GME: IOM Report Shines a Light on a Flawed System
It has been well documented that our nation faces a shortage of physicians, especially primary care physicians. Although there is agreement that our nation needs more physicians, there is disagreement on how to best educate and train a physician workforce capable of meeting the health care needs of the nation. What is clear, in the opinion of the AAFP, is that any attempt to simply expand our current system of graduate medical education (GME), will only produce more of the same and do little to meet the health care needs of our citizens.
Our nation has long recognized the value of supporting GME, and the first federal investment came in 1944 as part of the G.I. Bill. The most important step, however, occurred in 1965 when the United States committed to a stable source of funding for GME through Medicare. During the next 49 years, there have been legislative adjustments to our GME system, but until recently there had never been a comprehensive analysis of the program’s purpose and effectiveness. The good news is that this is starting to change as a result of efforts from the AAFP and like-minded organizations.
During the past three to five years, a national discussion about the current and future physician workforce and the process by which we train physicians began. The AAFP has been at the center of these discussions, which have led to an increased effort to research, analyze and ask some thought-provoking questions about the structure, governance and financing of our GME system. These activities have come from the AAFP, the U.S. Congress, foundations, think tanks, health services researchers and government advisory bodies such as the Medicare Payment Advisory Commission, the Council on Graduate Medical Education, and most recently, the Institute of Medicine (IOM).
On July 29, the IOM released its long-awaited report “Graduate Medical Education That Meets the Nation’s Health Needs.” This report was encouraged by several academic organizations, but a 2011 letter from seven senators requesting a study of GME and its financing was the catalyst to the IOM taking on this important issue.
The IOM report focused much of its attention on the relationship between GME financing and hospitals' priorities in physician training. The report notes that “giving funds directly to teaching hospitals, the payment system discourages physician training in the clinical settings outside the hospital where most people seek care. Primary care residency programs are at a distinct disadvantage because of their emphasis on training in ambulatory settings. Hospitals’ control over the allocation of GME funds may also encourage the overproduction of specialists in disciplines that generate financial benefits for an individual institution rather than for the health care system overall.”
The report also questions the validity of proposed policies that would expand the overall number of funded GME positions by stating that “the available evidence suggests that increasing the production of physicians is not dependent on additional federal funding.”
Finally, the IOM report discusses the inherent inequities in the geographic distribution of GME positions and funding. Today, 65 percent of the nation’s residents and fellows (74,195) are trained in 12 states, and 78 percent of all residents and fellows (88,736) are trained in a state east of the Mississippi River.
The IOM report includes five recommendations on how to improve the GME system:
- Maintain Medicare GME support at the current aggregate amount while taking essential steps to modernize GME payment methods based on performance, to ensure program oversight and accountability, and to incentivize innovation in the content and financing of GME. The current Medicare GME payment system should be phased out.
- Build a GME policy and financing infrastructure.
- Create one Medicare GME fund with two subsidiary funds.
- Modernize Medicare GME payment methodology.
- Medicaid GME funding should remain at a state’s discretion. However, Congress should mandate the same level of transparency and accountability in Medicaid GME as it will require under the changes in Medicare GME herein proposed.
The report has been met with mixed reactions in the health care community. Many of the nation’s academic health centers, colleges of medicine and hospitals issued negative statements, essentially stating that the recommendations of the IOM would destroy our nation’s GME system. Of course, we must be mindful that most of those expressing the strongest opposition are the ones that benefit most from the status quo. Overall, the AAFP is pleased with the content and direction of the report. Although we would prefer more immediate actions, the IOM report closely aligns with the AAFP's view of what comprehensive GME reform should accomplish.
As noted, the IOM report has opened communication channels, and a robust discussion on GME reform is occurring in Washington, D.C. The AAFP is seizing this opportunity, and on Sept. 15 we released “Aligning Resources, Increasing Accountability and Delivering a Primary Care Physician Workforce for America." You can read more about the Academy's proposal in a recent AAFP Leaders Voices Blog post by AAFP Board Chair Jeff Cain, M.D., and in AAFP News.
Although recent activities are encouraging and support the AAFP’s policy and advocacy objectives, change will not come independent of resistance. The American Hospital Association, in response to the IOM recommendations, stated that “cuts to GME funding would jeopardize the ability of teaching hospitals to train the next generation of physicians. They would limit the ability of teaching hospitals to offer state-of-the-art clinical and educational experiences.” The association went on to state that “reductions in the IME adjustment would directly threaten the financial stability of teaching hospitals.”
