AAFP Supports Health Care Reform Bill But Raises Concerns

The AAFP has responded to a House health care reform bill, saying in a recent letter to the three committees responsible for drafting the legislation that it supports the bill -- certain provisions in particular -- but that it has concerns about various parts of the legislation.

"We believe that the America's Affordable Health Choices Act (at the THOMAS Web site, type H.R. 3200 in the search box after selecting "Bill Number") will make significant progress toward payment and delivery system reforms and contribute to building a primary care workforce for the future," said AAFP Board Chair Jim King, M.D., of Selmer, Tenn., in a letter to the chairs of the House Energy and Commerce Committee, the House Education and Labor Committee, and the House Ways and Means Committee.

"The AAFP supports the bill's proposals to reform the insurance industry so that coverage must include people who have pre-existing conditions or who develop an illness while insured," said King. "Family medicine agrees with the bill's assurance of parity in benefits for mental health and substance abuse disorders and the inclusion of genetic nondiscrimination laws."

According to King, the AAFP supports sliding scale tax credits, coverage of evidence-based preventive services with no cost-sharing, and expansion of Medicaid to cover the poor, all of which are contained in the bill.

The bill also makes several key changes to how health care would be delivered, including via a greater reliance on primary care in the delivery system.

"The legislation frequently demonstrates recognition of the value of primary care as the foundation for health reform," said King. "It is (the AAFP's) strong contention that investment in primary care will yield better health for everyone, but also more efficiencies, less waste and less duplication."

The Academy also endorsed the bill's elimination of accumulated Medicare payment cuts called for by the sustainable growth rate, or SGR, formula -- a move that would pave the way for a permanent SGR fix. The bill would provide a new framework for future payment updates that would allow spending on physician services to increase at a rate higher than the gross domestic product and create a higher spending baseline target for evaluation and management and preventive services.

The bill also takes other steps to strengthen primary care. For example, it would increase Medicare payments by 5 percent for designated services provided by primary care physicians and would provide a 10 percent bonus for services provided in primary care physician shortages areas.

"However, the language in H.R. 3200 changes the definition of primary care services from the language in the draft bill in a way that might exclude many primary care physicians from being eligible for the bonus," said King. "(The AAFP) recommends that the eligibility criteria be modified to … incorporate the services typically provided by family physicians and other primary care physicians."

The AAFP also is concerned about expansion of the definition of physicians considered to be primary care providers for the purposes of this bonus. King urged the committees to return to their original definition of primary care, saying that family medicine, internal medicine, and pediatrics -- along with geriatrics -- are the only specialties that prepare residents and physicians in the broad competencies necessary for primary care practice.

In addition, King noted that the 5 percent bonus for primary care physicians falls far short of the 10 percent increase called for by the AAFP, the American College of Physicians and the American Osteopathic Association.

"The goal of this bonus payment is to signal to medical students that an effective and efficient health care system depends on an adequate number of primary care physicians to provide the vast majority of health care services," said King. "Primary care physicians believe that a 5 percent incentive is insufficient to send that signal."

The House legislation also addresses primary care workforce issues. For example, it would establish a national health care workforce commission to help set goals and policies to achieve a sufficient and optimal number and distribution of physicians and other clinicians.

"We support including policies to increase the number of physicians in family medicine, general internal medicine, general pediatrics and geriatrics, including increased funding from a dedicated trust fund," said King. "We also are pleased the legislation reauthorizes Title VII, Section 747 training in primary care medicine."

"(The AAFP) also agrees on the need to increase graduate medical education training positions for primary care specialties," said King, referring to another area of the legislation, which would establish health centers as teaching centers. The AAFP recommends "these important new training entities be funded with Medicare graduate medical education … dollars rather than with variable grant funding under Title VII," said King.

"It is vital that Medicare meets the training and patient care needs of the 21st century by supporting sustained funding of such training as strongly as Medicare supports nonprimary care training," said King.

He emphasized that training in community-based ambulatory care sites must be the future of primary care education. "Innovations in service delivery, such as the patient-centered medical home, require reform of and innovation in training. In this rapidly changing health care environment, the teaching health center, whether sponsored by a community health center, a family medicine center or another community-based site, is an innovation that will produce primary care physicians who are essential to help meet the patient care needs of our nation."

The legislation also provides authorization for an alternative payment model within fee-for-service Medicare known as accountable care organizations. These are physician-led organizations that are paid more money for taking responsibility for the costs and quality of care for patients in the long term.

"This model has promise for some larger practices that have access to a broad array of health care and community resources," said King. "But it may be problematic for solo and small practices that are often in rural and underserved areas with few of these resources. We recommend that Congress consider assistance to such practices as part of demonstration programs."