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Thursday Jan 19, 2012

Stressing the Importance of Fair Payment for Primary Care

Payment remains the No. 1 concern for AAFP members, and your Academy is working to address this issue in both the public and private sectors.

For example, on Jan. 12, AAFP leaders -- including myself -- met with representatives of Cigna at the insurer's Bloomfield, Conn., headquarters. I was encouraged by the tone of the meeting and the manner in which our message -- which emphasized the need for fair payment for primary care -- was received. Several of Cigna's medical officers have primary care backgrounds, including three who are AAFP members. They actively sought our input and were not merely listening to our grievances.

Still, much work remains to be done in our ongoing dialogue with one of the nation's largest private payers. Cigna's CEO received more than $15 million in total compensation in 2010, according to Forbes. Meanwhile, the company is offering family physicians in at least one state fee-for-service contract rates that are lower than Medicare.

This is simply unacceptable. Just as we told representatives of UnitedHealthcare during a meeting in October, we told Cigna that this outrageous approach to physician payment is killing primary care practices and giving physicians little choice but to move elsewhere. If unchanged, this policy will lead to primary care deserts as docs flee these distressed practice environments.

We emphasized that the fee-for-service payment system must be fixed because primary care is grossly undervalued. New payment models are likely to have fee-for-service as a base, so it is imperative that primary care is properly valued or these new models also will be severely flawed.

Cigna and other private payers have told us the employers they work with are unwilling to pay more for health care. Our contention is that paying more in total dollars is not the issue. The issue is spending more on primary care and thereby reducing money spent on subspecialty care, urgent care and hospital visits. It's critical that employers understand that coordinated primary care is worth the investment because it can reduce such avoidable costs.

On a positive note, Cigna informed us that it has submitted a letter of intent to participate in the Comprehensive Primary Care Initiative. In October, CMS and its Center for Medicare and Medicaid Innovation announced plans to collaborate with commercial and state health insurance plans to support primary care practices that deliver coordinated and seamless care.

The program will blend fee-for-service payments with a risk-adjusted per-patient, per-month care-coordination fee that ranges from $8 to $40. Participating practices also will have the opportunity to share in savings resulting from the program. (Just an aside: The AAFP and TransforMED are hosting a free CPCI webinar for members on Feb. 1 at 1 p.m. CST.)

It was encouraging to hear that Cigna plans to participate, but our conversation also made it clear that the amount of the per-patient, per-month care-coordination fee will be a topic of debate with payers. We will follow up with Cigna to ensure they understand the importance of coordinated care and the value of our members' time.

Meeting with large health plans can be frustrating, but it has the potential to pay long-term dividends. Although private payers may not change their policies solely based on our input, without that input they most certainly won't change. As advocates for family physicians and our patients, the AAFP will continue to engage major health plans on issues critical to family physicians. In fact, Academy leaders are scheduled to meet with representatives of Aetna in March.

What else is the Academy doing about payment?

The AAFP Primary Care Valuation Task Force will meet Jan. 24 in Washington, and leaders from the AAFP and other specialty medical organizations are planning to meet with legislators in late January on Capitol Hill to discuss the sustainable growth rate (SGR) formula.

The Academy also is launching another wave of its grassroots advocacy campaign aimed at getting rid of the SGR once and for all.

It's going to be a busy couple of weeks, so come back to the blog for updates. You also can follow me on Twitter and Facebook.


At the Annual Assembly last September, it was pointed out the some of the same insurers who are destroying family medicine by creating "distressed practice environments" also sit on the executive committee of the Patient Centered Primary Care Collaborative (PCPCC). We were told that this conflict would be discussed "within the coming weeks." Has any action been taken on this? Reading the presentations at the PCPCC's Annual Summit is an eye-opener. Lots of excitement about lower payouts (higher profits) for insurers. Lots of approving talk about PCMHs headed by non-physicians. But not ONE single word about fair pay for family physicians. Many of us feel that the PCPCC is a very pro-insurer, anti-doctor organization. Why does the AAFP participate in and support a group that is so hostile to America's family physicians?

Posted by D Brown on January 25, 2012 at 03:33 PM CST #

Unless, the one state mentioned above was Virginia, you can add another to the list where Cigna pays below Medicare rates. They are now reimbursing office visits at about 85% of Medicare. Like Dr. Brown, I am tired of lip service and would like to see some real results. Anthem is no better except that they actually respond (with no action) to my e-mails.

