A full plate of resolutions faced the Reference Committee on Practice Enhancement when the Congress of Delegates and various reference committee hearings commenced here on Sept. 12. From perceived public and private payer shenanigans to member dissatisfaction with the AMA/Specialty Society Relative Value Scale Update Committee, or RUC, the committee dealt with nearly 20 resolutions.
Delegate John Cullen, M.D., of Valdez, Alaska, authored one of four resolutions asking the AAFP to withdraw from the RUC or find an alternative to CMS' current system of establishing payment for CPT codes.
Many family physicians long have argued that the RUC, which advises CMS on the valuation of CPT codes, undervalues the evaluation and management codes most often used by FPs and other primary care physicians.
Cullen testified during the reference committee that he performs colonoscopies, and in the next breath, he said the procedure was overvalued. "It's embarrassing to get more money for that one procedure than for seeing patients the entire rest of the day," said Cullen.
In a separate interview, Cullen told AAFP News Now, "The RUC allows all physicians to speak with one voice, and that's a benefit, but procedures are overvalued compared to other parts of medicine." Cullen said the AAFP needs to look for alternative strategies. "This isn't a bluff. You have to have other plans in place," he said.
Delegate Stephen "Miles " Rudd, M.D., of Warm Springs, Ore., was even more adamant in his testimony. "We've had concerns for years about the flawed system the RUC represents," said Rudd. He was staunch in his opposition, despite the fact that the AAFP recently put the RUC on notice that changes to the organization were essential, not optional, and assembled a committee known as the Task Force on Primary Care Valuation charged with finding an alternative to the current valuation process.
"We still believe the process is fatally flawed," said Rudd. "We don't believe the RUC will make significant changes. The best step, at this point, is to remove ourselves from the RUC and come up with an alternative system."
- The Reference Committee on Practice Enhancement dealt with nearly 20 resolutions during the 2012 Congress of Delegation.
- Four resolutions expressing dissatisfaction with the work of the AMA/Specialty Society Relative Value Scale Update Committee were referred to the Board.
- The COD did not adopt a substitute resolution asking the Academy to establish a standard collaborative agreement as a guide for physicians and nurse practitioners.
- The COD combined and adopted two resolutions aimed at helping patients with asthma better afford their medications.
Other delegates were equally passionate about giving the AAFP's new task force a chance to do its work. Alternate delegate Anne Montgomery, M.D., of Spokane, Wash., was one of them. "We don't think taking our marbles and going home without anyone going with us accomplishes very much. Pursing this in a thoughtful, reasonable manner is likely to accomplish more," she said.
As the Academy's RUC adviser, Thomas Weida, M.D., of Hershey, Pa., knows the painful valuation process all too well. "I'm in the unenviable position of defending codes to the RUC," said Weida. "There's a difference between bold leadership and jumping off a bridge with no safe place to land. Who would determine our fees, the (insurance) carriers?"
Weida pointed out that CMS has rejected RUC-recommended codes -- such as those that would apply to the patient-centered medical home, telephone consultation and e-prescribing -- that help primary care. "It's premature to withdraw from the RUC," he said.
(Then) AAFP Board Chair Lori Heim, M.D., of Vass, N.C., told the reference committee that CMS acceptance of RUC recommendations had dropped from about 90 percent to around 70 percent. "We have been working to change the culture of the RUC for years. We understand we need to up the ante," said Heim.
In the end, the COD voted to refer all four RUC resolutions to the AAFP Board of Directors for further consideration.
The Reference Committee on Practice Enhancement also tackled a resolution from the West Virginia delegation asking for the AAFP's assistance with establishing a standard collaborative agreement that would guide the working relationship between FPs and nurse practitioners, or NPs.
Testimony reflected multiple arguments. Delegate Ronald Blum, M.D., of Patten, Maine, argued that adoption would give "tacit approval" to nurse practitioners desiring independent practice and possibly "open more doors" for them to do so. Blum said he'd like to see more evidence on the differences in training between physicians and NPs.
