MIPS: A Primer on the New Payment Model
Most of you are well aware that Congress repealed the flawed sustainable growth rate (SGR) in 2015 through the enactment of the Medicare Access and CHIP Reauthorization Act (Public Law 114-10). However, many of you probably have asked the questions, "What now?" and "What does this mean for me and my practice?"
Although we should celebrate the elimination of the flawed SGR, the AAFP recognizes fully that the implementation of the new delivery and payment models outlined in MACRA will require a series of important decisions and actions by family physicians. To assist you and your practices, the AAFP is launching a concerted education effort aimed at providing information and resources on how this new law impacts you and your practice and how you can best position your practice for success under this new payment policy. We will be sharing information and resources on our MACRA resource web page.
MACRA established two distinct payment systems for physicians. Those two systems are the Merit-Based Incentive Payment System (MIPS) and the alternative payment model (APM) program. This post is focused on the MIPS system, but I will be writing about the APM in an upcoming post.
As noted in my previous post, the implementation of the new payment policies is set for 2019. However, the performance year that will determine your payments in 2019 will start as early as 2017. This means we have a lot of ground to cover in the next 12 months.
MIPS Performance Evaluation
The MIPS program, by design, is based on the fee-for-service model. However, the program deviates from current practices whereby all services are paid on the standard Medicare physician fee-schedule. The law incorporates and aligns the three current physician quality and performance improvement programs -- physician quality reporting system (PQRS), value-based modifier (VBM), and meaningful use (MU) -- into a single performance program. This new program will establish a single score on a per physician basis versus continuing the fragmented three-part performance evaluation and penalty programs that exists under current law.
The MIPS program creates a robust quality and performance improvement program that will evaluate and score physician performance in four distinct areas -- quality, resource utilization, meaningful use, and clinical practice improvement activities. Each of these activities is assigned a percentage of the total composite score as follows:
|Clinical Practice Improvement||15%||15%||15%|
A few observations on the valuation of the MIPS performance categories:
- The values for meaningful use and clinical practices improvement activities remain consistent while the value percentages for resource utilization increase during the three-year period.
- The law places an increasing emphasis on resource utilization over time. Note that the values for quality measurement decrease in proportion to the increases in the values for resource utilization.
- The law allows the HHS secretary to decrease the values for meaningful use and shift those values to other categories if it is determined that the proportion of physicians who are meaningful users of electronic health records is 75 percent or greater.
- Any physician who practices in a certified patient-centered medical home will receive the full 15 percent for the clinical practice improvement activity. The law does not define "certified" and the AAFP will be working to influence this definition as the law is implemented.
MIPS Payment Adjustments
The performance threshold is established annually based on the mean or median of the composite performance scores during the performance period. The law prohibits any type of look-back at existing programs as a means of establishing the initial performance threshold and instead defers this authority to the secretary of HHS for the first two performance years.
Once a physicians' composite score is determined, that score will be weighed against the performance threshold and a payment adjustment will be established for the next payment year. Physicians will receive positive, neutral, or negative payment adjustments up to the allowed percentages for the specific program year, which are outlined in the following chart:
|Maximum Positive Adjustment||+4%||+5%||+7%||+9%|
|Maximum Negative Adjustment||-4%||-5%||-7%||-9%|
A few observations on the MIPS payment adjustments:
- We anticipate that CMS will continue to use a two-year look back period to determine payments. This means that payments for 2019 will be based on performance in 2017. Payments in 2020 will be based on performance in 2018 and so on. The AAFP has serious concerns with the two-year look back period and will be advocating that this time frame be shortened significantly.
- MIPS adjustments are budget neutral, meaning that there will be equal numbers of positive and negative payment updates.
- Physicians scoring in the lowest quartile will automatically be adjusted down to the maximum penalty for the performance year. Physicians scoring at the threshold will receive no adjustment. Physicians scoring in the highest quartile are eligible for a potential positive payment adjustments up to the maximum outlined in the chart above. The highest performers will receive proportionally larger incentive payments, up to three times the maximum positive adjustment for the year.
- For years 2019-2024, the law establishes a $500 million bonus pool designed to provide additional incentives of up to 10 percent for "exceptional performers."
- Unfortunately, the law does not provide a definition of an "exceptional performer," so we will be working closely with CMS to establish this definition.
The law established three exemptions from participation in the MIPS program. Those exemptions are:
- The physician is participating in the Medicare program for the first time. Under this scenario, the physician is exempt from MIPS for the first year of Medicare participation.
- The physician is participating in an eligible alternative payment models and qualifies for incentive payments through that program.
- The physician does not see a large enough number of Medicare patients and falls below the established volume threshold for participation.
This is an initial introduction to the MIPS program. I understand that it will likely raise more questions than it answers, but that is a good thing. We need you to raise questions so we can develop materials and resources to assist you and your practice.
2016 Advocacy Agenda: Four Things to Know
Happy New Year! As the calendar turns from 2015 to 2016, it's important to outline priority issues and areas of focus for the AAFP heading into the New Year.
As noted in my last posting, 2016 is an election year. Modern history suggests that opportunities to accomplish major policy objectives in an election year are limited, but we believe this year may be different. We also know that we must approach our work with a greater sense of urgency due to the rapid changes that are coming.
To articulate this, I have decided to borrow a catchy phrase from Sesame Street to describe the AAFP’s advocacy outlook for 2016. So here goes: “The AAFP’s 2016 advocacy agenda is brought to you by the letters M and A.”
MACRA -- On April 16, 2015, President Obama signed into law the Medicare Access and Children’s Health Insurance Program Reauthorization Act (P.L. 114-10). The enactment of MACRA capped a 15-year effort to repeal the flawed sustainable growth rate (SGR) and set in motion reforms that will more appropriately support new delivery systems and establish a path away from fee-for-service. These new delivery and payment models have an opportunity to end decades of de-valuing primary care by appropriately compensating family physicians and financing the functions of an advanced primary care practices.
The major reform provisions of MACRA -- the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Models (APMs) -- will not be fully implemented until 2019. However, the regulatory framework must be developed during the next 12 to 18 months, meaning 2016 is going to be a busy year for CMS and the AAFP. The Academy outlined many of its views on the major issues in our response to a 2015 CMS request for information (RFI) on MACRA implementation.
I encourage you to familiarize yourself with the implementation timeline. It is important that you and your practice start thinking about how you will transition into one of the two payment pathways established by MACRA. The AAFP will be rolling out extensive content and resources during the next few months and will feature extensive education opportunities for family physicians.
You can access AAFP content on our MACRA resource web page. We also anticipate publishing extensive related content through Family Practice Management.
