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- the Patient Protection and Affordable Care Act (ACA) isn't working and should be repealed.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.
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 (email@example.com).
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.
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.
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