Time for Congress to End 20-year Ban on Gun Research
If I told you the U.S. government stopped funding research into one of its most pressing public health concerns, you might conclude that the problem had been solved. But that would be incorrect. When a homegrown terrorist shot more than 100 people this weekend in an Orlando nightclub, it was the 176th time that the United States had experienced a mass shooting (four or more people injured) in a year that is not even half over.
Every year, more than 33,000 Americans die because of gun violence and more than twice as many are injured. Yet for two decades, Congress has restricted the CDC from conducting research related to gun violence.
The AAFP and more than 100 other stakeholder organizations sent a letter to Congressional leaders in April, urging them to end the ban on gun violence research. Today we are again calling on Congress to address this important issue.
Research into gun violence could provide us with valuable information about protecting children from accidental shootings, suicide prevention, the impact of various state gun policies and more.
As these events continue to happen -- from Newtown, Conn., to Fort Hood, Texas, and San Bernadino, Calif. -- there will be opportunities for physicians to step forward and ask what we can do differently. Ending the ban on research would be a wise first step.
I'm at the AMA meeting this week in Chicago, and the AAFP and other physician organizations are pledging to do what we can to heal our nation. I am proud of my colleagues at the American Academy of Pediatrics, American College of Physicians, American Congress of Obstetricians and Gynecologists, and American Psychiatric Association who joined with me to share the message of hope and healing below. Our nation must have an honest and frank discussion on reducing both the tendency and capacity for violence in our society. Hopefully, now is that time.
Wanda Filer, M.D., M.B.A., is president of the AAFP.
Get the Candidates Talking About Family Medicine Issues
After months of buildup, Iowans like me finally voted in our caucus this month.
Presidential candidates had been meeting with voters in the Hawkeye State for the past year to explain how they would lead the country (and how they would do it better than their opponents). The experience for me started last April during a meeting with Sen. Marco Rubio, R-Fla. I was invited by a friend, and we sat around a table with 15 others to hear Rubio's thoughts and to ask questions.
Of course, I asked about health care, and Rubio said he would repeal and replace the Patient Protection and Affordable Care Act (ACA). I asked what he would replace it with, but his response was vague. Since that meeting, Rubio has reiterated his desire to get rid of the ACA, but he still has not offered a specific plan for a replacement.
This is a frustrating part of the process, and it certainly is not unique to one politician or one party. The candidates like to repeat their favorite soundbites, but they rarely offer detailed solutions. Too often, discussions on the campaign trail are about getting elected rather than solving real problems.
In Iowa, candidates continued to meet with voters in increasingly large groups across the state as their campaigns went on. We were bombarded with TV and print ads. And for the unfortunate families that still have landlines, the phone calls were frequent. In recent weeks, our local newspapers covered every candidate visit and recapped what was said.
We Iowans take this process seriously; we try to stay informed and influence where we should go as a country. A record 186,874 Republican voters participated, while the Democrats drew 171,109 caucus-goers. That equates to a turnout of 15.7 percent of eligible voters.
It's worth noting that in states with primaries, polling stations typically are open throughout the day, and people can vote at their convenience. A caucus requires attendance and registration at one specific time of day, so voter turnout of nearly 16 percent is remarkable.
During the Republican caucus that my wife and I attended, roughly 450 people participated. Representatives for each candidate spoke for three minutes or less -- except Rubio, who spoke for himself -- in one final opportunity to reach voters. The speeches were respectful and in stark contrast to the contentious discussions and often unsavory behavior we have been subjected to in the candidates' televised debates.
Too often we can't talk about politics in our society. Many issues are polarizing, and people aren't willing to listen to what others have to say. Before the caucuses, my wife and I attended a discussion on civility. The speakers talked about things such as how to discuss controversial topics without being judgmental and how to defuse a tense situation. I think we were able to use that in discussions with our friends, neighbors, and colleagues to bring back meaningful political discussion. Just because someone disagrees with me does not make them wrong or uncaring. It simply means they have a different view on how the problem should be solved. We need to be able to work together to solve our problems, both locally and nationally.
We are done with the presidential candidates here in Iowa. Our state has only six electoral votes, so we likely won’t see them again before Election Day.
Many of you, however, will still have opportunities to vote in your state's caucuses and primaries. You can make connections with candidates or their staff members and talk with them about the problems our practices and our patients face -- issues that deserve more than their well-practiced talking points. Make your voice heard, and make your vote count.
