Primary Care: Defending What it Means and What It's Worth
Medicaid cuts are coming.
Section 1202 of the Patient Protection and Affordable Care Act increased Medicaid payments to Medicare levels for certain primary care services in 2013 and 2014. But unless Congress acts during the lame-duck session, Medicaid parity paymentsfor primary care physicians will stop, and payments will return to 2012 levels on Jan. 1.
This issue was debated in depth during the recent AMA Interim Meeting in Dallas. This was an important discussion because there is disagreement within the AMA about what constitutes primary care. In fact, many of our subspecialist colleagues claim that they provide primary care -- and therefore should qualify for parity payments -- because of their involvement in the management of certain diseases such as Parkinson's, diabetes and cancer.
|Jerry Abraham, M.D., M.P.H., of Los Angeles, and Joanna Bisgrove, M.D., of Fitchburg, Wis., represent the AAFP at the AMA Interim Meeting. Abraham, a first-year resident at the University of Southern California, was elected an alternate delegate to the AMA's Resident Fellow Section. Bisgrove is the AAFP delegate to the AMA Young Physicians Section.|
The globally accepted meaning of primary care, however, comes from Barbara Starfield, M.D., M.P.H., who defined it as "first contact, continuous, comprehensive, and coordinated care provided to populations undifferentiated by gender, disease, or organ system." From the AAFP perspective, only family medicine, general pediatrics and general internal medicine are the specialties that train physicians to deliver true primary care. Other specialty physicians might from time to time deliver certain services described as primary care, but they are not trained to deliver comprehensive primary care.
Although some subspecialty groups at the meeting attempted to change AMA policy regarding who should get Medicaid parity payments -- if they, in fact, continue -- the Academy's delegation was able to prevent action by the AMA House of Delegates that would have expanded the Medicaid parity payments well beyond their initial focus on primary care physicians only. This means that the AMA's support for proposed legislation that would extend parity payments for two more years will continue.
Next to repeal of the sustainable growth rate (SGR) formula, this is the most crucial piece of health care legislation the AAFP is focused on for passage during the lame-duck session. The continued cohesive voice of organized medicine on this issue represents an important success.
In addition to Medicaid parity, the AAFP's delegation also testified on other important issues, such as the significant threat to our patients and our members from the increasingly troubling network narrowing that we see impacting practices in more and more states. The AMA recognized that this is a significant challenge, and resolutions were moved forward to address this directly.
It's worth noting that the AAFP, the AMA and more than 100 other organizations recently sent a letter to the National Association of Insurance Commissioners voicing support for model legislation that would serve as a template for revising state provider network adequacy standards.
With strong AAFP support, AMA delegates also passed a resolution asking CMS to halt penalties related to meaningful use (free registration required) and look for ways to continue to incentivize use of electronic health records.
In addition, recognition of the changing landscape in terms of telemedicine was also a focus during the meeting. Related resolutions moving forward are consistent with ones we have acted on in the AAFP's Congress of Delegates.
The AAFP has one of the larger specialty society delegations to the AMA. Moreover, many of the 115,900 Academy members our delegation represents are themselves AMA members. These are dedicated family physicians who advocate for their patients and their communities through involvement with their state medical societies. Having more family physicians from different backgrounds at the AMA creates exciting opportunities for us as we continue to try to find a way to move the house of medicine in a coordinated fashion to recognize and value family medicine and primary care.
Over the years, our delegation has gained a stronger presence within the AMA as we continue to work to inform our discussions and share AMA policies. This is helped by the fact that there are five AAFP members who are on the AMA Board of Trustees:
- Past Chair David Barbe, M.D., M.H.A., of Mountain Grove, Mo.;
- Chair-elect Stephen Permut, M.D., J.D., of Wilmington, Del.;
- Gerry Harmon, M.D., of Pawleys Island, S.C.;
- William Kobler, M.D., of Rockford, Ill.; and
- Albert Osbahr III, M.D., of Hickory, N.C.
The Academy greatly values the relationship we have developed with these leaders of the AMA, and we look forward to more opportunities to work together. Your delegation is quite well respected within the house of medicine and is led by Joseph Zebley, M.D., of Baltimore, and co-chair Daniel Heinemann, M.D., of Sioux Falls, S.D.
Recently, we have been blessed by an influx of dynamic family physicians who are early in their careers. This year, our delegation included Uniformed Services chapter member Janet West, M.D., of Pensacola, Fla.; Aaron George, D.O., a third-year resident at the Duke Family Medicine Residency in Durham, N.C., and Ajoy Kumar, M.D., of St. Petersburg, Fla. In fact, we had many people from other delegations praise our organization for being able to bring younger voices to the table.
An impressive accomplishment for our delegation during this meeting was that Jerry Abraham, M.D., M.P.H., of Los Angeles, one of our resident members, was elected as an alternate delegate to the AMA's Resident Fellow Section. A first-year resident at the University of Southern California, Abraham will be sitting in the House of Delegates this summer during the AMA's Annual Meeting. This speaks well to his leadership skills not only within the AAFP but also the AMA.
The Academy continues to work for our members and our patients in every venue we can. The AMA meeting is certainly a different body and culture from our AAFP Congress of Delegates; however, the issues discussed at AMA directly impact our patients, our communities and our members. Thanks to all of the family physicians who are involved in the AMA. This is another important avenue for advocacy, and we appreciate your efforts. As they say at the AMA, together we are stronger!
Reid Blackwelder, M.D., is Board chair of the AAFP.
California AFP's Success Shows What Chapters, FPs Can Accomplish at State Level
It's that time of year again. For the past 15 years, by the end of October, I would start counting the wins and losses of my favorite college football teams in preparation for the Bowl Championship Series that crowns a national champion. However, with the introduction of a long overdue college football playoff this season, polls and computer rankings are no longer quite as compelling. Although I've been enjoying some great football games, I've been tracking and counting something even more interesting instead.