Meaningful Use -- The meaningful use program continues to be the most disliked regulation in existence and for good reasons. Family physicians have implemented electronic medical records at a significantly greater pace than physicians in other specialties. Family physicians also have demonstrated the value of EMRs in enhancing the quality of care provided to patients.
What continues to be a source of frustration is the complex set of regulations that have been developed and implemented through the meaningful use program. As a result of these frustrations, the AAFP has worked to aggressively reform the meaningful use program and eliminate physicians’ exposure to financial penalties that are associated with the program. I am pleased with the progress made in 2015, but more work needs to be done and we are getting some help from a surprising source.
In late December, Congress passed and the President enacted into law, legislation that will provide a hardship exemption from meaningful use stage 2 requirements for qualifying physicians. CMS has, at the time of this posting, not published the guidelines for how physicians can participate in the hardship program. Once this information is available, the AAFP will use multiple communication platforms to share the details with you to ensure that those who wish to seek the hardship exemption have the necessary information to do so.
On Jan. 12, CMS Acting Administrator Andy Slavitt, in a presentation at the JP Morgan Healthcare Conference, pleasantly surprised (totally shocked) the physician community when he publically stated that the meaningful use program may have “met its goals and served its usefulness,” and should be "replaced with something better."
He essentially announced the coming end of the meaningful use program when he said that the "meaningful use program as it has existed will now be effectively over and replaced with something better.”
Obviously the details matter, but the AAFP is pleased that our advocacy efforts have resulted in positive action on the part of Congress and CMS.
On that same day, the AAFP wrote to Slavitt, outlining a set of recommendations on how CMS should pursue revisions to the program. Among those recommendations, we prioritize the need to accelerate robust interoperability to support continuity of care and care coordination, the elimination of burdensome requirements on practices that detract resources away from patient care, and alignment of the numerous regulations governing patient care.
A is for Administrative Complexity and Alignment
Administrative Complexity -- Last year I wrote a posting on “Whacking the WAC.” The time and energy devoted to the administrative functions of a family medicine practice continues to be daunting if not overwhelming. The most frustrating aspect of this issue is few of the administrative functions required of family physicians have any measurable impact on the quality of care received by patients. Multiple surveys and studies have placed the overall time allotted to administrative functions at 15 percent to 17 percent for most physicians.
This is an astonishing allocation of time both from the perspective of meeting administrative requirements, but also the loss of patient care time that results from these administrative requirements.
The so-called “work after clinic” is a major contributor to physician burnout and, unfortunately, leads many physicians to make career decisions that may not be aligned with their personal and professional goals.
It also contributes to the belief that the intensity of work in primary care is not appropriately compensated by payers. To be blunt, the 15-minute office visit is really a 20-minute visit that is compensated at 15 minutes. This is what is inherently unfair about the system and why we are dedicated to reducing administrative complexity.
Alignment -- One of the greatest frustrations expressed by family physicians is the variation in quality and performance measures used by public and private health care payers. Physicians also express frustrations about the lack of congruency in the definitions and execution of delivery system programs such as the medical home or chronic care management programs. This frustration is completely understandable given that family physicians have such a diverse set of payers.
According to research conducted by the AAFP, 61 percent of family physicians have contractual relationships with seven or more payers, and 38 percent have relationships with 10 or more.
The AAFP places a high priority on this work. We continue efforts to educate and influence the commercial insurance plans through meetings and continuous communications with the leadership of these companies.
We also have a meaningful working relationship with America’s Health Insurance Plans (AHIP), which has allowed us to advance policy recommendations that would achieve some level of alignment between payers. We are optimistic that this work with AHIP will be rewarded through the adoption and implementation of a “core (quality) measure set” for primary care. If this comes to fruition, then family physicians would have a single set of quality measures that would be reported to Medicare and all commercial insurers.
I can assure you that this isn’t a comprehensive list of issues that we will be working on this year. This list does not include many priority issues. However, this is a solid summary of the major opportunities and challenges we see in family medicine. Nothing, and I mean nothing, is more pressing than these four issues. I look forward to engaging with you during the next year, and I remind you that your comments and feedback make our work better and more impactful for you and your practice. So, keep them coming.
2016 Election: Dates to Remember
"In this country people don’t vote for, they vote against.” -- Will Rogers
Happy New Year! As a good Oklahoman, I always feel it is appropriate to frame any conversation about elections and politics with a quote from the most famous Oklahoman, Will Rogers. Rogers, who was a newspaper columnist and social commentator as well as a cowboy, vaudeville performer and actor, had a deep respect for our democracy and a healthy skepticism for those that were elected to serve it. He also viewed the responsibility of voting as one of the most important rights granted to any citizen.
This year, you will have an opportunity to exercise this right on at least two occasions -- during your state's primary elections or caucus and on Election Day.
On Nov. 8, we, as a country, will elect a new president and vice president, 435 U.S. Representatives, 34 U.S. Senators, and 12 governors. In addition, the occupants of hundreds of state and local elected positions will be determined.
Unless you live a life free of communication with the outside world, you are probably well aware that the 2016 presidential election process is already well underway. There are 13 Republicans and three Democrats seeking their parties’ nominations. The two nominees will be determined through a series of primary elections and caucuses that begin on Feb. 1 with the Iowa caucuses.
While Iowa has the distinction of being the first in the nation, to vote, the state has an up-and-down record when it comes to picking the ultimate nominee so don’t rush out and buy your bumper stickers on Feb. 2.
And don’t tell Iowa, New Hampshire, or South Carolina, but there are really two key dates on the primary calendar that don't involve those early voting states -- March 1 and March 15. March 1 is Super Tuesday, a date when 13 states hold their primary elections, the largest number of states on any single day in the election cycle. This year Super Tuesday’s importance is amplified because it includes Texas, a state that will have tremendous influence over the Republican nomination process.
March 15 is probably the most significant day because it features elections in Florida, Illinois, Missouri, North Carolina, and Ohio. It is difficult to be elected president if you do not win Florida and Ohio. Those swing states represent 29 and 18 electoral votes, respectively.
A complete listing of the primary schedule is below for your reference.
Once the two parties have completed the primary process, they will convene for the nominating conventions. The Republican National Convention will be held July 18-21 in Cleveland, followed by the Democratic National Convention July 25-28 in Philadelphia. At the conclusion of the conventions, the real fun starts with the general election.
The general election is a 100-day sprint to the finish line featuring four debates, hundreds of millions in campaign advertisements, and more political commentary than any person should be asked to endure.
The presidential debates are always important opportunities to measure the candidates against each other, so I would encourage you to watch. To assist you with your scheduling or DVR programming, the debates will be Sept. 26, Oct. 9, and Oct. 19. The vice presidential debate will be Oct. 4.
