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Tuesday Apr 25, 2017

I'm Listening: Part II

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

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

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  • the Patient Protection and Affordable Care Act (ACA) isn't working and should be repealed.

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

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

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

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

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

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

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

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

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

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

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

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

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

Affordable Care Act

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

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

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

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

Wonk Hard

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

Comments:

I recently attended a national FM meeting, with many baby boomer generation docs. Most conversations reflected the above concerns, and most worrisome, the fact that most looked forward to early retirement due to those concerns interfering with actual patient care and the career they love.
. If CMS doesn't want a worsening collapse of access, this needs to be fixed in the next 12 months, without endless public comment periods and mindless bureaucrats.
This direct message to CMS Administrator Verma in the first five minutes of your meeting would have made us feel our Academy does listen to us.

Posted by David Engbrecht on April 25, 2017 at 01:09 PM CDT #

Thank you for your efforts, and for this update. Unlike the AMA, which sold us out long ago and operates from the back pocket of the Federal Government, the AAFP seems to actually be listening to its members. What a concept!

Your three-pronged summary is a fair reflection of my own views and concerns, which is refreshing to see. And, you seem to honestly feel accountable to us, which disarmingly unusual. Kudos to you. Keep it coming.

May I also suggest that the AAFP begin to work with other specialty organizations to form an alternative national physician organization, that actually represents real physicians? I've saved up my unpaid AMA dues for 15 years now, waiting for it... I have a feeling I'm not the only one.

Posted by Clay Prince MD on April 25, 2017 at 01:39 PM CDT #

Shawn,

Thanks for your detailed reply to these concerns. You have clearly studied and grasped the problem of administrative burden. But, I'm pessimistic these proposals -- sending letters to various powers-that-be -- will help in any significant way. At this point, there are too many financial and political interests in maintaining our complicated, opaque third-party billing system. Even if these suggestions were partially implemented, the problem cannot be solved by trimming around the edges of the monster (billing and payment models) we've created.

You mentioned in Part I of your blog that "direct primary care" was a secondary issue. I would argue that DPC growth is exploding precisely because it's the only clear, tangible solution to administrative burden in the near future; more and more physicians are realizing this. Scaling DPC to a larger population will obviously require the system (insurance, government) to adapt, but if we are aiming for a truly patient-centered -- including control of some portion of money -- system with a minimum of administrative burden, DPC is the solution.

Regarding high-deductibles, the only fixes for patients are . . . a) innovative models that provide transparency and lower costs to patients directly, and b) allow PCPs enough time to be true advocates, including financial considerations, for their patients when navigating the system. You know what practice model is already doing this?

Hope you can join us for the http://DPCSummit.org this June in D.C.

Ryan

Posted by Ryan Neuhofel on April 25, 2017 at 04:09 PM CDT #

You are correct that Meaningful Use was a separate and preceded the ACA. However, in The ACA per HHS:

"Section 937(f)--BUILDING DATA FOR RESEARCH.—

The Secretary shall provide for the coordination of relevant Federal health programs to build data capacity for comparative clinical effectiveness research, including the development and use of clinical registries and health outcomes research data networks, in order to develop and maintain a comprehensive, interoperable data network to collect, link, and analyze data on outcomes and effectiveness from multiple sources, including electronic health records."

Here is the HHS link:

https://aspe.hhs.gov/meeting-aca-mandate-build-data-capacity

SO, EHRs are mandated by the ACA, all be it, explicitly for the purpose of data collecting. Argue the details however you wish, since EHRs are mandated by the ACA, it is not stretch to argue that the core function of "Meaningful Use" is now part of the ACA. I believe it is fair to say that "Meaningful Use" has now been folded into the ACA. Just like ACOs have been folded into the ACA.

We are all frustrated by the encroachment of regulatory burden stepping on the joy of caring for patients. We must focus on having a unified narrative.

Posted by Robert McClees MD on April 25, 2017 at 06:38 PM CDT #

You are correct that the complexity of the programs from the government are becoming so difficult that small practices cannot master them. However, your comment about the ACA which, was supported by the AAFP, infers that PQRS and others of the alphabet soup programs were not the responsibility of the ACA is misleading. What you have stated above is true but it is only a partial truth to the technical aspects. The fact that PQRS was created in 2006 is correct but it was voluntary at that time and the incentive was 1.5% without a penalty and was for one year only. Then in 2007 it was extended and 2008 it was made a permanent program with an increased incentive of 2%. However, it was the ACA that mandated a penalty phase to the PQRS program since the PQRS program was absorbed into the ACA, so to say that the ACA did not create PQRS is a convenient truth. Unfortunately, for independent practices the alphabet soup continues with MACRA and all of its offspring which have taken the penalty phase to a new extreme pushing a great number of practices into DPC. DPC may work for more populated areas but is not a viable option for many rural areas. And MACRA is anything but simple. Also, the studies have shown that smaller, more efficient practices will likely be paying the penalties which will support the larger practices who will be more likely able to comply with MACRA. But, it will again be budget neutral so if you could get all practices to comply with MACRA, there would be no incentive for anyone. So, it becomes a choice for small practices, absorb the penalties or get nickel and dimed by joining a registry, practice transformation consultations, buying the webnars from the AAFP or joining an ACO where we have no voice and shoulder the expenses from the organization. I only have one question and that is when will the administrative burden decrease??

