Simply Reform It
“Social entrepreneurs are not content just to give a fish or teach how to fish. They will not rest until they have revolutionized the fishing industry.”
-- Bill Drayton, founder and chair of Ashoka: Innovators for the Public, a nonprofit organization dedicated to fostering social entrepreneurs worldwide
This post isn’t about fishing or the fishing industry. It's about the ability of each of us, individually and collectively, to drive change or, as the author above stated, “revolutionize” an industry.
Physicians aren’t necessarily the first group that people outside of health care think of when pondering professions that drive innovation, but physicians actually are among the most accomplished drivers of change in the world. And family physicians are at the front of that group. Throughout history, physicians have driven innovation in scientific research, revolutionized the practice of medicine, emphasized public health and dramatically improved the quality of life for millions of people worldwide.
As I examined the impact family medicine has had on revolutionizing the health of our nation, I was struck by just how much change our specialty has made. The AAFP has led the charge against smoking and tobacco, we are at the forefront of the obesity crisis, we were one of the first physician organizations to call for universal access to health care coverage -- recognizing that health insurance was a key indicator of health and wellness -- and we led the national effort to maximize vaccination rates.
Today, we continue this leadership through our efforts to modernize the care delivery system; the promotion of payment models that facilitate comprehensive, continuous and connected patient-centered care; and our efforts to place a higher value on the appropriate use of medical services through our work on the Choosing Wisely campaign. These are just a few examples of our efforts and accomplishments, but they demonstrate the positive impact family physicians and the AAFP can have on the health care system and the health of individuals when we organize our voice and speak loudly for change.
Now it is time for the AAFP to harness our energy and drive change in our graduate medical education system.
Today, family physicians from across the nation are gathering in Washington, D.C., for the AAFP’s 2015 Family Medicine Congressional Conference (FMCC). This event features presentations from notable health policy experts, researchers, a senior member of the Obama Administration, and two members of Congress. However, the most important opportunity FMCC provides is a chance for a group of family physicians to join together to drive change and innovation in health care. This year, we will focus our combined energy on revolutionizing our nation’s graduate medical education system.
Although Medicaid, the Veterans Health Administration and some private sources contribute to the training of our physician workforce, the majority of funding comes from Medicare. We spend more than $16 billion annually to train an estimated 120,000 physicians. The challenge for the country as a whole, and our elected officials, is to determine the return we are getting on this investment.
During the past year, there has been an increased awareness that we, as a nation, need to develop a comprehensive strategy on physician workforce. Our national GME policy was developed in the 1960s and continues to rely primarily on a hospital-based model that places a greater emphasis on training a workforce that reflects the needs of a teaching hospital rather than meeting the needs of its community or state. I am not one to diminish the important role teaching hospitals play and the value they add to our health care system. But we need academic health centers and teaching hospitals to play a role in our GME system rather than playing the leading role.
There are two talking points I use repeatedly to drive home the impact of the legacy hospital-based system. First, since 1965 there has been an increase in the number of recognized medical specialties from 10 to 145. Many of these are subspecialties of internal medicine, pediatrics and surgery, but some are new first-certificate disciplines. Second, 71 percent of all medical residents and fellows train east of the Mississippi River, and 60 percent of all residents and fellows are trained in just 10 states. These statistics demonstrate the economic power of GME and how GME finances have been consolidated to a handful of cities and communities.
To put it kindly, the AAFP believes the GME system is in desperate need of change, so we developed and put forth recommendations. In 2014, the AAFP released a report entitled “Aligning Resources, Increasing Accountability, and Delivering a Primary Care Physician Workforce for America.” This policy is thought-provoking by design, but we felt it was time to revolutionize GME -- not simply reform it around the edges.
Our policy proposal calls for limiting GME finances to first-certificate training -- meaning no more federal funding for fellowship training -- and establishes two levels of primary care accountability that hospitals must meet in order the secure their federal GME financing. Additionally, we create a pathway for more federal GME investment in community settings outside the traditional hospital-based system.
