As the AAFP Congress of Delegates churned toward the close of business here on Sept. 14, delegates and other attendees were treated to remarks by guest speaker Nancy Nielsen, M.D., serving in her new role as senior adviser to the Center for Medicare and Medicaid Innovation.
Nielsen, who was president of the AMA from June 2008 to June 2009, immediately connected with the audience when she revealed that her medical specialty was general internal medicine. And, she drew applause when she admitted her pet peeve: "It really makes me crazy when people talk about people who do primary care as primary care physicians and all the other docs as specialists; we are specialists in our field," said Nielsen.
In addition, Nielsen revealed that her personal physician was a family physician.
After establishing commonalities with the audience, Nielsen said the message from CMS that she came to deliver to family physicians was this: "Hold on. Help is on the way." Specifically, Nielsen was referring to the role family physicians will play in the implementation of the Patient Protection and Affordable Care Act.
The U.S. Supreme Court will rule on the constitutionality of the health care reform law, said Nielsen, but in the meantime, the country has to face up to a big problem -- namely, that there are not enough family physicians and other primary care physicians to take care of all the existing and future patients that will need health care.
- Nancy Nielsen, M.D., addressed the AAFP Congress of Delegates as part of her new role as senior adviser to the Center for Medicare and Medicaid Innovation.
- Nielsen said Washington knows that primary care is undervalued, and FPs should know that help is on the way.
- In addition, FPs should be happier with the final rule on accountable care organizations than they were with the first iteration.
There are many reasons for that, said Nielsen. "I'm the senior associate dean of my medical school and for years have done career counseling with my students. They make decisions -- career decisions -- and part of that (process) is money. There's no doubt about it," she said.
Nielsen said Washington knows that primary care is undervalued and changes in the payment system must be forthcoming or medical students will continue to pursue more lucrative subspecialties.
In addition, all stakeholders need to understand that primary care physicians have the skills desperately needed by the U.S. health care system, including the ability to communicate, manage resources and oversee the stewardship of finite resources.
Nielsen dived into the topic of accountable care organizations, or ACOs, with vigor. Although the release of the proposed ACO rule in April "was met with -- how shall I say it -- an underwhelming response by the medical community," said Nielsen, release of the final ACO rule is pending, and "I'm here to tell you that CMS has listened to the feedback."
She ticked off several of the bigger issues that primary care physicians had with the proposed ACO rule, such as the burden of adhering to 65 quality measures and a shared savings mechanism deemed unbalanced by many primary care physicians. "It has clearly been suggested to us that hospitals have the capital to start up an ACO, but it's really tough for doctors," said Nielsen.
"So it's been suggested to us that we give advance payment, and I'm here to tell you that very soon, you will see that, and very soon, you will like what you see."
According to Nielsen, an ACO can basically be defined as a group of people accountable for the care of patients, but physicians have always knowingly and willingly accepted accountability for the care of their patients. The advent of ACOs just means that another piece has been added to that accountability role: control and expenditure of resources.
Nielsen challenged family physicians to recall if they knew the real cost of ordering an X-ray or prescribing a medication. "I will tell you that never once in my 23 years of practice did I see data that showed me what it cost when I ordered an X-ray. I never saw that," said Nielsen.
The cost of procedures and treatments is important stuff, she noted, and it's the very thing from which physicians and patients have been insulated. Nielsen urged physicians to look at ACOs with an eye toward controlling resources.
"I do not believe that ACOs are a fad that are going away, that if we just wait it out and hold on and do the white-knuckle grip, that it will all go away. I think that this one is here to stay," said Nielsen.
"There will be new expectations and new tools given to primary care physicians" during the process, said Nielsen. "But you must help us achieve this. You must help us make sure that when the internecine warfare within the house of medicine begins, that we stand together and we say, 'Wait a minute, we are specialists, just like you are specialists; we have a critical role to play, and we need to have the tools to help us play that role.'"
"Stay tuned," said Nielsen, adding that family physicians are going to like the assistance that's coming from CMS.