FP Report -- December 1999
Academy goes to mat in federal arena for FPs
The coverage on this page explores the Academy's legacy in the federal arena from the late '60s to the present.
1970s to now
Congress funds family practice trainingIn 1970, an administrative assistant to newly elected Rep. Fred Rooney, D-Pa., moved to Washington and couldn't find a family doctor. The assistant complained to Rooney, who introduced a bill to fund the training of more family doctors.
At the time, the Academy had no Washington office. Michael Miller, J.D., the Academy's director of legislation (now deputy EVP), read new bills in Congress to keep tabs on D.C. from a distance. He happened across the training bill and was astonished.
"We took the bill to one of the most influential senators and got him to introduce it in the Senate," said Miller. It passed unanimously in the House and with only one dissenting vote in the Senate.
The Family Practice of Medicine bill went to President Richard Nixon for his approval within 10 days, but that period ended during Congress' Christmas break, and Nixon decided to pocket veto the bill. Such vetoes occur when a president fails to sign a bill within 10 days, and Congress is adjourned and can't override a veto. However, Congress was in recess until January, not adjourned.
"I periodically called the White House to see whether the bill had been signed," said Miller. "One day I called and got a message about the pocket veto. It seemed like something didn't smell right, but I wasn't sure. It ruined my Christmas break."
Eventually, Sen. Edward Kennedy, D-Mass., took the administration to court about the pocket veto and won the case -- but the time for implementing the bill had elapsed. Congress used other legislation, the Health Manpower Training Act, to secure line item funding for family practice training, the basis for the specialty's current Title VII funding.
"The funding provided impetus for creating family practice residencies," said Miller. "The Family Practice of Medicine bill got family practice on everyone's radar screen, and we've been there ever since."
30-year haul
Academy tackles Medicare issuesThe Medicare program was signed into law in 1965, four years before family practice became a specialty with its own certifying board.
In 1970, Rep. Fred Rooney, center, discussed the Family Practice of Medicine bill with AAFP President Edward Kowalewski, M.D., left of Akron, Pa., and Board Chair Robert Quello, M.D., of Minneapolis."The policies from the mid-1960s didn't fit in with the new model of family practice," said Rosemarie Sweeney, AAFP vice president for socioeconomic affairs and policy analysis. "But over time, successful legislative efforts have recognized the shift to increased training for family doctors."
Specialty differential. Medicare regulations from the mid-1960s said physicians should be reimbursed according to their usual, customary and reasonable payments. Carriers would pay a subspecialist more than a generalist for exactly the same service.
The Academy's Michigan chapter, supported by the Academy, filed suit against the government over the specialty differential.
"The government fought us with all its resources," said Miller, then general counsel. The case dragged on for 10 years, until the Supreme Court struck down the specialty differential.
Why was the case important?
For two reasons, said Miller. First, it established the legal precedent that family physicians should not be treated differently from other physicians.
Second, the case dealt with whether Medicare could be sued or whether plaintiffs had to go through the government's own administrative hearings, with the government as prosecutor, judge and jury. "The government said the courts didn't have jurisdiction," said Miller. "The Supreme Court said otherwise. The case has had great influence in the legal profession."
Paving the way for RBRVS. The Academy and the American Society of Internal Medicine joined forces in 1983-84 to win AMA's backing for a fairer Medicare payment system.
"The system based on usual, customary and reasonable payments led to inappropriate pay for cognitive services -- gathering data, analyzing health problems, diagnosing -- much lower pay than for procedural services," said Miller. "We knew we couldn't get the Medicare fee structure overhauled without AMA's support."
The AAFP and ASIM asked their members to introduce in state medical societies a resolution calling for the AMA to support fairer payment for cognitive services. Four societies sent the resolution to the June 1984 AMA House of Delegates. A reference committee recommended studying and not immediately acting on the resolution.
"Let's get this changed on the floor of the AMA house," said Sam Nixon, M.D., of Nixon, Texas, a past AAFP president and a Texas delegate to the AMA.
"Then the politicking started," said Miller. "The AMA was in a tough spot. It was clear the change in the Medicare system would benefit some specialties and work to the detriment of others." AAFP and ASIM leaders at the AMA meeting rallied delegates to the cause, and the AMA house voted for it.
A Harvard University study determined the fee schedule should adopt a resource-based relative value scale, reflecting the real costs involved in providing care. The U.S. Congress approved the RBRVS. Implementation began in 1994 and will be completed in 2002.
"RBRVS is still the subject of argument," said Miller. "I think our members probably don't think the RBRVS is the greatest thing in the world, because of the red tape. But their income has risen significantly because of the RBRVS."
GME funding. Medicare funding for graduate medical education historically favored technical specialties over ambulatory care specialties. Those requiring longer training before eligibility for board certification received more funding, and some fellowships also had federal support.
In 1997, the Academy won a cap on the extent of GME-funded training. The result: More training institutions receive the full amount of direct medical education funding only until residents are eligible for their first certification. More DME funds are therefore available for primary care specialties.
In addition, Medicare regulations proposed in 1995 required the teaching physician's presence in the exam room with the patient and resident in order for the physician to be paid for patient care. The proposed rule could have hampered the family practice resident's relationship with the patient. In a clear-cut victory for the specialty, the final regulation granted an exception to the physical presence rule for family practice and other primary care residencies.
On another front, the AAFP is still seeking Congress' correction of parts of the Balanced Budget Act of 1997 -- provisions that inadvertently disadvantage family practice residencies and rural training.
On the horizon: The Medicare Payment Advisory Commission, unfortunately, recently called for Medicare to pay for enhanced services in teaching hospitals but not in ambulatory sites. "Big GME issues will be on the table in the near future," said Sweeney.
1989 and counting
Academy speaks up for uninsuredA decade ago, the AAFP Congress of Delegates committed the Academy to seeking health care coverage for every American.
The search is far from over.
The Academy backed most of the comprehensive reform plan proposed by President Bill Clinton's administration in 1993, but the plan failed to win Congress' support. The Academy turned its energies to expanding coverage for various groups of uninsured Americans, beginning with support of the Children's Health Insurance Program.
This year, the AAFP Task Force on Universal Coverage began examining anew the question, "How can America achieve universal coverage?" Some answers may lie in the task force's report to the 2000 Congress of Delegates. Stay tuned.
By Jane Stoever, Associate Editor
FP Report is published by the AAFP News Department. Copyright © 1999 by American Academy of Family Physicians.
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