This policy remains the foundation of the AAFP’s advocacy efforts regarding comprehensive GME reform and will be the focal point of FMCC. This will not be an easy journey. GME finances are part of the economic fabric of many hospitals, cities and states, and they will not welcome the reforms we have proposed. We, as family medicine, must also recognize that we have a responsibility to change the GME system for the entire physician workforce, not just family medicine. I hope you will join your colleagues who are attending FMCC and lend your voice to driving innovation. Our country needs family medicine to once again be the catalyst of change.
This week, Atul Gawande, M.D., wrote a compelling article titled “Overkill” for The New Yorker about the changes that have occurred in McAllen, Texas, since his July 2009 article entitled “The Cost Conundrum.” Besides being one of the premier medical writers in the world (in my opinion), Dr. Gawande draws some interesting and encouraging conclusions on what has allowed McAllen to go from a high-cost, low-quality health care community to one that is high quality, low-cost. We should be proud of the answer, which is primary care.
I won’t ruin the article for you, but I will tell you my favorite line: “McAllen, in large part because of changes led by primary-care doctors, has gone from a cautionary tale to something more hopeful.”
That's just one more illustration of family medicine as a driver of change.
Final Thoughts on the SGR; A Look Ahead at MACRA
A strange thing happened recently in Washington, the U.S. Congress passed meaningful and impactful legislation in an overwhelming, bipartisan manner -- and the President signed it into law!
On April 16, the President signed into law the Medicare Access and Children's Health Insurance Program Reauthorization Act of 2015 (MACRA) (Public Law 114-10), bringing to a close one of the more frustrating and disruptive health policies of modern times. After 13 years. and 17 short-term fixes at a cost of nearly $170 billion spent, we can now shout from the mountain tops that the SGR IS REPEALED!
A round of applause and a heartfelt thank you to those who engaged with us on this important victory. Although we in Washington like to believe that we can make things happen, we understand fully that it is constituents who drive change, and we thank you for all you have done.
The enactment of this legislation was made possible by historic votes in the House of Representatives and Senate. All told, 484 members of Congress -- or 91 percent -- voted for the bill. AAFP News has an excellent story on the legislative actions and the official AAFP reaction.
For the AAFP, the enactment of this law brings to a close a sustained advocacy campaign that has spanned more than a decade. I want to publicly congratulate AAFP Director of Government Relations Kevin Burke and his team on this great accomplishment and thank them for their relentless pursuit of this legislative objective. It is hard to articulate or quantify the work done by Mr. Burke and his team, but I assure you it was significant.
So the question that likely is on many of your minds is, "what does the law do, and how does it impact me?" Great question. I encourage you to visit the Academy's MACRA resources. This Web page will be your one stop for information on MACRA and the resources the AAFP has available to assist you in your pursuit to implement and comply with the provisions of the law. Start with the Frequently Asked Questions document that provides a top-line summary of the law.
The most important provisions of MACRA are those that extended coverage and access to care for our nation’s children, seniors, and disabled. Extending coverage and access to physician services for these populations was a priority for the AAFP, and we are pleased that they were included.
For our members who see Medicare patients, the most important provision is the one that repeals the flawed sustainable growth rate (SGR) effective immediately. The elimination of this failed payment formula should be celebrated. Family physicians no longer face a lingering threat of losing one-fourth of their income due to the actions, or inactions, of Congress. The SGR not only impacted Medicare payment rates, but also influenced payment rates for commercial insurers who typically pegged their payment rates to a percentage of Medicare. This direct association between Medicare and the commercial insurers meant that a cut initiated by the SGR would reverberate throughout a physician practice. The annual threat of substantial reductions in payments due the SGR was unsettling for physicians.