At least they are honest. The key words in these sentences are “state-of-the-art” and “financial stability.” GME has been and continues to be a revenue stream for hospitals, not an education mission. We must shine a light on the shortcomings of our GME financing and governance structure, and the AAFP is just warming up its spotlight.
Changing Times, Changing Relationships?
One of the most important jobs the AAFP has is to analyze innovations in an effort to influence the future of health care delivery and its financing structure. Currently, there is not an issue more difficult to analyze than retail-based clinics.
The emergence of retail clinics can easily be viewed as innovative and responsive to consumer demand and, simultaneously, disruptive to a well-established health care market and the high quality of care that comes from longitudinal care models.
During the past few years, the AAFP has been engaged in meaningful conversations with the large companies that offer retail clinics about how family physicians and such clinics can, potentially, work together to improve access to health care for individuals in their communities.
To be clear, not all retail clinics are the same, and the AAFP does not view them as a homogenous industry. There are clear differences between the various business models. The challenge for each of us is to ensure we do not view every retail-based clinic through the same prism. The AAFP’s policy on retail clinics makes it clear that we do not support retail clinics providing continuous care to patients with chronic conditions. The policy also expresses, rightfully so, concerns that retail clinics may further fragment care delivery. However, our policy also expresses some belief that there is a potential role for retail clinics in the health care team or neighborhood, and this is what needs greater analysis.
Again, not all retail clinics are the same. There are clinics that are solely attempting to create a disruption in the marketplace and sell consumer products, but there also are companies that are serious about partnering with family physicians to create community delivery models. We need to identify the latter for collaboration and communicate with the former to better influence their business models.
Our motivations are multiple, but here are three primary reasons we are seeking potential collaborations:
- It is time that we acknowledge the existence, contributions and even the potential benefits of retail clinics to patients and family physicians. We can't pretend that retail clinics do not exist, nor can we legislate or regulate them out of business. According to the Convenient Care Association there are 1,500 retail clinics operating in 40 states and Washington, D.C. The impact of these clinics on the primary care system is unknown, but our observations are that the clinics are having a minimal impact on the family physicians in the communities where retail clinics are co-located. Additionally, there are several examples of collaboration that have expanded access for patients.
- Retail clinics may be complementary to family physicians through expanding community delivery partnerships that will enhance a practice's service to their patients and align retail clinics more closely with family physicians in their communities. The use of retail clinics as a part of the patient-centered medical home neighborhood holds great potential for patients and physicians. According to a 2012 RAND Special Feature: "Retail Clinics Play Growing Role in Health Care Marketplace," 44 percent of care provided in a retail clinic takes place at a time when physician offices are typically closed (nights and weekends). Furthermore, RAND notes that 43 percent of individuals seeking care at a retail clinic are between the ages of 18 and 44 (young/healthy). These two data points alone clearly define the demographic factors driving expansion of retail clinics -- young people seeking expanded access that is convenient to them and their family’s personal and professional schedules.
- As fee-for-service becomes a less dominant payment model, the economic pressures of “who provides” will be replaced by “is provided.” An Accenture report entitled "Retail Medical Clinics: From Foe to Friend?" notes the potential benefit of retails clinics to primary care physicians: “As the shortage of PCPs (primary care physicians) relative to demand continues to grow, one option for physicians will be to refer lower acuity cases to retail clinics. In addition to providing additional supply, the clinics would also leave PCPs free to deal with more complex cases, with correspondingly higher reimbursement.”
Although we can’t say with certainty that this scenario is achievable in all occasions, we do agree with Accenture that retail clinics, working with family physicians, can improve care delivery models in communities where they collaborate.
Since the concept first emerged onto the national scene in the late 1990s and early 2000s, retail clinics have been a source of controversy in many communities and a source of improved access and quality in others. Physician organizations were slow to acknowledge and analyze the economic and demographic drivers fueling the expansion of retail clinics. From a market perspective, retail clinics identified a gap in service and created a product to fill that gap. In blunt terms, they noticed that the delivery system was not always patient-centric and, in many cases, was unavailable to certain individuals.
The resistance to retail clinics expressed by the AAFP and other physician organizations during the past 15 years was appropriate. However, it has not impacted their rapid expansion. Is it time for a change? Can retail clinics contribute to the continuum of care for patients? These are important questions, and the AAFP is pursuing answers.