Robert Lee, M.D., is a member of the AAFP Board of Directors.
Family Medicine: The Force Awakens
I recently saw the latest Star Wars movie with my family, and I could not help but compare the plight of the Jedi to that of family medicine. With the many challenges facing us as family doctors -- payment reform, endless paperwork, putting patients back at the center of care, electronic health records and recruiting the brightest young family physicians -- it often seems like the good in all we do is menaced by the darkness of partisan politics, back-room lobbying and catering to special interests. But like the young Jedi Knights, if we are attuned to the Force, we can wield its power.
In medicine, the Force is the collective voice that speaks for our patients. Physicians use it when we defy the status quo and pressure the government, insurance companies, hospital corporations and Pharma to heed our concerns because we are the front line of medicine.
In The Force Awakens, we cheered for the Resistance, a group of passionate people who rally together to reclaim the good in their world. In the world of medicine, we got a great start on reclaiming the good when we won repeal of the Medicare sustainable growth rate last year, and CMS' announcement several months later that it plans to end meaningful use as we know it could be a good next step. But it will take determination to keep this momentum going so future payment models and new ways of measuring quality health care support our work as physicians.
Another family physician who covers OB call with me recently said, "I honestly know how much my voice matters. I know that I should be more present advocating on behalf of my patients, but I don't have the energy or the time. I can barely keep afloat in my small, rural practice."
He's been practicing for more than 20 years, and now he feels burdened by meaningless work to the point of exhaustion. He knows there is a sacred component to walking with patients through their important life moments -- a delivery, seeing a child grow to maturity, working through chronic addictions and illness or the end of life -- but he feels pressured to reduce all that to clicking boxes and being "productive." We mustn't allow the business of medicine to pull us from what we as physicians vowed to do, which is care for patients, and we must find the energy to fight for what matters.
I know that the doctors who the AAFP and our sister organizations represent are looking for their representatives to press CMS, Congress and others harder to enact meaningful change. Our practicing physicians deserve it and so do our patients. But success won't come if that burden rests only on the shoulders of a few. Everyone has to play a part to reclaim medicine and resist the bureaucracy that tries to steal the joy of practice from us.
Our members need to become emboldened. Each individual within our own Resistance has a special role to play. If we as family doctors do not speak to our legislators, then we have no ground to stand on. If we do not take the time to educate our communities about the things that make our practice of medicine difficult, then we lose their trust. If we do not continue to press the government by developing new and innovative practice models, then we will continue to fall prey to meaningless bureaucracy.
Our collective voice and our individual stories have weight and meaning. We can become the doctors we wrote about in our medical school personal statements. We have the power and the right to protect our practices, our patients and our joy of medicine. We have to remember that without us, the system of medicine fails. Let us not be bullied.
Colleagues, I urge you to contact your legislators and tell them your story. Stop accepting half-done business deals from the hospitals you work with. Take the time to write to the local paper. Contribute to FamMedPAC so it can continue to back candidates who support family medicine. Most importantly, don’t stop believing in the power we have as healers of our nation.
As a wise woman says in the movie, "Close your eyes. Feel it -- the light. It's always been there. It will guide you."
Marie-Elizabeth Ramas, M.D., is the new physician member of the AAFP Board of Directors.
Safeguard Your Sanity -- and Your Specialty -- With a Bold 'No!'
One day I walked into my home after a post-call clinic, having delivered a baby with dystocia and admitted a terminal cancer patient into hospice. It was a long, long call.
My daughter ran to my legs and hugged them, my son asked what was for dinner, and the newborn let it be known that she needed to nurse. I gave my husband a quick hug and kiss, thinking about how I was going to give my patients the quality care they need when my clinic has been paralyzed by our hospital's decision to implement a new electronic health records system without seeking input from physicians in its outpatient clinics.
This conundrum, I am sure, is common among physicians. We are conditioned to multitask, go the extra mile and do it without a grimace. As new physicians, we know all too well the pressures placed on us as medical students and residents to accept more work and excel. Despite working long hours with inadequate sleep, we are programmed to overachieve.
I am four years out of residency, working as a medical director of a rural health clinic, dealing with meaningful use and quality measures while also being a wife and mother of three, and I realize that without boundaries, I am at risk of burnout.
Think about it: In light of the changes occurring in our health care system, we new family doctors are groomed to be prime assets not only to our patients but also to our communities. We understand that, and we innately carry the responsibility of leadership. It is how we are made.