Starting on July 1, physicians participating in the Medicare program will receive a .5 percent increase in their payments. The .5 percentage increase will continue, annually, through 2019. All physicians participating in the Medicare program will receive these annual updates. Starting in 2019, physicians will have the option of pursuing their payments through an alternative payment model (APM) such as the patient-centered medical home or by staying in the fee-for-service system and participating in the Merit-Based Incentive Payment System (MIPS).
I appreciate that there is anxiety with the transition to APMs and the MIPS program, but remember that this transition does not happen for five years. Furthermore, the law provides resources -- $100 million -- aimed at assisting small and solo practices in the transformation process, ensuring that these important care settings have resources to succeed under the new payment models. This $100 million will be leverage alongside the more than $800 million available in the Transitioning Clinical Practice Initiative (TCPI) launched by the administration last fall. All told, almost $1 billion will be invested in assisting physicians, especially those in solo and small practices, succeed in alternative payment and delivery models.
We also are pleased that starting in 2019 the meaningful use, Physician Quality Reporting System (PQRS), and value-based modifier programs will be consolidated into a single program under the MIPS. This will result in harmonized quality measures and a reduction in the administrative burden of quality improvement programs for those participating in Medicare. The AAFP has long been concerned about the complexity of CMS's programs and the administrative burden they placed on small family medicine practices. This burden often prevents small practices from maximizing opportunities in incentive programs.
This law includes three provisions aimed at assisting solo and small practices remain independent, but also maximizing their ability to achieve full potential in alternative delivery and payment models. Those provisions will allow unaffiliated physicians to be evaluated in the MIPS as a virtual group, helping them lessen the burden of program’s requirements without sacrificing their independence; the Independent Risk Manager model, that would allow independent physicians to share risk without having to affiliate with a large system or accountable care organizations; and provisions that specifically look at ways in which fraud and abuse laws like the Anti-Kickback Statute may unintentionally be making it difficult for physicians -- particularly independent physicians -- to share risk in value-based models.
I know that change is both disruptive and daunting, but I contend that the provisions of this law are both good for family medicine and good for our health care system. The SGR was a truly horrible payment methodology that disrupted practices and perpetuated poor policy-making in Washington. Good riddance to this horrible payment formula, and may we never speak its name again!
Connecting Family Physicians to Communities in Need
A quick update: As reported in my previous post, the House of Representatives approved the Medicare Access and Children’s Health Insurance Program Reauthorization Act (H.R. 2) on March 26 by a vote of 392-37. The U.S. Senate is expected to consider the legislation this week. We continue to urge members to contact their Senators and urge them to support this important legislation.
In a world with good and bad government programs, the National Health Service Corps (NHSC) has to rank near the top of the good list.
Established in 1970 as part of the Emergency Health Personnel Act, the NHSC was designed to address growing physician shortages in primary care specialties and the decreasing numbers of primary care physicians practicing in underserved communities. Its mission was simple, “improve the delivery of health services to persons living in communities and areas of the United States where health personnel and services are inadequate.”
The AAFP has long viewed the NHSC as a central component of the nation’s primary care workforce strategy. We adopted our first policy regarding the NHSC in 1974, and it has been consistently reaffirmed by the AAFP Congress of Delegates since its initial adoption. That policy states clearly that the AAFP “supports the objectives of the National Health Service Corps” and that we will “assist the Corps in making information available to family medicine residents regarding practice opportunities and benefits in the Corps.”
The Academy continues to honor this directive through our advocacy and education activities. We are especially pleased that the NHSC, through the Medicare Access and Children’s Health Insurance Program Reauthorization Act (H.R. 2), would be funded for an additional two years. The funding extension is strongly supported by the AAFP and would allow the Corps to continue its mission of placing family physicians in underserved communities. Without such an extension, funding for this vital program is scheduled to stop on Sept. 30.