Bringing You Up To Date: New Information on Previous Posts
It's been a little more than two months since the AAFP launched this blog to provide members with timely information on health policy matters and what the Academy is doing on your behalf to address those issues. This edition of In the Trenches will take a look back at our initial posts and provide updates on the work we have conducted, relevant new tools and resources that are available, the advocacy wins we have secured and ways that we can collaborate to improve our ailing health care system.
Direct Primary Care
In our first blog, we introduced you to the AAFP’s work on direct primary care. This work continues, and the AAFP will offer three practice development programs on DPC this fall and winter. The first program will be held Nov. 8 in Tempe, Ariz.; followed by programs on Jan. 10 in New Castle, Del.; and Feb. 25 in Atlanta. You can learn more about these programs and register on the AAFP website.
Medicaid Parity Payment
On July 1, we discussed the work AAFP is doing to extend the Medicaid parity payment policy established by Section 1202 of the Patient Protection and Affordable Care Act. Those efforts are producing results. On July 30, Sens. Sherrod Brown, D-Ohio, and Patty Murray, D-Wash., introduced the Ensuring Access to Primary Care for Women and Children Act (S. 2694), legislation that would extend the payment policy for two years.
The AAFP supports this legislation and has communicated our support in a letter. We are engaged in an active grassroots campaign to build support for this legislation, and we could use your help. During the Labor Day weekend, please take a few minutes to Speak Out and send a letter to your senators urging them to support S. 2694. Ask your colleagues to do the same.
In our July 15 posting, we discussed the vast challenges at the Veterans Health Administration and our work to provide expanded access to veterans. As noted in that blog, the AAFP was the first physician organization to call on the Obama Administration and Congress to make fundamental changes that would allow civilian family physicians to provide care to veterans. As a result of our letters and lobbying efforts, Congress included provisions allowing expanded use of civilian primary care physicians in the VA health care system.
On August 7, President Obama signed into law the Veterans’ Access to Care Through Choice, Accountability, and Transparency Act. On August 13, the Veterans Administration announced that is expanding the Patient-Centered Community Care contracts as a means of expanding access to primary care services and reduce wait times. You can learn more about the PC3 program and how you can participate through the Department of Veterans Affairs. This law authorizes the Secretary of Veterans Affairs to create 1,500 new graduate medical education positions and instructs the Secretary of Veteran Affairs to place a priority on creating new primary care and mental health residency positions. The AAFP actively lobbied for these new positions, and we are pleased that Congress responded.
Home Sweet Medical Home
In my previous post, I shared with you the advocacy work the AAFP was doing with respect to patient-centered medical home (PCMH) recognition programs. Now I want to share with you information on the work we are doing to assist physicians with the transformation process and what tools and resources we have created for you and your practices.
The AAFP has long recognized that the PCMH transformation process may be more difficult for solo and small practices. These practices face challenges on at least two levels -- time and money. Solo and small practices often lack the staffing necessary to aggressively transform their practices and implement the full cadre of services outlined in the Joint Principles of the Patient-Centered Medical Home. They also lack the financial capital to make investments in staff and technology that would facilitate this transformation more rapidly. This is not meant to suggest that a solo or small practice cannot become a PCMH -- many have done so -- only an acknowledgement that it can be more difficult for them.
To assist these practices, we developed the PCMH Planner, an online, “do-it-yourself” tool that allows a practice to conduct a self-evaluation of its capabilities and start, or continue, progressing in its transformation to a PCMH. The Planner was researched and written by PCMH subject matter experts and provides practices with easy-to-follow, step-by-step work plans and links to downloadable tools and resources. This resource is available to AAFP members at a rock-bottom price and allows for multiple users from the same practice. No matter where you are in your journey -- evaluating the merits of practice transformation, just getting started, or well on your way -- I strongly encourage you to purchase the PCMH Planner. I am confident that you will find it valuable to your efforts.
For those practices that require additional assistance, you can contact TransforMED,the Academy's wholly owned subsidiary. TransforMED has a distinguished record of helping practices with transformation and is widely recognized as a national leader in this area. TransforMED’s services will require a financial investment on your part, but the outcomes should produce an appropriate return on your investment.
Home Sweet Medical Home
Since the creation of the Patient-Centered Primary Care Collaborative and the Joint Principles of the Patient-Centered Medical Home, in 2006 and 2007, respectively, we have seen a steady growth in the implementation of the PCMH in primary care practices. According to the 2013 AAFP Practice Profile Survey, 26 percent of family physicians report being in a recognized PCMH and 10 percent report that they have an application for PCMH recognition submitted and pending.
