Primary care was an important focus during the 2013 annual meeting of the AMA House of Delegates held here June 15-19, but as the meeting went on, it became increasingly clear that delegates had very different views of what "primary care" truly means.
Speaking on a measure involving Medicaid-Medicare payment parity that the AMA House of Delegates considered during its recent annual meeting, AAFP Board Chair Glen Stream, M.D., M.B.I., said, "We are all very sensitive to the need for fairness when dealing with the Medicaid system for all physicians."
Fortunately, as representatives of the only medical specialty devoted solely to primary care, members of the AAFP delegation joined with their allies in the AMA house to stave off subspecialists' attempts to waylay recent payment inroads made by primary care physicians who provide Medicaid services.
The disconnect first became apparent during a June 16 reference committee hearing marked by lengthy and often passionate testimony hearing on a resolution proffered by the Michigan delegation. As originally submitted, that measure asked the AMA to "advocate for the extension of Medicaid reimbursement rate increases to primary care physicians to include obstetrician/gynecologists."
The resolution is based on a section of the Patient Protection and Affordable Care Act that increases Medicaid payments for specified primary care services to Medicare levels for certain primary care physicians in 2013 and 2014. It's a program the Academy has fought hard to ensure was properly defined.
According to an AAFP overview, CMS' final rule implementing the Medicare-Medicaid parity provision specifies that the only physicians who can qualify for the payment increase are
- During the recent annual meeting of the AMA House of Delegates, members of the AAFP delegation succeeded in staving off subspecialists' attempts to waylay recent payment inroads made by primary care physicians who provide Medicaid services.
- The final measure delegates considered advocated extending the same Medicaid-Medicare payment parity that primary care physicians receive in very specific circumstances to "all physicians who furnish a substantial portion (60%) of their Medicare or Medicaid billings (allowable charges) for designated primary care services."
- Delegates agreed to refer the matter and likely will take it up again during the AMA's interim meeting in November.
- practicing physicians who self-attest that they are board-certified with a specialty designation of family medicine, general internal medicine or pediatric medicine, or;
- subspecialists related to those specialty categories as recognized by the American Board of Medical Specialties, American Osteopathic Association, or American Board of Physician Specialties who also self-attest that they are board-certified, or;
- physicians related to the specialty categories of family medicine, internal medicine and pediatrics who self-attest that at least 60 percent of all Medicaid services they bill or provide in a managed care environment are for an explicit range of evaluation and management and vaccine administration codes specified in the statute.
The original resolution's lack of specificity sparked concern among members of the AAFP delegation, who went to work even before the reference committee hearing to reach consensus among key stakeholders on amended language that would meet the simultaneous goals of increasing Medicaid beneficiaries' access to primary care services while safeguarding the integrity of the existing program.
Michigan alternate delegate Betty Chu, M.D., introduced the amendment during the hearing. The amended measure asked the AMA to "advocate for the inclusion of OB/Gyns in the extension of the Medicaid to Medicare payment parity beyond 2014 utilizing the current designated CPT code set and the 60 percent practice threshold criteria."
Although delegates from the American Congress of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatrics (AAP), the American College of Physicians and other groups supported the amendment during the hearing, the proposal drew fire from others.
"This is not about primary care," said Florida delegate and neurosurgeon David McKalip, M.D. Many subspecialists -- neurologists, psychiatrists and others -- provide primary care services for their patients, he contended. "All doctors should be paid Medicare rates for Medicaid services." Those sentiments were reiterated by representatives of other subspecialist groups.
In his testimony, AAFP Board Chair Glen Stream, M.D., M.B.I., of Spokane, Wash., acknowledged the need to more appropriately value physicians' services overall, but he urged caution in this instance. "It would be very precarious to open this (payment increase) up to the 2013-14 period," said Stream. "We could be putting the funding at risk."
Still, citing the mixed testimony, the reference committee's report recommended adoption of a substitute resolution that called for the AMA to "advocate for the extension of Medicaid payment increases to primary care physicians to include all physicians who furnish a substantial portion (60%) of their Medicare or Medicaid billings (allowable charges) for designated primary care services," as well as the continuation of the rate increase beyond its designated Dec. 31, 2014, expiration date.
That language prompted numerous calls for referral during the next day's business session, and Stream again went to the microphone to outline primary care's concerns about endangering the current program.
"We are all very sensitive to the need for fairness when dealing with the Medicaid system for all physicians," Stream said. "This is really an issue not about establishing that policy but about a nuanced strategy regarding advocacy -- regarding, specifically, primary care payment."
In fact, he noted, the AMA already has policy that supports bringing Medicaid payment up to Medicare levels(ssl3.ama-assn.org).
"So, that's really not the issue here," Stream said. "The issue is defining an AMA advocacy strategy about the Medicaid-with-Medicare parity when it reaches the end of its current period. We would agree that the language offered by the reference committee substantially changes this in ways that are important and really need study by our AMA board."
First, Stream noted, an expansion such as that suggested in the reference committee's substitute measure "would significantly increase the cost and, therefore, affect the probability of success in extending the parity" beyond its current endpoint. And secondly, "there's language in the proposed alternate language from the reference committee that refers to billings when, in fact, in this particular -- both in the legislation and in regulations -- it's specifically codes and not billings."
ACOG EVP Hal Lawrence III, M.D., was among those agreeing on the need to refer the measure. "This is a very complicated issue … and, as written, it does mix and confuse billings versus coding," he said.
Furthermore, Lawrence added, the potential impact on the current parity program has not been elucidated. "And I think most importantly, it could actually work against us in that it may sabotage our strong efforts for SGR reform."
AAP delegate Stu Cohen, M.D., also joined the call for referral, saying it was important to get the language right. "There is a critical access issue in this country. Forty-eight percent of all births are delivered to women on Medicaid. In many parts of the country, particularly rural and outlying areas, the family docs and pediatricians take care of the kids and the OB/Gyns are the back-up primary care doctor for the mother.
"We really need to make sure that there's appropriate access to care, and by that I mean primary care."
Ultimately, delegates agreed to refer the measure, ensuring it will receive further scrutiny before again being taken up by the AMA house.