In 1972, the NHSC placed an initial 180 volunteer physicians in 100 communities. Also in 1972, the Emergency Health Personnel Act Amendments established the NHSC Scholarship Program. This program awarded a full scholarship -- measured by tuition, fees, and stipends -- based on a commitment on the part of the scholar to serve in an underserved community. The NHSC continued to place volunteers in underserved communities between 1972 and 1977 while the first class of scholars completed their residency training. In 1977, the first class of NHSC scholars began their service.
In 1987, the NHSC was enhanced though the establishment of the NHSC Loan Repayment Program. This program afforded primary care physicians incremental annual payments that were applied against their student loans in return for service in an underserved community. The loan repayment program was important to the growth and reach of the NHSC because it allowed communities to immediately meet their health care needs, as opposed to waiting for a physician to complete his or her training through the NHSC scholarship pipeline.
Today, more than 9,000 physicians, dentists and other primary care professionals are participating in the program. Collectively, they provide care to more than 9.5 million people. All told, more than 45,000 primary care physicians, dentists and others have participated in the program, delivering health care services to millions of patients in our nation’s most vulnerable communities.
From early pioneers, like David Cutsforth, M.D., and David Grube, M.D., to the current generation of NHSC participants, like Brian Freeman, M.D. and Christin Donnelly, M.D., thousands of family physicians have participated in the NHSC program during the past 45 years. Through their service, millions of patients had access to health care they otherwise might not have had.
Future generations of family physicians will continue this proud tradition of service and will impact positively the lives of millions of people who reside in our nation’s health professions shortage areas (HPSAs) through participation in the NHSC program. For the thousands of family physicians who have participated in this program, we thank you for your service. For the current generation of medical students and family medicine residents, we urge you to consider the NHSC as a means of assisting with the financing of your education, but more importantly as a practice opportunity that will impact individuals who otherwise may not have access to your skills and compassion.
The AAFP values our relationship with the NHSC and is committed to securing adequate and stable funding for the program so that it may continue to improve the lives of people living in our most vulnerable communities.
In a 5-4 decision, the U.S. Supreme Court ruled in the Armstrong v Exceptional Child Centers Inc. that physicians and other health care providers could not sue states for higher payments under the equal access provisions of the Medicaid Act. The decision by the Supreme Court overturns a ruling issued by the 9th Circuit Court of Appeals. The equal access provisions of the Medicaid Act requires that states accepting federal Medicaid funding establish payment rates at levels that ensure access to care for beneficiaries.
The AAFP joined other physician organizations in submitting an amicus brief to the Supreme Court in support of the 9th Circuit decision. The majority opinion noted that physicians have administrative remedies for low payment rates. The opinion went on to suggest that “plaintiffs must first seek relief through CMS first before instigating legal action.”
March Madness Goes Into Overtime
Last week, in an overwhelming display of bipartisanship, the House of Representatives approved the Medicare Access and CHIP Reauthorization Act (H.R. 2) by a vote of 392-37. After 12 years of temporary patches, the House stated that the failed sustainable growth rate (SGR) formula should be eliminated from the Medicare program.
The AAFP issued a statement that praised the House for its overwhelming support of H.R. 2 and called on the Senate to follow the House’s lead and pass the legislation prior to adjourning for the annual spring recess.
Upon House approval, the AAFP swiftly informed members through an AAFP News article and direct emails to our state chapters and members regarding the House vote and called for aggressive advocacy targeted at the Senate. AAFP members and our state chapters answered the bell and made several phone calls to key Senate offices urging immediate action. AAFP President Robert Wergin, M.D., was in Washington when the House voted on March 26 and personally called several Senators during the course of the day, urging them to pass H.R. 2 prior to adjourning.
Unfortunately, the Senate didn’t share the House's sense of urgency and failed to consider the legislation prior to adjourning. The Senate is scheduled to return April 13. In a positive sign, Senate Majority Leader Mitch McConnell, R-Ky., said before the Senate adjourned on March 27, “It is encouraging this [H.R. 2] passed the House with such a large bipartisan majority, and I want to assure we’ll move to it very quickly when we get back. … I think there is every reason to believe it’s going to pass the Senate by a very large majority.”
