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Friday Jul 13, 2012

Senate Committee Hears Importance of Primary Care … And Not Just From AAFP

How refreshing.

We have been saying for years that primary care is the essential foundation of a successful, sustainable health care system, and the patient-centered medical home is the key to restraining costs and improving care. 

And now during a July 11 Senate Finance Committee roundtable about physician payment, we heard those same ideas being supported by other professional medical organizations.

I was privileged to represent AAFP as one of just five physician specialty societies invited to participate. Sen. Max Baucus, D-Mont., asked the panel for suggestions on how to replace the flawed sustainable growth rate (SGR) formula. Frank Opelka, M.D., (pictured with me below) associate medical director for the American College of Surgeons' Division of Advocacy and Health Policy, told the committee that the ACS has a plan to set payment updates using value-based targets.

"Is this for surgeons or other specialties as well?" Baucus asked.

"This is for patients -- all patients," Opelka replied. "Instead of being surgeon-related, it's patient-centered."

Opelka explained to the committee that the ACS would like to work with specialty organizations and other stakeholders to set physician payment updates based on specific targets. For example, he said a cancer program would not be just about oncology but also radiation therapy, surgery and primary care. Similarly, treating a digestive disease might involve gastroenterology, surgery and primary care.

"You can't get away from primary care," he said. "They're tied to every one of us."

Give the surgeons credit. They get it. They can't do it all, and they don't want to manage complex medical care. They want strong collaboration with primary care, and to have that collaboration in their communities, they need a strong primary care work force.

Opelka wasn't the only one voicing support for primary care and the PCMH. AMA president-elect Ardis Dee Hoven, M.D., an internal medicine and infectious disease specialist, also stressed the importance of care coordination and the potential it holds for long-term savings.

Family physicians can talk all we want about how important we are to our nation's health care system. (And I did. You can read our official statement to the committee here.) But it was great for this influential Senate committee to hear it from our colleagues.

This was the third roundtable the committee held on physician payment, following earlier meetings with former CMS administrators and private payers. Now we have some homework to do because legislators asked us to follow up with written recommendations for replacing the SGR as well as suggestions for medical liability reform.

You can watch the hearing in its entirety via C-SPAN.

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


While a capitated system doesn't appeal to all physicians, this would be a way to provide cost-effective medicine, but in the system quality review would be essential. I worked for Kaiser Permanente for 7 years after 12 years solo, and found this a good template for such a capitated system. Bonuses were based on quality care first, with cost-effectiveness scrutinized very carefully for each of us. Richard Elliott

Posted by Richard S Elliott on July 17, 2012 at 09:12 AM CDT #

I completely agree with Richard Elliott's comment: some form of capitation is key to restructuring primary care's work schedule. Not being tied to patient office visits all day is needed to free up time to be proactive, to reach out, follow up and systematically improve health. Think about it - there is usually no time scheduled to make phone calls, think and read about clinical challenges, or work through care management action lists. This is not the way to take good care of our patients. We need primary care capitation, combined with some baseline quality expectations - but we need to be careful here, because these are generally not risk-adjusted and cannot be validly compared between practices.

Posted by Paul Hartlaub on July 19, 2012 at 06:18 AM CDT #

Fee for service is not a favorite, but we continue to neglect one area over and over - health access. When you give it some thought, fee for service favors higher volume. Higher volume can move more millions from no access to some and from some to adequate. For 30 years with insufficient primary care, the focus must be more primary care delivery per graduate and this includes higher volume. Once we come close to resolving deficits, we can consider disincentives for volume which can include quality types of focus. Remember, quality cannot even begin without access.

Posted by Robert C. Bowman, M.D. on July 19, 2012 at 10:36 AM CDT #

I'm less impressed by these very tepid words of "support" for primary care. Actions speak stronger than words. As long as the AMA and its corrupt RUC are working to destroy primary care, making nice in front of the Senators doesn't count for much.

Posted by D Brown on July 19, 2012 at 02:27 PM CDT #

While I appreciate the verbal support AMA and ACS gave to primary care, I wonder how willing they are to provide financial support as well. That is, with Medicare supposedly going broke and health care costs out of control, the only way to increase payments to primary care without increasing the overall healthcare budget is to make cuts somewhere else. Are these specialists willing to take pay cuts to improve primary care compensation and reduce the income discrepancies? As for access, we can provide a lot of care management without face to face contact, but only get paid for the face to face contacts. Some ideas: 1. Treat the health history database we develope as a copywrited document and pay primary care everytime we provide the patient database/health history to consultant or other provider. This document saves the consultant time since they do not have to obtain/compile this information from the patient/family or multiple sources. 2. Have all diagnostic tests ordered through the primary care provider to reduce number of duplicate studies, and pay primary care to manage that information and provide periodic lab summaries to members of the patients care team. 3. Base primary care E/M payment on number of problems or systems addressed during an office visit, with different caps on how many times you can bill for the same problem within a certain time frame. Example-if I see someone for scheduled follow up of diabetes but also adjust dosing on their antihypertensive med, chol lowering agent, treat their acute illness (URI/UTI/muscle strain) and answer their questions about their recent encounter with a specialist who did not have time to answer those questions so ptl could understand, then I should get paid one amount for the chronic diabetes care and smaller additional payments for treating the acute illness, HTN, hyperlipidemia and answering their questions. This is definitely patient centered care since the alternative could require seperate office or urgent care visits for the acute illness, problem addressed by specialist, HTN and hyperlipidemia, costing more money/time and lost productivity. 4. Pay us for every prior authorization for meds that get approved (to discourage prescribing practices just to capitalize on this benefit.) Ins companies usually have all the information they request on prior auths in their claims data, but it is easier for them to waste my time than look for it, and I get approval 99% of the time. This would also discourage having to fill these forms out so often. 5. Pay primary care who see inpt as well as outpt at higher rate for inpt. care than hospitalists get paid since we provide the added value of continuity of care. This should only be for established patients, however. Again, just some ideas. Basically, I would like to see us (primary care physicians) get paid for all of the services we provide, and feel that would require un-bundling those services while monitoring for abuse of the system. Thanks for the opportunity to vent.

Posted by Ruth Guyer, MD on July 20, 2012 at 12:35 AM CDT #

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