While the AAFP and FamMedPAC do not participate in presidential politics, we do participate in House and Senate races. Our involvement in the election and re-election of members of Congress is an important component of our multi-faceted advocacy program. Advocacy takes three forms: grassroots advocacy, professional lobbying, and political advocacy. Seldom do I ask things of you in this blog, but I do encourage you to support FamMedPAC. Your support allows family medicine to be better represented and therefore more impactful in our political advocacy efforts.
FamMedPac is nonpartisan in its support. We look at where candidates stand on issues that affect family medicine rather than at party affiliations. We work to elect -- and re-elect -- legislators who are willing to work with the Academy on those issues.
2016 Primary Schedule
- Feb. 1 -- Iowa caucuses
- Feb. 9 -- New Hampshire
- Feb. 20 -- Nevada Democratic Caucus, South Carolina Republican Primary, Washington Republican Caucus
- Feb. 23 -- Nevada Republican Caucus
- Feb. 27 -- South Carolina Democratic Primary
- March 1 -- Super Tuesday (Alabama, Arkansas, Colorado, Georgia, Massachusetts, Minnesota Caucus, North Dakota Republican Caucus, Oklahoma, Tennessee, Texas, Vermont, Virginia, Wyoming Republican Caucus)
- March 5 -- Kansas, Kentucky Republican Caucus, Louisiana, Maine Republican Caucus, Nebraska Democratic Caucus
- March 6 -- Maine Democratic Caucus
- March 8 -- Hawaii Republican Caucus, Idaho Republican Primary, Michigan, Mississippi
- March 15 -- Florida, Illinois, Missouri, North Carolina, Ohio
- March 22 -- Arizona, Idaho Democratic Caucus, Utah
- March 26 -- Alaska Democratic Caucus, Hawaii Democratic Caucus, Washington Democratic Caucus
- April 5 -- Wisconsin
- April 9 -- Wyoming Democratic Caucus
- April 19 -- New York
- April 26 -- Connecticut, Delaware, Maryland, Pennsylvania, Rhode Island
- May 3 -- Indiana
- May 10 -- Nebraska Republican Primary, West Virginia
- May 17 -- Kentucky Democratic Primary, Oregon
- May 24 -- Washington Republican Primary
- June 7 -- California, Montana, New Jersey, New Mexico, North Dakota Democratic Caucus, South Dakota
- June 14 -- District of Columbia
- Aug. 16 -- Alaska
Meaningful Use Hardship Extended
On Dec. 18, the House and Senate approved the “Patient Access and Medicare Protection Act” (S. 2425). This legislation included a provision granting CMS the authority to expedite applications for hardship exemptions from meaningful use stage 2 requirements for the 2015 calendar year.
Under current law, physicians were required to attest that they met the requirements for MU stage 2 for 90 consecutive days or face financial penalties. However, CMS failed to publish the modifications rule for stage until October 16, which failed to provide adequate time for all physicians to comply with the modified attestation requirement.
CMS has previously stated that it will grant hardship exemptions for 2015 if eligible providers are unable to attest due to the lateness of the rule. However, under current law, CMS can only grant such exemptions on a case-by-case basis. This case-by-case requirement would essentially prevent hundreds of physicians from gaining the hardship exemption.
A provision of S. 2425 grants CMS the authority to process requests for hardship exemptions to physicians through a more streamlined process, alleviating burdensome administrative issues for both providers and the agency. Physicians seeking a hardship exemption must apply prior to March 15. The AAFP will be working closely with CMS on the hardship process and will distribute information as soon as it is available.
Poll: Drug Costs Top List of Public's Health Care Concerns
Prescription drugs have emerged as one of the leading health policy issues for the 2016 election. Regardless of party affiliation, polling shows growing concerns about the costs and availability of pharmaceutical and biologic treatments.
An October Kaiser Family Foundation Health Tracking Poll found that the public's top two health care priorities for the president and Congress were:
- making sure that high-cost drugs for chronic conditions, such as HIV, hepatitis, mental illness and cancer, are affordable to those who need them; and
- government action to lower prescription drug prices.
Concern about medications for chronic conditions was mentioned by 77 percent of respondents (85 percent of Democrats, 75 percent of independents and 73 percent of Republicans), while the need for government action was cited by 64 percent (74 percent of Democrats, 60 percent of independents and 56 percent of Republicans).
It is interesting that 56 percent of Republicans think that the government -- yes, the government -- should take action to lower prescription drug prices. The bipartisan concerns demonstrate why the issue of prescription drug access and pricing has emerged as such a dominant political issue.
The contributions of the pharmaceutical industry to our country and the world are countless and indisputable. As a result of pharmaceutical and biologics we have eradicated diseases, turned what were once fatal diagnosis into chronic conditions, improved the quality of life for millions, and provided hope to those who face the most daunting challenges of their life. At this time of year, millions of people will be able to gather with their families for the holidays because of a pharmaceutical intervention. We cannot and should not overlook the value pharmaceuticals and biologics play in the delivery of health care.
We also should not overlook the simple fact that many pharmaceutical treatments are out-of-reach for a growing portion of the population -- even if they have insurance. Family physician Kyle Jones, M.D., recently wrote a blog on this specific issue and how costs of pharmaceuticals are hindering his patient population. We also should not overlook the impact escalating pharmaceutical costs are having on purchasers of health care, whether they are individuals, employers or governments.
The true costs of pharmaceuticals to individuals, employers, and government programs are honestly impossible to determine due to the variation in deductibles, co-pays, formularies, and other policies that influence the negotiated price of some products. However, it is possible to determine how much of the overall health care spend is devoted to pharmaceuticals and, not surprising, it is sky-rocketing. The CMS Office of the Actuary, in its recent report on health care spending, determined that increased costs associated with prescription drugs were a major driver of the overall increase in health care costs from 2013 to 2014. This impact was also outlined in a recent Wall Street Journal article, which showed spending on pharmaceuticals represents 10 percent of total health care costs.
The same article showed that pharmaceutical costs represent 19 percent of the costs for employers in their health insurance programs. To put this in perspective, the article notes that in-patient hospital care represents 23 percent of total costs for employers.
Finally, the impact on government health care programs is alarming. According to the Medicaid and CHIP Payment and Access Commission, (MACPAC) spending on pharmaceuticals in the Medicaid program increased 14.1 percent between 2013 and 2014 in non-expansion states and an alarming 24.6 percent in expansion states. MACPAC also found that significant increases in the costs of generic drugs.