In a statement the Academy expressed its disappointment that the Senate failed to follow the House’s lead and protect Medicare patients and children’s access to care prior to adjourning. We called on senators to promptly approve H.R. 2 upon their return, thus preventing disruptions in care for millions of Medicare beneficiaries.
The Senate’s failure to act on HR 2 prior to adjourning means that the 21 percent cut scheduled for April 1 will take effect. As a result, all services provided by Medicare participating physicians on or after Wednesday, April 1 – continuing until the Senate passes HR 2 and the law is enacted into law by the President – will be subject to the 21 percent cut. CMS has instructed its carriers to “hold,” for 10 business days, any claims for services provided on April 1 and beyond, until legislation can be passed and signed into law that reverses the 21 percent cut. The 10-day hold means that April claims will be held through Tuesday, April 14. Under current law, no claims can be paid sooner than 14 calendar days from their receipt, so this hold will have a minimal impact on Medicare remittance in the short-term.
However, the claims hold period does complicate billing for co-payments and claims reconciliation. Family Practice Management has created a resource, “Preparing for a Medicare Fee Cut,” that is designed to help you and your practice prepare for any reductions in revenue that may occur as a result of the cut.
Since it is spring, I am going to offer a golf analogy. It is often stated that the Masters is “won or lost on the back nine on Sunday afternoon.” Well, my friends, it’s Sunday, and we are on the back nine of the SGR issue. The only remaining question is whether we win or lose. I want to win, and I believe you do as well. The AAFP has engaged you on this issue multiple times during the past two months, and you have responded. The advocacy engagement of our members is one of the reasons 392 members of the House voted to repeal the SGR. We thank you for all of your great work, but we need more.
Between today and April 13 you need to communicate your strong support for the House-passed Medicare Access and CHIP Reauthorization Act (HR 2) to your senators. Please visit our Speak Out page, and send a letter to your Senators. After you send a letter, call your Senators. The AAFP has a toll-free phone system that allows you to do this conveniently. Simply call (866) 629-5269, provide your state, and you will be connected to your senate offices. Once connected, simply tell them you are a family physician practicing in their state, and you urge them to vote yes on HR 2 when it is considered by the Senate. That’s it – simple. Call them every day. Tell your colleagues to call. Tell your patients to call.
The AAFP has worked tirelessly on this issue for more than a decade, and with your continued help, we can finally repeal the flawed SGR formula. Victory is in sight, but we must stay focused and engaged for these final days.
SGR Deadline Looms; ACA Faces SCOTUS Challenge
In my previous In the Trenches post, I implored (some might say begged) you to write a letter to your members of Congress urging the full repeal of the flawed sustainable growth rate formula. I want to thank those of you who took the time to communicate with your elected officials. For those who haven’t yet sent a communication, I continue to urge you to do so.
A full repeal and replace bill is expected to be considered any day now, and your elected officials need to hear from family physicians who support this legislative proposal. This is not a test, this is real. And we need your help.
I urge you to watch this passionate communication from AAFP President Robert Wergin, M.D., and then Speak Out.
ACA Turns 5. Will It Turn 6?
On March 23, the Patient Protection and Affordable Care Act (ACA) will celebrate its fifth anniversary. This date is a cause for celebration for many in our country and a reminder of one of the darker days in our nation’s legislative history for others.
Regardless of political affiliation, there was a strong bipartisan consensus in early 2000s that our health care system was broken, wasteful and a drag on individual and business economic growth. It is often difficult to recall the context in which policy decisions were made, especially in a society that consumes and disregards information at such an alarming rate. This is why I think it is important that we look back at the decade prior to the enactment of the ACA to remind ourselves of the challenges we faced as individuals and as a country.
In 2001, 39.8 million people, or 14.1 percent of the population, were uninsured. By 2006, the number of uninsured had increased to 47 million or 15.8 population of the population. In 2010, the year the ACA was enacted, there were 49.9 million people uninsured or 16.3 percent of the population. Ponder those numbers for a moment.