With that in mind, however, I find myself redefining leadership as a means to make a deliberate impact. For me, it has become a much more thoughtful process than it once was. For the first time in my career, I have the ability to tailor my experience and maximize my talents and gifts so that I can become the type of doctor that I once wrote about in my medical school essays.
With this new approach, I see that I must be willing to take a stand to make a difference. Most importantly, there is power in saying no.
Say no to things that do not feed your vision. Medicine, especially family medicine, is as much a calling as it is a job. Although not everyone is passionate on a national level, we each have an impact within our unique settings. But without vision, we can fall prey to spreading ourselves too thin, leading to burnout. With vision, it is easier to say no to demands made by insurers, employers, clinic managers and others.
Before entering medical school, I always envisioned myself working within the family unit and caring for people worldwide. I didn't know at that point that the image of medicine that motivated me to excel was that of a family doctor.
I thrive by providing quality care to all members of my community, not simply those who can afford it. Now, I take care to prioritize my work with my life's vision. The more that vision crystalizes, the more centered I become in life.
Say no to interactions that do not respect you for the asset that you are. We are valuable revenue builders for our health system, and without primary care physicians, the health system could not function. Although our self-worth goes much deeper than our bank accounts, given the years of both social and financial sacrifice we've made, the way we are compensated is an important reflection of respect.
I work as an independent contractor for a hospital-owned clinic, so I have had to develop confidence in my professional worth that I draw upon during contract negotiations. We women often are paid less than our male colleagues, but it is important to find a work environment that aligns with your value. I am no longer afraid to ask for fair compensation.
Beyond money, it is imperative that we guard our time, which is so valuable. It is no secret that family doctors are the backbone of the medical system. We need to be bold enough to say no when we are asked to do work that is not equitable compared to that our colleagues are asked to do. In contract negotiations, we need to be willing to walk away from a bad deal. We need to demand what we value -- money, time off, quality improvement, professional development or educational allowances.
We need to be bold enough to say no to outside sources that attempt to dictate how we practice medicine. We are bogged down by prior authorizations, Physician Quality Reporting System requirements, filing scripts for durable medical equipment and supplies, or even finding a specialist for our patients who lack insurance. It will only get worse if we as a collective don't take a stand against the administrative hassles that drag us away from our patients.
Part of our job as healers is to protect the sacred space between doctor and patient. The only way we can do that is by being a presence our local, state and national leaders know and respect. Until we are recognized for the immense role we play in health care, the pressures of the system will continue to fall on our backs.
When we are ready to hone in on our time, we gain the ability to say yes to more fulfillment. Let's say yes to less burnout. Let's say yes to fair compensation. Let's say yes to better quality of life. Let's say yes to better patient care. Let's say yes to the freedom and joy of serving in such a noble calling.
Marie-Elizabeth Ramas, M.D., is the new physician member of the AAFP Board of Directors.
AAFP to Congress: Primary Care Plays Vital Role in Mental Health
It's no secret that among health care employers, family physicians have been the most highly sought-after type of physician in this country for the past decade. But what some may not know is that psychiatrists are close behind, ranking as the third-most highly recruited specialty.
The shortage of psychiatrists is so acute that nearly 4,000 places in this country have been designated as mental health care health professional shortage areas It would take more than 2,700 mental health professionals to adequately address the problem in these areas where, on average, only half of the need for mental health services is being met.
With a dearth of these subspecialists, primary care physicians provide the majority of mental health services in the United States. Unfortunately, payers and policymakers often are not attuned to this reality. That lack of awareness creates an additional barrier for patients who need help because of the difficulties primary care physicians face regarding payment for mental health services.
Last week, AAFP leaders were on Capitol Hill to speak with legislators and congressional staff about a number of issues concerning family physicians, including payment, meaningful use, funding for primary care programs, the newly created Primary Care Caucus and mental health reform. On Nov. 4, AAFP Board Chair Robert Wergin, M.D., and I met with Sen. Bill Cassidy, M.D., R-La. -- a gastroenterologist -- and Joe Dunn, the legislative assistant to Sen. Chris Murphy, D-Conn.
Sens. Murphy and Cassidy are the authors of S. 1945, the Mental Health Reform Act, which is one of two major mental health reform bills under consideration by Congress. The other, H.R. 2646, or the Helping Families in Mental Health Crisis Act, was introduced in the House by Rep. Tim Murphy, Ph.D., R-Penn., who is a clinical psychologist.