We also have seen an explosion of PCMH programs in health care systems, both public, and private. Today, most major insurance companies have implemented the PCMH at some level. The PCMH was included in the Affordable Care Act, and as of June 2014, 47 states that have adopted policies and programs to advance medical homes in their Medicaid programs, and 30 states are making advanced payments to medical homes within their programs. The growth is something to be proud of, but we also recognize that many challenges must be overcome if we are to realize the full potential of the PCMH.
One complaint that we hear frequently is the difficulty and complexity of the recognition process. There are several organizations that have PCMH recognition programs -- NCQA, URAC, AAAHC, Joint Commission -- and there also are many state and insurance company-sponsored recognition programs. Although the AAFP is agnostic on these programs, we do recognize that NCQA is the dominant player in this market, and a majority of our members have chosen to participate in the NCQA PCMH recognition process. We continue to advocate among all of the recognition programs for standards that meaningfully represent the most important and effective principles of the PCMH and for application processes that are less cumbersome for family physicians.
The Academy recognizes that there is value in PCMH recognition, and such validation of practice capabilities is central to our advocacy efforts for increased payment for PCMH practices. Simply put, practices need to demonstrate transformation and the resulting improvements in processes and outcomes, not simply declare that they are doing so. However (and this is a big however) these recognition programs need to add value to patient care, be measurable, and most importantly be meaningful. This is where the AAFP is working hard on your behalf.
The AAFP met recently with representatives of NCQA to discuss its PCMH recognition program. We expressed several concerns along three major themes:
- Cost -- The AAFP continues to be concerned that recognition programs are placing undue financial strain on practices. According to the 2013 AAFP Practice Profile Survey, 22 percent of family physicians found the expense of the PCMH recognition programs to be a substantial barrier. The costs are both the actual fee for the service, and the financial costs to the practice in the form of human resource allocations and lost revenue due to time spent away from patient care while completing the application. We also continue to express concerns that new forms of the recognition products are solely aimed at securing additional business and fees with little to no meaningful impact on the practice or patient care.
- Complexity -- The AAFP thinks that all recognition programs are overly complex. The Joint Principles included seven items, yet the NCQA process has more than 100 metrics -- this is a disconnect to put it kindly. According to the 2013 AAFP Practice Profile Survey, 54 percent of family physicians’ found the data and documentation requirements for PCMH recognition to be a substantial barrier, and 46 percent said the staffing demands to complete the application presented a substantial barrier. The AAFP continues to advocate for changes in the recognition process that place a greater focus on those key elements that have are demonstrable to improved patient care.
- Efficacy -- The early results on the efficacy of the PCMH are positive, but there are several studies that have raised some meaningful questions, particularly about the efficacy of the NCQA process. The PCPCC published a comprehensive analysis of PCMH programs nationwide. The Medical Home's Impact on Cost & Quality: An Annual Update of the Evidence, 2012-2013 clearly shows that the PCMH has been effective in reducing the overall costs of health care in some key areas and is improving the quality of care – especially for those patients with multiple chronic conditions. The AAFP continues to believe that the PCMH is impactful and will improve quality and lower the overall costs of health care as demonstrated in the PCPCC study, but there are areas that lend themselves to improvement in the PCMH transformation and recognition processes.
We will continue to work with the NCQA and others on refining and improving their recognition programs, especially in those areas outlined above. To their credit, the NCQA and others have been receptive to our concerns and open to our recommendations.
PCMH transformation is challenging and takes time (up to two or three years for some practices) and the benefits take even longer to realize. This is a work in progress and we applaud those practices that have taken on the hard work of transformation and continuous quality improvement. Today there are more than 500 PCMH initiatives or incentive programs nationally. This movement is growing and the foundation for both ACOs and future opportunities for value-based payment. The Academy wants family physicians to be positioned for success in the future health care environment.
We're Not Gonna Take It: Network Optimization Disrupts Continuity of Care
Hundreds of family physicians recently have been informed that they are no longer eligible to provide care to patients covered by certain insurance policies. Sadly, most of these physicians were not notified directly by insurers. Instead, patients told the affected physicians that they received a letter stating that their family physician is no longer covered by their insurance plan. These patients and their family physicians were not given any justification why these actions are being taken. They were only given a date on which their relationship would be terminated. These patients are rightfully upset, their family physicians are mad, and the AAFP is taking aggressive action.