Like many of you in your own states, I also advocate on health care issues in my home state of California. As the legislative session comes to an end for the California State Assembly, the California AFP's record is pretty impressive. Of the CAFP's 19 priority bills, Gov. Brown signed 17 of them this year. Among the victories for CAFP were budgetary expansions for primary care workforce training and the elimination of a retroactive 10 percent reduction in California Medicaid (Medi-Cal) provider payment to the tune of more than $42.1 million.
Other Medi-Cal related wins include the creation of an oversight body for children's health, streamlining enrollment, and expansion of enrollment eligibility categories. New laws will also require Medi-Cal managed care plans to provide interpretation and translation services to their participants. Several new pieces of legislation will strengthen team-based care by allowing physician assistants to certify claims for disability, authorizing medical assistants to handout labeled and prepackaged medications after consulting with appropriate health care professionals, and requiring schools to provide emergency epinephrine auto-injectors.
On the workforce front, in addition to increased funding for primary care training, new legislation has cleared the way for graduates of accelerated and fully accredited medical education programs to become licensed physicians in California.
Hard work by CAFP staff and members culminated in the passage of a resolution regarding patient-center medical home (PCMH) definition. For the past six years, this piece of legislation was kicked about by some as leverage for their own political ambitions. In previous sessions, it had been snatched from the jaws of victory by last-minute legislative maneuvering and was dismissed by the governor as an "evolving concept."
Just as with any successful football team, team work made the difference in getting it done this time. CAFP enlisted and energized attendees of its All Member Advocacy Meeting by focusing them on passing priority legislation. We trained an army of family physicians to become expert patient advocates on PCMH issues. In addition, contributions to FP-PAC, California's family medicine political action committee, opened doors for our well-trained grassroots advocates to meet with influential legislators.
Furthermore, 2014 was declared "The Year of the Family Physician" in California when a resolution sponsored by CAFP passed the legislature. The hashtag #2014YearFP was a Hail Mary idea dreamed up by Ron Fong, M.D., M.P.H., at the University of California-Davis Family Medicine Residency Network. During the year, it gained momentum within local communities and city councils and was picked up in social media around the nation and the world.
Although the Year of the Family Physician is drawing to a close, an even broader effort touting the value of family medicine and primary care is just getting started. As we embark on the road to achieve the goals of Family Medicine for America's Health and the Health is Primary campaign, I strongly invite your input and involvement in this vital process as we transform our medical neighborhoods. Keep informed and get involved.
And finally, I would be interested to hear about your state chapter's legislative wins in the comments field below. Tell me about your success stories!
Jack Chou, M.D., is a member of the AAFP Board of Directors.
We’re Doing Our Part to Keep SGR Issue on Congress' Radar
I will only be AAFP president for three more weeks, but there's a lot to do in this final month of my term. Throughout the year, I have had opportunities to represent the Academy at meetings with a number of organizations as we discuss important concepts such as team-based care and the patient centered medical home. One such opportunity came just this week when I participated on a panel for a Capitol Hill briefing that addressed payment reform, including the need to repeal the Medicare sustainable growth rate (SGR) formula.
This event was organized by the Society for General Internal Medicine (SGIM), which reissued a 2013 report developed by the National Commission on Physician Payment Reform. Many of the principles and recommendations in the report are in line with what the AAFP has been advocating for several years. Given the urgent need to push for passage of the bipartisan, bicameral legislation on SGR repeal already in play, this was an ideal time for the commission's report to be reissued.
I joined a panel that was moderated by SGIM president William Moran, M.D., and included SGIM health policy chair Mark Schwartz, M.D., and American College of Physicians EVP Steven Weinberger, M.D., also a member of the commission. We used this opportunity to review the principles and recommendations in detail with a room packed with legislative aides from both the House and Senate. Our most important ask was to encourage legislators to pass the SGR repeal proposal before the Congress adjourns in December.
The commission's report, like the Academy's longstanding advocacy position, stressed the need to repeal the SGR, which again poses a looming threat to cut physician Medicare payments by more than 20 percent if Congress doesn't act by March 31.
As part of this briefing process, we reviewed many of the report's recommendations, which are in line with what the Academy has been saying in our own discussions with CMS, legislators and congressional staff for years.
Some of these important recommendations include the need to transition away from the fee-for-service model. We outlined the perverse incentives that this model has given rise to in our health care system. Although fee-for-service will continue to be important for some aspects of payment, we have to fix the disparities in current fee-for-service payment rates because they will be a foundation for future payment models. There have to be opportunities to rebalance fee-for-service payments, to boost undervalued evaluation and management codes, and to recalibrate overvalued codes -- many of which have not been revisited in more than 20 years despite huge gains in efficiency.
Our patients' health is becoming increasingly complex to manage, especially in a Medicare population in which 60 percent of patients have three or more chronic conditions. This additional complexity further accentuates the dramatic disparity between how our fee-for-service model pays for procedural services compared to primary care services. New technology has reduced the time it takes to perform certain procedures, yet payment for these services has not been reduced. This contributes to the erosion of primary care incomes which exacerbates our primary care workforce shortage.
We emphasized the real need to recognize that compared with procedural services, primary care services require face-to-face time that cannot be shortened to increase volume without decreasing patient-centeredness and quality.
Another recommendation specifically addresses the significant potential for cost savings and improved care for patients with chronic conditions. The commission report noted that 5 percent of patients in this country account for 50 percent of our health care spending. This will continue to drive an increasingly disproportionate share of spending as more and more patients develop multiple chronic conditions. This is an area that has significant potential for cost savings as we continue to transform our practices.
As family physicians, we know what to do. Much of the answer lies in the patient-centered medical home, and implementing better and more efficient team-based care. Our country needs a stronger primary care foundation -- the essential message of the Commission’s report. The more incentives we can find for primary care and improving access for all of our patients, the more we will save in terms of downstream costs.
