Distressed Practices, Fair Payment Take Center Stage at Town Hall Meeting

AAFP members who attended the Sept. 11 Town Hall meeting here had plenty on their minds and no hesitation about sharing those views with their colleagues and the Academy leaders who facilitated the event. Small wonder, when in one form or another, payment issues dominated the conversation.

AAFP President-elect Glen Stream, M.D., M.B.I., of Spokane, Wash., introduced the evening's first topic: distressed practice environments. As defined by the New Jersey AFP, which recently brought the issue to the AAFP Board's attention, these distressed environments are characterized by

Moreover, the "monopolistic behavior" of some private health plans in these areas translates into significant underpayment for evaluation and management, or E/M, codes family physicians commonly use -- "payments as low as 50 and 60 percent of Medicare," according to Stream.

While acknowledging that much more information is needed to mount a comprehensive response to the problem, Stream said the Academy already has taken concrete steps to address some of the issues raised by the New Jersey chapter.

One of those steps has been to discuss with the board of directors of the Patient-Centered Primary Care Collaborative, or PCPCC, the fact that a number of private health plans involved in patient-centered medical home pilots, which are intended to bolster primary care, simultaneously are offering PPO contracts to family physicians that pay only a fraction of what Medicare pays. Some of these health plans, Stream noted, are members of the PCPCC's executive committee, and the PCPCC has pledged to address this conflict in the coming weeks.

Meanwhile, AAFP staff members have begun the process of determining what data exist on family physician locations, ratio of primary care specialists to subspecialists, migration of FPs to other states and similar factors. The Academy will examine patterns of distress revealed by the data, said Stream, identify and fill any knowledge gaps, and engage affected chapters in formulating an action plan. The topic also will be referred to the AAFP Commission on Quality and Practice for discussion and recommendations back to the Board.

The Academy clearly recognizes the urgency of this issue, Stream assured the more than 300 FPs and others who attended the Town Hall. "This isn't happening just in New Jersey" he said, "it's happening in other areas of the country." And it's often not a statewide phenomenon. Rather, FP practices in certain regions within a state may flourish while those in other parts of the state decline.

"We heard that loud and clear from other chapters at ALF," agreed New Jersey AFP President Robert Eidus, M.D., M.B.A., of Cranford, referring to the AAFP's Annual Leadership Forum, which brings together chapter leaders from across the country. "While we think family medicine is trending up in many areas," he added, there remain "family medicine deserts" in others.

"This is very much a cancer," affirmed New Jersey delegate Richard Corson, M.D., of Hillsborough, "and it may metastasize."

Fair payment was the focus of a second hot topic discussed at the Town Hall -- the longstanding battle to convince the AMA/Specialty Society Relative Value Scale Update Committee, or RUC, of the need to correctly value the work done by FPs and other primary care physicians.

Composed of 29 members -- 23 of whom represent medical subspecialties -- the RUC acts as an expert panel and makes recommendations to CMS on the relative values of CPT codes. CMS typically has honored those recommendations, which tend to favor procedural codes used by subspecialists over the E/M codes primary care specialists often use.

"We firmly believe that the RUC has to change its structure, change its culture, change its process if primary care is valued appropriately," said AAFP Board Chair Lori Heim, M.D., of Vass, N.C. Still, she noted, the RUC is the only game in town when it comes to valuing physicians' services, which is why the AAFP Board has deliberated long and hard on how to approach the fair payment dilemma.

In June, the Academy called for the RUC to eliminate the three current rotating subspecialty seats on the committee, add four seats for "true" primary care specialties, and implement voting transparency, among other things.

At the same time, the AAFP announced it would launch a Primary Care Valuation Task Force to review methods used to evaluate health care services provided through Medicare and make recommendations on how to properly value and pay for services primary care physicians provide. That task force held its inaugural meeting last month and, according to Heim, is well on its way to examining the many variables involved in developing a new methodology for valuing physician services.

Some Town Hall participants, however, seemed to favor a more aggressive approach to dealing with the payment inequities perpetuated under the RUC.

"I have recently sued Medicare for the future of family medicine," declared Paul Fischer, M.D., of Augusta, Ga. In a lawsuit filed in the U.S. District Court for the Maryland District, against CMS and HHS, Fischer and his primary care colleagues at the Center for Primary Care in Evans, Ga., have alleged that the RUC's relationship with CMS is illegal because the committee does not follow guidelines laid out for such entities that advise federal government agencies.

Even so, said Fischer, "The problem's not just the RUC. The problem is that the codes just don't work for us." Unlike subspecialists, who often bill and are paid for multiple procedures during a single visit, primary care physicians typically are denied payment for more than a single code per visit. "No other specialty is treated like that," he said.

"I think this is one of those issues where we figure out what codes work for us," agreed New Jersey alternate delegate Mary Campagnolo, M.D., of Lumberton. "We need to come up with concrete measures of what we do and the value we bring to our communities."

Lloyd Van Winkle, M.D., of Castroville, Texas, shared that sentiment. "We're the ones who direct patients to the right care, not the most care," he observed.

"If this (the RUC) were a drug, it would have been withdrawn years ago because the deformities it causes are fatal."

AAFP President Roland Goertz, M.D., M.B.A., of Waco, Texas, next laid out recent steps the Academy has taken to urge federal lawmakers to abandon the sustainable growth rate, or SGR, formula used to calculate Medicare physician payment. Only through congressional action can physicians who care for Medicare patients avoid a looming 29.5 percent pay cut required by the SGR for 2012.

The latest move, according to Goertz, has been to bend the respective ears of the dozen legislators appointed to the congressional Joint Select Committee on Deficit Reduction last month. "As soon as we found out who those 'Super 12' were, we contacted them with our ongoing (SGR) message," he said. The fact that the committee operates under an unusual set of rules -- no amendments can be made to its final recommendations, the recommendations are not subject to filibuster and only a simple majority of both houses is needed to pass them -- may work in the Academy's favor.

"One of the biggest things is going to be getting our members' voices heard," Goertz said, "and we're here to help you do that." The AAFP plans to create a series of videos to illustrate what family physicians do every day, he announced, calling on participants at the Town Hall to distribute the videos as widely as possible.

Some at the meeting, however, noted that "mission fatigue" has become an issue when it comes to enlisting the support of FPs and their patients to fight SGR-mandated pay cuts. "This is living under the sword of Damocles, and it seems to be getting duller because we've been there so many times," said Florida delegate Dennis Saver, M.D., of Vero Beach.

Goertz acknowledged that sense of frustration. "We may be in the position of shooting for everything and hoping we get anything," he said.

"I know we've been doing that for 10 years, but as one politician told me, 'Politics takes patience.'"