The factors that determine the costs of pharmaceutical products are numerous and complicated. It is irresponsible to think that the costs are a simple factor of corporate executives maximizing return-on-investment. Well, for one executive that is exactly what they are doing (see Shkreli, Martin) but for the rest of the industry there are many factors that influence price with profit being one of those factors. Pharmaceutical companies may not always be pure of heart in the minds of some, but they do have to operate inside a complex and intertwined set of regulations and manufacturing standards -- which increase costs of production. They also must generate capital that can be invested in the next generation of pharmaceutical and biologic products. Without some level of profit, the ability to conduct research and development is limited, which results in a decrease in new discovery and new products.
One of the leading "cost-drivers" that continues to draw criticism is direct-to-consumer (DTC) advertising. DTC has always drawn the ire of some physicians, and it is rapidly becoming a policy issue that is drawing increased scrutiny from consumer advocates, physicians, and policymakers. According to Kantar Media, the industry spent $4.5 billion on DTC in the past year and has increased its DTC spend by more than 30 percent in the past two years.
The AAFP policy on DTC reflects the complexity of the issue. Our policy states that, "The AAFP supports efforts by manufacturers … to provide general health information to the public. At the same time, the AAFP urges that any direct-to-consumer advertising of prescription drugs … be based on disease state only, without mention of a specific drug by name." In other words, we see value in raising awareness, but we see detriment in traditional advertising tactics that drive consumer consumption.
Despite a high level of scrutiny, most legal experts believe that legal precedent has determined that such advertisements are protected speech and any such ban would violate the First Amendment. However, at the recent AMA Interim Meeting, a resolution calling for an outright ban on DTC passed with overwhelming support. The AAFP delegation, during reference committee deliberations, discussed the value of DTC in raising awareness among patients and caregivers, but in the end agreed with the intent of the resolution and supported its passage.
Although it may not be legal to ban DTC outright, there are examples of how DTC advertising is regulated in a manner that is adherent to the First Amendment, yet mindful of social responsibility. The most prominent examples are tobacco, firearms and alcohol. Each of these industries is allowed to advertise their products, but they all face restrictions on how, when and where they are allowed to do so. I would suggest that this model of regulation may have some applicability to the pharmaceutical industry.
Policymakers have proposed a variety of solutions to this issue ranging from allowing the federal government to negotiate prices in the Medicare program -- as it does in the VA and DOD programs -- to allowing the importation of drugs from Canada and other countries. There also is an increased focus on the appropriateness of one treatment versus the others, largely being driven by comparative-effectiveness research. Each of these solutions has merit, and they all face political challenges. The one thing that seems certain is that people are paying attention to the issue and are eager to identify ways to lessen the economic impact on individuals and payers. How remains unclear.
This is my last posting of 2015. As we conclude the year, I wanted to acknowledge the talented and hardworking staff at the AAFP. They work tirelessly and selflessly to make the health care system a better place for patients and for you, our members. I am proud to be their colleague and to have the opportunity to share with each of you their amazing work. So on behalf of the entire AAFP team, I wish each of you a happy holiday season and a healthy and prosperous New Year. 2016 will be a busy year! Rumor has it we get to elect a president!
Barriers Hindering Use of Telemedicine
The Jan. 17, 1960 edition of the comic strip Our New Age by Athelstan Spilhaus provided a glimpse into the future of technology in health care -- at least as envisioned by the scientist.
Although the comic strip did not coin the term "telemedicine," it did portray a future where a patient might have an encounter with a physician who was not physically present in the room with the patient. The comic strip reflects the country's fascination with science that existed in the 1960s, but interestingly, it does accurately capture a scenario where a patient receives a diagnosis and treatment plan from a physician without actually being physically seen by the physician. Today, we refer to this type of patient-physician interaction as telemedicine.
Historically, telemedicine has been viewed as a modality that could extend health care services to rural and frontier communities. This led to telemedicine primarily being used in one of three ways: remote monitoring, store-and-forward digital imaging evaluation, and consultation with specialty physicians. During the past decade, as technology has become more readily available and inexpensive, interest in expanding the use of telemedicine and other digital health platforms has grown among both patients and physicians. This increase in interest has led to corresponding increased interest among policymakers, payers, and regulatory agencies about how to regulate and compensate telemedicine in an evolving health care system.
The AAFP first established policy on telemedicine in 1994. This policy was modified and reaffirmed by the Congress of Delegates in 2010 and 2015. It reflects the value of telemedicine as a means of extending timely access to physicians, especially for those in underserved or rural communities. The policy also reflects concerns about the appropriate and ethical use of telemedicine and ensuring that telemedicine does not supplant a continuous relationship with a family physician.
The policy also expresses our strong support for adequate payment.
Sensing the growing interest in telemedicine, the AAFP's Robert Graham Center for Policy Studies in Family Medicine and Primary Care opened a research portfolio on the issue. During the past two years, the Graham Center has engaged in a comprehensive analysis of the views and opinions of family physicians about telehealth and telemedicine. The project, conducted through a funding partnership with Anthem, produced a report entitled: “Family Physicians and Telehealth: Findings from a National Survey.”
Here are the key findings of the report:
- Fifteen percent of family physicians have used telehealth in the past 12 months. The most frequent users were isolated rural practices (29 percent as compared to 11 percent in urban settings).
- Family physicians that use telehealth are more likely to practice in a rural location, be younger, have practiced for 10 or fewer years, and employ an electronic health record.
- Among users, the most common clinical uses were for diagnosis and treatment (55 percent), chronic disease management (26 percent) and follow-up with patients (21 percent).
- Barriers to using telehealth include the cost of equipment, lack of training, and the lack of payment for such services.
- There were some differences in opinions among users and non-users of telehealth. Specifically, 89 percent of users agreed that telehealth improves access for patients while 77 percent of non-users felt this was true. The most substantive differences between users and non-users were associated with patient preferences. When asked if patients prefer to see a physician in person, 94 percent of non-users said yes, while only 82 percent of users agreed with this statement.
- More than 85 percent of all respondents (users and non-users) agreed that they would use telehealth if they were adequately paid for such services.
The report summarizes the analysis as follows: "Overall, the findings of this survey confirm that family physicians see promise in the ability of telehealth to improve access to primary care services. The findings also suggest that telehealth is on the cusp of advancing from a tool used occasionally to a tool implemented on a routine basis. However, use of telehealth services will not become widely adopted until health systems are reformed to address barriers."
The Graham Center and Anthem recently received a Robert Wood Johnson Foundation grant to extend their collaboration and research on telemedicine. Results from this second study will be published in spring 2017 .
On Dec. 2, CMS released the 2014 National Health Expenditure Accounts. According to this report, in 2014, health care spending increased 5.3 percent breaking a five-year trend of lower than expected spending growth. Total spending on health care now exceeds $3 trillion and represents 17.5 percent of the gross domestic product. Per capita spending increased 4.5 percent to $9,523. Pharmaceutical spending increased 12.2 percent in 2014 accounting for $297.7 billion in total spend. Hospital spending increased 4.1 percent accounting for 971.8 billion in 2014, and physician and clinical services increased 4.6 percent accounting for $603.7 billion in total spends.
