I recently had an office visit with one of my longtime patients, a 67-year-old, developmentally disabled man who we will call "Mike." Mike is extremely personable and fairly independent, despite his limitations, and he rarely complains, which is remarkable considering that he also has a long list of chronic conditions:
AAFP President Glen Stream, M.D., M.B.I.
- chronic kidney disease;
- cystectomy for bladder cancer; and
Mike had come to see me for a follow-up appointment related to his chronic conditions. On top of those issues, however, he also had an acute cough that required an X-ray, and he was dealing with an acute psychosocial stress because his sister -- his primary caregiver -- had passed away recently.
Mike's scheduled 15-minute appointment stretched to 40 minutes, and his multiple health issues presented me with a dilemma that family physicians face every day. When dealing with evaluation and management (E/M) codes, we are only allowed to bill for four diagnoses, despite the fact that our patients -- unlike, say, a dermatology patient who presents with a single problem -- often have more than four issues they need managed.
Evaluation and management codes, such as 99213 and 99214, are limited by Medicare billing rules. More importantly, they fail to reflect the complexity of our patients' conditions, the effect one of those conditions might have on another, and the intensity of the services we routinely provide. It's one of many factors that have left primary care physicians undervalued, underpaid and extremely frustrated.
On March 12, the AAFP sent recommendations from its Primary Care Valuation Task Force to CMS, asking the agency to adopt a series of short-term strategies to improve primary care payment. During development of the recommendations, CMS had an observer in the room, and during a recent meeting with CMS Acting Administrator Marilyn Tavenner, B.S.N., M.H.A., she indicated she was eager to receive and consider our recommendations.
The recommendations, which were developed by the Primary Care Valuation Task Force during the past seven months and approved by the AAFP Board during a recent meeting in Washington, include
- new CPT codes -- specifically for primary care -- for E/M services,
- valuation of these codes that reflects the intensity and complexity of primary care,
- enhanced payment options for primary care physicians that are based on three definitional functions of primary care, and
- payment for telephone and online E/M services.
CPT codes typically are created by a CPT committee convened by the AMA. The AMA/Specialty Society Relative Value Scale Update Committee (RUC), which has historically undervalued primary care services, then makes recommendations to CMS regarding how individual CPT codes should be valued. By sending our task force's recommendations on primary care payment directly to CMS, we sidestep the flawed RUC process.
This is appropriate because we are asking CMS for short-term improvements for primary care payments to be included in the 2013 Medicare physician fee schedule, which is under development now. Going through the AMA's process would not reflect the urgency this situation requires.
Participants in the RUC process, including the AAFP, have been informed that if they participate in the RUC they are obligated to not go around it. However, we have informed the RUC and the AMA that we are advocating directly to CMS, and we will do what is necessary to improve payment for primary care services.
So where does this leave us with the RUC? The AAFP Board decided this month to remain involved in the RUC -- for now -- but that participation will be subject to ongoing review.
Last June, the AAFP sent a letter to the RUC, calling on the committee to make changes in its structure, process and procedures to more fairly represent and value primary care. Specifically, we asked the RUC to
- add four primary care seats to the RUC, with one each from the AAFP, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association;
- create three new seats to represent outside entities, such as consumers, employers, health systems and health plans;
- add a seat to represent the specialty of geriatrics;
- eliminate the three current rotating subspecialty seats when the current representatives' terms expire; and
- implement full voting transparency.
The RUC's response was inadequate. It agreed to add one seat for geriatrics and one rotating primary care seat. The RUC did not add seats for public members, and it did not eliminate rotating subspecialty seats. The committee made only minimal improvements in voting transparency.
So why did the Academy elect to stay in? It wasn't because we're satisfied with the RUC's past work or its response to our requests -- we're not. The RUC has been devastating to primary care.
However, the Board made the difficult decision to stay in because of the belief that it is the best strategy to achieve our ultimate goal of better payment for family physicians. We will continue to work within the RUC to reform its processes while also working outside the RUC. We're staying engaged, and we will continue to advocate changes that benefit family medicine.
I realize this is an issue many of you are passionate about. Last year, multiple resolutions advocating leaving the RUC were introduced at the Congress of Delegates. There also is a group of primary care physicians involved in an ongoing lawsuit against CMS based on its relationship with the RUC. The decision to stay at the table within the RUC was not made lightly.
Multiple factors played a role in the decision.
- Important strategic political partnerships outside the RUC could have been damaged if we withdrew, and that could have harmed the Academy's advocacy efforts.
- If we withdrew, we would have gone alone. None of the other primary care physician organizations were interested in leaving the RUC.
- Withdrawing the AAFP from the RUC would not delegitimize the RUC, which would continue to fill its family medicine and primary care seats while claiming that it has improved its representation for primary care through the new seats it is adding. We would, however, lose our chance to have a relationship with those representatives and to hear an insider voice on what happens on the RUC.
- We cannot depend on the current level of support we now have from the administration and CMS. If things change after the November elections, we run the risk of losing our voice entirely if we're off the RUC, and CMS, under a different administration, does not see our importance the same way.
- Withdrawing or not withdrawing has no impact on our moving forward with task force recommendations to CMS. We are doing the same things now that we would be doing if we had withdrawn.
Had the AAFP elected at this point to withdraw from the RUC, this dramatic statement may have gotten some fleeting media attention. But our strategic goal is to improve payment to family physicians, and that goal is best achieved by the dual approach of continuing to work within the RUC and directly with CMS.