We must move away from “wrong care, wrong place, wrong time” to ensuring patients get the right care, in the right place, at the right time and from the right person.
Overall, attendees of the briefing were interested in the recommendations. We stressed that this push is a unique opportunity that brings together all of organized medicine in support of proposed legislation. In addition, once the 2014 midterm elections are over, the unique political landscape of a lame-duck session could grease the skids for passage of the bill.
Once the 114th Congress convenes in January, the SGR repeal legislation will lapse. In addition, because of retirements and potential election-driven shifts in power, significant changes will occur within the committee leadership in Congress, posing potential roadblocks to restarting the bipartisan process. Therefore, this lame-duck session is a unique and rare opportunity for some congressional lawmakers to put a feather in their hat by moving forward on an important and long-sought-after repeal of this fatally flawed formula.
You can help by contacting your legislators to let them know this must be a priority!
Reid Blackwelder, M.D., is president of the AAFP.
Walk the Talk: Students, Residents Step Up to Support AAFP Advocacy Efforts
If you want students and residents to get involved in an issue, sometimes all you have to do is ask.
At an AAFP Board of Directors meeting earlier this year, we heard a report on FamMedPAC, the Academy's political action committee, which helps elect candidates to the U.S. Congress who support the AAFP's legislative goals and objectives.
During the National Conference of Family Medicine Residents and Medical Students, we challenged our respective member segments to see who could raise the most money for FamMedPAC, the Academy's political action committee. Residents and students donated more than $1,000 during the three-day event.
The report included data on the relatively small category of student and resident support. As the resident and student members of the Board, we thought that category could -- and should -- be much larger. The perception has been that students and residents don't have a lot of money to contribute and, therefore, typically aren't a focal point for fundraising efforts.
However, we thought our colleagues would step up to the plate if given the opportunity, so we came up with the idea of the FamMedPAC Challenge. During the National Conference of Family Medicine Residents and Medical Students in Kansas City, Mo., last week, we rallied our respective groups of students and residents to support the PAC. We knew that the residents and students would answer the call and donate, but the results exceeded our expectations.
Advocacy consistently ranks among the top Academy priorities for students and residents, and both groups consistently bring issues to the AAFP's attention because they feel so passionate about the advances that can be made for our specialty and, more importantly, our patients. There were nearly two dozen resolutions in the resident and student congresses at National Conference that related specifically to advocacy.
During the conference, AAFP President Reid Blackwelder, M.D., of Kingsport, Tenn., gave a presentation on advocacy, and the room was packed. As part of that session, students and residents worked up an advocacy issue, which they then transformed into short "elevator speeches" in small groups. Each group practiced pitching their talking points to the entire room, and we were blown away by how well they articulated their messages.
Throughout National Conference, we spoke about the FamMedPAC Challenge and the PAC from the stage, but we also got the word out through social media and, of course, lots of old-school, face-to-face chatting. Both of us handed out donation forms with $1 (an actual dollar bill from our personal accounts) and a PAC donor ribbon attached. Many students and residents had already donated during the past year, but some gave again by adding $9 to our $1 for a $10 contribution, the minimum amount to get their respective group a point toward winning the challenge. Most donors, however, were new.
The FamMedPAC Challenge was a huge success. We had 51 donations: 31 residents contributed a total of $629, and 20 students gave a total of $431 for a three-day total of $1,060, which is by far the most money ever donated to the PAC during National Conference.
Now we'd like to challenge the rest of the AAFP membership. If medical students and residents -- with their ever-growing student loan burdens -- can reach into their pockets and make a donation to help advance our specialty, won't you?
Kimberly Becher, M.D., and Tate Hinkle, M.D., are the resident and student members, respectively, of the AAFP Board of Directors.
Teamwork: AAFP, PA Groups Find Common Ground
I recently represented the AAFP at meetings with leaders from the American Academy of Physician Assistants (AAPA) and the Association of Family Medicine Physician Assistants (AFMPA), and I was honored to be an invited guest to the AAPA meeting in Boston a few weeks ago. The leadership of the AAFP and the AAPA have previously attended each other's board meetings to review proposed legislation at state and national levels. This is a critical interaction that allows our organizations to identify areas in which we can work together.
For example, in Boston, I learned about a proposal in Missouri regarding so-called assistant physicians, who are not PAs but medical school graduates who have not completed residency training. Not only does this proposed measure create potential confusion because of the title of these would-be health care providers, it also would create significant challenges in terms of how unlicensed providers should be designated, regulated and utilized.
|I recently met with leaders from the American Academy of Physician Assistants, including (from left) President John McGinnity, PA-C; President-elect Jeffrey Katz, PA-C; CEO Jenna Dorn; and Board Chair Lawrence Herman, PA-C.|
This issue was directly addressed by the AMA House of Delegates at its annual meeting last month. The AAFP delegation coordinated with our PA colleagues and testified about concerns raised by this issue. A resolution opposing the use of medical school graduates as assistant physicians was adopted with wide support.
Our common interests with the PA groups aren't limited to advocacy. PAs are trained in the medical model of care involving diagnosis and treatment, as are physicians, and they follow rigorous and standardized educational, certification and licensing processes. Last fall, we reached a unique arrangement with the AAPA, which was working to identify activities that would fulfill the performance improvement requirements for its new certification of maintenance program. The AAPA came to us seeking a collaborative agreement through which the AAPA could offer the Academy's four METRIC (Measuring, Evaluating and Translating Research Into Care) performance improvement modules within the AAPA's own learning management system.
METRIC is the AAFP's flagship performance improvement product line and is critical for lifelong learning and maintaining certification. This agreement has been finalized, and PAs may now purchase and access the AAFP's METRIC modules directly from the AAPA, which coordinates marketing and accreditation of the modules. This joint venture represents an important way to share resources and not reinvent educational wheels as we move toward quality improvement in continuing education. Moreover, this relationship reinforces the value that others see in our educational offerings.