Posted by Glenn Mizrach on January 26, 2012 at 08:52 AM CST #

Glen, I want to thank you for all the hard work you are doing on behalf of the AAFP membership...what you have outlined above all makes sense, but one area that I would focus on is educating the public directly. When they demand their Family Physician be justly compensated and fully supported, the insurances will have to respond. I know advertisement is expensive, but it is critical we define who we are and what we do and what services we can do for the public. We need to encourage them to shop carefully for their health insurance and move to higher deductibles and lower premiums (HSAs, flex. spend accounts, etc) and emphasize how critical and cost effective prevention and wellness plans are with the Family Doctors, as a hedge against the high cost of being ill. AAFP should highlight the already intrinsic value of Family Medicine Physician in their community, and that of the independent personal physician (those who are salaried are working for someone else's bottom line and will not have time to properly diagnose and coordinate care). The remaining 24% of Family Doctors still in private practice is the best model for quality vs. quantity patient care when quality is emphasized. Models of Primary Care which depend less on third party payers and more on the patient's own resources might be a faster way to see immediate improvement in unjust reimbursement and undervalued services, but I applaud you for meeting with the health insurance industry and congress. I would add to that list, meeting with hospital systems pointing out that each of their community Family Doctors are worth 2 million dollars in direct/indirect income and they should take some of their excess dollars and support community-based primary care centers of excellence directed by Family Physicians who are independent. In the end this would benefit them, payback the primary care doctors who have not been properly supported over the years by their local hospital systems or in the arena of reimbursement, and most of all restore Family Doctor back to his/her rightful place as Navigators of patients' healthcare and their sub-specialty and hospital referrals. Expand the vision outside the box beyond historical methods of reimbursement. Never has the time been better than to take our case directly to the public, after all , it's our patients who value us the most.

Posted by Robert T Bailey, PharmD, MD, FAAFP on January 26, 2012 at 07:45 PM CST #

Thank you D. Brown, Glenn Mizrach, and Robert Bailey for your comments and concerns. AAFP concerns about payment for family medicine services have and continue to be presented to the PCPCC, leadership in AHIP (America's Health Insurance Plans), and with the individual major health plans. This is a process of advocacy and not negotiation due to anti-trust issues. It is not the role of the PCPCC to tell its members, including the health plans, how to do business. However, it's worth noting that the PCPCC strategic plan addresses the importance of promoting and supporting primary care and the patient-centered medical home. And in this context, the Collaborative will be advocating for improved payment for primary care practice redesign and care delivery in the context of the PCMH. The PCPCC is certainly not anti-doctor. Four primary care organizations, including the AAFP, are represented on its board of directors. As I stated in this blog entry, the AAFP is keeping an open dialogue with health plans about fair payment for primary care physicians. We already have met with UnitedHealthCare and Cigna in recent months and will meet with Aetna in March. Meanwhile, the Academy is developing more data on the subject of distressed practice environments. With this data we will be able to continue to press the health plans to move to improved models of payment for practices who achieve PCMH designation. While some health plans might be paying at levels less than Medicare in a particular state, the same company may be running a PCMH pilot program that evaluates alternative payment models in another state. We will continue to engage the major health plans and attempt to influence their view of primary care, and the way they value primary care, over time.

Posted by Glen Stream, MD on January 26, 2012 at 09:23 PM CST #

Dr Stream, does the AAFP truly believe high quality primary care can only be practiced in the context of a Patient Centered Medical Home? I’m asking you to search your heart and tell me that my small very rural solo practice has to invest many tens of thousands of dollars and undergo tremendous upheaval for the sake of this model. I cannot afford to do this. Nor do I want to. I know that my practice is already very patient centered, my patients know this, and I don’t think I need to become a PCMH to prove it. I serve my patients. As the president of the AAFP you are supposed to represent all Family Physicians including those in small and solo practices. My already large administrative burden is the cross I bear so I can be in the exam room where I belong. I am being buried in a blizzard of paperwork from every direction; HIPPA, e-prescribing, PQRS, MOC, HITEC, ICD-10 etc. and now my own academy is pushing to add overwhelming complexity to my already substantial administrative burden. By promoting this model you strive to homogenize our practices instead of celebrating the diversity small and solo practices bring to the field of medicine. Perhaps the PCMH should only apply to those practices large enough to become bureaucratically dysfunctional. I realize the AAFP stands to profit financially from the success of TransforMED. I believe this to be an inherent conflict of interest when your actions serve to drive us from small and solo practices. Why not just advocate for primary care in general and Family Medicine in particular wherever and however it is practiced. Why does the AAFP have this perverse fixation on the PCMH? There is already a crisis of access in rural America; this will just make it worse.

