During the AAFP's annual Congress of Delegates meeting here Sept. 19-21, hundreds of family physicians spent many hours crafting resolutions designed to guide the Academy's work in 2016 and beyond. Dozens of resolutions were divvied up among five reference committees for consideration.
After listening to a long line of family physicians talk about their discontent with prior authorizations, Nebraska alternate delegate Ivan Abdouch, M.D., of Omaha, adds his perspective: "This might be more of a culture change than a policy change," he says during the Sept. 19 Practice Enhancement Reference Committee hearing.
The Reference Committee on Practice Enhancement more than pulled its weight in this effort by deliberating 17 resolutions. Family physicians, some serving as chapter delegates, some speaking on behalf of themselves, eagerly expressed their opinions on topics that dealt with how they practice, care for patients and are paid for their work.
Here is a sampling of those conversations.
The first three resolutions on the committee's agenda all had something in common -- prior authorizations -- and based on the amount of testimony offered, it's a topic that clearly frustrates family physicians.
The first resolution asked the AAFP to encourage the development of a specific time-based CPT code. Its intent was articulated by Montana delegate Dennis Salisbury, M.D., of Butte.
- During the AAFP's 2016 Congress of Delegates, the Reference Committee on Practice Enhancement discussed 17 resolutions.
- Family physicians focused their attention on topics that impede their ability to take the best possible care of their patients.
- Delegates adopted resolutions dealing with a number of issues, such as prior authorizations, Medicare's annual wellness visit, telehealth and independent practice.
"The resolution is clear. It's in the insurance companies' best interest to make authorizations for drugs or (imaging) studies more difficult so that some of them don't get through the process. This serves us and our patients badly," said Salisbury. "Compensate us for the time we spend on our patients' behalf."
Another resolution asked the Academy to advocate for a per-member, per-month (PMPM) fee from payers to help compensate physician practices for prior authorization services.
Justin Bartos, M.D., of North Richland Hills, Texas, spoke about the financial impact prior authorizations have on his practice and how a PMPM fee would help.
"My nurse spent 32 minutes on the phone with Express Scripts trying to get a prior authorization through for one patient. This whole process is time-intensive and requires a sustainable revenue stream in order to support what needs to be done," said Bartos.
He noted that a PMPM fee would allow his practice to hire someone to help deal with prior authorizations because the practice would have some idea of the amount of money coming in to cover the work.
Both resolutions were referred to the AAFP Board of Directors for further consideration.
The final resolution on the topic asked the Academy to develop a specific policy on prior authorizations, educate members about the AAFP's advocacy efforts in this area and provide related member resources.
Washington delegate Russell Maier, M.D., of Yakima, told the committee that he was "batting cleanup" with his introduction of Resolution No. 303.
This resolution "notes that we do not have a specific policy around this critical issue. I would request that this body make this formal policy," said Maier.
Arizona delegate William Thrift, M.D., of Prescott, directed the conversation away from payment and focused instead on patient care. He spoke of a patient in the hospital with Pseudomonas pneumonia who was sent home and then denied the drug he needed "because it was the expensive drug at the time," said Thrift.
"The patient went back to the hospital for another costly stay, and it cost the entire system a lot of money."
Delegates ultimately adopted the measure.
Annual Wellness Visit
Another resolution focused on the fact that independent service providers have been allowed to perform Medicare's annual wellness visit (AWV) without sending results to the patient's primary care physician.
Physicians also have run into payment issues with these visits. Georgia AFP President Mitzi Rubin, M.D., of Atlanta, said her time spent with a patient on an AWV was uncompensated because the service had already been provided to the patient by another source.
"Outside companies are doing this for money … but this visit should be done by the patient's primary care physician," said Rubin. And when these services are provided, no feedback is provided to the primary care physician, she added.
"The annual wellness visit should be helping the patient, but these outside companies are gathering data, taking money and not really helping the patient," said Rubin.
Texas alternate delegate Troy Fiesinger, M.D., of Sugar Land, reported a similar experience. One patient told him, "Oh, they came by a week after I saw you last. These people are coming to my house. I think it's a Medicare scam. Do you know about this, Doctor?"
Fiesinger said his practice gets frequent solicitations from companies who offer this service.
He warned that under the Medicare Access and CHIP Reauthorization Act, Medicare would, in the near future, attribute primary care patients to whichever health care provider does the AWV.
Kathleen Saradarian, M.D., of Branchville, N.J., summed up the conversation best: "The annual wellness visit is important primary care best performed by a primary care provider. And yes, I'll say it: This is an important revenue stream for us."
Delegates adopted a substitute resolution that was further amended in the full Congress session on Sept. 21. It directed the AAFP to seek a ruling from CMS stating that Medicare would pay only for AWVs performed by a clinician within the patient's primary care practice.
A resolution introduced by the Georgia AFP dealt with issues surrounding the exploding business of telemedicine and the fact that the primary care physician often is not made aware of the results of a telemedicine encounter.
Prashanth Bhat, M.D., M.P.H., of Loma Linda, Calif., tells the Practice Enhancement Reference Committee that he supports a resolution on telehealth but calls the subject a "vast topic" that will open a Pandora's box when it comes to agreeing on a definition.
Georgia delegate Leonard Reeves, M.D., of Rome, testified in the reference committee hearing that he'd seen wonderful advances in technology over the years. And although there had been some opposition to telemedicine in the past, "it's here and it's impacting how our patients are being seen.
"We want to make sure that the primary care physician is in the loop," said Reeves. "We're asking the AAFP to work with payers so that the primary care physician is notified when one of these services is used," and to ensure that an account of the telemedicine visit is sent to the patient's primary care physician.
"We want good patient care, and good patient care happens when information is shared," said Reeves.
Rebecca Hafner-Fogarty, M.D., M.B.A., of Avon, Minn., told the reference committee that she wears two professional hats -- she see patients in a small clinical practice and has spent the last few years building a national telehealth company.
She asked the committee to strengthen the resolution's wording. "As a leader of a national telemedicine company, I don't want to be painted with the same broad brush as those who are keeping family physicians out of the (information) loop," she said.
In the end, the delegates adopted a substitute resolution that directed the AAFP to, among other things,
- strongly urge telehealth companies to request the name of the patient's family physician,
- encourage telemedicine companies to partner with local family physicians and health systems to ensure that the patient's family physician is informed of all of telemedicine visits, and
- ask telemedicine companies and payers to adopt models that appropriately triage patients to their family physicians when additional evaluation is required to decide on a diagnosis and treatment plan.
Despite the fact that many family physicians now report that they are employed physicians, the AAFP's support for independent practice is still critical. This fact was underscored by the introduction of a resolution from the Washington and Texas chapters that asked the AAFP to create a policy statement "explicitly supporting family physicians in private practice."
According to the resolution, that support should include updating existing educational materials to assist these physicians and ensuring that new physicians understand their options regarding private practice.
Texas alternate delegate Douglas Curran, M.D., of Athens, got a chuckle from the audience when he said he could speak authoritatively on the topic "because I've been in private practice since Moby Dick was a minnow." He said it was important to preserve private practice as one of many career options available to family physicians and called on the AAFP for mentoring, suggestions and support.
The reference committee recommended that the resolution be adopted as written, and the delegates agreed.
A full accounting of the work of the 2016 Congress of Delegates is available online, where AAFP members can read reports from all five reference committees in their entirety.
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