Although the spending numbers will garner the most attention, we should not overlook the fact that the number of uninsured individuals fell by 8.7 million, a decline of 19.5 percent. The percentage of the population that is insured now sits at 88.8 percent, the highest percentage since 1987.
Maximizing MACRA for Family Medicine
"The pen is mightier than the sword." – English writer and politician Edward Bulwer-Lytton, 1839
In the past two weeks, the AAFP has submitted more than 60 pages of comments and recommendations on the delivery system and physician payment reforms outlined in the Medicare Access and CHIP Reauthorization Act (MACRA) (Public Law 114-10). Optimistic that the phrase made famous by Bulwer-Lytton 176 years ago still holds true, the Academy is exercising its "pen" to influence the implementation of MACRA in a manner that best benefits family physicians and their patients.
On Nov. 9, the AAFP responded to CMS’ request for information regarding the Merit-Based Incentive Payment System, Promotion of Alternative Payment Models, and Incentive Payments for Participation in Eligible Alternative Payment Models. The AAFP’s 53-page response responds directly to the 126 questions in the RFI.
On Nov. 19, the AAFP responded to the Alternative Payment Model Framework Draft White Paper published by the Health Care Payment Learning and Action Network (HCPLAN), a group assembled by CMS to assist with MACRA implementation .
MACRA was signed into law April 16, bringing to a close the 13-year drama that was the sustainable growth rate (SGR). Repealing the SGR was a significant accomplishment that created an environment whereby we can begin the transition away from episodic and fragmented delivery and payment models towards those that promote continuity, coordination and connectivity. MACRA represents the future -- albeit a somewhat confusing future.
The transition from legislation to regulation is one of the most important processes in government. It also is the arena where the AAFP must perform at the highest level on behalf of our members. We take the regulatory process very seriously. The emphasis we are placing on the implementation of MACRA is driven by our desire to realize the full potential of delivery and payment system reform and our understanding that MACRA refers decisions to the secretary of HHS more than 100 times.
The AAFP response to both documents advance the importance of increasing the overall investment in primary care and not building new delivery and payment models on the biased and inaccurate relative value data used in the fee-for-service system. Our letters strongly recommended that CMS and private payers do more to ensure that Medicare and all other public and private programs pay appropriately for primary care physician services. Appropriate, obviously, means more than current levels.
To achieve this goal, the AAFP urged CMS to use its authority and take administrative actions to increase the values of primary care services in the Medicare program. Additionally, the AAFP outlined a comprehensive payment proposal that would move a larger percentage of payments from the traditional fee-for-service model toward alternative payment models. With respect to primary care, the AAFP proposes that payments for primary care services under this advanced primary care delivery model be made on a per-patient basis through the combination of a global payment for direct patient care services and a global care management fee.
Our letters also raised concerns about several barriers that may prohibit successful participation in the new payment models. The most significant barrier is the poorly designed meaningful use program and its lack of interoperability standards, which prohibit the sharing of patient information. Family physicians continue to face significant challenges with their EHRs and meeting meaningful use standards. Until this program is improved and the EHR issues are resolved, it is difficult to foresee a large percentage of physicians -- particularly physicians in small and independent practices -- being successful in MACRA programs.
We continued our advocacy aimed at encouraging CMS to use the Joint Principles of the Patient-Centered Medical Home and the key functions of the Comprehensive Primary Care (CPC) initiative as criteria for determining what constitutes a medical home. The Joint Principles, when aligned with the five key functions of the CPC initiative, capture the true definition of a PCMH and its performance thresholds. The AAFP clearly states in multiple places that we do not believe a physician should be required to pay a third party to secure the PCMH recognition necessary to participate in a Medicare program.
Finally, we strongly urged CMS to streamline, harmonize and reduce the complexity of quality reporting in the MIPS and APM programs. Out letters outline a vision for quality improvement programs that promote continuous quality improvement and measure patient experiences. The AAFP expresses opposition to any approach that requires physicians to report on a complex set of measures that do not impact or influence the quality of care provided to patients. Instead, we suggest that all measures used must be clinically relevant, harmonized among all public and private payers and be submitted in a manner that is minimally burdensome on physicians.
Our letter offers recommendations on numerous additional topics, but the above information captures the major themes. Clearly, the implementation of MACRA will be a major undertaking, and the AAFP is committed to influencing this process in a manner that benefits family physicians and their patients. This undertaking will not be easy, but our team is capable and ready. I encourage you to follow our work on your behalf on our MACRA resource webpage.
I anticipate that many of you are prepared to utilize your "pen" to communicate your views on MACRA and the choices family physicians face in the next few years. I look forward to your comments, thoughts, and suggestions. More importantly, I look forward to learning from you and your experiences so that we can better serve you and your practice.
The IMS Institute for Healthcare Informatics has released a new report, Global Medicines Use in 2020: Outlook and Implications that project global spending on pharmaceutical products will increase 30 percent by 2020, resulting in a global spend of $1.3 trillion. The report notes that the spending will be driven by expensive new drugs, price hikes for existing drugs, increased use of generic drugs in developing countries and an aging population. IMS projects that, by 2020, annual use of medicine will hit 4.5 trillion doses, up 24 percent from this year. Additionally, the report projects that more than half of the world’s population -- currently 7.6 billion -- will be taking more than one medicine dose per day. Finally, IMS projects that roughly 90 percent of U.S. prescriptions dispensed in 2020 will be for generic products.
Beat the PQRS Deadline, Avoid 2 Percent Medicare Cut
CMS has announced that it is extending the 2014 informal review period for the Physician Quality Reporting System to Nov. 23. The previous deadline had been Nov. 9. All physicians who participate in the Medicare fee-for-service program, the Comprehensive Primary Care Initiative, PQRS group practice reporting option, or an accountable care organization are required to report quality measures through the PQRS program.
Starting in 2016, physicians who did not report quality measures in 2014 face a negative 2 percent payment adjustment on all Medicare services. If you are uncertain about your status with respect to the 2014 PQRS reporting year, the AAFP encourages you to contact CMS and initiate an informal review. All informal review requests must be submitted electronically via the Quality Reporting Communication Support Page (CSP) by 11:59 p.m. Eastern on Nov. 23. According to CMS, all informal review requestors will be contacted via email with a final decision within 90 days of the original request.