According to the Kaiser Family Foundation, in 2000, a family of four paid an average of $6,438 for its health insurance. By 2010, this same family paid more than $13,000 for the same policy. Insurance costs for individuals also increased dramatically going from an average of $2,471 in 2010 to more than $5,000 in 2010. Between 2000 and 2010, health insurance costs increased 159 percent, and wages increased 42 percent. As a result, the number of uninsured and underinsured exploded.
By 2008, both presidential candidates and a large swath of the U.S. Congress were calling for comprehensive health reforms. In 2010, Congress delivered a bill to President Obama, and he signed it – with cheers of jubilation from most corners of society (and over loud cries of opposition from others). In 2011, the law survived a Supreme Court challenge and implementation began. It didn’t go so well, but it began.
So where are we today? In the latest open enrollment period, 11.4 million people enrolled in an insurance product sold through a state or federal Health Insurance Marketplace. Medicaid expansion, in those states where it has been implemented, has expanded health care coverage to more than 7 million people.
Although it would seem that a fifth anniversary would signal stability, the ACA is far from stable. On March 4, the Supreme Court heard oral arguments in King versus Burwell, which seeks to establish that the tax subsidies created by the ACA and aimed at assisting low-income individuals in the purchase of health insurance, are not applicable to individuals purchasing an insurance policy in the federal Health Insurance Marketplace. The plaintiffs in the case argue that the law only allows such tax subsidies for individuals who purchase a health insurance policy through a state-established Health Insurance Marketplace.
The immediate and real-world implication of a ruling in favor of King is that 13.4 million people would become uninsured immediately. Now, there are pathways for those individuals to retain their health coverage, but those pathways require action by Congress, but I wouldn’t look for white horses to come galloping to the rescue. It also would send the insurance market in many, if not all, state into chaos. Neither of these events is good for our health care system.
The AAFP has advocated for universal health care coverage since 1989 when the Congress of Delegates approved a resolution entitled “Health Care for All: A Framework for Moving to a Primary Care-Based Health Care System in the United States.” With few modifications, this policy has stood the test of time. At the core of this policy is the following statement, “Ensuring that all people in the United States have health care coverage is essential to moving toward a healthier and more productive society.” This policy is central to the AAFP’s advocacy efforts and, in my opinion, to family medicine.
Each of you understands the importance of health care coverage because you see it every day in your practices. Of course, people with health insurance sometimes still face challenges accessing health care services because insurance companies aren’t always the most helpful partners. But despite some administrative burdens, individuals with health care coverage have better opportunities to be healthy than the uninsured.
Decades of research shows that there are two leading drivers of a quality health care system: health care coverage and a continuous relationship with a physician, most often a primary care physician. These two indicators, when combined, have demonstrated the ability to improve the health of individuals and do so in an economically efficient manner. Regardless of your political stripes, 13.4 million uninsured is an undesirable outcome.
SGR: Time to say goodbye to a familiar foe
In politics, as in many things in business and life, the hardest tasks often are those that come at the end. This is where we find ourselves on a familiar and extremely frustrating issue -- the Medicare sustainable growth rate (SGR).
In less than 30 days, Medicare will implement the largest and most damaging payment cut in its history as a result of the flawed and failed SGR formula -- unless Congress intervenes. Should Congress fail to act and this draconian cut is realized, many of you will face trying questions about your future participation in the Medicare program, and Medicare beneficiaries across the nation could face challenges in securing access to care.
The AAFP is focused on preventing both of these scenarios. In fact, we are committed to ensuring you and your Medicare patients never have to face this dilemma again. Last week the AAFP Board of Directors was in Washington advocating on your behalf. Now, we need your help. We need you to raise your voice and advocate for your patients, yourself and your colleagues. I will tell you how later in this post. For those that can’t wait, please go to Speak Out, and send a letter to your representative and senator today!
