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Tuesday Jun 06, 2017

Things Are Heating Up Outside and On Capitol Hill

 "I've got to run to keep from hiding"
-- Allman Brothers

I hope each of you had a nice Memorial Day. The holiday is the symbolic start of summer, which brings us longer days and the return of humidity and warmer temperatures here in Washington, D.C. The District really is built on a swamp, and the summer months have a way of reminding us of that fact. Summer also is a busy time for health policy, and this summer is shaping up to be a busy one for the AAFP.  

Here are updates on three key issues that we will be working on this summer:

Health Care Reform
Efforts to repeal and replace large portions of the Patient Protection and Affordable Care Act remain a priority for the Trump Administration and many congressional Republicans. How they accomplish this priority is still unclear and growing more complicated by the day.

The House, after a couple of starts and stops, approved the American Health Care Act on May 4 on a narrow 217-213 vote. Twenty Republicans -- largely moderates from "purple" states -- joined all 193 Democrats in voting against the legislation. The Washington Post published a comprehensive analysis of the House vote, including a listing of how each representative voted.  

In general, Republican opposition centered on two major items -- Medicaid cuts and the potentially negative impact the AHCA would have on people with pre-existing conditions. There were secondary issues such as the significant loss of coverage, the impact on part-time workers and students, and the fact that the AHCA would rescind numerous consumer protections available under current law; but the primary sources of opposition were concerns about Medicaid and pre-existing conditions. In the end, Republicans convinced enough of their members to vote yes even though the true impact the AHCA was undefined.

On May 24, 20 days after the House approved the AHCA, the Congressional Budget Office (CBO) released its analysis of the AHCA. The CBO score was not good, finding that 14 million people would lose their health coverage in 2018, and 23 million would lose coverage by 2026. Furthermore, the CBO found that the legislation would have a net-positive, but relatively minimal impact on premiums for younger and healthier individuals. However, the CBO found that premiums for older adults, especially those on the lower end of the income spectrum, would increase at alarming rates.

The Senate is in the early stages of its work on repeal and replace legislation. To date, the Senate has formed a working group comprised of 13 senators. In addition, there are several smaller groups working on policy proposals and political solutions.  

The AAFP can verify that Senate staff worked during the Memorial Day recess to draft legislative specs that will be presented to all Senate Republicans today. Where we go from here is unclear, but we do know that Senate Republicans are not willing to walk-away from full repeal. Therefore, this issue will stick around for the summer.

Medicare Access and CHIP Reauthorization Act
CMS will issue its proposed 2018 MACRA Quality Payment Program (QPP) regulation in the coming days. We are about half way through the 2017 QPP performance period under the Pick Your Pace criteria. We continue to encourage those who are eligible clinicians under the program to engage in the Pick Your Pace program to avoid negative payment updates in 2019.

The AAFP has been working closely with CMS on the 2018 proposed rule for several months. There are several areas where we are informing and educating CMS, but there are four areas where we are strongly advocating for changes to the existing regulatory framework:

  • reducing the administrative burden of participation in merit-based incentive program (MIPS);
  • establishment of virtual groups; 
  • more opportunities for family physicians to participate in alternative payment models (APM); and 
  • allowing CME to count for improvement activities under the MIPS program.

The reduction in administrative burden will be our top priority in the 2018 MACRA QPP rulemaking process. The AAFP has already engaged CMS on this issue and is actively working with the agency on making the program more user-friendly for physicians. On April 26, the AAFP wrote to CMS Administrator Seema Verma to outline a series of recommendations regarding how the QPP could be simplified to reduce the administrative burden on participating physicians. These recommendations are common sense approaches that would reduce the quality reporting requirements, decrease the prescriptive nature of the Advancing Care Information requirements, and allow for a greater number of family physicians to participate in primary care alternative payment models.  

AAFP President John Meigs, M.D., met with CMS on these issues on April 11 and May 23. Both meetings went well, and CMS is considering  our recommendations.

Comprehensive Primary Care Plus
On May 18, CMS announced the expansion of the Comprehensive Primary Care Plus program to four additional regions: Louisiana, Nebraska, North Dakota, and Buffalo, N.Y. The application period runs from May 18 to July 13.  

We believe the CPC+ payment model, which provides increased and up-front payment for primary care, is beneficial for family physicians. AAFP policy supports fully the three components of the CPC+ program that de-emphasize fee-for-service and increase payments to support practice improvement. Those three components are:

  • care management fee;
  • performance-based incentive payment; and
  • fee-for-service payment under Medicare physician fee schedule for some services.

In addition, family physicians participating in CPC+ are eligible to participate in the Advanced APM pathway versus the MIPS pathway under the QPP program. The AAFP continues to strongly support the CPC+ program. If you live in one of these regions, we encourage you to apply. You can find comprehensive information on the program and the application process on the AAFP’s CPC+ resource page.


RE MACRA, let me warn my fellow colleagues of the risk to your patients and your practices in participating even in the 'low minimum' requirement necessary to avoid the penalty. While tempting, you have to check a box that you attest that you are 'not information-blocking' and that you will exchange information electronically. As one who serves on some HIT-related committees, I have not heard a detailed description of this requirement; but I see major red flags in that once you attest, you have to comply - and if you comply, even by sending your patient data to clearinghouses for quality analysis etc., you run a very real risk of re-identification of the data, and of major liability if that is done and the data gets into the wrong hands. Keep in mind that the liability is not capped by statutory limits as malpractice would be in some states; and this is a largely untapped market for plaintiff attorneys.

The AAFP is urged to lobby strongly for the 'no information blocking' requirement to be removed from MACRA; as well as for some safe harbor legislation to protect doctors who in good faith and with diligent attention to HIT privacy and security measures, send data electronically for patient care and quality reporting. However, until there is a safe health IT security framework in the U.S. (and there certainly is NOT, according to the recent HHS cyber security report), we as a professional association must speak strongly on behalf of our patients and members that the government must NOT coerce us to put our patients' most personal data out there onto a system which is absolutely not ready.

There are ways we can get there, such as by standardizing the privacy / security and cyber security protocols that practices should follow internally; as well as standardization of data storage and transfer protocols industry-wide. But right now, the 'no information blocking' requirement is a major mistake - one which could cause patient harm, and practice-closing liability disasters.

* footnote - for an example that the government means business when they regulate health IT, look up what happened such that E-clinicalWorks EMR allegedly settled for $155M to satisfy a government-related inquiry; good intentions notwithstanding.

Posted by J. Stefan Walker, M.D. on June 06, 2017 at 12:54 PM CDT #

CPC Plus is a good alternative for family physicians. Nevertheless its requirements are overwhelming for small offices. For example, the recently released Implementation Guide is over 200 pages long. There is also a lot of time and energy needed to bring up your EHR vendor up to speed for the reporting requirements.
AAFP should work to provide
for further simplification and ease of use of the CPC Plus program.

Posted by Chris on June 10, 2017 at 09:38 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.