Family physicians from across the country assembled here this week to participate in the AAFP's annual Congress of Delegates. The 2015 Congress, in session from Sept. 28-30, served as a platform for members to discuss policy issues that centered on physicians' ability to run their practices efficiently and take the best possible care of their patients.
Georgia alternate delegate Harry Strothers, M.D., of East Point, tells the Congress of Delegates that his electronic health record system, implemented in 2002, still doesn't work as intended. His message to vendors: "Produce what we need or get out of the business."
The Reference Committee on Practice Enhancement tackled a variety of resolutions and heard passionate testimony on many of those measures in its Sept. 28 hearing. The issue of electronic health records (EHRs), in particular, sparked additional debate in the following day's Congress session.
Although family physicians have, during the past decade, embraced EHRs in greater numbers than physicians in any other specialty, faulty software and a lack of interoperability among systems continues to frustrate many.
During the reference committee hearing, resolution author and Georgia delegate Bruce LeClair, M.D., of Evans, cited information from numerous reports that emphasized the need for interoperability and safety of EHRs. He noted a lack of "innovation and oversight" in the EHR arena.
However, Donald Lurye, M.D., of Elmhurst, Ill., was one of several physicians at the hearing who were concerned about the possibility of FDA jurisdiction. He noted the FDA already was "overwhelmed" with its food and drug safety responsibilities and that exposing EHRs to a 2.3 percent medical device tax (as required by the Patient Protection and Affordable Care Act) would make the technology "even more expensive" for physicians to implement.
- During the AAFP's 2015 Congress of Delegates, the Reference Committee on Practice Enhancement tackled resolutions centering on practice efficiency and quality care.
- A resolution suggesting that electronic health records be designated as medical devices -- and regulated by the FDA -- engendered lengthy discussion and, ultimately, was referred to the AAFP Board of Directors.
- The committee heard extensive testimony on a variety of issues, including contraceptives, generic medications, telehealth and patient satisfaction.
Delegates ultimately overturned the committee's recommendation against adoption and voted to refer the resolution to the AAFP Board of Directors.
The committee handled a number of resolutions that dealt with contraceptives, including two measures, ultimately combined, that asked the AAFP to support policy ensuring public and private health plan coverage of long-acting, reversible contraceptives.
Concerns focused on placement of these devices in postpartum women before hospital discharge, as well as physician payment for placement of such devices separate from the global fee. During the reference committee hearing, family physicians testified extensively on the issue.
Shani Muhammad, M.D., of Fresno, Calif., a member constituency alternate delegate, spoke bluntly: "Many of our patients only show up (in the clinic) pregnant, when it's too late" to address pregnancy prevention.
Ohio alternate delegate Sarah Sams, M.D., of Hilliard, said that in her state, Medicaid laws consider the service to be an outpatient procedure -- a determination that is problematic.
"Spacing of pregnancy is important, and often, we don't get another chance (to insert a contraceptive device) because many of our patients don't come back for their six-week postpartum checkup," said Sams. Providing the service for "at-risk patients" while they are still hospitalized after delivery is very important, she added.
Providing contraceptives to patients with Medicare disability coverage also was debated at length.
"I care for a number of patients who have Medicare through disability, and not being able to have access to coverage for typical contraception just because they have Medicare is not what we should be practicing when we have a reproductive population," said Kristen Koenig, M.D., of Killeen, Texas, a delegate representing the new physician constituency. "For a woman who has a disability, pregnancy could put her health at risk."
Rhode Island alternate delegate Melissa Nothnagle, M.D., of Pawtucket, also supported the resolution. "These patients need the most effective forms of contraception," she said.
Pennsylvania delegate Russell Breish, M.D., of Philadelphia, spoke of a patient in her twenties who lived in a long-term facility. "She told staff she was having intercourse with visitors," and they refused to act, he recounted. After a missed menstrual period and a pregnancy scare, the facility worked to get her contraception covered, said Breish.
Bringing the situation to light "also offers the AAFP an opportunity to educate the public as to who is on Medicare: not just grandmum, but grandson or granddaughter, as well," he added.