To quote the 1980’s rock band Twisted Sister, “We’re not gonna take it.” Last week, the AAFP wrote letters to America’s Health Insurance Plans (AHIP) and United Healthcare notifying them of our concerns and urging them to take a more responsible approach to the formation of their provider networks – especially with respect to primary care physicians.
We also wrote a letter to CMS Administrator Marilyn Tavenner, M.A., expressing concern with actions taken in Tennessee with respect to TennCare, the state’s Medicaid program. TennCare, operated by UnitedHealthcare Community Plan, recently informed hundreds of individuals that they would need to change primary care physicians or face higher out-of-pocket expenses for their health care.
In addition to these letters, we are meeting with representatives from the insurance industry as well as individual plans to identify ways to curb the negative impact of these decisions. We also are working closely with state chapters to draft letters to governors and state insurance commissioners questioning the legality and purpose of such actions.
Our recent actions are in addition to the "friend of the court" brief the AAFP joined, along with several other medical societies, in support of two Connecticut medical associations that sued United Healthcare in 2013, challenging its actions to summarily “dump” more than 2,000 physicians from its Medicare Advantage network in the state of Connecticut.
Although the practice of “network optimization” is not new, the disruptive manner in which it is being executed is troubling to the patients, their family physicians and the AAFP. Fearing that insurance companies may tighten networks -- similar to health maintenance organizations in the 1980s and 1990s -- Congress included in the Affordable Care Act provisions that require insurance plans participating in the Health Insurance Marketplaces to provide an “adequate” network of physicians and hospitals. The compelling criteria are that insurance plans include a “choice of providers” and that networks include “essential community providers.” The National Association of Insurance Commissioners (NAIC) has a great paper on network adequacy that provides an excellent overview of the issue.
The AAFP is deeply concerned with actions being taken by insurance companies. Decades of peer-reviewed studies have shown that there are two factors that contribute to better health outcomes for individuals – health care coverage and a usual source of care. We also know from research that patients that have a continuous and longitudinal relationship with a primary care physician have better health care outcomes at lower costs than those who do not have a continuous relationship with a primary care physician.
The AAFP has evidence that thousands of patients, in multiple states, are being told that they must identify a new family physician in the next few months as a result of their family physicians being dropped from certain insurance products as a result of insurers optimizing their provider networks to better align resources. Many of these patients will have years' long relationships with their family physicians terminated in the name of efficiency. These actions are tremendously disruptive to a physician practice, but we are most concerned with the disruption patients face as they are told to change primary care physicians without any input in the decision – not to mention the lack of an appeals process in many cases. These patients face intrusive disruptions in their care and an uncertain future as a result of these actions.
We recognize that insurers have a responsibility to align networks of physicians and hospitals to maintain affordable premiums while ensuring quality and efficiency, but we feel that disruptions to the patient-physician relationship at the primary care level are contrary to both of these goals. Primary care is relatively inexpensive as compared to specialty or hospital care. It also benefits from continuity and trusting relationships. We are baffled by the language used by insurers who say they support patients having a continuous relationship with a primary care physician and then act in a way that make this impossible. In short, we are no longer flattered by insurers’ language that speaks to our policy goals but are demanding action that aligns their public comments with their actions in the health care market place.
If you have received a letter from an insurance company notifying you that you or your practice is being dumped -- oh, excuse me, “optimized out of network” -- please notify your AAFP chapter. We are in close contact with the chapters on this issue, and it benefits our efforts to organize actions by states and regions.
The Congressional Budget Office (CBO) has released its 2014 Long-Term Budget Outlook and predicts that the Independent Payment Advisory Board (or IPAB) created under the Affordable Care Act will not go into effect for the next 10 years due to a slowing in overall Medicare spending. IPAB, in concept, is a 15-member panel tasked with achieving specified savings in Medicare if spending growth exceeds a set target. They are not allowed to negatively impact benefits, coverage or quality – meaning they can only cut payments. The controversial panel has yet to have any members appointed to it, and its funding was cut by $10 million in the most recently enacted spending bill.
Jonathan Easley at Morning Consult wrote a great explanation on the politics of IPAB.
Are Family Physicians an Answer to VA's Primary Care Crisis?
In the wake of an escalating scandal involving the Department of Veterans Affairs and the Veterans Health Administration, the AAFP was the first physician organization to make specific recommendations to President Obama and Congressional leaders about how they could facilitate the use of civilian family physicians to enhance access to primary care services for veterans.
Here's a look back at how the situation unfolded and a look ahead at the important work that remains to be done.