The AAFP has not yet endorsed either bill, but both include policies the Academy supports, including the integration of primary care and behavioral health. During our meetings with Cassidy and Dunn, we voiced our support for such integration while also emphasizing the important role family physicians play in mental health care and the need to eliminate barriers to care created by inadequate reimbursement in primary care settings.
Too often, payers have carved out mental health care as the purview of psychiatrists and psychologists despite the fact that nearly one-third of primary care visits by adults 75 and younger involve mental health issues.
Faced with payers who won't pay adequately -- if at all -- for mental health services, primary care physicians have been forced into creative billing. Rather than submit a code for depression that is likely to be rejected, primary care physicians often code for the symptoms of the disease instead and get paid for things such as treating insomnia or fatigue. Unfortunately, this scenario perpetuates the fallacy payers have bought into, because claims data thus indicate far less mental health care is provided in the primary care setting than is actually given.
Furthermore, the combination of inadequate reimbursement, physician shortages and other factors leads to shortcomings in both diagnosis and treatment. Mental Health America estimates that only 49 percent of patients with clinical depression and 52 percent of those with generalized anxiety disorder receive treatment.
The bill that Sens. Murphy and Cassidy are sponsoring would make an important change to Medicare and Medicaid, allowing patients to access mental health and primary care services at the same location on the same day. The bill also would allow for the creation of grants related to models of care, early intervention and more.
It remains to be seen what will transpire with either of these bills, but our recent meetings made it clear that the Academy plans to play an active role in the debate on this important issue.
John Meigs Jr., M.D., is the president-elect of the AAFP.
Physician Burnout: The AAFP Is Winning Battles For You
I have long been concerned about the impact of physician burnout on the health of our colleagues, our profession and ultimately our patients. Most of us realize that the issues of physician burnout are complex and involve factors related to personal resiliency (which can be addressed at the individual level), practice management (which must be addressed at the system level) and regulatory burdens (which must be addressed at the legislative level).
We all know burnout is a huge problem at a time when primary care physicians already are in short supply. Earlier this year, I wrote a blog noting that more than 40 percent of U.S. physicians experience at least one symptom of burnout (loss of enthusiasm for work, feelings of cynicism and a low sense of personal accomplishment). In that post, I wrote about the importance of managing stress, seeking support and removing the stigma associated with burnout.
Since then, additional blogs and editorials published by AAFP News have addressed personal resiliency. One blog post discussed the need to provide residents with resources to recognize, treat and prevent burnout. And we also have confronted the issue of physician suicide.
| AAFP President Robert Wergin, M.D., testifies about electronic health records during a Senate Health, Education, Labor and Pensions Committee hearing.
Although I am glad to see the increased awareness of burnout, I remain dismayed that many of the conversations about issues related to burnout reflect a sense of hopelessness. It is disheartening to realize the sense of frustration of some members who think the Academy isn’t willing or able to help. That being said, I can appreciate that our members on the front lines of primary care may be so busy in practice that they are unaware of all the activities that the AAFP is undertaking on our behalf.
The Academy is, in fact, working to change many of the drivers that lead to burnout, including payment reform and administrative burdens. Here's a look at the progress we've made on some critical issues this year.
The AAFP repeatedly called on CMS to ease the administrative burden associated with meaningful use. In April, CMS included two changes the AAFP advocated for in a proposed rule regarding stage 2 -- shortening the attestation period to 90 days and making requirements related to secure messaging with patients more attainable.
In March, the agency published it proposed rules for stage 3. The Academy pushed back, arguing that implementation should be delayed. Last week, the Senate Health, Education, Labor and Pensions (HELP) Committee agreed, and its chairman, Sen. Lamar Alexander, R-Tenn., called for a delay in enforcement of stage 3 requirements, which are scheduled to take effect in 2017.
The HELP committee has heard from both AAFP President Robert Wergin, M.D., and family physician David Kibbe, M.D., M.B.A., in recent months. Wergin spoke about the burden of electronic health records and the need for interoperability at a March hearing, and Kibbe spoke this month about business practices that impede information sharing.
The Academy also has seized opportunities for public comment and written letters to federal agencies in recent months regarding meaningful use stages 2 and 3 and the Office of the National Coordinator for Health Information Technology's interoperability roadmap. All of this correspondence has stressed the need for improvements in interoperability.
Finally, the Academy's Alliance of eHealth Innovation is conducting a study on the benefit and burden associated with meaningful use and is expanding its work on improving health IT usability and implementation.
