Health Care Reform: FAQ's

The legislation in the House of Representatives contains numerous provisions that are designed to support primary care physicians. There is a bonus payment to primary care physicians of 5 percent (10 percent if the practice is in a physician shortage area – usually rural areas). The SGR is eliminated (which is good for all physician practices) and the replacement system has higher conversion factors for E/M and preventive care services, which are the ones that most family physicians provide. Primary care services in Medicaid are paid at least at the Medicare rate, which is a substantial increase in some states. The legislation invests in a broader pilot-testing of the medical home practice model. And payments to departments of family medicine and to family medicine residencies are increased, and there is increased tuition assistance for medical students who choose family medicine (or other primary care specialties). The legislation is the first major investment in primary care that the federal government has made in years. Finally, the bill is consistent with our long-term policy of supporting health care coverage for all – and this legislation is a step in that direction.

There is nothing in the current bills that would take away Medicare. Please tell your patients that Medicare will still be there for them – even if health care legislation passes Congress. The legislation does not eliminate the program, nor does it eliminate benefits.

The legislation preserves the private insurance market, so medicine will not be socialized. But what it is intended to do is to provide some competition for insurance companies, especially in areas where one company is dominant or a monopoly, which are often rural and where many of our members have no leverage in negotiating with the major plans. Members have been asking for years to find some method to give them some bargaining power with the major plans. While this is not the best mechanism, it is a start.

In addition, it is not at all clear whether or not a public plan will be part of any final bill. Many Members of Congress – particularly in the Senate – are discussing the idea of a “co-op,” which would be a non-profit entity run by the members at the state or national level.

However, the AAFP Board of Directors discussed public plans at length, since this option has been part of the discussion for quite some time. The Board came up with principles on a public plan option, consistent with those set forth in the New America Foundation document “A Modest Proposal for a Competing Public Health Plan” (12-page PDF file; About PDFs).

These principles are:

We have used these principles as a yardstick to measure the public plans in the House and Senate bills. We have found that the bills are consistent with our policy. The bills do not force providers or patients to participate and plans will negotiate rates with providers.

The House bill includes language that replaces the current SGR formula with another volume-control payment method. This includes better payment rates for cognitive services, like office visits and preventive health services, than for procedural services. The new formula is GDP + 2 percent for E/M and preventive services and GDP + 1 percent for all other services.

This does not benefit primary care physicians exclusively, since most physicians provide at least some cognitive health care services. It encourages the effective use of a physician’s training and skills. Whether it is sufficient is always an open question until the data is in. Our early review of the revised payment structure suggests that it is a step in the right direction for our members and is a good down payment for better enhancement for primary care.

And, without the House bill, physicians get a 21 percent cut in Medicare next year and cuts in the 5 percent range annually for the foreseeable future. This bill is a major step forward out of a failed Medicare formula that has plagued us since 2001.

The Senate Finance committee has not yet released their legislation so we cannot review it at this time.

The cost of health care reform may be significant, but part of the reason is that we have postponed dealing with the problem. As significant as the cost is now, it will only get higher if we continue to put off the necessary decisions. Paying for health reform will require a combination of measures like tax increases, reductions of tax benefits, and efficiencies in the health delivery system.

The goal of the legislation is not to increase the deficit. Specifically, while the House legislation would rebase the SGR, and this money would be added to the deficit, members of Congress continue to seek various means to pay for the reform legislation.

We do not believe that more knowledge about how various treatments, procedures, and products compare with each other will lead to rationing. Instead, we believe that the more objective information physicians and patients have about health care issues the better their choices will be. It is valuable to have a respected agency like the Agency for Health Care Research and Quality as a disinterested moderator of this information.

There are clearly additional costs due to defensive medicine. The AAFP’s policy has called for a cap on non-economic damages, and we have signed a letter to Congress, along with several other physician groups that calls for medical liability reform. There are many alternatives that Congress has considered from time to time. For example, we have supported bills that would give some states authority and resources to try out alternative methods of dispute resolution and liability settlements.

Right now, the bills do not contain medical liability reforms, but we know that many Members of Congress are interested in including different reforms. We are advocating that these reforms be added later as the legislation works its way through the process.

No. Members of Congress are keenly aware of the differences in training between physicians and nurse practitioners. Nevertheless, in an effort to help provide health care access to some rural areas, the House bill does make some changes.

While nurse practitioners are potentially able to head primary care medical homes, this is only in pilot programs and only in states where they have independent authority to practice. In addition, their payment rates under Medicaid – like physicians’ – are increased, but the differential between NPs and physicians is maintained. Finally, both physicians and nurse practitioners are eligible for Medicare payment incentives – 5 percent for selected primary care services. This language is part of the House bill’s overall goal of providing more funding for primary care.

In the House bill, employers are prohibited from selecting the public plan for their employees. They are required to provide coverage or pay a payroll tax. Specifically, their options are to continue to buy a group policy as they do today; set up a self-funded plan, or make a defined contribution so that their employees may purchase a plan through the Exchange.

In the HELP bill, there is a requirement that if someone is offered employer sponsored coverage they cannot enter the gateway and thus the community health insurance option unless that offer is unaffordable to them (using a rigorous test). CBO has estimated no net loss of employer-sponsored coverage.

Good question and here’s the difference. The medical home model is on which patient care is an integrated team with the primary care physician at the center.

Patients are active participants in their own health and well-being. They are cared for by a physician who leads the medical team that coordinates all aspects of preventive, acute and chronic needs of patients using the best available evidence, appropriate technology, and referrals to sub-specialists when needed.

The short answer is no. In the medical home model, the primary care physician and the patient decide together which path to take. If they decide that the patient would benefit from a particular treatment provided only by a subspecialist, then the primary care physician would work with the patient to make that happen. Importantly, however, the primary care physician would stay involved, i.e., after a particular treatment, both physicians would discuss next steps, in conjunction with the patient.

As physicians who all have take the Hippocratic Oath, we clearly believe that our sub-specialist colleagues will continue to see patients, even under a reformed health care system that places more emphasis on primary care. In addition, our sub-specialist colleagues will be able to treat those extraordinarily complex cases, in conjunction with the primary care physicians, for which they have been trained.

Nevertheless, there is no simple way to predict how physicians – or the market – will react. Our goal in supporting health care reform simply is to establish the best system that provides the right kind of care for the patient at the right time.

The AAFP is strongly committed to health care reform legislation that will increase the number of family doctors and boost your Medicare payments.

The House bill offers strong support for primary care in a variety of ways, including medical home demonstration projects, improving Medicare payment for primary care physicians, expanding scholarships and loan programs for those who choose careers in primary care, and reforms the way that Medicare updates physician pay rates that recognized the value of primary care.

The bill that was passed by the Senate HELP committee also includes a number of primary care provisions. While the committee does not have jurisdiction over Medicare – that is handled by the Senate Finance committee -- the HELP bill supports training for family medicine; gives priority to programs that educate students in team-based approaches to care, including the patient-centered medical home; Increases the supply of qualified health care workers by providing low-interest student loans and loan repayment programs and creates a Primary Care Extension Program to provide assistance to primary care providers about evidence-based therapies, preventive medicine, health promotion, chronic disease management, and mental health.

It also funds Community Health Teams to support the development of medical homes and to ensure a patient’s care is coordinate by a team that includes primary care providers.