This is all worth noting, in part, because 40 percent of AAFP members work with PAs, who assist us in ensuring that we provide effective care and improve our patient outcomes. Team-based care is important to meeting the goals of the quadruple aim -- improving patient outcomes, improving patient and provider satisfaction with the system, and doing so at lower cost.
Family physicians and PAs are working together not only at the practice level but also at the national level, and I look forward to further discussions and collaborations with these groups. Together we are making progress in providing better, more effective care for our patients.
Reid Blackwelder, M.D., is president of the AAFP.
Changing the Conversation: What Would It Take to Make Using Our EHRs Truly Meaningful?
During one of the state chapter meetings I attended as a member of the AAFP Board of Directors, I asked participants if they were using electronic health records (EHRs). About 80 percent said they were. Then I asked the group how many of them were satisfied with their EHRs. Only a few hands went up. In fact, I heard some angry comments.
Administrative hassles are hindering family physicians. “Just one more thing,” is a common refrain, with the implication being that if there is one more thing to report or document -- or anything else that gets in the way of patient care -- it could be the “one more thing” that prompts a physician to quit.
ICD-10, the Physician Quality Reporting System, meaningful use -- how much more will it take before family docs just say no?
It's clear the creators of meaningful use had good intentions. The concept was intended to help physicians transition to EHRs. The carrot was financial. The money saved throughout the health care system by using EHRs could be shared with physicians, thus encouraging them to implement EHRs. (With the stick, of course, being a financial penalty for not complying.)
The idea was that going electronic would:
- improve patient care,
- decrease medical errors,
- improve office efficiency and
- avoid redundancy in ordering tests.
Having healthier patients, fewer medical errors, less testing and improved efficiency would net an obvious health care savings. In fact, researchers predicted in 2005 that health information technology would save the country more than $80 billion a year. Yet U.S. health care expenditures have continued to skyrocket due to many factors, including the health IT shortcomings.
So, did we go wrong somewhere?
Interoperability has been, and remains, a major stumbling block despite the Academy's hard work on the issue for more than a decade. Back in 2003, there was a lack of awareness among policymakers and EHR vendors that interoperability was even an issue. So, the AAFP worked with legislators, federal agencies and vendors to get it on their radar.
The AAFP knew standards were needed, so next, the Academy collaborated with other stakeholders to help create the ASTM Continuity of Care Record (CCR), a patient health summary that can be created, read and interpreted by EHRs developed by different software companies. That standard has become part of meaningful use.
As AAFP President-elect Robert Wergin, M.D., of Milford, Neb., recently pointed out in his blog on the topic, when a patient leaves a primary care practice for a subspecialist consultation, the respective EHRs at the primary care practice and the subspecialist’s practice aren’t necessarily able to communicate. This is a barrier to care coordination, and the Academy continues to work with the Office of the National Coordinator (ONC) for Health Information Technology on this issue.
This critical shortcoming is why the Academy was an early contributor and founding member of the direct exchange project, which allows physicians to send secure, confidential emails to other physicians.
Unfortunately, EHR developers have little incentive to change. The ONC recently issued a proposed rule for 2015 that included voluntary updates related to certification criteria, interoperability and regulatory improvements. In a letter to the ONC, the AAFP said that voluntary guidelines would create confusion about what is and isn't required, adding undue complexity to an already complex program. The Academy urged the agency to urge work with stakeholders to create better means than a voluntary certification program.
It seems unlikely that EHR developers are going to fix the issue of interoperability on a volunteer basis. But just think how much more “meaningful” my use of an EHR would be if it could communicate with the EHR of the radiologist or cardiologist across town.
Add to that the fact that many EHRs aren’t user-friendly at all. Documentation and reporting has become cumbersome, and being conscientious about keeping thorough electronic patient records results in less time for patient encounters. In fact, there have been indications that EHRs that satisfy meaningful use and appropriate coding protocols can:
- interfere with patient care,
in mixed patient outcomes,
- increase overall costs, and
- complicate office workflow.
The main thing that electronic records have accomplished is improved billing. But surely this isn't all we want to see come from this investment. We are seeking a system that would improve patient satisfaction and improve patient outcomes. The electronic record is a natural for following patients with chronic disease and surveying your patient population for health concerns.
While tracking specific metrics such as a hemoglobin A1c has improved with use of electronic records, tracking actual improvements in health has not worked so well. What would it take to make this happen?
It is estimated that one-third of health care expenditures overall can be attributed to unnecessary administrative burden. Of that, the time spent doing administrative work and documentation during a patient encounter has been estimated to be as high as 60 percent.
There is a section in the Patient Protection and Affordable Care Act -- Section 1104 -- that seeks to improve these hassles. This "administrative simplification" section was passed by Congress even before meaningful use reporting began. However, the same rules should apply. The section includes operating rules for HIPAA transactions, utilizing a unique identifier and setting up certain rules that would simplify reporting for health plans.
Wouldn't it be great to see a patient and not have to worry about how many bullets are included in the current history of illness? Instead, you could just look at the past medical history as it applies to the patient, review only symptoms that are specific to the patient's problem and pursue only clinical decision-making specific to patient care needs. Charting this way would involve minimal amount of physician time, and patient care documentation would be the purpose. The dual worries of coding and reporting would go away.
My practice is sending one of our physicians to an out-of-town course to become an EHR "superuser" so he can help the rest of us become more efficient in using our system. It seems odd that after years of medical training we need even more training to become IT experts.
Through our state chapter visits and other channels, the members of the AAFP Board of Directors have heard members' concerns -- believe me! We will continue working to ease administrative burdens. We are looking at ways to decrease the number of codes and the complexity of coding. In the meantime, we can all continue to educate ourselves so we can make best use of the current system.
So here's my final question: For better or worse, how has using an EHR changed your practice?
Daniel Spogen, M.D., is a member of the AAFP Board of Directors.