"We have concerns as a state that has fought this," said delegate Erica Swegler, M.D., of Keller, Texas, adding that there is no standardized education for NPs across the country. "There are programs in the state of Texas where you can have as little as 150 clinical hours in your master's program for nursing education, and you don't have to be a four-year degreed R.N. to go into those nursing programs."
Swegler worried that a collaborative agreement could be used against physicians in her state because, "the legal definition of 'collaboration' in Texas is different than in other states. She added that the resolution "could cause loosening of (existing) tight standards in some states."
Resident and student testimony was more positive. Brent Smith, M.D., of Brandon, Miss., the newly named resident member of the AAFP Board, said it was appropriate for the AAFP to give guidance to state chapters. "We (the AAFP) haven't had a unified position even though 17 states have said 'Yes' to NPs" in independent practice. Many states have dodged the issue, he added.
Aaron Meyer, of St. Louis, Mo., student alternate delegate to the COD, said simply, "This would alleviate confusion among students."
During debate in the COD, alternate delegate Andrew Carroll, M.D., of Chandler, Ariz., added one more dimension to the argument when he said that adoption of the resolution would put at risk the good working relationship that he and many other FPs have with physician assistants, or PAs.
"We don't have anything like this for PAs, for the group of PAs who have agreed to work with physicians. That's their role. They recognize it. They want it. If you put this (resolution) out there, you'll risk affecting every PA that works for a physician," said Carroll.
Ultimately, delegates opted to not adopt a substitute resolution offered by the reference committee.
Two resolutions submitted by the Minnesota delegation considered by the reference committee related to asthma. One resolution addressed the high cost of asthma medications, a situation the authors attributed to the recent switch to hydrofluoroalkane, or HFA, propellants for inhalers, which resulted in the removal of all generic inhalers from the market.
Alternate delegate Kurtis Elward, M.D., M.P.H., of Charlottesville, Va., said it was a chlorofluorocarbon, or CFC, issue, referencing the FDA's decision in 2010 to phase out metered-dose inhalers that contain CFCs and replace them with HFA devices for which there are no generic choices.
The situation is a "significant impediment" to asthma treatment said Elward, who serves as the AAFP's liaison to the Heart, Lung and Blood Institute's National Asthma Education and Prevention Program. "It's keeping us from providing the care we want to provide for our patients and the care that they need," he said.
Delegate Keith Stelter, M.D., of Mankato, Minn., said, "Patients get that deer-in-the-headlights look when I tell them how much their medication will cost."
A second resolution addressed the lack of insurance coverage for inhalation rate-controlling spacers that alert users with a buzzing sound when inhalation rates are too fast.
Both resolutions noted that many insurance companies grade physicians' quality of care on their ability to keep patients' asthma well controlled.
In the end, the COD adopted a substitute resolution that combined the two original resolutions. The substitute resolution directs the AAFP to work with public and private payers to ensure the lowest copays for at least one inhaled steroid and one short-acting, beta adrenergic inhaler in their drug formularies with any copays at the lowest tier level, and one rate-controlling spacer for which any copays would be in the lowest tier level.
- direct the Academy to urge CMS to provide per-member, per-month payment incentives to FPs who attain patient-centered medical home recognition;
- ask the AAFP to advocate for adequate payment to family physicians who provide weight-loss counseling to patients;
- seek standardization of quality and outcome measures for public and private pay-for-performance programs; and
- call for the establishment of an insurance-wide, real-time, point-of-service claims adjudication process.
Referrals to the board included resolutions or substitute resolutions that
- seek to abolish CMS' regulation for home health services that would require an initial 30-day and repeated 90-day face-to-face encounter between physician and patient;
- look for ways to capture low-cost, cash-paid prescriptions in claims data; and
- push for universal insurance industry claims processing standards.