AAFP Letter to Congress
FOR IMMEDIATE RELEASE
Thursday, July 17, 2003
Please contact me if you would like to interview a family physician about this or any other health topic.
American Academy of Family Physicians
(800) 274-2237, Ext. 5224
The bills contain numerous provisions not directly related to the pharmaceutical benefit, and the Academy would like to provide you with our views on many of these provisions.
Medicare Physician Reimbursement
The Medicare Physician Fee Schedule conversion factor was cut by 5.4 percent in 2002. This was the largest physician payment cut in the history of the Medicare program and would have been followed by a 4.2 percent cut in 2003 if Congress had not acted to prevent it. AAFP members are greatly appreciative of the legislation that resulted in a modest 1.6 percent increase in Medicare physician reimbursements. However, physicians are now facing cuts in the range of 4 percent for each of the next several years. If the CMS projections become reality, the Medicare payment rates in 2005 will be lower than they were in
The cut in 2002 was the fourth time in 11 years that Medicare physician payment rates were reduced. During that time, physicians have been inundated with expensive new requirements to comply with numerous federal regulations. Overall, during the same 11 years, Medicare payments have risen by an annual average of just 1.1 percent, or 13 percent less than the governments own estimate of practice cost inflation.
This volatility, insufficiency and unpredictability of Medicare reimbursements translate to a lack of confidence on the part of physicians in the Medicare program. This no-confidence analysis ultimately translates to access problems for Medicare beneficiaries. Thus, it is critical that this flawed formula be replaced or at least substantially revised. AAFP urges the conference committee to adopt the House bill provision (Sec. 601). We are committed to working diligently with Congress over the next two years to fix this flawed formula used to determine Medicare payments to physicians.
Health Care Reform Dialogue
The Senate bill also includes a provision (Sec. 422) that would make automatic the 10-percent Medicare Incentive Payment to physicians who provide services to Medicare beneficiaries in rural underserved areas. The House bill (Sec. 417) would retain the current MIP program, but would create an additional incentive program. This payment of 5 percent for primary care physicians in scarcity areas would be directed to those rural counties that have the fewest physicians compared to the number of Medicare beneficiaries. Physicians practicing in the lowest 20 percent of these counties would receive this additional bonus.
The Academy opposes any adjustments to the Medicare physician fee schedule, unless such adjustments are designed to achieve a specific public policy goal (such as encouraging physicians to practice in underserved areas). The provisions in the Senate bill clearly meet this criterion, and the Academy urges the conference committee to include them in the final bill. The AAFP supports the House version since it is similarly helpful if the new scarcity area is added to (rather than is substituted for) the Senate MIP program provisions.
Graduate Medical Education
Regarding volunteer teaching time, the Centers for Medicare and Medicaid Services (CMS) has retroactively denied volunteer teaching time in ambulatory settings in hospital audits. In addition to these retroactive denials, CMS published a proposed rule May 19 that would require hospitals to provide compensation for teaching in non-hospital settings. Both the denials and the language in this section of the proposed rule contradict past regulatory policy. More importantly, they severely affect family medicine residency programs: not only have these programs been acting in accordance with earlier CMS provisions, but family medicine programs typically do not reimburse their doctors for teaching duties. Specifically, at least 55 hospital programs that CMS has audited were denied volunteer teaching time in ambulatory settings and were required to make repayments to the agency translating to millions of dollars. The language in Section 411 would clarify that physicians may continue to volunteer their teaching time.
Another problem in the proposed rule is the new application of Medicare principles regarding redistribution of costs and community support to direct GME reimbursement. The practical effect is to prohibit direct GME reimbursement to settings that have received non-Medicare funds at some point since the inception of the program. The principles of community support and redistribution have not been applied in the last 16 years, so the proposed rule breaks new ground in its sudden denial of direct GME reimbursement. As a result, family medicine training programs that have received outside funds (e.g., state dollars) at anytime in the past would be prohibited from receiving direct GME reimbursement. Section 411 clarifies current law so that programs may continue to receive these outside funds and remain eligible for GME payments.
Finally, Section 418 would slightly increase the indirect medical education adjustment for teaching hospitals. Right now, this section would increase the rate from 5.5 percent to 5.53 percent for 10 years beginning in FY 2004. One of the major purposes of the IME adjustment is to compensate teaching hospitals for the additional costs of training physicians. Unfortunately, the Balanced Budget Act of 1997 cut the IME adjustment from 6.5 percent to 5.5 percent, resulting in a loss of revenues for these crucial institutions. While we are pleased that a slight increase to this adjustment was included in the bill, we urge you to increase this rate to 6.5 percent in conference.
International Classification of Diseases- (10th Edition)-Procedural Coding System (ICD-10-PCS
The AAFP has long supported the Current Procedural Terminology (CPT), which is an instrument that accurately describes the procedures administered to patients in an outpatient ambulatory setting. We believe that switching to ICD-10 would require that all resource-based relative value scale (RBRVS) relative value units would need to be revised, because they are based on CPT codes. The RBRVS system is essential to physician reimbursement. It is troubling that switching to ICD-10 could delay the appropriate and timely reimbursement of rendered health care services. A mandatory, industry-wide change to ICD-10 would be highly disruptive, burdensome and costly. Such a requirement would impose a massive new regulatory burden on physicians offices that is grossly inconsistent with regulatory relief and the Academy asks that it be deleted in conference.
