Provisions in the health care reform legislation that affect primary care, including accountable care organizations, or ACOs; primary care bonuses; and graduate medical education, or GME, funding, were topics on the table during a recent meeting between AAFP leaders and the new head of CMS.
During a Sept. 21 meeting with CMS Administrator Donald Berwick, M.D., AAFP President Lori Heim, M.D., of Vass, N.C., and EVP Douglas Henley, M.D., emphasized the importance of primary care as a foundation for provisions in the Patient Protection and Affordable Care Act.
The three key areas the AAFP leaders addressed included creation of ACOs, which is called for in the legislation; concerns about the 10 percent bonus for primary care physicians in the Medicare program; and revamping payment for GME to support primary care residencies. In each of these areas, a primary care-based system is the key to enhancing access, improving quality and saving costs, Heim and Henley told Berwick.
"Dr. Berwick is certainly well aware of the need for care coordination and medical homes from his work in performance improvement and office redesign," said Heim in an interview with AAFP News Now shortly after the meeting. "I think he understands very well how foundational primary care is to achieving care coordination."
For example, the health care reform legislation encourages physicians and hospitals to form ACOs, but Heim and Henley stressed to Berwick that the ACO model should be based on a foundation of primary care and the patient-centered medical home.
"We know, and I think (Berwick) also understands, that in order for us to be successful with ACOs, they have to be primary care-based," Heim said.
Heim said that she and Henley also expressed their concerns about various parts of other provisions in the health care reform legislation. For example, although the law provides a 10 percent Medicare bonus for physicians whose primary care services comprise 60 percent of their total Medicare services, Heim and Henley informed Berwick that the threshold is too high
In the final analysis, a 60 percent threshold could prevent many primary care physicians from receiving the bonus. In particular, said Heim, in many rural and underserved parts of the country, primary care physicians are the only physicians around. Their remote location means they often are required to provide services that would not fall into the category of primary care. This makes it difficult, if not impossible, for primary care physicians in these areas to meet the 60 percent threshold required for the primary care bonus.
"Dr. Berwick is aware of the situation," said Heim. "But it is helpful to have that reinforced."
According to Heim, the AAFP leaders also stressed that most primary care training takes place outside of the hospital setting, so it is important that GME funding go directly to residencies instead of to sponsoring hospitals or organizations.
She added that they also discussed with Berwick bringing Medicaid payments up to the level of Medicare payments in 2013 and 2014. Heim pointed out to him that many primary care physicians would have reservations about taking on more Medicaid patients if the enhanced payment rate expires at the end of 2014.
"That is not something that CMS can correct," said Heim. "But we wanted to make sure it got on (Berwick's) radar screen and that he understands the issue, particularly as the AAFP and others push to have that (payment increase) extended."
Heim described Berwick as "very much in a listening mode" during the 45-minute meeting. "He was reaching out for our input and listening to our big concerns," she said.
The meeting itself represents the AAFP's ongoing efforts to ensure that the views and perspectives of primary care and family medicine are taken into consideration as the implementation of health care reform moves forward, Heim noted.