Senate Reform Legislation OK in Some Areas But Doesn't Meet Some Basic Health Care Needs

Although the AAFP is in favor of various provisions of the Senate health care reform bill, it also has concerns about the legislation, which it expressed in a recent letter to Senate Majority Leader Harry Reid, D-Nev.

Certain parts of the legislation, which is known as The Patient Protection and Affordable Care Act, (at the THOMAS Web site, type "H.R. 3590" in the search box after selecting "Bill Number") need to be strengthened, and the bill itself should include additional measures to fortify the provision of primary care services, said AAFP Board Chair Ted Epperly, M.D., of Boise, Idaho, in the letter.

Epperly noted that the Academy appreciates several features of the legislation, especially the provisions to extend health coverage to as much as 94 percent of the nonelderly American population. "Extending coverage to as many people as possible is a basic provision of the AAFP's Health Care for All policy," wrote Epperly. It also is an essential part of health care reform, he added.

"In addition," he wrote, "we applaud the much-needed reforms of the health insurance market, including the requirement for guaranteed issue and renewability; the prohibition on lifetime and annual limits; the extension of dependent coverage to age 26; and the prohibition of waiting periods of longer than 90 days."

The legislation also would create a public health insurance option and would require HHS to negotiate payment rates with physicians as other health plans do, while giving physicians and health plans the option of participating in the plan. All of these provisions are supported by the AAFP.

In addition, the bill provides a 10 percent Medicare payment increase during the next five years for physicians whose primary care services account for more than 60 percent of their practices. Epperly described this provision as an "important step toward signaling to medical students that health care in this nation should be based on the availability of primary care."

However, said Epperly, "this provision should be strengthened if it is going to accomplish the task of bringing more talented medical students to the primary care specialties."

"We have recommended that the bonus payment be made permanent and that it be extended to all Medicare services provided by eligible physicians," Epperly said. "In addition, the eligibility threshold should be a more realistic 50 percent of a physician's services in primary care."

The Robert Graham Center, the AAFP's health policy research arm, estimates that the 60 percent threshold would allow only 59 percent of family physicians to qualify for the bonus; a 50 percent threshold, however, would allow 69 percent of family physicians to qualify.

"The higher threshold disadvantages physicians in rural and underserved areas who are called on to perform a higher percentage of non-primary care services precisely because of the lack of other providers," said Epperly.

In addition, unlike the House health care reform bill, the Senate legislation does not provide a permanent solution for the sustainable growth rate, or SGR, formula. Physicians are facing a 21.2 percent reduction in Medicare physician payment rates on Jan. 1, unless Congress intervenes to block the cut. The House legislation would eliminate the SGR, but the Senate bill would only provide a 0.5 increase in the payment rate in 2010, creating a one-year fix that "misses an important opportunity to finally fix the formula," Epperly said.

"We strongly encourage you to discard this decade-old formula that generates an ever-growing deficit," said Epperly. "Continued delays only make fixing the formula more costly."

Epperly also took issue with the amount of support the Senate bill provides for patient-centered medical home, or PCMH, demonstration projects. Although the bill creates Medicaid demonstration projects and establishes a Medicare Innovation Center, or MIC, that would test innovative payment and service delivery models, such as the PCMH, the provisions are "too limited and may jeopardize the validity of the demonstrations," Epperly said.

The Medicaid medical home demonstration, for example, is limited to "patients with chronic conditions," and the MIC demonstration gives preference to demonstrations of medical homes for "high-need applicable individuals."

"There are enormous practical and ethical problems with physicians providing different standards of care to portions of their patient population," Epperly said. "Therefore, those practices that participate in a medical home demonstration will offer the same care to all of their patients."

The legislation also creates an Independent Medicare Advisory Board, or IMAB, which would present comprehensive proposals to Congress on how to reduce excess cost growth and improve the quality of care for Medicare beneficiaries on a yearly basis. Epperly noted that although the IMAB has the "potential to become a useful mechanism to address health system costs ... it cannot do so if major segments of the health system, like the nation's hospitals, are exempt from the scope of the IMAB's recommendations."

"We strongly object to the exclusion of certain segments of the health care system in this manner and urge the Senate to change the legislation to ensure that the IMAB oversight is inclusive of all segments of the health care system," wrote Epperly.

At the same time, he added, IMAB membership should specifically include a qualified primary care physician and a representative from the consumer community. It also is essential for the IMAB recommendations to be subject to a public comment period before its decisions become final and before Congress acts on them, said Epperly.

The Senate legislation also addresses workforce development in a variety of ways, including via the establishment of teaching health centers to train primary care residents in nonhospital settings, which is where most primary care is delivered. However, noted Epperly, it is imperative that funding for such teaching health centers not be drawn from funds that currently support Title VII health professions grants. Title VII of the Public Health Service Act is the only federal program that supports the education and training of primary care medical students and residents.

The AAFP has proposed additional provisions to improve the legislation in this area. For example, Epperly calls for giving CMS the authority to pilot-test the use of graduate medical education funds for direct support of primary care residencies to determine if there are better methods for teaching primary care physicians.

"The AAFP also believes the Senate should reinstate the student loan deferment program known as the 20/220 pathway," Epperly said.

In addition, the AAFP called for eliminating cost-sharing for preventive health services, and urged the Senate to equalize Medicaid payment rates nationally with those of Medicare as they relate to primary care services.

Moreover, Congress should eliminate the antitrust exemptions used by health insurance plans and should "address the medical liability system in this country," said Epperly. "At a minimum, Congress should provide sufficient funding for states to experiment with alternative dispute resolution systems," he added.