For years, family physicians fought for the repeal of the Medicare sustainable growth rate (SGR), the faulty formula that repeatedly threatened to cut physician payments. On April 14, Congress finally passed the Medicare Access and CHIP Reauthorization Act, repealing the SGR formula. The law will provide needed payment stability in the Medicare program with several years of modest payment increases for physicians. The law also funds for two years the Children's Health Insurance Program, the National Health Service Corps, the Teaching Health Center Graduate Medical Education program and the federal community health centers programs.
The Academy will continue to communicate with HHS and CMS as they develop new payment models.
CMS announced this month that it will provide greater flexibility -- a one-year grace period from claims denials and audits -- during the transition to ICD-10 billing codes. The AAFP was one of numerous medical organizations that had written to CMS in March, urging further testing and risk mitigation.
Advance care planning
CMS recently released its proposed 2016 Medicare physician fee schedule. It discusses the establishment of advance care planning codes -- which the Academy has advocated for -- that would pay physicians for our expertise and time in assisting patients and their families with advance care planning services.
The Department of Veterans Affairs (VA) announced in March that roughly twice as many military veterans will be eligible to see a physician who is not affiliated with the VA under a new standard for measuring the distance from a veteran's home to the nearest VA facility. The AAFP pushed for that change while also expressing continued concerns about VA payment rates being less than Medicare rates.
This spring, CMS proposed -- at the Academy's behest -- covering HPV testing in conjunction with a Pap smear test (once every five years for asymptomatic Medicare beneficiaries 30 to 65 years old who wish to extend the screening interval).
I know many challenges and frustrations remain. The increasing complexity and administrative burdens being placed on family medicine have been piling up for years. The Academy is committed to stopping this landslide.
The AAFP is continually communicating with Congress and federal agencies to ensure they know about these important issues. Legislators and policy makers must understand that transforming health care will require a strong family physician workforce, which in turn requires improving the health and wellness of our colleagues, and our practices, by decreasing the regulatory and system burdens that cause physician burnout.
Lynne Lillie, M.D., is a member of the AAFP Board of Directors.
Advocacy Agenda Shifts With SGR Behind Us
Last week, I attended the Family Medicine Congressional Conference (FMCC) in Washington, and for the first time in 17 years, we did not have to lobby legislators and congressional staff about the Medicare sustainable growth rate (SGR) formula.
We did thank legislators who voted overwhelmingly to repeal the fatally flawed SGR. Now we're moving into a post-SGR world. This doesn’t mean everything is fixed, but it does allow us to focus our energies and our voices on addressing other much-needed changes in our health care system, including payment reform, graduate medical education reform and truly valuing primary care.
© 2015 Michael Laff/AAFP
Here I am meeting with Sen. Sheldon Whitehouse, D-R.I., (center) along with members of our Rhode Island delegation: Roanne Osborne-Gaskins, M.D., Keith Callahan, M.D., (second from right) and resident Jason Kahn, M.D. (far right). Hundreds of family physicians met with legislators and congressional staff last week during the Family Medicine Congressional Conference.
FMCC is an inspiring event. I looked around the room and saw remarkable people who I have “grown up with” during six years on the AAFP Board of Directors, including three as an officer. It has been rewarding to see family physicians who I installed as state chapter presidents developing as leaders.
These meetings also affirm one of the core attributes of family medicine -- it really is about relationships. Attending an Academy meeting is like coming to a family reunion. The biggest frustration for me is not having enough time to spend with all the people with whom I wish to catch up. (So, if I didn’t get to you this time, I’m sorry and I look forward to our next meeting!)
FMCC has a different focus than other occasions when AAFP officers are on Capitol Hill advocating for our specialty. The Academy staff does an incredible job providing information to chapter leaders and creating opportunities for legislators to address critical topics.
I was honored that my own congressman, Rep. Phil Roe, M.D., R-Tenn., came to speak at one of the plenary sessions. Although he’s an OB-Gyn, he told stories just like we all do to make his points. He’s excited about moving away from the contentious SGR debates and toward new issues. He has appreciated that near the end of the SGR process, physicians learned to speak with one voice and more clearly about health care reform. He understands the value of primary care, and, in the words of one of our attendees, “He gets it.” More and more of our legislators are getting the message about primary care, and its important role in our health care system. They are beginning to understand that the term “primary care physician” is best associated with the specialty of family medicine, and that we need to make many more changes to link value to this recognition.