In April, news of a “secret” waiting list at an Arizona VA facility emerged in local media reports in that state, where hundreds of sick vets were forced to wait for care. Dozens died while waiting. In May, a Government Accountability Office (GAO) report -- and subsequent media reports -- exposed the profound and systemic deficiencies in care delivery, access and management within the VA, especially regarding primary care and mental health services.
In a matter of days, the Secretary of Veterans Affairs and two senior officials had resigned or retired, and the public, media and Congressional outrage reached a fever pitch.
Staff in the AAFP Division of Government Relations took note of the GAO report and began developing policy options that would allow civilian family physicians to provide care to veterans. During the same time period, several AAFP members raised concerns about the situation during the annual summer meeting of the Academy's commissions.
Through a series of conversations and policy discussions, AAFP leadership determined that we should communicate directly to President Obama and Congress on how America’s family physicians could assist in the short-term to alleviate backlogs in the VA system.
On June 3, the AAFP made specific recommendations to President Obama and Congressional leaders regarding the use of civilian family physicians to enhance veterans' access to primary care services. Those recommendations focused on four major areas:
- permitting veterans to fill prescriptions from civilian physicians at VA pharmacies,
- allowing civilian physicians to order diagnostic tests and therapy services inside the VA,
- permitting for the referral of veterans by civilian physicians to specialist inside the VA, and
- extending federal tort claims act protections to civilian physicians.
Our letter was received positively and led to ongoing communications between the White House and the AAFP.
Simultaneously, Congress moved quickly and developed legislation that would immediately expand access to care for veterans and implement systems changes to prevent similar failures from occurring in the future. The AAFP worked to communicate quickly with legislators of the House and Senate to advance our policy priorities and ensure their inclusion in the legislation.
A few weeks later, the AMA House of Delegates approved a resolution calling on the AMA and the full house of medicine to support policies similar to those advanced previously by the AAFP.
On June 10, the House approved legislation that would invest $50 billion per year during the next decade to improve access and quality within the VA system, including allowing veterans to access the services of civilian physicians. The Senate approved similar legislation a day later.
Given the rapid process, the AAFP determined that it would be advantageous to further define and articulate our policy priorities, which were submitted to the House-Senate Conference Committee June 23, a day before the committee began its work.
In addition to the policy recommendations in the Academy's letters dated June 3 and June 23, we believe that the VA is fertile ground for workforce development, including graduate medical education, and we are advancing these ideas aggressively. Specifically, we are calling on the conference committee to dedicate significant financial resources to the establishment of family medicine, internal medicine and psychiatry training programs inside the VA -- with or without an external academic partner. We believe that the VA has untapped capacity to train family physicians and, at the same time, expand access to primary care services. This is an idea that has support within the conference committee, and we are working hard not only to build support for the concept, but also to make the policy-political arguments for why they should invest money to create this new VA program.
The legislative process slowed significantly during the Fourth of July recess, but the AAFP’s efforts haven’t. The Academy's government relations staff continues to conduct meetings with the legislators and staff of the conference committee to advance the policies outlined in our written communications. We have made this work a priority, and we are pressing to ensure that our policy recommendations are included in the final VA reform legislation.
While nothing is certain in Washington, we are fairly confident that the conference committee will conclude its work, and both the House and Senate will approve a final bill, prior to the congressional recess. Although partisanship is high in this election year, lawmakers from both parties would like to avoid returning home in August and having to explain why this scandal happened in the first place and why they haven’t demonstrated leadership in correcting this national tragedy.
Merritt Hawkins has released its 2014 Review of Physicians and Advanced Practitioner Recruiting Incentives, and for the eighth consecutive year family physicians were No. 1 on the list. The Merritt Hawkins report is illustrative of the rapid changes in our health care system and the dominant role primary care physicians are playing and will play in new delivery and payment models. Of the 3,158 searches conducted between April 1, 2013 and March 31, 2014, 23 percent were for a family physician. Internal medicine was second at 7 percent. Despite strong promotion from the media and policy-makers, nurse practitioners were the focal point of only 4 percent of searches, and physician assistants came in at 1 percent. A majority of searches, 59 percent, were for positions in communities with populations of less than 100,000 people -- just another demonstration of why graduate medical education needs to be diversified away from urban academic health centers.
