The AAFP recently seized the opportunity to lay out for leaders of the powerful Senate Finance Committee a comprehensive array of recommendations to address the growing health care burden posed by chronic disease in the United States.
To set the stage: In May, Finance Committee Chair Orrin Hatch, R-Utah, together with Ranking Member Ron Wyden, D-Oregon, and other committee members, announced the formation(www.finance.senate.gov) of a chronic care reform working group tasked with studying the complex issues involved in chronic care management and producing an in-depth analysis of potential legislative solutions. Sens. Johnny Isakson, R-Ga., and Mark Warner, D-Va., co-sponsors of the Care Planning Act, were named co-chairs of the group.
Barely a week later, the working group reached out to public and private sector stakeholders, asking them to offer their ideas on ways to improve health outcomes for Medicare patients beset by chronic disease. According to Hatch's statement, "Stakeholder input is critical for this committee to work toward the goal of producing bipartisan legislation that can be introduced and marked up in the Finance Committee later this year."
The Academy responded to that call in a June 22 letter(13 page PDF) from AAFP Board Chair Reid Blackwelder, M.D., of Kingsport, Tenn., to the four senators, offering a veritable laundry list of sage advice. First and foremost was the declaration that "family medicine is at the center of chronic care."
- The AAFP recently provided leaders of the powerful Senate Finance Committee a comprehensive array of recommendations to address chronic disease in the United States.
- In a June 22 letter to the committee's chronic care reform working group, the Academy called for process improvements to the Medicare Advantage program, as well as payment that recognizes the work family physicians do every day.
- The letter also called for fewer restrictions on telemedicine services and greater accountability in graduate medical education funding.
"Family physicians are trained to deliver and practice primary care, which the AAFP defines as 'health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health settings,'" said Blackwelder in the letter.
He went on to stress the critical importance of the "continuing healing relationships" family physicians have with their patients, in which they oversee and care for all of their patients' health needs, often in collaboration with other health care professionals.
"Therefore, the AAFP agrees with the Committee's Working Group that preventing, treating and managing chronic illnesses are essential in order to meet the Triple Aim of improved population health, improved patient care, and lower costs," said the letter.
Improve Medicare Advantage
Blackwelder outlined four recommendations focused on Medicare Advantage plans, calling on Congress to:
- Encourage plans to align care management functions within the primary care practice, rather than as a stand-alone function;
- Require plans to make more patient data available to primary care physicians;
- Require plans to implement and reimburse for the new Medicare chronic care management (CCM) code, CPT 99490; and
- Encourage plans to place greater emphasis on caregiver education.
Noting that the AAFP has had years of practice transformation experience and leadership, Blackwelder pointed out that the true value of care managers is realized when they are "aligned with and embedded within the (physician) practice."
Basically, the same goes for patient data, he added. Medicare Advantage plans collect and analyze large volumes of such data, which is important in coordinating care for patients with multiple chronic conditions. "Providing greater amounts of usable and applicable data to a patient's primary care physician would permit greater coordination of care, limit duplicative services, and facilitate improved health outcomes and lower costs," Blackwelder noted.
The Academy's call to pay primary care physicians for coordinating Medicare Advantage patients' chronic care is not new, with the AAFP having previously reminded CMS(3 page PDF) that traditional Medicare Part B began paying for the code as of Jan. 1 of this year and urging the agency to require Medicare Advantage plans to do the same.
Alternative Payment Models
As an advocate of a blended payment model that combines payment for enhanced fee-for-service, incentives for quality performance and a per-patient per-month care management fee to cover care that falls outside of typical office visits, the AAFP also recommended that Congress establish a risk-adjusted, per-patient per-month care management fee for primary care practices. Most of the core activities the Academy envisioned such a fee covering are "nonface-to-face activities for which current fee-for-service payment systems provide little to no support," the letter explained.
Blackwelder pointed to the positive early results realized by practices participating in the four-year, multipayer Comprehensive Primary Care initiative pilot now playing out in seven geographic regions of the United States as strong evidence that increasing support for primary care can improve quality and lower costs. He therefore called on Congress to press HHS Secretary Sylvia Burwell to use her existing authority to expand the program and its payment model "across all of Medicare."
If that option cannot be rapidly pursued, Blackwelder urged lawmakers to take the intermediate step of adding to Medicare's fee-for-service program another code for chronic care management that could be used to "bill for outliers in terms of beneficiaries who require significantly more than the typical time per month, which cannot be easily accounted for otherwise under the current single code."
Furthermore, said the letter, Congress should eliminate Medicare beneficiary cost-sharing for the current CCM service code, which causes confusion among beneficiaries (since other preventive services such as various cancer screenings are provided with no cost-sharing) and difficulty for physicians who try to collect the payment.
The Academy's letter also included recommendations on:
- Not permitting routine substitution of generic drugs for prescription medications,
- Easing restrictions on telemedicine and telehealth services as a means of expanding access to care in remote areas; and
- Promoting accountable graduate medical education funding practices that target and deliver the physicians the nation needs to provide care to an aging population plagued by chronic illness.