At FMCC, we addressed the fact that legislation and regulations need to value primary care in practical and immediate ways. For example, we need to push to remove co-pays from chronic care management fees to remove the hurdle that patients and family physicians face in obtaining and providing needed chronic care coordination, and in accessing primary care.
We need to be sure that the definition of primary care is clearly understood, especially when medical schools are still touting, sometimes in a misleading manner, high graduation rates of primary care physicians. We need to make sure that when people are praising primary care, and vowing to value it, that we’re all on the same page in this regard, and the foundational component of family medicine as the primary care specialty is understood.
Although we are pleased that the National Health Service Corps and the Teaching Health Center Graduate Medical Education program have been funded for two more years, we need to continue to push for these vital programs to be recognized as the successes stories they are. Although they were extended by the same legislation that repealed the SGR, they should be permanently removed from the budgetary chopping block.
GME reform was emphasized as a vital issue during last week's event. We’re challenging legislators to look at ways of increasing transparency regarding GME funding and demanding accountability for the $13 billion put into the medical education system each year. The current system is not producing the workforce we need despite the tremendous investment.
It was refreshing to see things come together regarding the way that families and communities care for each other. FMCC featured a plenary about family caregiving. One of our requests of the legislators we met with was that they join the recently formed Assisting Caregivers Today caucus. This effort creates an opportunity for many stakeholders to work together to find ways to care for people outside of hospitals. In so many ways, this echoes our call for people to receive right care in the right place at the right time from the right person. Ultimately, the best answer for providing this care is through team and community-based care.
Finally, I was honored to join our state chapter leaders during visits with their state legislators and congressional staffers. I was incredibly impressed with the Oregon chapter’s discussions with staff members of Sen. Ron Wyden, D-Ore., the ranking democratic member of the Senate Finance Committee. Melissa Hemphill, M.D., who is just two years out of residency, took the lead during this meeting, and she did as good a job as any AAFP officer or other veteran advocates in articulating our perspectives.
I also joined the Rhode Island delegation for a meeting with Sen. Sheldon Whitehouse, D-R.I. He impressed me with his understanding of medical issues, especially as they related to his state. Roannne Osborne-Gaskin, M.D., and Keith Callahan, M.D., clearly expressed the challenges they face in their practice settings in that state. I was impressed with the good work that our state leaders are doing.
It's worth noting that FMCC came right on the heels of the Academy's Annual Chapter Leader Forum, which offers training in areas such as advocacy, communication and more. The process of leadership development and relying on the informed voices of state leaders is such a key aspect of making change. As an Academy, we continue to advocate for our patients and practices.
There is still much work to be done, but I see several doors opening that had been closed for so long. Thanks for all you do, and keep up the great work.
Reid Blackwelder, M.D., is Board chair of the AAFP.
Take a Bow, Physicians -- You Defeated the SGR
No more patches.
No more payment cuts looming on our calendars.
We did it!
When the U.S. Senate passed the bipartisan Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act, or MACRA, tonight, more than a decade of frustration with and instability in the Medicare program ended. The legislation contains many provisions that have long been supported by AAFP members, most notably repeal of the Medicare sustainable growth rate (SGR).
In recent weeks alone, AAFP members weighed in with about 5,000 letters or phone calls to legislators, urging them to support this important legislation.
Thank you for making your voices heard. The long-awaited action by Congress retroactively negates a 21 percent cut in Medicare payments that took place when the most recent patch expired March 31.
How did we get to this point? Congress created the SGR formula as part of the Balanced Budget Act of 1997 as a way to determine annual updates to the Medicare physician fee schedule. By 2002, the SGR was mandating reductions in physician payments, and we began a nearly annual dance of threatened pay cuts and congressional patches.
In all, Congress used 17 temporary patches to avoid payment cuts at a total cost of nearly $170 billion. The longstanding uncertainty regarding Medicare payments has had adverse effects on the long-term health of our practices, as well as on patients' access to care. In a 2013 survey of Academy members, 9 percent of respondents said they had stopped taking new Medicare patients in the past year, and 10 percent said they had stopped taking new Medicare patients more than a year earlier.
Still, nearly 80 percent of AAFP members continue to take new Medicare patients despite years of uncertainty, and the Senate's vote on MACRA is a victory for us and our patients. In addition to repealing the SGR, the legislation will establish an alternative set of annual payment updates. The legislation also extends funding for critical programs that affect primary care:
- community health centers;
- the National Health Service Corps; and
- teaching health centers.