Primary Care: 'A Matter of Priorities'
Tucked away inside the Patient Protection and Affordable Care Act (ACA) is a provision that is one of the law's more important policies aimed at improving the quality of care for individual patients and controlling the overall costs of health care for the government. Section 1202 of the ACA requires that Medicaid compensate primary care physicians at 100 percent of Medicare payment rates for a defined set of primary care services in 2013 and 2014. This provision is set to expire on Dec. 31, and all family physicians participating in the Medicaid program will see cuts -- dramatic cuts in many cases -- in their Medicaid payments.
Why is this provision so important? Because it takes the necessary steps to ensure that health care coverage is met with access to primary care physician services. In other words, it makes health insurance a tangible item for millions of Medicaid beneficiaries and not health care coverage in name only.
It's no secret that patients who have health care coverage and a usual source of care have better outcomes than those who lack one or both. It also is no secret that Medicaid, historically, has been an extremely poor payer.
For decades, states have decreased payments to physicians and other health care professionals as a means, in part, to finance more expansive benefit packages for beneficiaries. Physician participation rates reflect the low payment rates, and access to care for Medicaid patients has been challenging (or non-existent) in many areas of the country.
In the good news category, the ACA provision that increased Medicaid payment for primary care services has, apparently, single-handedly solved our nation's primary care shortage. It is amazing how many physicians are providing “primary care” to Medicaid patients and claim to deserve this bonus payment. If you listen to other physician organizations tell it, there are about 800,000 physicians providing primary care in the United States.
The AAFP agrees that a number of physician specialties provide some primary care services just as a large percentage of family physicians provide some cardiology services. The difference is family physicians don’t clamor to be called cardiologists. Just because a physician provides some “primary care services” does not mean that they provide continuous and comprehensive primary care – especially if their discipline ends in “ologist.”
According to Merriam Webster, “ologist” means “specialist.”
Mark Miller, Ph.D., executive director of the Medicare Payment Advisory Commission (MedPAC), was asked during a recent House Ways and Means Committee hearing about the inclusion of physicians who provide primary care services in incentive payment programs. His answer was aimed at the Medicare program, but it is completely applicable to the Medicaid payments and closely aligns with the AAFP’s views on the issue.
“There is great concern that the procedural side of the fee schedule is overvalued," he said. "If you go to the cognitive side there is concern that that is undervalued. … But if you have to pick priorities, and there’s limited amounts of dollars, then the commission’s point is: The first concern is the primary care sets of services. … So it’s not that the commission completely disagrees; it’s more a matter of priorities.”
Well stated, Dr. Miller. The AAFP shares these priorities, and we are working hard to ensure that this policy regarding Medicaid parity continues and allows millions of people to realize the goal articulated in the beginning of this article -- making sure that their health care coverage is met with access to care.
Since 2012, the AAFP has been working to build support for the extension of this important policy. This policy was a focal point of AAFP’s annual Family Medicine Congressional Congress, at which Academy members met with more than 115 Members of Congress and Senators to urge extension of the payment policy for at least two years. Additionally, we have partnered with other physician and patient advocacy organizations to form a coalition aimed at developing legislation that would extend the program and better define eligibility and covered services. In recent weeks, the AAFP has engaged with congressional staff to assist in the drafting of legislation that would extend Medicaid parity payments for at least two years. This process is far from complete, and there is much work to do, but we are pleased that there is movement.
Here is what needs to happen to successfully extend this program. First, we have to articulate to legislators and congressional staff why this program should be limited to true primary care physicians trained in comprehensive primary care. AAFP staff and leaders will handle this task. Second, we need to demonstrate the impact this policy is having on patients and physicians, and this is an area where family physicians can make a big difference in our advocacy efforts. We need your assistance. The AAFP is collecting information on how increased Medicaid payments are improving patient access to primary care services. Your stories can enhance the Academy's advocacy efforts. Please visit our Speak Out page and submit your story by Aug. 1.
We are No. 11! The Commonwealth Fund has released “Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally.”
So, how did we do? According to the report, “Among the 11 nations studied in this report -- Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States -- the U.S. ranks last, as it did in the 2010, 2007, 2006 and 2004 editions of Mirror, Mirror.” It is worth noting that countries that prioritize primary care tend to be at the top of this list.
Is Direct Primary Care Right for You?
I want to welcome you to In the Trenches, a blog devoted to providing family physicians timely information on health policy matters, the work being done on your behalf by the AAFP and insights into the advocacy and political activities that drive our national health care debate.