The PQRS program, established by the Tax Relief and Health Care Act of 2006 and signed into law by President George W. Bush on Dec. 20, 2006, requires physicians participating in Medicare to submit quality data to CMS. The program initially provided positive payment incentives, but starting this year penalties were implemented. The negative 2 percent payment adjustment being implemented in 2016 will remain in effect until the PQRS program is revised by the Merit-Based Incentive Payment System, established by the Medicare Access and CHIP Reauthorization Act.
The AAFP has extensive PQRS resources that can assist you. Family Practice Management also has information that you may find beneficial. You may also wish to review CMS’s 2014 Physician Quality Reporting System (PQRS): Incentive Eligibility & 2016 Negative Payment Adjustment -- Informal Review Made Simple. Finally, you can contact the CMS QualityNet Help Desk at 1-866-288-8912 (TTY 1-877-715-6222) or Qnetsupport@hcqis.org Monday through Friday from 7 a.m. to 7 p.m. Central.
On Oct. 29, Paul Ryan, R-Wis., was sworn in as the 54th speaker of the House of Representatives. He was elected to the position by the full House following the retirement of Speaker John Boehner, R-Ohio. Ryan, who was the Republican candidate for vice president in 2012, was first elected to the House in 1998 at the age of 28. He is a former chairman of the House Budget Committee and was most recently chairman of the powerful House Ways and Means Committee. He is the co-author of the Bipartisan Budget Act of 2013, better known as the Ryan-Murray. This legislation averted a sustained financial crisis and looming government shutdown -- scenarios he once again faces as the new speaker.
On Nov. 4, the Kevin Brady, R-Texas, was selected to replace Ryan as the chairman of the House Ways and Means Committee. Congressman Brady was previously chairman of the committee’s Subcommittee on Health.
BMJ has published a new report entitled “Physician Spending and Subsequent Risk of Malpractice Claims: Observational Study.” The authors examined the long-standing issue of the relationship between medical liability claims against physicians and defensive medicine. They note that, “Despite widespread agreement that physicians practice defensive medicine to reduce malpractice liability, there are no studies of whether greater resource use by physicians, whether it is defensively motivated or not, is associated with reduced claims for malpractice. This lack of evidence is surprising, given that defensive medicine is premised on greater resource use reducing malpractice liability.”
So what did the researchers find? Well, defensive medicine likely grew due to the simple fact that it may actually work. According to the findings, “in six of seven specialties, we found that greater resource use was associated with statistically significantly lower subsequent rates of alleged malpractice incidents.”
The authors note that this study has limitations, but the findings have important policy implications. In an era where the costs of health care are front of mind for individuals and policy-makers, it may be time to place greater emphasis on medical liability reform as a means of managing escalating costs.
Whack the 'WAC'
How many of you can relate to this statement? "I am self-employed, but I work for the government and insurance companies."
This is a common refrain from physicians in all specialties, but it is an especially frequent complaint among family physicians. The administrative burden on family physicians is mind boggling. A majority of family physicians have contractual relationships with seven or more payers. That means there are seven different prior authorization forms, seven different quality reporting systems, seven different prescribing formularies, seven different appropriate use programs, seven different … Well, you get the idea.
Family physicians not only hate red tape, but there is growing evidence that it contributes to lower quality of care and is a major driver of physician burnout.
Have you ever experienced a sequence of events that crystalizes an issue for you? This happened to me earlier this month through a conversation with a family physician from rural North Carolina, a comment by an AAFP member from California, and a statement by a prominent author -- all driving home the same point -- the administrative burden on physicians is a HUGE problem.
This sequence of events started with a phone conversation I had with a family physician in North Carolina who is in a solo practice in a rural community. "You just have no idea how hard it is to take care of my patients," he told me. The thing that caught my attention was the fact that he wasn't complaining about the time, money, or the hassle on him or his staff; his concern was the red tape preventing him from taking care of his patients.
That conversation was followed by a conversation with a member from California who, during a large meeting, stated that physicians are tired of the "WAC." I was not familiar with that term, so I did what any inquisitive person would do. I shouted out, "What is the WAC?" He responded, "Work after clinic." This physician said that the volumes of administrative activity that require physicians to spend hours working after seeing patients was hurting patient care and destroying the love of practice among family physicians. He said that the AAFP needed to help physicians "whack the WAC."
The third and final event in this sequence was a paragraph in the closing chapter of Steven Brill's latest book, "America's Bitter Pill," which reads as follows:
"We should recognize that the quality of medical care is going to continue to be jeopardized by the broken economics of the marketplace, which provides rich incentives to everyone except those actually treating all of these newly covered patients. As doctors remain bogged down in paperwork and face mounting business pressures, the portion of our best and brightest who want to care for the sick instead of cashing in on the business of healthcare is likely to drop.”
Administrative simplification is something that has been a priority for the AAFP for many years. AAFP resources on administrative simplification say, in part, "The AAFP is determined to help family physicians reduce these roadblocks by identifying and eliminating regulations and processes that add cost while undermining the efficient and effective delivery of quality care."
In addition, we have pursued extensive advocacy initiatives aimed at reducing the administrative burden associated with Medicare and Medicaid. These efforts include establishing a core set of primary care quality measures that would be used by all payers, including Medicare. We also continue to press CMS and commercial insurers to forgo the implementation of complex prior authorization and appropriate use programs that delay access to care for patients and add to the “WAC.”
The most meaningful and important work we are doing to "whack the WAC" is our aggressive efforts to delay and reform the flawed meaningful use program. Last week, CMS and the Office of the National Coordinator for Health Information Technology (ONC) advanced meaningful use (MU) stage three regulations despite widespread criticism from the AAFP and other physician organizations.
In 2009, Congress passed the HITECH Act. This law instructed CMS and ONC to establish a program that would result in the adoption and implementation of electronic health records among physicians, hospitals, and other health care providers. It also instructed ONC to establish a standard for the interoperability of those EHR products. The legislation did not instruct CMS and ONC to create a complex, three-phase regulatory framework that would add layers of administrative complexity on physicians and throw cold water on any enthusiasm that existed among physicians to implement EHRs in their practices, yet this is exactly what has happened.
Only 10 percent of physicians have attested to MU stage two, and 43 percent of physicians face penalties in 2015. It is unacceptable and unreasonable to impose further punishments on physicians when more time and evaluation of the MU program is clearly needed. The AAFP strongly supports Congress' efforts to transition our health care system from paper-based to electronic health records, however, current MU regulations place unnecessary administrative and financial burdens on family physicians, favor software vendors over physicians and patients, and do little to improve the quality of care we provide.
Are you tired of inputting meaningless data into your patient records simply to comply with a regulation and avoid a financial penalty on your practice? Are you tired of your EHR working for vendors and failing to work for you and your patients? It is time to "whack the WAC," and let's start with the meaningful use stage 3 regulations. Use the AAFP's Speak Out resources and tell your representative and senators to pause the implementation of the stage 3 MU regulation.
