Preserve Patient Access to Primary Care Physicians with Accurate Physician Directories, Reduced Out-of-Pocket Expenses, AAFP Tells CMS

Wednesday, Dec.16, 2015

Leslie Champlin
Senior Public Relations Strategist
American Academy of Family Physicians
(800) 274-2237, Ext. 5224

LEAWOOD, Kan. — The Centers for Medicare & Medicaid Services can help patients buy meaningful health insurance by ensuring they have reliable information about each plan’s network of physicians and by reducing out-of-pocket costs for primary care and generic medicine, according to the American Academy of Family Physicians.

In a letter to the Department of Health and Human Resources and the Centers for Medicare & Medicaid Services, AAFP Board Chair Robert Wergin, MD, welcomed CMS programs that help Americans apply for and enroll in insurance marketplace health plans. He suggested those plans could be more meaningful to patients if rules governing the marketplaces required insurers to:

  • Provide information on cost and coverage differences between primary care and subspecialty physicians and between office-based and facility-based settings.
  • Promptly provide accurate and current directories of health professionals and facilities within the plans’ networks.

Among the most helpful would be mandated standardized plans that allow patients to compare costs and benefits to easily identify the one that works best for them. The  proposal encourages the standardization of plans, and recommends that they include primary care visits, generic drugs and other services as a covered benefit before the deductible is applied.

“The AAFP appreciates CMS recognizing and encouraging the value of primary care for patients who would enjoy ‘first dollar coverage’ for that care,” Wergin wrote. “We believe this insurance design feature to be extremely important for patients with long-neglected ailments, who are gaining health insurance for the first time. Covering primary care visits, generic drugs, and other services as a covered benefit before the deductible is applied would provide an appropriate incentive to enrollees to use the preventive care and chronic disease management, as well as early diagnosis and treatment of acute conditions offered by family physicians and other primary care providers.”

Wergin also called on CMS to act now, rather than later, to establish and enforce provider network standards. Such standards, he said, would help ensure patients have access to a sufficient number of primary care and subspecialty physicians who provide the health care services covered by the plan’s contract.

“The issue of network adequacy stems, at least in part, from a problem regarding unfair provider termination from networks,” Dr. Wergin wrote. The AAFP urged CMS and private payers to make public the performance measures, in addition to patient feedback, used in determining which providers are included in which network. The AAFP also remained concerned with tactics deployed by health insurance companies that arbitrarily eliminate physicians from networks, forcing patients to secure the services of a new physician. Wergin stated that, “This so-called ‘network optimization’ is disruptive to patients and their physicians, and the AAFP urges CMS and plans to minimize such actions.”

Of equal importance is financial access to care, Wergin continued.

“The AAFP applauds CMS’ decision to exempt from the deductible primary care and generic drugs in the 2017 Standardized Plan Options and urges CMS to make that part of an essential health benefit in the future,” he wrote. “Primary care should be covered without a deductible at all three metal levels to encourage consumers to rely on the preventive health care and chronic disease management offered by primary care physicians. … Exempting primary care services from the deductible would encourage consumers to visit their primary care physician for conditions they might feel they could ignore.”

The AAFP response also suggested that, “if Navigators emphasize this benefit, then access to care for routine, chronic, and neglected conditions would increase, overall medical spending would decrease (from reductions in hospitalization, emergency visits, etc.) and enrollees would realize some up-front value for their premium dollars.”

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Founded in 1947, the AAFP represents 124,900 physicians and medical students nationwide. It is the only medical society devoted solely to primary care.

Family physicians conduct approximately one in five office visits -- that’s 192 million visits annually or 48 percent more than the next most visited medical specialty. Today, family physicians provide more care for America’s underserved and rural populations than any other medical specialty. Family medicine’s cornerstone is an ongoing, personal patient-physician relationship focused on integrated care.

To learn more about the specialty of family medicine, the AAFP's positions(5 page PDF) on issues and clinical care, and for downloadable multi-media highlighting family medicine, visit For information about health care, health conditions and wellness, please visit the AAFP’s award-winning consumer website,