The Academy recently hammered home its position on items important to family physicians in a written response to CMS' proposed rule for revisions to the physician fee schedule for 2006.
In the September letter, (then) Board Chair Michael Fleming, M.D., of Shreveport, La., told CMS Administrator Mark McClellan, M.D., Ph.D., that although the AAFP supports most of CMS' proposed changes in its practice expense methodology, it continues to disagree with CMS' decision to use physician work relative value units (a building block of the physician fee schedule) rather than physician time in its formula for allocating indirect expenses.
"By definition, physician work is a product of time and intensity," said Fleming in the letter. "We would contend that physician time is more likely than physician work to drive indirect expenses since we are not convinced such expenses vary with physician intensity." An example: Consider two in-office services that involve the same amount of time but different levels of intensity. "Does it make sense to say that the cost of the utilities varies with intensity of the service when, for example, the cost of the electricity is in fact, a function of the time the lights are on while the service are being done? We do not think so," said Fleming.
In response to CMS' proposal to transition practice methodology changes over four more years, Fleming pointed to the decade-long delay that already has occurred in moving to resource-based practice expenses, noting that Congress enacted the legislation mandating the use of such expenses in 1994. "We find it ironic that CMS proposes to further draw out that transition," said Fleming. "We would encourage CMS to shorten or eliminate the transition and finally complete the process of implementing resource-based practice expenses."
On the topic of telemedicine, Fleming urged CMS to revise its definition of an interactive telecommunications system to include interactive audio and one-way video telecommunication equipment. He said the Academy sees the use of information technology and telecommunication as enhancing health care delivery. "We believe that telemedicine can enrich the delivery of medical care at remote sites such as rural areas, and by creating ready access to information, can provide rural physicians with current medical information that may not be available in an isolated setting," said Fleming.
While acknowledging that two-way video telecommunication is optimal, Fleming said telehealth services using interactive audio and one-way video equipment should be allowed if that's all that's available. "We believe it is the nature of the service, not the nature of the technology, that is paramount," said Fleming.
Regarding the proposed negative physician payment update for Medicare for 2006 and its tie to the sustainable growth rate, Fleming reiterated the AAFP's position that the SGR payment update formula is inherently flawed. "We oppose expenditure targets, including the SGR, which are linked to the gross domestic product, in favor of a system based on a fair representation of physicians' costs of delivering care," said Fleming.
Fleming suggested an immediate administrative adjustment: "Specifically, CMS should immediately remove, retroactive to the inception of the SGR, the physician-administered drugs from the SGR. These in-office medications are not reimbursed under the Medicare physician fee schedule and should never have been part of the formula used to calculate the conversion factor for physician services," he said.
On the topic of pay-for-performance, Fleming said the AAFP supports moving to such a system in the Medicare program "with the goal of continuously improving care of patients." However, Fleming stressed that a value-based purchasing or pay-for-performance program will fail to improve health care quality if it's not done well.
"'Doing it well' means phasing in a value-based purchasing program that provides incentives for structural and system changes, that encourages reporting of data on performance measures and, ultimately, rewards continual improvements in clinical performance," said Fleming. "Yet, moving the Medicare program in this direction cannot be accomplished in an environment of declining physician payment."