During the 113th Congress, a bipartisan group of representatives and senators introduced the SGR Repeal and Medicare Provider Payment Modernization Act of 2014. This legislation was supported by the AAFP and endorsed by an overwhelming majority of physician and health care organizations. Additionally, it secured the support of the two House committees and one Senate committee with jurisdiction over the Medicare program.
The support for this SGR repeal legislation was bipartisan and solid. Sadly, negotiations on how to finance the legislation prevented its consideration by the full House and Senate, and -- for the 17th time in 12 years -- Congress enacted a safe, comfortable and cowardly short-term patch.
The AAFP continues to strongly support this proposal. On March 2, we wrote to House and Senate leaders urging the immediate enactment of this policy.
There are plenty of provisions in this proposal that will cause some to gnash their teeth, but on the whole, this proposal is a significant step in the right direction and is good for family medicine. The proposal not only repeals the flawed and failed SGR formula, it also puts in place a path for the implementation of new delivery and payment models that transition our health care system from an episodic and volume-driven model to a longitudinal and quality-driven model. Additionally, it provides family physicians practicing in advanced practice models enhanced payments and a simplified administrative burden.
We applaud the work that led to this policy and work that is ongoing to pursue its enactment into law. The 17 short-term fixes Congress has enacted have cost the nation more than $169 billion. We urge Congress to move beyond the short-term, stop-gap measures that have become the accepted course of action on this issue.
The Medicare program relies on access to a robust primary care physician workforce, yet payment and regulatory policies make it difficult for each of you to provide care to your patients. Since the establishment of the SGR, physician payments have fallen greater than 20 percent below medical inflation. These stagnant payments have come during the same period that Congress piled more than 20 rules, regulations and new programs on you. Today, each of you are asked to comply with a complex web of regulations that prevent you from focusing on patient care and push you to a level of frustration that elicits some non-printable comments.
Family physicians are not only providers of essential health care services; they also are small businesses that create well-paying jobs and contribute to the economic viability of communities small and large. Family physicians are economic engines for your communities. On average, each of you employ five full-time employees and directly produce nearly $1 million in economic activity. Collectively, family physicians nationwide employ more than 350,000 people and generate more than $46 billion in economic activity. It is improbable to believe that any small business can endure a 21 percent reduction in its revenue and an explosion in mandatory compliance to regulations.
Your frustration with this issue is understandable and I don’t blame you for being annoyed that I am asking you to once again take action in support of repealing the SGR. However, I am asking for you to take action, and I am asking you to channel those 12 years of frustration at your elected officials. I am asking you to SPEAK OUT on behalf of your patients. I am asking you to SPEAK OUT on behalf of yourself and your practice. I am asking you to SPEAK OUT on behalf of your colleagues. Finally, if it helps, I am asking you to SPEAK OUT simply as a means of venting your frustration. I don’t care which of these factors motivates you to write a letter, but I urge you to do so.
Meaningful Use and PQRS Extensions
On Feb. 25, CMS and the Office of the National Coordinator (ONC) announced an extension in the reporting and attestation periods for eligible professionals participating in the EHR Meaningful Use and PQRS programs. Practices now have until March 20 to complete their attestations and reporting. The AAFP worked closely with CMS and ONC on this extension and is pleased that they made a decision to extend the reporting periods. We were concerned that widespread winter weather events would prohibit many family physicians from meeting the deadlines.
Creating A Medical Home is About Improvement, Not Checking Boxes
My medical home has a first name, and it’s not NCQA.
Eight years ago this month, the AAFP joined with the American Academy of Pediatrics (AAP), the American College of Physicians (ACP), and the American Osteopathic Association (AOA) to publish the Joint Principles of the Patient-Centered Medical Home (PCMH). The Joint Principles were grounded in the AAP’s work on children’s medical homes established in 1967 and supported by the AAFP’s 2004 Future of Family Medicine project -- which called for every individual to have a medical home -- and ACP’s work to develop an “advanced medical home,” which started in 2006.