Posted by Peter Lueninghoener MD on April 25, 2017 at 07:30 PM CDT #

I really like AAFP's Agenda for Regulatory and Administrative Reforms mentioned above. While all of the Sections are very important to me, I am especially interested in the mention under E/M Services that all members of the care team should be able to contribute to the completed note. For example, MA's and even the pt's themselves should be able to construct the HPI, without me having to retype/re-dictate, employ scribes or otherwise devise some workaround to get through my day. Then, to ask for elimination of documentation guidelines for primary care physicians- WOW, now that's being Bold! Now, how do we get some of this done??

Posted by Jeff Harwood on April 25, 2017 at 09:24 PM CDT #

Too little, too late. Largely as a result of the ever-increasing insurance and government meaningless requirements, I sadly closed by solo practice of 32 years on 4/14/2017. I just could not continue working until mid-night most nights with no hint of any improvements actually coming.

Posted by Lawrence Varner on April 26, 2017 at 08:06 AM CDT #

Good post, appreciated very much.
1. RE prior authorizations, the fact we are failing to acknowledge here is an ugly one but necessary if we are going to address it: prior authorizations are MEANT to be difficult. They serve the same purpose as speed bumps do for parking lots. They obstruct by design. There are good reasons insurance companies do put such obstructions in the way, and some nefarious and unethical reasons. Some common sense reforms would be: ways for doctors to earn 'gold plated' or 'blue ribbon' status with payers as being appropriate ordering physicians, and removing a layer of complexity on the part of payers for these exemplary doctors who do not waste but take good care of patients. Or for insurance companies to make the drug formularies available in a reasonable, consumable manner that is seamless, so doctors can pick the meds that are covered in an efficient manner (hint: the formulary feature on the EMR is NOT that means).
2. RE MACRA / MIPS: this is a failed situation and along with the more advanced meaningful use requirements, does little to advance quality care while actually presenting unnecessary and burdensome administrative requirements on doctors that are not sustainable. Our answer to both at my practice: ignore them and take the hit on Medicare; and continue to provide our currently excellent standard of care to patients. Sadly, not all of our colleagues provide excellent care, which is one reason these programs had to be designed. But they are certainly not the answer to the problems of health care. PCMH and ACOs are another example of a largely disappointing solution, although both of these two acronyms do have some wins; they are just not the game-changing solutions desperately needed.

In my humble opinion, the answer lies in rewarding primary care doctors for being accessible, including in offering extended hours and phone-based care (both of which have to be paid for / compensated), and for offering complete primary preventive and chronic care services to a mutually accountable, defined patient panel. I truly believe that a system which pays doctors a good wage for providing these critical (and lacking) items will attract more talent into our ranks, and will begin to organically solve much of the health care system ills - not the least of which will be our own, which are the subject of these blogs. This would make a lot of the advocacy and high-tech, high-wonk solutions being discussed here less necessary to our daily survival and more in the realm of thoughts about the future.

This being said, I do sincerely thank you and the AAFP, and my colleagues who read and comment here, for what you all do. Let us not give up. It is still an exciting and blessed time to be in medicine.

Posted by james walker on April 26, 2017 at 11:23 AM CDT #

Thanks Shawn for your update. My feeling remains that somewhere along the line, the powers that be, including the AAFP, stopped believing in comprehensive family medicine and instead began to believe in "transformation" to prove worth. Starfield proved that family medicine is the solution for a lower cost, higher quality health care system, and that it should be defined by access, longitudinal continuity, comprehensiveness, and coordination (not by checking boxes on a computer screen). The leadership of the AAFP needs to understand this simple but important concept and be hitting both insurance companies and the government daily with infographics and letters showing what really constitutes quality. As far as I can tell, the AAFP is reacting to the increased burden (and I do thank you for that) but is still not solving the underlying flaw in the thought process (that disease based metrics fail at measuring quality in primary care). Unless and until the advocacy arm for family medicine (i.e. the AAFP) understands and articulates that we cannot be judged by specialist standards (because of underlying multimorbidity), administrative burden will continue to explode and those of us on the front lines will continue to close up shop, consolidate, or retire. Letters are nice, but they are a band-aid on an arterial bleed.
I have posted it before, but here is a 2009 editorial by Starfield published in FPM predicting the failure of the current "quality" programs and suggesting where we should be focusing our attention. We were obviously not listening to her a decade ago. Is it too late to start listening now?
https://pdfs.semanticscholar.org/119f/c831aef11e2112fe3a63b7145bb8cedcfd91.pdf

Posted by John Brady on April 26, 2017 at 01:44 PM CDT #

Long story short it takes me three to four hours after the last patient leaves to finish my charting. I used to see 30 to 35 patients a day and now I see 17-20. All this computer box checking to appease people in ivory towers is ruining patient care and creating tremendous access issues, and I don't know what has to happen before it stops. People who don't deliver care are controlling health care and something needs done. Also plugging in nurse practitioners to be primary care physician replacements is not the answer.

Posted by Michael Poland MD on April 27, 2017 at 06:20 AM CDT #

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About the Author



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

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