Support the Primary Care Caucus
A congressional caucus is a group of legislators that meets to pursue common objectives. Formally, caucuses are formed as congressional member organizations (CMOs) through the U.S. House of Representatives and governed under the rules of that chamber.
There are more than 100 Congressional Caucuses, and there already are several pertaining to health care -- including the Arthritis Caucus, the Academic Medicine Caucus, the Rural Health Caucus, the Disability Caucus and the Affordable Medicine Caucus. Then there is the always important Bourbon and Wine Caucuses and -- my favorite -- the Internet of Things Caucus.
Throughout history, however, there has never been a congressional caucus devoted to primary care. On Oct. 8, that changed.
I am pleased to inform you that Rep. David Rouzer (R-N.C.) and Congressman Joe Courtney (D-Conn.) have launched the Bipartisan Congressional Primary Care Caucus. The AAFP was honored to participate in the formal launch, which took place as part of a Congressional briefing entitled “The Impact of Primary Care on Rural and Urban Underserved Communities.” In addition to the events on Oct. 8, Rouzer and Courtney recorded a video message announcing the formation of the Primary Care Caucus and outlining their motivations.
The formation of the Primary Care Caucus is a significant and important development for the AAFP and primary care. The AAFP strongly supports the Primary Care Caucus and applauds Rouzer and Courtney for their leadership. We are excited to partner with the caucus to inform and educate members of Congress and the public on issues of importance to family medicine and primary care.
The AAFP has launched a Speak Out campaign aimed at encouraging other members of Congress to join and support the Caucus. You can learn more about the caucus and send a letter to your representative urging them to join by using Speak Out. Also, follow the activities of the caucus on Twitter using #PrimaryCareCaucus.
On Oct. 1, physicians and other health care providers were required to convert their billing systems from ICD-9 to ICD-10. The AAFP is carefully monitoring the situation and we are eager to learn how your practice is handling the transition and if you are having any challenges. You can submit your feedback through our practice management resource page. Information you provide will assist the AAFP in our advocacy on your behalf
The Commonwealth Fund has released its annual report on health care entitled “U.S. Health Care from a Global Perspective: Spending, Use of Services, Prices, and Health in 13 Countries.” The Commonwealth Fund, using data from the Organization for Economic Cooperation and Development (OECD), analyzed health care spending, supply, utilization, prices and health outcomes from 13 high-income countries: Australia, Canada, Denmark, France, Germany, Japan, Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States. It is important to note that the data used in this report is from 2013, the year prior to the full implementation of the Patient Protection and Affordable Care Act.
So what did the report find?
Well, our trend of higher spending and lower quality continues. On average, the United States spent $9,086 per person on health care in 2013 -- the highest of the 13 countries. The next highest per person spend was Switzerland at $6,325. The lowest was the United Kingdom at $3,364 per person. Although the spending is concerning, what is even more troubling is the fact that despite spending significantly more on health care, the United States has a significantly lower life expectancy as compared to the other countries. In 2013, the life expectancy in the United States was 78.8 years. Switzerland was 82.9 years. The highest life expectancy is found in Japan at 83.4 years.
The authors suggest that higher spending in the United States is largely driven by greater use of technology and higher prices per health care service, rather than an over-utilization of physician services. The report found that the average person in the United States saw a physician four times in the evaluation year, which landed the U.S. in the bottom third of physician utilization of the evaluated countries. The highest number of annual physician visits was 12.9 in Japan. The lowest was 2.9 visits per year in Switzerland.
This report is important because it continues to shed light on what has been a consistent finding over several years -- the U.S. spends significantly more per person but has not improved long-term quality outcomes or life expectancy as a result of such spending. I will suggest that those countries that have lower spending and high life expectancy all have one thing in common as compared to the U.S. They place a much greater emphasis on primary care.
Ready Or Not, ICD-10 is Here
The moment of truth is upon us. ICD-10 is here.
On Oct. 1, all physicians and health care providers must convert their billing systems from ICD-9 to ICD-10. This also will mark the day that all payers -- Medicare, Medicaid, private insurance -- will no longer accept claims for care provided that does not include an ICD-10 code.
I understand that there remains a fading glimmer of hope that Congress will step in and avert the implementation of ICD-10, but as we have stated for much of the past year, Oct. 1 will come and ICD-10 will be implemented. Although I am approaching Oct. 1 with cautious optimism that the conversion will go smoothly, I recognize fully that a conversion of this size will not occur independent of challenges. The AAFP’s top priority is making certain that you have the resources you need to make the transition and deal with any problems that may arise as a result of the conversion.
To this end, I want to call attention to the AAFP’s top ICD-10 resources:
- ICD-10 Referential Flash Cards;
- Frequently Asked Questions;
- Countdown to ICD-10;
- ICD-10 Webinar: Think Outside the Book; and
- Family Practice Management eBook Anthology.
The AAFP will be carefully monitoring this transition and will be communicating all information we receive from family physicians directly to CMS. If you encounter challenges with claims submission or, more importantly, claim rejections please let us know so we can work with you to resolve these issues. The AAFP has created a direct communication link. (Log in required.) I wish each of you luck.
Frustrated With Meaningful Use? Speak Out for Reform
The AAFP continues to be extremely concerned about the future of the meaningful use program and the administrative burdens family physicians face in their efforts to comply with these regulations. In July we called for a delay in the implementation of stage 3 and outlined a series of reforms we believe should be implemented to make stage 2 more simple and therefore achievable for physicians. As noted in my Sept. 1 post, the AAFP is actively advancing legislation that would reform the meaningful use program.
On Sept. 17, the AAFP joined a number of physician organizations in sending a letter to Secretary Sylvia Burwell urging a delay in the implementation of meaningful use stage 3.
Although we remain hopeful that the administration will take the necessary actions to both delay the implementation of MU3 and make much needed improvements in MU2, we are not sitting by and hoping for the best. We are actively engaged with the House and Senate on advancing legislation that would require action on the part of the Office of the National Coordinator (ONC) for Health Technology and CMS. Specifically, we are strongly supporting the Further Flexibility in HIT Reporting and Advancing Interoperability (FLEX-IT 2) Act (HR 3309) introduced in July by Rep. Renee Ellmers, R-N.C.
The FLEX-IT 2 Act would:
- Eliminate the “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 electronic health records (EHRs) undergo interoperability testing.
- Harmonize CMS quality reporting standards across all programs.
The AAFP voiced our strong support in a letter to Rep. Ellmers, and we are aggressively lobbying for the passage of this important legislation. I encourage each of you to take a few minutes to lend your voice to our effort and signal the strong support of family physicians for this legislation. Please use our Speak Out campaign and tell your representative to support of the FLEX-IT 2 Act. Your voice matters, and it needs to be heard.