I promise this will not be your typical advocacy newsletter. I will focus on providing inside information on what the AAFP is doing to advance family medicine in public and private health care systems. This blog will be informative, deliver a perspective not found in other mediums and will include a healthy dose of commentary on those things that drive debate behind the scenes. Additionally, we will tap the inner health policy wonk in each of you by providing analysis and perspective on emerging issues that will drive the next generation of health policy.
Disruptive Innovation in Family Medicine
The AAFP has a distinguished history of driving innovation in health care. We are, as you recall, the organization that started a national discussion around “advanced primary care” and the need to transform our nation’s health care system and make primary care its foundation. Although this effort manifested itself through the patient-centered medical home (PCMH) during the past decade, the PCMH is not the only innovative delivery and/or payment model supported by the AAFP.
If you aren't already familiar, let me introduce you to a concept gaining strong interest among family physicians, policy-makers, business and -- most importantly -- patients: direct primary care (DPC). The AAFP views the DPC model as a significant and positive contributor to expanding access to primary care for millions of patients, improving the quality of care provided by family physicians, and increasing patient and physician satisfaction. In 2013, the AAFP Congress of Delegates approved an official policy on DPC.
In recent months, the AAFP has amped up its advocacy efforts with respect to DPC. We have met with numerous insurance companies to convey our support for this model and demonstrate the cost-saving potential it presents by reducing downstream health care costs. The Academy also has reached out to policy-makers to educate them on this promising model of care.
For example, the AAFP will host a briefing for Senate health care staff this week to educate them on DPC. Additionally, the Robert Graham Center will host a primary care forum focusing on Disruptive Innovations in Primary Care. DPC will be prominently featured at this event.
Also this week, the AAFP will participate in the Direct Primary Care Summit, a program we are proudly sponsoring. Physicians from across the nation will gather in Washington, D.C., to discuss DPC and share information on this emerging practice model.
One of the driving factors in our interest in this innovative practice model is the shifting framework of health insurance. Since the enactment of the Patient Protection and Affordable Care Act, there has been an increase in the number of individuals who have high-deductible health insurance products -- many with deductibles greater than $4,000. This trend means more primary care, outside of the mandatory preventive services, will be provided on a cash basis. Therefore, patients will have responsibility for the cost of their health care, up to the deductible of their insurance plan, and physicians will have responsibility for collection.
DPC is well positioned to ensure that these patients have access to affordable primary care, while maintaining comprehensive insurance coverage through their high-deductible insurance plan. In addition, by creating a more direct relationship between physicians and patients, both parties are no longer obligated to deal with the complexities associated with insurance companies.
Before you label this as concierge care, please let me tell you why this is superior to concierge practices and why so many people are taking a hard look at this model as a contributor to improving access to primary care. Concierge care practices charge patients a monthly or annual fee for enhanced access to a physician or practice. Physicians participating in this delivery model have, in response, limited their panel to a select set of patients -- thus decreasing the overall capacity and effectiveness of the primary care system. Additionally, physicians in a concierge practice continue to bill their patients' insurance for services provided.
In comparison, DPC practices use a membership model where patients pay a reasonable, monthly fee for all their primary care services. Patients save on insurance premiums with a low-cost, wraparound policy to only cover subspecialists, hospitalization and catastrophic care.
The defining characteristic of a DPC practice is that it offers patients the full range of comprehensive primary services, including routine care, regular checkups, preventive care and care coordination in exchange for a flat, recurring fee. The most compelling case for DPC is it allows family physicians to do what they do best, care for their patients. Since physicians are no longer generating revenue solely on the basis of how many patients they see per day, many physicians in DPC practices report that they have significantly more time to spend with patients in face-to-face visits. To put it bluntly, this model is patient centered and genuinely affordable.
The AAFP has DPC resources available. Additionally, we are developing a comprehensive practice development program that will launch at AAFP Assembly in October in Washington to assist family physicians who are interested in this model. This resource will include toolkits and in-person education programs that will provide what you need to know as you evaluate this promising practice model.
Again, this model isn’t for everyone, and it does not replace the need for the PCMH and other advanced primary care practice models. It is, however, a model of care that is consistent with AAFP policies on advancing continuous and comprehensive primary care as the foundation of our health care system.
Castlight Health, a San Francisco-based company that works with employers on controlling health care costs, has released a new analysis on price variations in health care. Using claims data, Castlight found wide variations in what patients pay for a variety of health care services -- including primary care. For example, the cost of a routine primary care visit ranged from $95 in Miami to $251 in San Francisco. Price transparency is an emerging policy issue, and reducing the wide variations in health care prices is seen as a means of controlling overall costs. You can read the report online.
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