"I'm in favor of having us meet (quality) measures but not using it (pay-for-performance) to rank me as platinum, gold, silver or a rusty nail," says Lisa Casey, M.D., a women's delegate from Metairie, La., in testimony before the Reference Committee on Practice Enhancement.
AAFP members recently gathered here for the annual three-day National Conference of Constituency Leaders (NCCL).
From May 5-7, AAFP members representing themselves or one of five constituency groups -- women; minorities; new physicians, international medical graduates (IMGs); and gay, lesbian, bisexual or transgender (GLBT) physicians or those who support GLBT issues -- created resolutions and discussed them in reference committee hearings on the second day of the conference.
On the final morning, all participants gathered for more debate on some of the thornier issues before delegates decided whether or not to adopt reference committee recommendations.
The Reference Committee on Practice Enhancement covered a lot of ground on issues that ranged from pay-for-performance (P4P) rankings to end-of-life discussions with patients. However, all the resolutions reflected an underlying theme -- that of securing family physicians' ability to take the best possible care of their patients.
- Family physicians at the National Conference of Constituency Leaders Reference Committee on Practice Enhancement debated a number of issues to reduce interference with patient care.
- Top topics the committee addressed included pay-for-performance issues, end-of-life discussions, direct-to-consumer advertising and physician burnout.
- One resolution calls on the AAFP to strongly advise insurance companies to stop ranking physicians and/or removing them from panels based on pay-for-performance measures.
The fact that two separate resolutions addressed perceived problems with pay-for-performance (P4P) programs shows how much these ranking programs frustrate physicians.
The first resolution stated that insurance companies were ranking physicians according to performance measures -- some of which physicians have no control over, such as patient compliance and socioeconomic factors -- and that insurance companies were gathering physician statistics via inconsistent methods.
Physicians testified that the issue affected access to care for patients -- most notably when physicians who don't meet measures are removed from insurance company panels. And in some cases, patients who often can ill-afford a higher copay are forced into that unfortunate position.
Lisa Casey, M.D., a women's constituency member from Metairie, La., co-authored the resolution. "Because I’m not a 'platinum' physician patients have to pay $40 to see me where they can see a platinum physician for free," she told the reference committee.
She added that some physicians were dropping patients from their panels for noncompliance, which was creating a downstream effect and "limiting access to care for everyone."
According to Jay Lee, M.D., M.P.H., a general registrant from Long Beach, Calif., a good portion of a patient's health is related to social determinants and genetics. "I would be in favor of measuring quality if that's what is measured. I abhor the fact that folks are being removed from insurance panels because of bad measures," he told the committee.
Delegates adopted a substitute resolution that called on the AAFP to strongly advise insurance companies to stop ranking physicians and/or removing them from panels based on P4P measures.
A second P4P-related substitute resolution that the delegates adopted asked the AAFP to amend its current P4P policy by removing language that includes patient-controlled quality measures and benchmarks such as lab values and medication fill rates and also asked the AAFP to support legislation that would eliminate patient-controlled measures from P4P programs.
Attendees also spoke passionately at the reference committee about the need for ongoing physician education regarding how to conduct end-of-life care discussions with patients.
Resolution authors, including Karla Booker, M.D., a general registrant from Lilburn, Ga., referenced a 2016 physician survey that indicated 46 percent of respondents did not know what to say to patients and 29 percent said they had no formal training upon which to rely.
Authors also noted that 89 percent of patients surveyed wanted their physicians to engage in such discussions and pointed out that advance care planning is now a reimbursable Medicare benefit.
Booker put it this way: "The biggest bang for our buck is really face-to-face" conversations with our patients.
Erica Swegler, M.D., a general registrant from Austin, Texas, told the committee that she supported efforts to make additional education available to physicians but was distressed by the 30-minute time element called for in the CPT code that would pay her for providing the service.
"I read the rules and said this is going to make it very difficult for me to do. We need to make this work for the individual family physicians," said Swegler.
Asim Jaffer, M.D., testified as a general registrant from Peoria, Ill., and noted that he also holds a designation from the American Academy of Hospice and Palliative Medicine. "Certainly you can counsel," he told the committee. "It's better for family physicians to have this discussion with their patients rather than a consultant who doesn't know them at all."
Delegates agreed and adopted a resolution calling for the AAFP to prioritize member education in areas including how to initiate conversations about end-of-life planning, benefits of palliative care and hospice intervention, and the importance of advance directive and physician orders for life-sustaining treatments documentation.
Family physicians also took aim at pharmaceutical advertising directed at patients. Resolution co-authors, including Cathleen London, M.D., a women's constituency member from Milbridge, Maine, noted that the United States and New Zealand are the only two countries(www.ncbi.nlm.nih.gov) to allow direct-to-consumer pharmaceutical advertising that includes product claims.
London told the committee, "Other countries have decided these advertisements are not in the best interest of patients." She added, "These are barriers to the care of our patients."
Madalyn Schaefgen, M.D., a women's constituency member from Allentown, Pa., noted in her testimony that if physicians accept so much as lunch from a pharmaceutical representative it has to be reported and becomes public information. "Yet they (drug companies) are allowed to do all that advertising to patients -- who have less knowledge and understanding of the drugs," than do physicians, she said.
Schaefgen pointed out that physicians spend a lot of face time with patients explaining why a drug they heard about on television may not be appropriate for them. "It drives up the cost of care," she said.
Jorge Plasencia, M.D., a member of the IMG constituency from Saginaw, Mich., testifying on his own behalf, said he counsels medical students on the issue.
He elicited good-natured laughter with a story about an elderly female patient who has been coming to his office for years and recently asked why he'd never checked her prostate. When Plasencia inquired why she was asking, she responded, "Because the commercial said to ask my doctor."
"This is a danger we encounter on a daily basis," he noted.
Delegates adopted the reference committee's substitute resolution that asked the AAFP to create a public campaign aimed at educating patients about the dangers of direct-to-consumer advertising. The AAFP adopted a policy on such advertising in December 2015.
Cecil Bennett, M.D., a general registrant from Atlanta, testifies in favor of a resolution asking for more screening resources and support services to help physicians suffering from burnout. "We know we're burned out, but what do we do with that information once we have it?" he asked.
Conference attendees were also concerned about physician burnout. In a resolution considered by the Practice Enhancement Reference Committee, coauthors noted that 54.4 percent of physicians reported at least one symptom of burnout in 2014. Furthermore, they said family physicians were among the top four specialties experiencing burnout.
Coauthor Jessica Richmond, M.D., a new physician delegate from Milo, Maine, testified that most resources currently available put the burden on the physician when the most prominent systemic issues that have been identified are those over which physicians have no control.
She called for an educational tool for employers and administrators that would "take the onus off of individual physicians," when it comes to recognizing burnout and seeking treatment.
Meghan Lelonek, M.D., a new physician delegate from Bellingham, Wash., also a coauthor, called the resolution "a cry for help," and described the hectic pace of her private practice setting where she still does hospital call, delivers babies and cares for patients in the clinic.
"We need to focus more of our resources on small private practices and individual physicians," said Lelonek.
The delegates adopted a resolution asking the AAFP to create a toolkit for health organization leaders to provide screening and supportive resources to address physician burnout.
Delegates also asked the AAFP to take action on other fronts that included
- handling of patient reviews on social media,
- capturing measures for social and behavioral domains in electronic health records,
- increasing point-of-care ultrasound education and
- advocating for telemedicine payment parity.
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