In the end, delegates adopted a substitute resolution that directed the AAFP to support Medicare coverage for all FDA-approved methods of contraception and to advocate to CMS that these contraceptive options be fully covered for men and women of reproductive age.
Generic medications -- both their rising cost and their non-inclusion in pharmacy benefit plans -- also were a hot button issue for family physicians.
During the reference committee hearing, Florida alternate delegate Ajoy Kumar, M.D., of St. Petersburg, gave this testimony: "Patients have had success with generics, but many generics are simply excluded from formularies with no real relationship to the cost. We have to do the right thing for our patients and not go through a guessing game as to what drug is supposed to be cheaper. Generics should never break the bank."
Michigan alternate delegate Peter Graham, M.D., of East Lansing, advised his colleagues to be cautious when considering a resolution that would ask public and private payers to include as "covered" more than 75 percent of available generic drugs in each therapeutic category.
"Costs from insurance companies get passed on to us, and single-source generics can become breathtakingly expensive," he said.
New Jersey delegate Mary Campagnolo, M.D., of Lumberton, stated a differing opinion: "I would like to see the covered generics be 100 percent, not 75 percent." She said she sometimes needs a prior authorization for a generic drug and argued that "schizophrenic insurance companies are doing this to us."
The resolution -- which also asked the AAFP to encourage the Federal Trade Commission to investigate gouging and price fixing in the generic medication market -- was referred to the Board.
A resolution put forth by the Mississippi delegation asked, in part, for the AAFP to insist that telemedicine and mobile health be utilized only as part of an established patient/physician relationship that includes recent face-to-face encounters.
South Dakota alternate delegate Victoria Walker, M.D., of Vermillion, tells her colleagues she supports high-quality telemedicine care, but limiting telemedicine only to established patients will keep family physicians and their patients from seeing the full potential and scope of the model.
But more than one concerned family physician testified that placing such tight restrictions on telemedicine would be detrimental to patients.
Robin Barnett, D.O., M.B.A., of Cedar Rapids, Iowa, a member constituency delegate, asserted that telemedicine would play an ever-increasing role in the future. "It's not going away, and it's another way to establish care with these patients," she said.
"I took a call from a woman saying, 'My husband is having a heart attack.' Right then and there, I established a physician/patient relationship," Barnett recounted. The tight definition suggested by the resolution, "only limits our ability to establish a relationship," she added.
Mississippi delegate Luke Lampton, M.D., of Magnolia, argued that the "established relationship" phrase should be viewed as the highest quality of care even if physicians couldn't always live up to the definition. He added that telemedicine would, in time, become an extension of family medicine and would help patients avoid seeking care at a "kiosk in Walgreens."
"Nothing can take the place of the physical exam in an exam room," observed resident physician constituency alternate delegate Alex McDonald, M.D., of Fontana, Calif., "but medicine won't be practiced that way in 50 years."
Ultimately, the measure was referred to the Board for further discussion.
Family physicians want their patients to be satisfied with the care they receive, but physicians are unhappy with current satisfaction measurement practices. A resolution introduced by the Michigan chapter asked the AAFP to advocate that standardized and clinically validated instruments be used to assess patient engagement and experience.
Testifying for a second time, Michigan delegate alternate Peter Graham, M.D., agreed that the patient experience was important. However, "it's difficult to look at patient engagement measurements and trust that they are telling us what we need to know. Buying a car is not the same experience as taking care of patients," he said.
Florida alternate delegate Ajoy Kumar, M.D., also stepped to the microphone again, this time to argue that patient satisfaction scores should be decoupled from payment.
Eventually, the Congress adopted a substitute measure that, among other things, asked the Academy to advocate that patient satisfaction measures be used as incentives, not penalties, and be cost-effective for physicians in small practices.
Delegates also adopted resolutions dealing with
- issues that complicate the care of patients with Medicare Advantage health plans,
- costs attributed to maintaining a patient-centered medical home practice, and the
- release of transitions-of-care information from hospitals to primary care physicians.
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