ONC Launches Website for EHR Complaints
ONC has launched a website where physicians can voice complaints about EHRs, including sharing concerns about information blocking, safety concerns and questions regarding the performance of certified EHR products. Deputy National Coordinator Jon White outlined the website in a Sept. 16 blog post. The AAFP has long encouraged ONC to launch a direct communication medium with physicians, and we are pleased that they have followed our recommendation.
You should contact ONC if:
- Your challenge appears to be related to health information blocking.
- You are not able to share or receive health information.
- You are concerned about the usability of your EHR.
- The certified capabilities of your product are not performing as you expected.
- You have concerns about the safety of your product.
AAFP's Annual Meeting Offers Plenty to 'Experience' in Denver
For me, fall is hands down the best of the four seasons. First, the temperature finally drops below unbearable in Washington, D.C. Second, baseball pennant races heat up, and college football season starts. Third, it’s the season when family medicine gathers in a single city for fun, fellowship and education.
Thousands of family physicians will gather Sept. 29-Oct. 3 in Denver -- the Mile High City (insert your own joke here) -- for the AAFP Family Medicine Experience (FMX). The Academy's annual meeting (formerly Assembly) is a collection of high quality education programs and social events that aims to provide you with information that will enhance your knowledge on timely clinical, practice and professional issues. It also is an opportunity for you to interact with your colleagues from across the nation on those issues impacting family medicine.
I look forward to seeing many of you at FMX and will be interested in hearing your latest thoughts on the array of health policy and practice management issues you are grappling with in your practices. You can find me at AAFP Exhibit & Marketplace (Booth 407), inside the Expo Hall.
Physicians can earn up to 35 prescribed credits in four days, and there are 235 CME sessions to choose from. In addition, the event will feature three outstanding plenary speakers. I urge you to review the full menu of FMX education offerings and review the bios of this year’s outstanding faculty.
I am hesitant to highlight one session over the numerous others, but I am going to do so anyway. At 4:30 p.m. on Sept. 29 there will be a panel discussion on “Capitalizing on Team-Based Care to Improve Quality and Office Efficiency.” This panel will feature one of the nation’s premier health policy leaders, Thomas Bodenheimer, M.D., M.P.H. He has impacted health policy at an unprecedented level and is a physician whose writings and opinions matter to me. If you are able, I would urge you to attend this session. It will be repeated at 12:30 p.m. on Sept. 30.
I will focus on three FMX activities -- practice management and practice improvement education programs, member interest groups and FamMedPAC.
Practice Management and Practice Improvement Programs
Each year, the AAFP offers several hours of education on practice management and practice improvement topics, and this year is no exception. We are excited to offer three education tracks on timely practice management and practice improvement topics. These tracks aggregate a series of education programs into a 3.5 hour time period so you can receive comprehensive education on a single topic or closely aligned topics.
The education tracks are on practice management, motivational interviewing and direct primary care. Here are the dates and times:
- Practice management -- 8 a.m.-11:30am on Sept. 30.
- Motivational interviewing -- 8 a.m.-11:30 a.m. on Sept. 30.
- Direct primary care – 8 a.m.-11:30 a.m. on Oct. 1 and Oct. 2.
During the past year, I have shared information on the numerous changes in our health care system and the resources the AAFP makes available to assist you and your practice in adjusting to these changes. An important part of this blog is the interaction it provides. I learn from you, and your comments influence the work of the AAFP. Yes, we're listening.
We also use your feedback as guidance on what education and services we should provide. To this end, we are pleased to offer education programs on topics that are frequently noted by you as priorities. Here are a few examples with times and dates:
- Assessing the Cost of Sustaining a PCMH -- 8 a.m. and 10:30 a.m. on Oct. 3.
- Meaningful Use -- 1:45 p.m. on Sept. 30.
- Negotiating an Employment Contract -- 9:15 a.m. and 1:30 p.m. on Oct. 1.
- Annual Wellness Visit -- 8 a.m. and 10:30 a.m. on Oct. 2.
- Chronic Care Management -- 1 p.m. on Sept. 29; 12:45 p.m. on Sept 30; 9:15 a.m. on Oct. 1; and 10:30 a.m. on Oct. 2.
- Team-Based Care -- 4:30 p.m. on Sept. 29 and 12:30 p.m. on Sept. 30.
- Alternative Payment Models -- 9:15 a.m. on Sept. 30 and 10:30 a.m. on Oct. 3.
Member Interest Groups
In 2014, the AAFP established member interest groups (MIGs) as a way to define, recognize and engage groups of AAFP members who have shared professional interests. These groups are excellent venues to connect with colleagues, share your ideas, conduct peer-to-peer learning and develop recommendations on how the AAFP can better serve its members. There are 11 MIGs (so far). There will be a reception for members currently participating in MIGs and those interested in learning more at 5:30 p.m. on Thursday, Oct. 1. In addition, each MIG will hold business meetings at the date and times listed below. Please consult the official program for locations.
- Emergency Medicine/Urgent Care -- 12:30-2:30 p.m.
- Global Health -- 12:30-2:30 p.m.
- Oral Health -- 6:30-8:30 p.m.
- Rural Health -- 6:30-8:30 p.m.
- Single Payer Health Care -- 7:30-9:30 a.m.
- Adolescent Health -- 9:15-10:30 a.m.
- Hospital Medicine -- 1:30-3:30 p.m.
- Telehealth -- 1:30-3:30 p.m.
- Independent Solo/Small Group Practice -- 7-9 p.m.
- Reproductive Health Care -- 10 a.m.-noon
- Direct Primary Care -- 8-10 a.m.
In a previous post, I introduced you to FamMedPAC, which is the AAFP’s federal political action committee and one of our most important advocacy resources. I am a firm believer that there are three forms of advocacy -- lobbying, grassroots and political. Each is complementary of the other two, and each is less effective if the others do not exist.
FamMedPAC also represents a great way for family medicine advocates to participate in federal elections and influence the larger health policy debate from the political angle.
FamMedPAC will have a major presence at FMX, and I urge you to stop by its booth in the AAFP Exhibit and Marketplace. You can make a contribution and engage our staff on the latest political news and the AAFP’s efforts to influence federal elections. If you are currently, or become, a contributor at the Club George level ($365 per year for active members or $52 for students and residents) or higher, we invite you to join us for the annual FamMedPAC reception, which will be held from 5:30-7 p.m. on Sept. 30.
FMX promises to be an informative and fun event. If you are attending, I urge you to participate in the education programs offered, and please stop by and see us at our booth in the Exhibit Hall.
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.
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