Extension Programs, Eliminating Doughnut Hole Gain Support From AAFP Delegates

Delegates at the AAFP 2009 Congress of Delegates here moved forward on a number of issues important to family medicine on Oct. 13, adopting resolutions that call for the Academy to support so-called primary care extension programs, enhanced Medicare drug coverage and federal legislation that would ensure medical care in patient-centered medical homes is directed by primary care physicians.

A resolution calling on the AAFP to develop and support a policy regarding primary care extension programs drew a lot of support from members during the Reference Committee on Advocacy on Oct. 12. The primary care extension program is modeled on the U.S. Department of Agriculture, or USDA, extension service program and is designed to help family physician practices transition into patient-centered medical homes.

The idea for the primary care extension program was first introduced by AAFP member Kevin Grumbach, M.D., professor and chair of the department of family and community medicine at the University of California, San Francisco, with support from the AAFP's Robert Graham Center.

Georgia AFP President Bruce LeClair, M.D., of Evan, spoke in favor of the resolution during the reference committee hearing, explaining that the extension program would deploy personnel to work with physician practices and would primarily provide assistance to practices in rural areas.

Russell Kohl, M.D., of Vinita, Okla., testified that the extension program would "establish a pipeline between practicing physicians and academic medical centers."

"The extension agents (in the USDA program) don't farm the land for you," said Kohl. He said that the agents in the primary care extension program would be local physicians who would know the people in the area. The agents would "serve as a conduit from the academic centers to bring the newest information out to the people who are actually using that information and to take the practical information back to the academic medical centers."

New Jersey AFP alternate delegate Mary Campagnolo, M.D., of Lumberton, pointed out that similar programs already exist for health information technology, and she asked whether the program would duplicate the efforts of existing area health education centers, or AHECs.

After clarifying that AHECs are focused on academic programs and the extension program would be centered on practice enhancement, reference committee members offered, and the delegates adopted, a substitute resolution that directs the Academy to "support expansion of the primary care extension program."

Another resolution addressed during the Reference Committee on Advocacy hearing called on the AAFP to support closing the Medicare Part D coverage gap, also known as the "doughnut hole." Submitted by the Virgin Islands AFP, the resolution asks the AAFP to "support closing the Medicare Part D coverage gap (doughnut hole) more quickly, so that all Medicare beneficiaries can afford needed medicines."

Under the Medicare Part D program, patients pay 25 percent of their pharmaceutical costs until they reach a $4,550 threshold. Patients then are responsible for 100 percent of their costs until they reach the $6,000 mark; at that point, the federal government pays 95 percent of their costs for the rest of the year.

Members testified that patients who reach this $4,550 threshold often face difficult decisions about paying for their medications or other essentials.

It is the sickest patients and the ones most in need who encounter the doughnut hole, testified Massachusetts delegate Laura Knobel, M.D., of Walpole. "We need to close it, and close it fast."

Reference committee members offered a substitute resolution that eliminates reference to the doughnut hole, which they said was too colloquial. Delegates adopted the substitute resolution, which calls on the AAFP to "support closing the Medicare Part D coverage gap so that all Medicare beneficiaries can afford needed medicines."

Discussion was vigorous on a resolution submitted by the New York AFP that asked the AAFP to "lobby the U.S. Congress to pass laws and regulations to support the public purchasing of vaccines and to support the free distribution of these vaccines to physicians to administer to their patients, in the manner of the Vaccines for Children program."

During testimony, several members said that although vaccines are a fundamental tenet of public health, their practices could not afford to pay for them.

But others said the resolution could have unintended consequences, because it did not define which vaccines the federal government should pay for. The reference committee referenced the current AAFP immunizations policy and recommended against adopting the resolution. However, the issue was brought up again on the floor of the COD, and delegates referred the matter back to the Board of Directors.

Other resolutions addressed during the Reference Committee on Advocacy included a resolution introduced by the Colorado AFP that called on the AAFP to "promote the principle that medical care provided in patient-centered medical homes be directed by a primary care-trained physician," and that the AAFP "oppose any federal legislation or federal program implementations that do not support the principle that medical care provided in patient-centered medical homes be directed by a primary care-trained physician."

Members who testified expressed concern that both nurse practitioners and subspecialists have attempted to have their practices designated as medical homes, but others warned that excluding these categories of practice would lead to less availability of health care services for patients.

In the end, the committee combined the clauses in the original resolution into a substitute resolution that directs the AAFP to "support federal legislation or federal program implementations that include the principle that medical care provided in patient-centered medical homes be directed by a primary care physician." The substitute resolution was adopted by the Congress of Delegates.

The Colorado and Ohio chapters both introduced resolutions regarding electronic prescribing of controlled substances.

During reference committee testimony, AAFP members said that electronic prescribing of controlled substances would decrease paperwork and administrative burdens, as well as provide greater accountability and reduce the chances of medication errors and diversions. Several members said, however, that the Drug Enforcement Administration requires the use of tamper-proof prescription paper for controlled substances, precluding them from employing electronic prescribing for those medications.

In the end, the delegates adopted a substitute resolution that directs the AAFP to "support secure electronic prescribing and electronic signatures of controlled substances in any setting."