A question about the AMA/Specialty Society Relative Value Scale Update Committee, or RUC, and what the AAFP is doing to address the RUC's shortcomings led off a spirited exchange of queries, comments and ideas between AAFP members and leaders during the May 6 Town Hall meeting here at the Annual Leadership Forum/National Conference of Special Constituencies.
AAFP member Marguerite Duane, M.D., M.H.A., of Washington, D.C., asks Academy Board members if the AAFP is open to innovative models of payment reform. Duane's question came during the Town Hall meeting at the 2011 Annual Leadership Forum/National Conference of Special Constituencies.
Roland Goertz, M.D., M.B.A., of Waco, Texas, was the first to respond to the question, which arose out of recent calls for the AAFP to withdraw from the RUC to protest a mechanism that has often undervalued primary care when recommending Medicare physician payment rates.
"The Board has had in-depth, considered and serious discussions about the RUC," said Goertz. But a decision about whether or not the AAFP should withdraw from the RUC cannot be made lightly, he noted, and the Board needs to consider all the ramifications of withdrawing on family physicians and their patients. A decision is forthcoming, but the Board has to have more discussion before that can happen, Goertz added.
Board Chair Lori Heim, M.D., of Vass, N.C., chimed in to further explain the Board's discussions about the RUC, which was formed by the AMA to make recommendations to CMS regarding physician work relative values for CPT codes. "The RUC is a really thorny issue," said Heim. The AAFP is fully committed to ensuring that primary care physicians are fairly paid for the value they bring, she said, but, "the Board spent over two days discussing it, and we're not done yet." She assured members, however, that as soon as a decision is made, they will know about it.
Accountable care organizations, or ACOs, were the next issue of concern. Audience members wanted to know what the AAFP's position is on proposed ACO regulations from CMS that are currently in the open comment period.
Goertz agreed that the proposed regulations are a concern. He noted that comments from the AAFP are in development and will be released by mid-May.
ACOs can be a significant change for good in the health care industry if they are set up the right way, said Goertz. But the rule, as currently proposed, is too prescriptive, and there is not enough room for small- and medium-sized practices. "There are a number of areas we have concerns about," he said.
AAFP President-elect Glen Stream, M.D., of Spokane, Wash., noted that the AAFP was at the table when the rule was first being discussed, but not all of the Academy's requests are reflected in the final proposed rule. "We're disappointed our input was not reflected in the final rule," said Stream. For example, he noted, as currently proposed, ACOs would require a large, upfront financial commitment, which would create a strain on physician groups wanting to form ACOs of their own. They likely would need to partner with a financial entity to make the initial investment possible, said Stream. That would leave many smaller practices unable to participate in forming ACOs.
Electronic health records, or EHRs, and the recent release of meaningful use standards designed to help EHR users receive incentive payments were on the mind of AAFP member Colette Willins, M.D., of Westlake, Ohio, during the meeting. She asked if there are opportunities for modifying the meaningful use requirements as set out by CMS.
According to Willins, 30 percent of the patients she sees need to be Medicaid recipients to qualify for the incentives, but pediatricians only need to reach a 20 percent Medicaid threshold. In addition, she noted, her Medicare patients who are also in an HMO do not count toward meeting the meaningful use criteria. "This seems counterproductive to the goals of CMS," said Willins.
Stream agreed that patients in programs such as Medicare Part C are not eligible to be included in the criteria for either meaningful use or electronic prescribing incentives. He said he hasn't heard any discussion about changes in the program, "but that doesn't mean we can't advocate for (changes)."
However, Stream added, a year of experience with the programs might be helpful. A year would provide real numbers that the AAFP could then use to seek modifications to the incentive programs.
In addition, said Goertz, "We'll take this back to the ONC (Office of the National Coordinator for Health Information Technology)." He noted that the Academy has an ongoing working relationship with the ONC, and said he would make sure that office is aware of the issue, which also affects rural health clinics.
Increasing the family physician workforce and retaining young physicians represent the Academy's "number one priority," said Heim in response to a question that asked what the Academy was doing to boost the FP workforce. "If we don't retain our young physicians, we know what that means for our specialty," said Heim. This also has been a topic for Board discussion, she added, and Board members know that increasing primary care physician payments by 10 percent just isn't enough to draw more students into family medicine.
Even the Association of American Medical Colleges is making the case for family medicine, said Goertz. "Academic centers are going to be very challenged by the health care transition," he noted. Some of those schools may choose to sit on the sidelines, but most will choose to change their way of doing things to put more emphasis on primary care. "That will help get more students to go into family medicine."
In addition, the recent Council on Graduate Medical Education report on the future of medical education notes that payment is a barrier to getting more students to go into primary care. That is a voice separate from the Academy's advocating for changes that we can point to in our discussions with legislators, said Goertz.
AAFP EVP Douglas Henley, M.D., had an opportunity to point to some of the AAFP's resources for members when asked what the Academy is doing to help them negotiate contractual arrangements, particularly in the current health reform environment, because some practices are signing contracts that potentially could be dangerous to their continued existence.
The Academy has resources to help members with contract negotiations, as well as specific information about ACOs, said Henley. However, he pointed out, state law varies, so medical practices need to make sure they have appropriate legal counsel when negotiating these types of contracts.
Marguerite Duane, M.D., of Washington, D.C., sparked applause with her question on the health care reform law. It's not really health care reform, said Duane. It's really an insurance reform law. She asked what the Academy is doing to advance alternative health care models that modify actual care and incorporate innovative payment models.
Goertz responded that individual state laws make it hard for the AAFP to endorse any one model, but the Academy's position has always been that if a model works for family physicians and their patients, that is a good thing. "We cannot predict how any one model will work, but we can advocate for innovative approaches," he said.
Stream agreed that regulations vary a lot among the states, and that makes it difficult for the AAFP to support just one proposal. However, he noted, the AAFP can serve as a central repository for such innovations and provide information on how the models are working for the practices piloting them.