How Family Medicine Upstaged Ben Affleck
It's not an everyday occurrence when a family physician proves to be a bigger draw -- at least for a few minutes -- than a two-time Academy Award winner. But that was the case last Wednesday when Sen. John McCain, R-Ariz., stepped out of a Senate Foreign Relations Committee hearing (where Ben Affleck was testifying about issues in the Congo) to talk with me about the sustainable growth rate (SGR) formula and the need to extend funding for teaching health centers.
The AAFP Board of Directors was meeting in Washington, but we made time in the agenda to talk to our own legislators about these critical issues. I had met with McCain's staff several times in previous trips to our nation's capital, but this was my first visit with my state's long-time senator. The meeting was quite encouraging. In fact, McCain was one of nearly two dozen members of Congress who agreed to co-sponsor the SGR Repeal and Medicare Provider Payment Modernization Act last week.
The bipartisan legislation introduced last month in the House and Senate would permanently repeal the SGR and enact reform that would support improvements in health care delivery. If Congress doesn't act before March 31, the SGR would cause Medicare payments to physicians to be cut by 24 percent.
It's easy for individuals to think they can't make a difference against huge challenges like this one, but the reality is that legislators might not even be aware of a problem unless a constituent is willing to bring it their attention. That was the case with the issue of teaching health centers -- or the lack of them -- in Arizona.
Fewer than half of the states have teaching health centers, and Arizona is one of those on the outside looking in. Sen. McCain wasn't aware of that shortcoming. But when I told him about the benefits of teaching health centers and why funding should be extended beyond 2015, he wanted to know more. I will certainly follow up with his staff to make sure he understands the value and importance of teaching health centers.
Arizona, a state with 6.5 million people, has only eight family medicine residencies, including the University of Arizona Family Medicine Residency Program where I am an associate professor. Adding a teaching health center would be a huge step in the right direction, ensuring family medicine becomes a more vigorous force in health care delivery.
Carlos Gonzales, M.D., is a member of the AAFP Board of Directors.
Primary Care Education at Forefront of Obama Budget Proposal
Washington, D.C., is always an exciting place to be, but it especially was for me this week because the AAFP Board of Directors is meeting here to advocate for our members and improved health care for all Americans. But today was an even better day than I expected. As we gathered this morning before our meeting, we were encouraged by some good news in USA Today.
For months, the AAFP has been working with the White House and the Health Resources and Services Administration (HRSA) to address the need for increased funding in graduate medical education (GME). Today, information provided by the White House Office of Management and Budget reveals that there will be some good news for primary care Tuesday when President Obama releases his 2015 budget.
Specifically, the document released by the Office of Management and Budget to USA Today (and later shared with the Academy) says the Administration plans to budget an additional $5.23 billion during the next 10 years to train 13,000 more residents in primary care "and other physicians in high-need specialties." The document does not specify what those high-need specialties are, but last year the Council on Graduate Medical Education (COGME) called for increases in GME funding in "high priority specialties," including family medicine, geriatrics, general internal medicine, general surgery, high priority pediatric subspecialties and psychiatry.
The AAFP has long advocated that our country put more resources into graduating more medical students into primary care to meet the workforce needs of our country as our population continues to grow, as it continues to age, and as more patients get health insurance because of health care reform. This proposed budget speaks directly to this need.
Additional residency positions in primary care also are needed to keep pace with the opening of new medical schools and expanding medical school class sizes. COGME recommended that Congress continue funding existing GME positions and increase funding to support 3,000 more graduates per year. The President's budget would take a step in the right direction, providing additional funds through HRSA to train an additional 1,300 residents per year in high-need areas, including rural areas. It is critical, however, that any such increase that is implemented must ensure a majority of these positions be in primary care: family medicine, general internal medicine and general pediatrics.
Reinforcing this need, the document says residencies vying for the additional slots would have to demonstrate that they "train and retain physicians in primary care and use team-based models of care that enable all providers to work at the full extent of their abilities, and adopt new models of care, such as the patient-centered medical home or accountable care organizations."
It is important that we identify and finance training sites that may be outside the traditional hospital setting. The budget document says that for the new competitively awarded residency slots, priority would be given to hospitals and other community-based health care entities.
National Health Service Corps
One proven way of getting physicians into primary care is through the National Health Service Corps (NHSC). During the past several years, we have seen important growth in this program. The number of physicians serving in the NHSC has more than doubled during the current administration, from 3,600 in 2008 to 8,900 last year. The President's proposed budget would provide $3.95 billion in mandatory funds, expanding the number of NHSC health care providers in underserved areas to 15,000 each year from 2015 through 2020.
The AAFP has strongly supported growth in the NHSC, which offers scholarships and loan repayment assistance to support qualified family physicians and other health care professionals who are willing to work in communities across the country that are designated as health professional shortage areas. The program makes it easier for students to choose primary care careers without facing insurmountable debt and helps address critical access issues by placing new physicians in areas where they are needed most.
The AAFP has been advocating for the increase of Medicaid payment rates to Medicare levels for more than four years. The proposed budget would extend increased Medicaid parity payments for primary care services through 2015 at an estimated cost of $5.44 billion.
We thank the administration for this proposed increase, and look forward to working with Congress to extend these increased rates for five years to create a period of access stability as our members continue to transform their practices to more effective patient-centered medical homes, and as we transition away from payment models that pay for volume to models that pay for value.
It's important to remember that Tuesday's announcement will be regarding a proposed budget. These specific proposals from the White House directly address the workforce needs of our country, and would help produce the critically needed primary care physicians Americans need and deserve. We are eager to continue our discussions with this administration and Congress to work to achieve these outcomes.
Much work and debate will remain before it is finalized, but this proposed budget is an important step forward as it is a real and meaningful investment in primary care. It represents recognition of the foundational role that primary care must play in our transforming health care system. The AAFP stands ready to help ensure that all Americans get the right care from the right person in the right place at the right time.