Through a process that originated in 2006, these four organizations developed a set of seven principles that described the characteristics of a PCMH. Those seven principles call for each patient to have an ongoing relationship with a personal physician in a physician-directed medical practice and team. The physician and the team are responsible for providing all the patients’ health care needs, coordinating care across all elements of the health care system, expanding access, and providing patient-centric care. The final principle states that payment should appropriately recognize the added value of PCMH to patients, caregivers and physicians.
The four organizations mentioned above, along with IBM, also founded the Patient-Centered Primary Care Collaborative (PCPCC), and the seven principles continue to serve as the North Star for that organization. The Joint Principles have been cited in numerous academic articles, the Congressional record and functioned as the substance of several state and federal laws and regulations. Furthermore, they are the guiding values of hundreds of PCMH programs run by insurance plans across the nation.
The PCMH, unlike other practice models -- such as managed care -- was created by physicians and not by others for physicians. The Joint Principles embodied an approach to the practice of medicine that many physicians had used throughout their careers. In many ways, the PCMH reflected how physicians wanted to provide care for their patients and not how someone else felt they should do so. It was organic and originated from the physicians who would ultimately practice in the model.
The enthusiasm surrounding the PCMH was palpable in the years following, and many family physicians saw the PCMH and the Joint Principles as the path forward to a better health care system focused on patients and supportive of physicians' sincere desires to “get off the hamster wheel.” The AAFP and our partner organizations were thrilled that the movement was based on a set of achievable characteristics that appealed to physicians in all practice settings.
In recent years, ownership of the medical home has moved from the physicians and physician organizations that created it towards the quasi-government agencies that recognize the practices. As a result, physician enthusiasm for the model has waned -- to put it mildly.
Third-party recognition is important if it is supported by a business case in your practice or local market, meaning there are payment incentives available. The Joint Principles contained a recommendation that “all practices should go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient-centered services consistent with the characteristic of the PCMH as articulated in the Joint Principles.” However, we never thought that this service would be provided only by, let’s say, the National Committee for Quality Assurance (NCQA). We envisioned a recognition process whereby an insurance plan or collection of insurance plans, a quality improvement organization, or a Medicaid program that was offering enhanced payments for PCMH would verify practice capabilities.
The AAFP remains agnostic on PCMH recognition programs. If you think your local market or practice business plan would benefit from recognition, then discuss with your local payers and/or pursue collaboration with any of the organizations that provide PCMH recognition programs such as the Accreditation Association for Ambulatory Health Care (AAAHC), URAC, the Joint Commission, or the National Committee for Quality Assurance (NCQA). The process of becoming a recognized medical home should be collaborative and focused on the characteristics of the Joint Principles. It should not be a collection of chart extractions, screen captures and checklists. It should be focused on practice and performance improvement. It should not be a product you purchase -- or repurchase every two or three years.
In short, don’t consider PCMH practice redesign and NCQA designation as synonymous. This line of thinking has taken a practice redesign and patient care model once celebrated by primary care physicians and turned PCMH into a dreaded phrase in primary care. I encourage every family physician to transform your practice based on the principles of the PCMH. And, you should consider third-party PCMH designation if that is beneficial to your practice, but please free yourself from thinking that NCQA recognition is the only organization that can recognize you as a PCMH because there are others.
The most important activity for family physicians is providing high quality care to your patients, and I believe that practice transformation consistent with the characteristics of the PCMH will help you in this endeavor by focusing your practice on process improvement, quality improvement, team-based and patient-centric care, and reform at a pace that benefits your patients and your practice. The AAFP has a variety of resources to assist you. Our approach is to meet you where you are and assist you in transforming at your own pace. The PCMH Planner is the perfect tool because it has a full complement of resources and allows you and your practice to move at a comfortable pace.
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