AAFP Praises Bill That Would Strengthen Primary Care Infrastructure

The AAFP has endorsed a primary care bill that seeks to rebuild and strengthen the nation's primary care infrastructure by providing scholarships, loan forgiveness, deferral of loan repayments and grants for practices to incorporate the patient-centered medical home, or PCMH.

"This is a significant bill that makes an important statement about the value of primary care physicians in reforming the American health care system," said AAFP Board Chair Jim King, M.D., of Selmer Tenn., in a letter to Rep. Allyson Schwartz, D-Pa., chief sponsor of the legislation.

The bill, which is known as the Preserving Patient Access to Primary Care Act, (at the THOMAS Web site, type "H.R. 2350" into the search field after selecting "Bill Number") incorporates several steps to address ongoing shortages of primary care physicians. For example, it would provide scholarships of as much as $35,000 per year for students who agree to serve as primary care physicians in "critical shortage health facilities." The bill also would grant loan forgiveness of as much as $35,000 for physicians who work in primary care in critical shortage areas, and it would defer educational loan repayment for primary care medical residents until after completion of their residencies.

The legislation also would provide higher Medicare caps on the total number of full-time equivalent residents and would require that existing teaching institutions increase or at least maintain their primary care residency capacity. Another provision would eliminate barriers to increased training in ambulatory settings, a measure the AAFP is particularly pleased with, according to King.

In his letter to Schwartz, King wrote, "As you point out, health care in the United States is fragmented and not patient-friendly because there is a shortage of physicians trained in primary care. Your legislation addresses many of the reasons for this shortage."

The bill already has 87 co-sponsors, 17 of whom serve on the House Ways and Means Committee, one of three House committees with jurisdiction over health care legislation. This type of support "speaks to the importance of primary care," said Schwartz in an interview with AAFP News Now.

"There is strong support and understanding (in Congress about) the importance of primary care and the need to take some very clear steps to increase the number of primary care providers," she said.

Schwartz added that the legislation has a better chance of passing as part of a larger health care reform bill than as a single, stand-alone measure.

"Research shows that when medical students do not choose primary care specialties, (such as) family medicine, a major reason is the disparity in income between primary care physicians and other physician specialties," wrote King in his letter to Schwartz. "Your legislation tackles this important problem, as well."

For example, the bill would increase the budget-neutrality limits set by the physician fee schedule to consider the effect of primary care in achieving system-wide Medicare savings. According to Schwartz's legislation, Medicare would have to consider the effect of care coordination by primary care physicians in achieving measurable reductions in avoidable hospital admissions for patients with chronic conditions. This would make it easier for Congress to find offsets for increased payments to primary care physicians.

Medicare also would pay for specific care-coordination services billed on a fee-for-service basis, which have been shown to improve outcomes for patients with chronic diseases. In addition, the bill would require Medicare to increase payments for services principally provided by primary care physicians through a separate modifier or unspecified bonus payment.

In addition, the legislation promotes use of the PCMH model. It would provide grants to states to incorporate the PCMH into their Medicaid and Children's Health Insurance Programs, and it calls on the federal government to implement all payer demonstration projects.

According to the legislation, Medicare would be required to transition to a new payment methodology for qualified PCMHs by allowing medical home practices to receive monthly payments for care coordination, as well as performance-based bonus payments.

"We commend you for speeding up the process for making the patient-centered medical home services a Medicare benefit supported by a monthly care-coordination fee and a performance-based bonus payment," said King. "The evidence is clear that a patient-centered medical home will give patients access to a well-organized medical team that will coordinate care and maintain effective communications with their patients about wellness and prevention, mental health, and physical health activities and treatments in the context of same-day appointments and e-mail contacts."

The PCMH "supports the patient/doctor relationship, particularly the patient/primary care provider relationship," said Schwartz. "That is key to improving quality and outcomes."

The legislation also would allow nurse-practitioner-managed practices to serve as medical homes, as long as they meet the same standards applied to physician practices. Not surprisingly, this has prompted concern from the AAFP.

"We have some concerns with the way that the legislation includes nonphysician providers in a role similar to that of physicians, especially in the implementation of the patient-centered medical home," King said. "Without data showing the comparability of nonphysician providers to primary care physicians -- whose training and experience are much more intense and extensive -- it is a risk to allow these providers to deliver these services without the standard level of supervision."

However, King expressed support for other provisions in the bill, including the elimination of time restrictions for initial preventive physical examinations and the elimination of cost-sharing for preventive benefits under Medicare.

The legislation also contains provisions that