MACRA also addresses another key issue that affects our practices and the health of our patients. The legislation makes interoperability of certified electronic health records a national objective. HHS will be required to establish interoperability metrics next year to measure progress toward achieving that goal by the end of 2018.
The passage of this bill illustrates the value of primary care and the strength of our voice. Thank you for standing with family medicine.
Robert Wergin, M.D., is president of the AAFP.
On the Hill: Academy Promoting Family Medicine's Perspective
The AAFP Board of Directors spent a day lobbying last week on Capitol Hill. We each met with legislators and congressional staff from our own states, meaning that the offices of representatives and senators from more than a dozen states heard about issues critical to primary care.
Although the conversations undoubtedly varied, many of the topics covered in our meetings were the same. We asked Congress to do the following:
- Avoid the 21 percent Medicare payment cut scheduled to take place April 1 and work to repeal and replace the flawed sustainable growth rate formula;
- Reauthorize and adequately fund the Teaching Health Center Graduate Medical Education program, which is responsible for training more than 500 residents at 60 residency programs in two dozen states;
- Reform graduate medical education funding; and
- Increase Medicaid payments for primary care.
| Photo courtesy Architect of the Capitol
Rep. Robin Kelly, D-Ill., whose husband is a physician, was receptive to my message about the need for action on these pressing issues. And, although members of the Board covered a lot of common ground about payment and education in our separate meetings, my meeting with Kelly also offered a chance to discuss important clinical issues.
Kelly serves as chair of the Congressional Black Caucus (CBC) Health Brain Trust, which collaborates with stakeholders in the health care system to address issues of health equity. Some of the Health Braintrust's priorities overlap with those of the AAFP, including addressing social determinants of health, expanding access to primary care and tackling health disparities.
In addition to the CBC's legislative efforts to address health equity, the group's Health Braintrust supports research related to how education, economic stability and neighborhood affect a person's health. The group also hosts health fairs across the country and annually hosts a fall health policy event organized as part of the CBC's Annual Legislative Conference, as well as a spring forum on health disparities. It also holds monthly meetings with health advocates and policy experts.
When opportunities present themselves to promote primary care and advocate for our practices and our patients, we have to seize those opportunities. The CBC was seeking feedback on a number of health issues, and the Academy provided this group -- which includes nearly 50 members of the House and Senate -- with as much information as possible.
In addition to my meeting with Kelly on Feb. 25, Academy staff participated in a Feb. 27 Health Braintrust roundtable meeting that included Kelly, congressional staff, advocates and representatives from the American Hospital Association, Morehouse School of Medicine, the National Medical Association, the National Urban League and others.
With such a diverse group, the latter meeting covered a wide range of topics, including access issues associated with health care reform and technology. In addition, the forum addressed public health issues such as federal nutrition standards, healthy communities, health disparities and violence prevention. The Health Braintrust sought feedback on its agenda and how to address these issues. The group plans to continue to engage stakeholders and generate short-term and long-term goals for health priorities, and we were eager to provide family medicine's perspective.
For our issues to be addressed, it's important for legislators to hear from their constituents. It's worth noting that hundreds of family physicians from across the country will be in Washington May 12-13 for the Family Medicine Congressional Conference. That event offers a full day of advocacy training followed by a day on Capitol Hill. It's not too late to lend your voice.
Javette Orgain, M.D., M.P.H., is vice speaker of the AAFP Congress of Delegates.
A Day On the Hill: Meaningful Use, Medicaid, Medicare and More
There is a long list of time-sensitive issues facing primary care -- meaningful use, impending Medicaid cuts, the Medicare sustainable growth rate (SGR) formula, and funding for graduate medical education, just to name a few -- and on Nov. 20, AAFP officers had a chance to discuss all of these concerns (and more) with legislators, congressional staff and representatives from federal agencies.
Here's an overview of the whirlwind day I spent on Capitol Hill with AAFP President Robert Wergin, M.D.; Board Chair Reid Blackwelder, M.D.; and Academy staff.
In a meeting with Karen DeSalvo, M.D., M.P.H., the National Coordinator for Health Information Technology, and other senior leaders at the Office of the National Coordinator (ONC), we addressed the fact that the cost of complying with the meaningful use program presents a huge challenge for many family physicians. Specifically, we laid out three of the biggest obstacles family physicians face:
- complying with meaningful use stage two and the almost impossible task presented by stage three;
- the anticompetitive behavior of certain electronic health records vendors, who have established so-called "vendor lock" in many communities around the nation; and
- the overall lack of accountability among vendors marketing these products.