Chiropractor Demonstration Project
The Academy is strongly opposed to any expansion of the current Medicare chiropractic benefit. A large body of peer-reviewed medical literature exists stating chiropractic care is marginally useful for acute low back pain. The current Medicare benefit appropriately reflects the limited medical effectiveness of this procedure. It is also worth noting that there is no requirement that the demonstration project assess patient outcomes for quality or whether treatment conforms to existing medical clinical guidelines. The Academy requests that this provision be struck during conference.
Nurse Practitioners as Attending Physicians under Hospice Benefit
Physical Therapist Demonstration Project
Finally, such a timetable is wholly unrealistic for family physicians most of whom practice in groups of three or less. AAFP is concerned that a new mandate with a deadline for compliance of 2006 could create an unrealistic technological and financial requirement for these small businesses.
The Academy asks that the conference committee instead accept the Senate language (Sec. 121) regarding electronic prescribing. The Senate bill would require HHS to develop and adopt standards for transactions and data elements to enable the electronic transmission of medical information, including prescriptions. The Academy feels that this is an appropriate governmental function that will allow the rapid and orderly development of more comprehensive electronic medical records that would be timely, organized and beneficial.
The Academy requests that conferees adopt the following provisions in H.R. 1 relating to physician regulatory relief:
- [Sec. 935(a)] Limits extrapolation only to cases in which a provider has a high claims error rate or in which documented education efforts have failed to correct a problem.
- [Sec. 935(a)(5)] Allows physicians additional time to submit information regarding claims in dispute before consent settlements are issued.
- [Sec. 941] Establishes a process and requirements for developing and testing new Evaluation and Management (E/M) code documentation guidelines.
- [Sec. 903(c)] Allows physicians who rely on written guidance from contractors to avoid sanctions or repayment requirements if that guidance is in error.
- [Sec. 921(c)] Requires contractors to respond to written inquiries from physicians within 45 business days, and to maintain a toll-free number to answer physician inquiries on a range of routine transactions.
- [Sec. 938] Requires the Centers for Medicare and Medicaid Services (CMS) to develop Advance Beneficiary Notices for certain categories of items and services.
Both H.R. 1 and S. 1, as currently written, would implicitly sanction a proposed regulation recently published by CMS that would require an extensive new physician enrollment process. In comments offered separately to CMS, the Academy has noted that this proposed regulation describes an enrollment system that is unduly intrusive and onerous in the extreme.
For example, if physicians must regularly update every item on the proposed forms as proposed, it would constitute a large, new regulatory burden on physicians and their staffs. Further, the variety of detailed items requested within the enrollment forms raises questions about how Medicare carriers will be able to undertake the substantial expansion of responsibility to process, store and verify the material contained within.
We cannot conceive why CMS would create such a giant new regulatory scheme to gather information on physicians. In recent years, CMS has made great efforts to reduce the regulatory burden on physicians. The proposed rule moves the agency away from its goal of reducing the needless paperwork burden placed on physicians. At a time when many physicians are questioning their continued involvement with the Medicare program, the revised enrollment forms and proposed re-enrollment process are not helpful. The AAFP asks the Conference Committee to direct CMS to reconsider the physician reenrollment regulation in consultation with medical specialty societies.
Health Performance Measures
AAFP opposes the creation of unreasonable barriers to the practice of telemedicine across state borders by state licensing boards. Therefore, the Academy supports the approach embodied in Sec. 450 of the Senate bill, but recommends that Congress strengthen the advisory role of physicians and other health care providers and patients in the development of the implementing regulations. We suggest that any regulation should include (but not be limited to) capabilities, technical standards, costs and cost-effectiveness, reimbursement policies, efficacy, acceptability to providers and patients, appropriate use, and development of processes of care via telemedicine that are associated with optimal patient outcomes.
The House bill contains a provision (Sec. 415) that would extend the telemedicine demonstration project for three years. The Academy believes that an effective telemedicine system would assist beneficiaries in remote, underserved areas and we hope that the final bill would include this provision.
Warren A. Jones, MD, FAAFP
Chair, Board of Directors
# # #
Founded in 1947, the AAFP represents 110,600 physicians and medical students nationwide. It is the only medical society devoted solely to primary care.
Approximately one in four of all office visits are made to family physicians. That is 240 million office visits each year — nearly 87 million more than the next largest medical specialty. Today, family physicians provide more care for America’s underserved and rural populations than any other medical specialty. Family medicine’s cornerstone is an ongoing, personal patient-physician relationship focused on integrated care.
To learn more about the specialty of family medicine, the AAFP's positions on issues and clinical care, and for downloadable multi-media highlighting family medicine, visit www.aafp.org/media. For information about health care, health conditions and wellness, please visit the AAFP’s award-winning consumer website, www.FamilyDoctor.org.