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Wednesday Oct 12, 2011

A Conversation About Fair Payment

According to a recent survey, payment issues are the No. 1 concern for AAFP members. We heard you and wanted you to know that we are actively working on this topic for you with both public and private payers.

Academy leaders, including myself, met with about a dozen representatives from one of the nation's largest private payers on Oct. 10 to discuss payment and your concerns.

During the four-hour meeting -- which included representatives from UnitedHealth Group and its subsidiaries, UnitedHealthcare and Optum -- the AAFP discussed distressed practice environments and clearly spelled out for company representatives that paying fee-for-service rates that are below Medicare rates harms primary care physicians and jeopardizes patients' access to care.

A number of members practicing in distressed environments have asked the AAFP for help.

Evidence has shown that primary care leads to better outcomes and lowers overall health care costs. However, these distressed environments -- where primary care payment is especially low -- have low per capita primary care physician penetration rates, high per capita subspecialist penetration, low retention of primary care trained residents, aging primary care bases, and a decreasing number of primary care physicians.

Many health plans are offering family medicine practices -- especially in rural areas and in areas with small- and medium-sized practices -- contracts for fee-for-service payment that are up to 40 percent less than Medicare. Sadly, these practices have no room to negotiate. It's take it or leave it.

We told United's representatives that such tactics are outrageous. This approach is killing primary care practices. Meanwhile, some subspecialists in these same geographic areas are being offered fee-for-service rates at or above Medicare rates, steering medical students away from primary care, driving family medicine residents out of these areas and exacerbating shortages in the primary care workforce.

Paying less than Medicare also conveys the public message that UnitedHealthcare, as both a payer and employer, does not value primary care. We urged company representatives to reconsider their corporate policy in this regard.

The AAFP's Commission on Quality and Practice is looking into the problems faced by family physicians in these distressed practice environments. In addition, a staff working group is collecting data on factors that lead to these environments, where they exist and ways the AAFP can work with constituent chapters to address the problem.

The Academy also has asked the Patient-Centered Primary Care Collaborative(www.pcpcc.net) (www.pcpcc.net)to address the fact that some private health plans involved in the PCPCC are offering family physicians contracts that pay significantly less than Medicare.

It is up to you as an individual physician to decide who to contract with. However, it is important that part of that decision-making process is an evaluation of whether the offered payment leads to a viable practice with quality patient outcomes.

For years, the AAFP has urged public and private payers to adopt a blended payment model that rewards primary care physicians for coordinating and managing patient care. Our meeting with United came soon after some good news on that front. On Sept. 28,  CMS and its Center for Medicare and Medicaid Innovation, or CMMI, announced the launch of the Comprehensive Primary Care InitiativeThe initiative will involve CMS collaborating with commercial and state health insurance plans to support primary care practices that deliver coordinated and seamless care.

The program will give participating practices fee-for-service payments and a risk-adjusted per-patient, per-month coordination fee ranging from $8 to $40, plus the opportunity to share in savings resulting from the program. This model is what AAFP has been advocating in support of the patient-centered medical home, and we encouraged the United companies to participate.

Commercial insurers interested in participating in the initiative need to submit a letter of intent to participate by Nov. 15. CMS will then recruit 75 primary care practices in up to seven regional markets for the initial phase of the project. Participating physicians will benefit from the blended payment model for Medicare and Medicaid patients as well as patients enrolled in participating private insurance plans.

AAFP leaders are scheduled to meet with CMMI staff Oct. 20 in Washington, D.C. to talk about the initiative, and we plan to discuss it again with UnitedHealthcare sometime after that CMMI meeting.

I'm confident this initiative will further demonstrate that patient outcomes improve and costs are saved when the health care system values primary care by paying for all the services we provide to our patients.

Monday's meeting with UnitedHealthcare was a first for me but not for the Academy. The AAFP meets regularly with private payers, and similar meetings with other large commercial insurers are being planned for 2012. As with Monday's meeting, the focus will be on payment and improving care coordination and quality.

Our message is simple. To ensure patients' access to care, primary care physicians must be paid at a level that matches the value of our service.

 

Posted at 12:18PM Oct 12, 2011 by Glen Stream, M.D., M.B.I.

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