2014: Year in Review

Payment Tops AAFP's List of Advocacy Issues

January 06, 2015 03:56 pm News Staff

A host of legislative issues were at the forefront of the AAFP advocacy agenda during 2014. Efforts to maintain or even boost payment to primary care physicians -- especially family physicians -- continued, while new concerns, such as insurers narrowing their provider networks, arose.

[AAFP Advocacy]

A number of these issues will still be on the table for 2015, so it's worth taking a look back to see what the specialty has accomplished to date and what remains to be done.

SGR Repeal

For more than a decade, a ghost of the Balanced Budget Act of 1997 has haunted family physicians and policymakers alike in the form of a series of annual cuts to Medicare physician payments according to the sustainable growth rate (SGR) formula.

Since 2003, Congress has enacted 17 short-term patches to forestall the SGR cuts. The total price tag for the patches to date: nearly $170 billion.

Early last year, however, there were signs of optimism as lawmakers introduced a bipartisan, bicameral bill that included a permanent repeal. The bill, known as the SGR Repeal and Medicare Provider Payment Modernization Act of 2014, called for a 0.5 percent annual increase in Medicare payments for physicians until 2018.

Yet despite receiving widespread support on both sides of the aisle, legislators could not agree on a way to pay for the repeal and eventually passed a one-year stop-gap measure. Absent further congressional action, scheduled Medicare cuts for 2015 amount to 21.2 percent and will take effect on April 1.

It's worth noting that the legislation implementing the most recent patch did include a silver lining, of sorts, according to Kavita Patel, M.D., a practicing primary care physician at Johns Hopkins Medicine in Boston and managing director for clinical transformation and delivery at the Brookings Institution's Engelberg Center for Health Care Reform.

In an interview with AAFP News, Patel noted that the bill supported community-based mental health centers and boosted funding for outpatient mental health services. It also increased payment for Medicare Advantage participants with special needs and delayed the scheduled conversion to ICD-10-CM code sets for outpatient diagnostic coding until Oct.1 of this year, a move Patel said would likely be particularly welcome news for small physician practices.

The Academy, along with other stakeholder groups, continued its call for SGR repeal throughout the year, most recently joining with dozens of those groups to urge House and Senate leaders to follow through on eliminating the flawed formula. The latest Congressional Budget Office estimate for complete repeal of the SGR with a 10-year freeze on payments is $119 billion, the groups noted, a figure they said will no doubt continue to rise unless and until Congress takes definitive action.

CMS Deputy Administrator Cindy Mann, J.D., listens carefully as family physicians and AAFP chapter leaders pepper her with questions and suggestions about how to strengthen Medicaid for patients and physicians.

Medicaid-Medicare Parity

Since its inception in the 1960s, a major downside of the Medicaid program has been the relatively low payments physicians who participate in the joint state and federal government program receive. Even among participating physicians, some are reluctant to take on additional Medicaid patients because reimbursement rates are simply too low.

In an attempt to address this shortfall and, thereby, boost access to care for low-income patients -- at least in the short term -- a specific provision of the Patient Protection and Affordable Care Act (ACA) increased Medicaid payments for certain primary care services provided by FPs and other primary care professionals to reach parity with Medicare payment rates in 2013 and 2014. The provision, however, was set to expire at the end of 2014, prompting Sens. Patty Murray, D-Wash., and Sherrod Brown, D-Ohio, to introduce legislation in August intended to extend the Medicaid payment hike for two more years.

During a visit with AAFP chapter leaders in October, CMS Deputy Administrator Cindy Mann, J.D., laid out the Obama administration's support for continued funding of the Medicaid payment increase and noted that 27 states and the District of Columbia had expanded their Medicaid and Children's Health Insurance programs as part of the ACA implementation.

Although Congress allowed the payment to expire, a number of states plan to continue to expand Medicaid, and 15 states have pledged to continue the payment increase even without support from the federal government. Another 24 states and the District of Columbia will not continue the payment, and 12 states remain undecided.

Narrow Provider Networks

Many patients in Tennessee and other areas of the country who carry insurance with UnitedHealthcare received disturbing news this year: They were told their physician would no longer be included in their insurance plan and were given just 60 days to choose a new one. The insurer had previously taken similar steps in Connecticut, Florida, Ohio and Rhode Island, where it specifically sought to limit the size of its Medicare Advantage network.

[Faces and X's on chart connected by lines]

Dubbed "network optimization," the strategy has left many patients who have established long-time relationships with their primary care physician without a suitable option.

In response, the AAFP sent letters to UnitedHealthCare and America's Health Insurance Plans seeking an explanation as to why insurers at the state level had chosen to restrict their networks when health care costs are shown to drop when a patient maintains a pattern of care with the same physician. The Academy also wrote to CMS Administrator Marilyn Tavenner, M.A., raising concerns about the process.

And UnitedHealthCare is not the only insurance carrier taking aggressive steps to pare down the number of available physicians to patients. An AAFP survey of members highlighted the spread of narrow networks in numerous states, finding that Humana in Texas and Cigna in Wisconsin are following suit by reducing the number of physicians in their networks.

In a subsequent meeting with Tavenner and Mann, (then) AAFP Board Chair Jeff Cain, M.D., of Denver, presented results from the survey that demonstrated the growing trend of limited choice for patients. CMS officials told Cain it was the first time they had seen such detailed statistics on a national level.

Although the agency cannot regulate private insurance at the state level, it has influence over insurance companies that participate in Medicaid and Medicare Advantage. Cain asked CMS officials to consider introducing a policy that would allow patients who sign up for an insurance plan to have access to the same list of physicians for at least one year. He also requested that CMS encourage insurers to provide cost and quality data to physicians that those insurers use when determining a physician’s participation in a network.

Veterans' Health Needs

Caring for individuals who served in the military and need medical care became a major legislative priority after a series of troubling media reports detailed how veterans often had to wait several months to see a physician at a Department of Veterans Affairs (VA) hospital.

In a letter to the White House and congressional leaders, the AAFP outlined several steps that could alleviate the backlog at VA hospitals, noting that some administrative restrictions would need to be lifted to improve access for veterans.

Several of the recommendations were heeded, and legislators responded by passing the Veterans Choice, Access and Accountability Act, which became law in August. The law allows the VA to hire more physicians and permits veterans who face long wait times for appointments or who live far from a VA facility to see a primary care physician who is not affiliated with the VA. Physicians who want to provide care for veterans under the act sign a provider agreement to do so.

In a separate move, primary care was added to a list of medical services that could be provided outside VA facilities as part of the department's Patient-Centered Community Care program.

Open Payments Transparency Program

Another big development in 2014 involved giving patients insight into financial relationships physicians may have with pharmaceutical companies or other vendors. Specifically, CMS launched its Open Payments transparency program to implement the Physician Payments Sunshine Act passed as part of the ACA, and the AAFP took pains to make sure members knew about the program and its deadlines.

A series of miscues during the summer caused angst among physicians who were anxious to ensure information submitted about them by industry was accurate before being publicly released by CMS. AAFP News kept members posted about website closures, review timelines and the release of the first set of data on Sept. 30.

An estimated 26,000 physicians and 400 teaching hospitals reviewed their data in the Open Payments system before it was published. Disputed data will be published at some point in 2015, but CMS has not provided a specific date yet.

Data published to date include information on 4.4 million payments made to 546,000 physicians and nearly 1,360 teaching hospitals.