Posted by on February 02, 2012 at 11:07 AM CST #

THANK YOU,, for articulating so well what many family physicians think. Yes, you are correct: the AAFP has created a tremendous conflict of interest for itself. It is impossible to, on the one hand, fairly represent the interests of dues paying members, and, on the other, be in the business of selling the PCMH. This conflict is epitomized by the fact the the AAFP proudly lists as paying clients some of the same insurers who are creating "distressed practice environments." There are many of us who are saddened as we see the AAFP quickly become the most rigid, dogmatic, bureaucratic of all the medical societies. It seems as if the Academy wants to be a regulatory agency micromanaging our practices and funneling business to the NCQA, rather than a support for ALL of America's family physicians. Does the AAFP plan to keep representing all of us who are working to do what we think is best for our patients and ourselves, or only those of us who buy into this one-size-fits-all version of family medicine?

Posted by D Brown on February 07, 2012 at 07:52 PM CST #

My name is Jim Nordal, and I wasn't trying to post anonymously. I'm not sure what is.

Posted by Jim Nordal on February 08, 2012 at 10:03 PM CST #

Dr Stream, my questions in the post above were not rhetorical. I really am anxious to hear how the AAFP rationalizes its priorities. You must know that the stance you take on so many issues directly impacts thousands of us who may not have practices like yours, and indirectly affects the millions of patients we care for. How can the AAFP continue to advocate for a single model of practice that can’t work everywhere?

Posted by Jim Nordal on February 09, 2012 at 11:02 AM CST #

I'd like to thank everyone for their contributions to this important discussion. The AAFP is not alone in its support of the patient-centered medical home (PCMH). That support dates back to 2004 when the Future of Family Medicine report found that our specialty cannot succeed without fundamental changes to the U.S. health care system. Changes recommended in that report included taking steps to ensure that every American has a medical home and making patient-centered care based on a patient-physician relationship the cornerstone of a new health care delivery model. That report was a collaborative effort of the family of family medicine: the AAFP, the AAFP Foundation, the American Board of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group and the Society of Teachers of Family Medicine. The Future of Family Medicine report also called for the creation of "a financially self-sustaining national resource … to provide practices with ongoing support in the transition to the New Model of family medicine." The AAFP assumed responsibility for that resource, which became TransforMED. I disagree with the assertion that TransforMED -- which is a not-for-profit entity -- poses a conflict of interest, and it's worth noting that a significant portion of the practices TransforMed is helping are the kind of small and solo practices Dr. Nordal is concerned about. Dr. Nordal, you are correct in that I work in a large practice. However, my early career was in a small town practice where, like you, I believe I provided excellent care. The current AAFP Board of Directors, like past boards, includes family physicians from varied backgrounds, including small and solo practices. At least one current board member from a small practice has seen his practice's revenue increase dramatically in recent years because of practice transformation, including achieving NCQA Level 3 recognition. A primary objective of the Future of Family Medicine project was to recommend changes that would allow family physicians to better meet the needs of our patients in a changing environment. And things definitely are changing. Some health plans already are offering enhanced payment for practices that meet certain criteria, including NCQA recognition. Dr. Brown takes issue with the AAFP working with health plans, but it is just that kind of collaboration and long-term engagement that results in the kind of primary care program that WellPoint recently introduced. All the major professional organizations representing primary care physicians are promoting transformation to the PCMH including the American Academy of Pediatrics, American College of Physicians, and the American Osteopathic Association. The health care world is changing and we must evolve with it. We must build on the best traditions of our specialty and adopt the components of the PCMH to meet the needs of a 21st Century health care system. The bottom line is that the Academy is committed to helping members take advantage of opportunities to earn more money, to be prepared for potential changes and not to be left behind in the future. That commitment extends to members in all practice settings including solo and small groups.

Posted by Glen Stream, MD on February 10, 2012 at 10:06 AM CST #

Dr Stream, Thank you for your response.

Posted by Jim Nordal on February 10, 2012 at 02:37 PM CST #

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.