Reid Blackwelder, M.D., is President of the AAFP.
Advocacy Improves Community Health Far Beyond Exam Room
I have been involved in advocacy, in one form or another, since middle school: collecting money for the Jerry Lewis telethon, arranging a speaker for my high school class and working on teen pregnancy issues in residency. The issue that helped me fully understand the nuances of advocacy, however, was the death of a patient who was a victim of domestic violence.
Knowing that I wanted to help to change the health conversation, I asked myself, "Who else in the community has a stake in this issue, and what existing programs might need assistance?" Then I met with the local women's shelters to find out what they needed and how family physicians could connect women who need help from these resources. I also worked with law enforcement officials, educated myself and eventually figured out how to get things done.
Family physicians face a lot of challenges, including payment issues, new regulations, public health issues and more, but we don't always know how to fix the problem or create change in our communities.
|As President of the Pennsylvania division of the American Cancer Society, I spoke during an event at the State Capitol. Our advocacy efforts helped the Clean Indoor Air Act become law in 2008.|
It helps to be able to take our frustration with these various issues and turn them into opportunities for change and leadership. Getting involved in advocating on our issues can provide an opportunity to get off the daily routine hamster wheel and develop and use different skills. We are trained in family and community medicine, so engaging in pressing issues can be a great fit for our skills. Addressing and fixing these nagging problems can help us reenergize, improve our professional satisfaction and build our professional network.
Start by asking, "What am I passionate about?" "What issue is hurting my practice or affecting too many of my patients?" The basic process of identifying a problem, gathering stakeholders, setting goals, developing a communications plan and engaging the community can be applied to an array of public health issues. For example, when I was on the board of the Pennsylvania division of the American Cancer Society, a state senator had been working for years -- without success -- on a bill regarding clean indoor air.
This is where those different skills I mentioned kick in. In this effort, I was able to provide testimony in my state legislature and inform the public about the issue by working with the media. By networking, with persistence and professionalism, we were able to bring critical allies -- including the state restaurant association -- into the discussion. The addition of physician partners adds urgency and credibility to an issue. You can be that valued partner.
By pulling other physicians and medical organizations into the effort, we were able to provide powerful stories from patients whose health had been affected by smoking in public places. We were able to gather data related to the high medical costs associated with working in a smoke-filled environment. These two factors personalized the story and proved to policymakers and the public that this was a public health problem that needed to be rectified.
Finally, the Clean Indoor Air Act was signed into law in 2008, prohibiting smoking in public places and workplaces statewide.
For some, advocacy means stepping out of their comfort zone, or at least expanding it. Speaking in front of large groups can be nerve-racking, especially when cameras are rolling. But the results -- healthier communities and personal growth -- can be fantastic.
Our communities -- and our country -- need us, and not just in our practices. Being involved in these types of issues, whether locally or nationally, showcases who we are, what we do and the fact that primary care physicians are leaders in community health.
On April 7-8 in Washington, family physicians will have an opportunity to learn about advocacy at the Family Medicine Congressional Conference. Attendees will learn how to engage legislators and share stories from their practices in a way that can inspire change. I hope to see you there.
Wanda Filer, M.D., M.B.A., is a member of the AAFP Board of Directors.
Academy is Working to Define, Value Care Management
Editor's note: During the AAFP's Scientific Assembly in San Diego, a panel discussion on practice transformation generated far more questions than the panelists could answer in the time allotted. This is the second post in an occasional series that will attempt to address the issues members raised -- including the valuation of care management fees -- during the panel.
The AAFP has been advocating for years that a designated care management fee should be paid on a per-member, per-month basis as part of a blended payment model that also includes enhanced fee-for-service and performance-based incentives.
Family physicians always have done what is needed to care for our patients. We answer phone calls and e-mails, review and compile information from subspecialists, coordinate care transfers in referrals and in the hospital, handle prior authorizations, and ensure so many more aspects of making sure our patients get the care they need are covered. Although all these factors are critical for good patient outcomes, none of them generate payment for family physicians doing this important work.
The AAFP is pushing for payers to recognize the value inherent in care management services. Although we are seeing progress in this area, our efforts are complicated because of the amount of confusion -- and disagreement -- regarding what care management services should include and what they are worth. The Academy is working to define patient care management so that these services can be understood and valued appropriately.
For example, the AAFP's Robert Graham Center for Policy Studies in Family Medicine and Primary Care has conducted a literature review that considered more than 600 studies that offered evaluations of care management fees and reimbursement in care management and/or care coordination. Sixty-one articles were deemed relevant for inclusion in the review.
The range of fees found in that review was striking, with a low of 60 cents per beneficiary per month in one demonstration to a high of $444 per beneficiary per month in a congestive heart failure program. Some payers are offering $2 to $4 per beneficiary per month. Obviously, these low numbers are unacceptable.
Some disagreement exists as to what dollar amount per beneficiary per month would be most appropriate to properly value the work required to provide high quality care, but we are working on a process to help make these critical decisions.
The Graham Center's work will be used as the basis for a concise document that defines what the AAFP considers to be the essential elements of care management fees. That document will be vetted in February during a meeting of the Academy's Commission on Quality and Practice.
The next step will be for the health care advisory firm Avalere Health LLC -- which has been working with the Academy on payment issues since 2012 -- to value the AAFP's definition of a care management fee. That valuation, the definition and the underlying literature review then will be used to create a policy document on the valuation of care management fees. That document is expected to be presented to AAFP Board of Directors later this year.
When the work is done, we'll have one seamless document we can take to payers -- both public and private -- and say, "Here is what we do for our patients. This is what care management means. It should be valued and paid for, and this is a reasonable care management fee."
The document also will be used to help AAFP members evaluate contracts that include care management fees.
We'll keep you updated on our progress.
Reid Blackwelder, M.D., is President of the AAFP.