The last point is a particularly critical element of our advocacy efforts. Barring a hardship exception, physicians who have not yet attested to meaningful use will see a 1 percent Medicare payment reduction beginning Jan. 1. Those penalties can climb to as much as 5 percent over time.
© 2014 Michael Laff/AAFPAAFP President Robert Wergin, M.D., (far left), Board Chair Reid Blackwelder, M.D., (second from right) and I meet with Sen. Lamar Alexander (R-Tenn.). AAFP officers and staff met with congressional staff, legislators and representatives from federal agencies Nov. 20 in Washington.
It's a problem the AMA House of Delegates tackled during its interim meeting earlier this month, when the AAFP delegation backed a resolution directing the AMA to urge CMS to halt penalties related to meaningful use. This same point was emphasized during our meeting with ONC representatives. Why do physicians face penalties for noncompliance, but vendors are not held financially accountable for the performance of their products or their service?
During our time on the Hill, AAFP officers and staff met with legislators and congressional staff from both chambers and both parties. In these meetings, we discussed a variety of topics, including the importance of repealing the SGR and replacing it with value-based payment, preventing cuts in Medicaid, and renewing funding for teaching health centers.
Physicians face a 21 percent cut in Medicare payment beginning April 1 unless Congress intervenes. Legislators have patched the SGR issue 17 times during the past 12 years at a cost of more than $169 billion. Bicameral, bipartisan legislation introduced earlier this year would repeal the SGR and replace it with new methods of value-based payment, but to date, Congress has not passed the bill, in part because legislators have not agreed on how to offset the cost of the fix.
Overall, the mood among lawmakers and staff was that enacting a permanent SGR fix would be challenging during the lame-duck session but that Congress could summon the will to enact the repeal-and-replace legislation by the end of March 2015. You can help by telling your legislators to support the bipartisan legislation.
For primary care physicians, cuts to Medicaid payments are even more imminent. Section 1202 of the Patient Protection and Affordable Care Act (ACA) required state Medicaid programs to raise payments for certain primary care services to Medicare levels in 2013 and 2014, but barring an extension, states will be free to drop Medicaid payments back to 2012 levels on Jan. 1.
We emphasized that these cuts -- which vary by state but average more than 40 percent -- represent a severe disruption to the business of practicing medicine and pose a threat to patients' access to care. In fact, total health care spending for Medicaid patients could increase if they can't access their family physician and instead turn to emergency departments.
The Academy supports a bill that would require Medicaid programs to extend the parity payments for primary care for two years. This would not only bolster primary care practices and ensure access to care, it would give us more time to show how important it is for patients to have a regular source of comprehensive care. There is long-term value in providing preventive care, and health care costs can be reduced when chronic conditions are controlled.
Here's another opportunity for you to help. Voice your support for preventing cuts to Medicaid by contacting your legislators through the Academy's Speak Out tool.
Teaching Health Centers
Teaching health centers face two obstacles. First, federal funding for the Teaching Health Center Graduate Medical Education program established by the ACA will end after the 2015 fiscal year absent congressional intervention. The AAFP is one of more than 100 organizations that recently sent a letter to congressional leaders about extending support for teaching health centers.
Additionally, the Health Resources and Services Administration (HRSA) announced this month that awards for teaching health centers will be reduced from $150,000 to $70,000 per resident for the 2015-2016 academic year. The Academy wrote to HRSA officials about this issue last week, and we drove the point home again in our meetings with congressional staff and legislators.
Residents who train in these programs are more likely to practice in underserved or rural areas when they complete their training. Not only does the funding need to be continued beyond its scheduled expiration on Sept. 30, it should be expanded.
Other Agency Meetings
We also met with family physician and AAFP member Joe Selby, M.D., executive director of the Patient Centered Outcomes Research Institute (PCORI). PCORI requested the meeting, during which we discussed our practice-based research networks and the work of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care.
Finally, in a meeting with Rajiv Jain, M.D., assistant deputy undersecretary of health for patient care services at the Department of Veterans Affairs (VA), Wergin discussed our members' ability and willingness to help care for veterans and the need to break down barriers to doing so. Wergin also expressed concern that some family physician practices may struggle to serve veterans if the VA does not pay at least Medicare-level rates.
Wanda Filer, M.D., M.B.A., is president-elect of the AAFP.
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.
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