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Friday Oct 26, 2012

New Partnership Aims to Strengthen Academy's Efforts With RUC, CMS

Earlier this year, the AAFP Board of Directors made the difficult decision to stay involved with the AMA/Specialty Society Relative Value Scale Update Committee (RUC), despite the fact that the committee has historically undervalued primary care services in its recommendations to CMS. I explained at the time that though we would continue to participate in the RUC process, the Academy also would advocate directly to CMS.  

      As part of our commitment to improving payment for primary care services through this two-pronged approach, the AAFP recently reached an agreement with the health care advisory firm Avalere Health LLC. Academy staff met with representatives from Avalere this week in Washington to discuss four specific areas in which the firm might assist the AAFP in our efforts:

  • Collect and aggregate data that demonstrate primary care evaluation and management services are different and should be valued differently than services done by other specialties. This aligns with a recommendation of the AAFP's Primary Care Valuation Task Force.
  • Identify overvalued and undervalued services in the resource-based relative value scale (RBRVS), which CMS uses to help set Medicare physician payments.
  • Help the Academy's participants in the RUC and CPT processes work more effectively in those arenas.
  • Define the content and value of care management fees.

Avalere is expected to provide preliminary data for the first three items by March. The proposed timeline will give the Academy time to influence the proposed rule for the 2014 Medicare physician fee schedule.

The fourth item likely will take longer. The AAFP  promotes a blended payment model that includes a fee-for-service component, quality incentives and a per-member per-month care management fee (PMPM) to support the patient-centered medical home. However, no one has consistently defined what a PMPM care management payment should cover or its true value. Medicare is paying an average of $20 -- with a range from $8 to $40 -- in CMS' Comprehensive Primary Care initiative. But private payers' PMPM fees vary widely, and some are as low as $2.

Avalere will help us demonstrate the value of our ability to coordinate and manage care and the return on investment for payers.

We're optimistic this partnership will strengthen our position in our dealings with the RUC as well as in advocating directly to CMS. Primary care physicians must be paid differently than subspecialists and more fairly than we have been. The outcomes from this project should make that clear once and for all.

Glen Stream, M.D., M.B.I., is Board Chair of the AAFP.


Appreciate keeping this a MUST fix, front burner issue. Still difficult to appreciate how only one seat on the subspecialty dominant RUC will lead to change. My partialist friends think any value based pay is anathema. Please pursue the new independent route with greater vigor.

Posted by on November 01, 2012 at 07:06 AM CDT #

Dr. Stream: Could you please explain why the AAFP aggressively pushes for the inclusion of pay-for-performance programs as part of the compensation for family physicians? During the last five years, there has been a plethora of good studies showing that P4P does not change physician behavior, does not improve patient health, and does not reduce costs. These programs are expensive, administratively burdensome, and error-prone. They encourage cherry-picking of patients, and discourage shared physician-patient decision making. They discriminate against physicians who see high volumes of uninsured and Medicaid patients, and those who practice in demographically difficult areas. Very significantly, they are inherently biased in favor of practices with favorable fee schedules, so that those who are already being paid well tend to prosper even more. This is a classic example of the AAFP pushing policies that discriminate against solo and small practices. What is the EVIDENCE that supports the AAFP's policy decision? Thank you.

Posted by r stewart on November 13, 2012 at 06:08 PM CST #

You make some good and valid points. Pay-for-performance has not been adequately tested in the context of a blended payment model or in a capitated model. Most studies look at an isolated incentive that is a very small portion of total income and would not be expected to cause change in isolation. If the proportion of FFS is still 90-plus percent with only a small percentage as incentive you would not expect substantial changes in behavior. Well organized and systematic practices will do better with any payment model. We believe that solo and small practices have the opportunity to be well organized and systematic, and our experience with TransforMED supports this assertion. Even in large groups, the fundamental changes in process and systems has to occur at the micro-system level (i.e. one or two docs, NP, nurse, front desk and billing/coding clerk). We have advocated for the PCMH as a way for practices to redesign their work to help them be successful in the value-based purchasing environment. Pay for performance is only one aspect of that new environment. The strength of our organization is that we have the resources to see and predict long-term trends and prepare tools and resources for our members in time for them to be ready. No organization, including the AAFP, has the resources to "stop this train" of change.

Posted by Glen Stream, M.D., M.B.I. on November 27, 2012 at 10:35 AM CST #

Thank you, Dr. Stream, for taking the time for your thoughtful reply while you're off fighting Medicare battles! However, I have to disagree with just about everything you say. I think you severely underestimate how uneven the playing field is now. In my community, we have solo docs who get paid X for a 99213, and large practices where the docs get 4x X plus a facility fee for the same service (some of which they use to fund an entire administrative department that massages their quality data). Telling the solo doc that spending the time and money to become a PCMH (for which they won't get a red penny in this neck of the woods) will allow them to compete with the better funded practices, is simply not true. It's completely invalid to compare the two on quality standards if they're being paid at such different rates. Do you pay Motel Six rates for a room and then demand that they measure up to the Ritz Carlton? This is exactly why so many of us feel that the AAFP leadership is hostile to small practices. I agree with you when you state that "pay-for-performance has not been adequately tested in the context of a blended payment model." So why in the world is the AAFP pushing so hard for it? Shouldn't our position be that there is no evidence to support this payment model, and we totally oppose its use in any payment formulas? You indicate that the AAFP's role is to tell its members which way the train is headed. I'm sorry, but this sounds like you're pushing this because it's what the insurers want. Shouldn't the AAFP be willing to say, at some point, that the train is headed in the absolute wrong direction? AAFP policies should be evidence based and be beneficial to the membership: P4P programs fail on both standards. Again I ask, why does the AAFP support them? Thank you.

Posted by r stewart on December 06, 2012 at 07:38 PM CST #

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