AAFP Takes SGR Message to Capitol Hill
After spending a week at the AMA Interim Meeting in National Harbor, Md., AAFP leaders met with members of Congress and congressional staff Nov. 19-20 in Washington to discuss the repeal and replacement of the sustainable growth rate (SGR) formula and other issues of importance to family medicine. AAFP President Reid Blackwelder, M.D., offers an update on the Academy's advocacy efforts in the video below.
Reid Blackwelder, M.D., is President of the AAFP.
The Good, the Bad and the Ugly … A Tale of Three Bills
Congratulations to our Louisiana, Ohio and Pennsylvania chapters for winning Leadership in State Government Advocacy Awards at the AAFP's State Legislative Conference, Nov. 1-2 in Broomfield, Colo. Our national and state legislative leaders spent that weekend discussing issues related to scope of practice, the Patient Protection and Affordable Care Act, opioid abuse and rural workforce. This annual event presented a great forum for knowledge sharing and cross pollination of legislative strategies across the states.
If you have spent any time at your state legislature, you know that actions are worth more than words, and that legislators -- despite good intentions -- may craft bills that are good, bad or just plain ugly when it comes to public health and the practice of medicine.
My state legislature is no exception. In California, we just ended the first of a two-year legislative session, which meant that all bills were chartered, killed or pushed onto a second year session for more work. This year, we saw three scope-of-practice expansion bills: one for pharmacists, one for nurse practitioners and one for optometrists.
Here is the low down on each of these bills.
The first in this triad of bills became law, allowing pharmacists to furnish self-administered hormonal contraceptives, nicotine replacement products, and prescription medications not requiring a diagnosis that are recommended for international travelers. In addition, they will be allowed to order and interpret tests for the purpose of monitoring and managing the efficacy and toxicity of drug therapies in coordination with the patient's primary care physician, including by faxing or entering results in patients' medical records. And finally, they are allowed to initiate and administer routine vaccinations recommended by the CDC's Advisory Committee on Immunization Practices.
Why, you ask, is this expansion good for family physicians? The house of medicine initially opposed the bill. However, after several thoughtful discussions with pharmacists, the bill was amended to bring pharmacists into a patient-centered medical home model, which allows them to become a part of the health care delivery team in their area of expertise. This will result in more coordination between a patient's primary care physician and pharmacist, and it will decrease the barriers our patients may face in obtaining certain treatments.
It is always good when each member of the health care team is participating to the maximum that their training allows.
In stark contrast to the pharmacists, the nurse practitioner scope bill exemplified how bills should not be worked through the legislature. After years of working with physician organizations -- including by supporting several prior bills that were passed to allow increased scope of practice for nurse practitioners within a collaborative agreement structure -- nurse practitioners tried to pull a fast one on the legislature this year. Nurse practitioners argued that they can fill in primary care shortage gaps where family physicians cannot or are not willing to do so.
However, physician organizations successfully argued to the legislature that independent nurse practitioners would not improve quality and may adversely affect patient safety. This argument was further augmented by data provided by the California AFP showing that independent nurse practitioners would not improve primary care misdistribution in our state.
To their credit, state legislators heeded our message, and the bill failed to pass out of committee. By focusing on obtaining independence, nurse practitioners sought to further fragment the health care delivery system and to further undermine the cornerstone of health care reform by putting their financial self-interest above coordinated, patient-centered care. The nurse practitioner bill simply highlighted deficiencies in our fragmented health delivery system without providing a workable solution to the primary care workforce shortage.
The last of the three scope bills would have allowed optometrists to diagnose and treat all conditions presenting with ocular manifestations. It would not only allow them to initiate treatment of chronic diseases -- such as diabetes and hypertension -- but also complex conditions such as systemic infections and autoimmune diseases.
Needless to say, the house of medicine was strongly opposed to this bill. Yet, the author, an optometrist himself, would not take on any amendments to his bill. He was able to move this bill out of the committee that he chaired. But facing a high likelihood of defeat on the floor, he pulled the bill for further work next year.
I had an opportunity last week to participate in a community chronic disease forum hosted by the author of this trio of scope bills. After some careful repartee sitting around a small table, I came to realize that he, like many, if not all, legislators, drafts bills with the best of intentions. In this vein, it would be in our best interest as family physicians to keep close tabs on all our legislators and develop relationships with them. Successful advocacy takes good will and influence to bring about change.
So, what can you do? You can join the thousands of family physicians who have signed up to become key contacts for advocacy. Key contacts receive regular updates from the Academy's government relations staff on issues important to family medicine, and they occasionally are asked to reach out to their legislators by phone or e-mail to tell their stories and let lawmakers know how issues are affecting family physicians and our patients.
For those who aren't able to get directly involved with advocating for family medicine, you can still make a difference by supporting FamMedPAC, the Academy's federal political action committee. FamMedPAC enhances AAFP advocacy efforts by making direct, nonpartisan contributions to candidates for the U.S. House of Representatives and the U.S. Senate. FamMedPAC provides AAFP members with an easy way to get involved in the political process and to support candidates who support family medicine.
With mid-term elections approaching, you'll be helping to improve the delivery of health care in this country, and helping put family physicians on equal footing with the powerful insurance companies and trial lawyers. It's one way to ensure our voice is heard on Capitol Hill.
Jack Chou, M.D., is a member of the AAFP Board of Directors.
The Challenge of Working With Health Plans
Every year, AAFP leaders and staff members meet with several of the nation's largest health insurance companies to discuss payment and other issues important to family medicine. Last week at the Academy's headquarters in Leawood, Kan., we met with UnitedHealthcare (UHC), and it provided us with an opportunity to express our concern regarding UHC's recent move to make significant cuts to its Medicare Advantage provider network just a few weeks before Medicare open enrollment.
UHC representatives told us they made the decision because in some markets their networks were significantly larger than their competitors, who already have taken similar steps to reduce the size of their networks. They felt they needed to “optimize” those networks to align with their competitors. A narrower network, UHC's representatives said, will allow the company to invest more in certain practices through incentive payment programs and also will eliminate unwanted variations in care.
Regardless of whether UHC's business decision was good for the insurer, it was poorly timed, catching physicians and patients off guard during a critical time of year. We stated again that decisions that affect such a significant number of patients and physicians -- up to 18 percent of primary care physicians who contract with UHC in some markets -- should be communicated to the Academy in advance so we can alert our chapters and prepare our members.
According to UHC, the company did not remove patients from coverage altogether. Instead, it is working to move them to other practices in their network. As we told them, however, cutting large numbers of physicians could create capacity and access issues in some markets because many of our members do not have the ability to significantly increase their patient panels.
Despite the above matter, we were able to find common ground on some important issues. For example, United agreed that we need a more continuous dialogue at the staff level, and we identified a few issues that we will be actively engaged in with UHC moving forward.
UHC representatives also said they want to work with the Academy -- as well as other payers -- to standardize and align quality measures, which would vastly reduce the reporting burden physicians face. They also want to hear more about the new evaluation and management codes for primary care physicians that the Academy has recommended to CMS.
Care management fees are another issue we will be discussing with UHC, which has publicly stated that it plans to have at least 50 percent of its provider network working under value-based contracts, rather than strictly fee-for services arrangements, by 2015.
Fee schedules that pay less than Medicare in some regions also were a topic of discussion. We emphasized that other payers in these areas do pay above Medicare rates, and to be viable, family medicine must be valued appropriately.
Working with health plans can be challenging, but we can build on common issues that keep the patient's best interest as our primary focus. We will stay engaged and continue to promote the value of family medicine.
Robert Wergin, M.D., is President-elect of the AAFP.
When Congress Is Ready to Listen, We're Ready to Talk
What a week this could have been.
making my first visit to Washington as the AAFP's President-elect, but the
agenda is a little thin. My schedule for Tuesday and Wednesday shows a trip to
the White House, meetings with legislators and staff from both houses of
Congress -- and both political parties -- as well as discussions with leaders
from three federal agencies.
like most Americans, I'm waiting for federal employees to go back to work and
for members of Congress to stop pointing fingers and start solving problems. The
perpetual problem we had hoped to discuss with legislators -- one Congress
created -- is the sustainable growth rate (SGR) formula. For the first time,
Congress actually seemed to be taking clear steps toward replacing the flawed
Medicare formula before the government shutdown Oct. 1. In July, the House
Energy and Commerce Committee unanimously approved a Medicare physician payment
bill that would
abolish the SGR. The Senate Finance Committee is expected to release its own
version, or at least it was before things ground to a halt last week.
Without congressional intervention, the SGR will trigger a nearly 25 percent reduction in Medicare physician payments Jan. 1. Rest assured, we will reschedule our meetings with legislators and continue our advocacy efforts as soon as Congress stops is intransigence.
In addition to our meetings with legislators, Academy leaders were scheduled to meet this week with representatives from
- the Agency for Healthcare Research and Quality to discuss primary care research;
- the CMS Innovation Center to discuss studies related to the patient-centered medical home model; and
- the Office of the National Coordinator for Health Information Technology to discuss meaningful use regulations.
With roughly 800,000 federal workers furloughed, those meetings won't happen this week either.
I am disappointed but not discouraged. There will be another day to deliver family medicine's message.
How will the shutdown affect our patients and our practices? Will the prospect of resolving the SGR again be delayed by the process of resolving our budgetary crisis?
For now, there are a more questions than answers. In the past few days, taking care of a critically ill 2-year-old in my ER and seeing patients in my office has made the problems in Washington seem secondary, at least for a few precious moments. We are on the right path, creating access for our patients and providing high quality primary care one patient at a time.
We will get through this, and when Congress is ready to listen, we definitely will be ready to talk.
Robert Wergin, M.D., is President-elect of the AAFP.
Make a Difference Beyond the Exam Room: Join an Academy Commission
During my residency, I treated a woman -- who we'll call Maria -- three times for chlamydia infection. Each time I treated her, I urged her to tell her partner to come see me -- or to see another physician -- and get treated so that Maria wouldn't get infected again.
However, her partner didn't have insurance, had no regular access to care and was reluctant to see a physician while asymptomatic.
I wanted to do more for Maria, but what could I do?
A year later I was in Springfield, Ill., as a member of the Illinois AFP's Governmental Relations Committee, lobbying state legislators about expedited partner therapy, which would allow me to give Maria (and other patients like her) extra medication and instructions for her partner. This legislation passed a few years later and now is a regular part of my practice to prevent reinfection in my patients and the spread of sexually transmitted diseases in the population in general.
It was important for me to be part of my state chapter's advocacy efforts at that time, and later, I was part of the AAFP's Commission on Governmental Advocacy, which allowed me to advocate on the federal level on behalf of members, patients and communities.
Your patients and your practice likely are facing their own issues. What can you do to make a difference?
Nominations now are open to state chapters for the AAFP's national commissions, and there is a commission to match any family physician's passion. Whether advocating for federal policy on payment reform, influencing the future of education or updating the AAFP's official clinical recommendations, we all can do more for our profession, patients and communities by being bold champions and active voices as members of one of seven AAFP commissions.
To be considered, your chapter must
provide the following:
- letter of nomination,
- typed commission nomination form,
- passport photo and
- completed online conflict-of-interest form.
If you are interested in participating in the Academy's decision-making process, contact your constituent chapter before the Oct. 15 nomination deadline. You can find more information about the process online.
In addition to 21 physician positions available on the commissions, the Academy also must fill four slots on its AMA delegation and select a nominee for the American Board of Family Medicine Board of Directors.
These are great opportunities to contribute to our specialty, share your perspective and make your voice heard.
Ravi Grivois-Shah, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.
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