Organizations Urge Congress to Strengthen Primary Care Provisions in Health Care Reform Bills

The AAFP and several other primary care physician organizations have sent a letter to House and Senate leaders that praises various primary care provisions in the House and Senate health care reform bills but that also urges lawmakers to include other measures to strengthen the nation's primary care infrastructure.

The House and Senate bills -- H.R. 3962 and H.R. 3590, respectively -- (at the THOMAS Web site, type "H.R. 3962" or "H.R. 3590" in the search box after selecting "Bill Number") would reform Medicaid and Medicare payment policies to recognize the value of care provided by primary care. They also would create new programs and expand existing ones to train more primary care physicians, according to the letter, which was signed by the AAFP, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association. These four organizations represent the vast majority of primary care physicians in the country.

Although the four organizations expressed support for the bills' goals to provide the vast majority of legal residents in the United States with access to affordable health insurance coverage, the groups also pointed out the necessity of having enough health care professionals. "Access to health care is more than giving someone an insurance card. It requires that patients also be able to find a primary care physician who can provide first contact, comprehensive, continuous, preventive and coordinated care for most of their health care needs," said the letter.

"Proposals to expand Medicaid coverage to the poor and near-poor will not ensure access if low Medicaid payment rates make it financially impossible for many primary care physicians to accept new additional Medicaid patients, not to mention straining the current Medicaid programs and their enrollees."

In addition, patients enrolled in Medicare often find it difficult to locate a primary care physician who is accepting new patients, a problem that will worsen as more patients reach retirement age and as more primary care physicians retire. The number of medical students choosing a career in primary care, meanwhile, has reached an all-time low, according to the letter.

This combination of factors has created a growing crisis regarding access to primary care. Without public policies to increase the number of primary care physicians, the crisis will become more acute as health reform brings greater numbers of people into the health care system, according to the letter.

"We strongly support the proposal in the House bill ... to increase Medicaid payments for primary care to no less than the comparable Medicare rates within four years," the letter said. "We urge both the House and Senate to include this in the final bill."

Both the House and Senate bills would add tens of millions of low-income individuals to Medicaid, making it critical that Medicaid payments to primary care be increased to at least 100 percent of Medicare rates to ensure that primary care physicians will be able to afford to accept new Medicaid patients into their practices, according to the letter.

Although the House and Senate bills would provide additional bonus payments for designated services by primary care clinicians, the two bills differ on the percentage amount of the bonus, the designated services that would be eligible for the bonus, and the criteria required to qualify for the bonus. In the letter, the organizations said the payment provisions in the two bills should be combined and modified to permanently adopt the Senate's 10 percent increase in payments for designated services instead of the 5 percent bonus contained in the House legislation. Moreover, the bonus should apply to designated services contained in the House bill, such as office, nursing home, domiciliary, home and hospital visits.

The organizations also asked Congress to adopt the House's threshold for eligibility -- 50 percent of a physician's total Medicare billing for primary care services -- instead of the Senate threshold, which is 60 percent of a physician's total Medicare billing.

The letter also calls for the replacement of the Medicare sustainable growth rate formula with a new system that provides predictable updates and takes into account increases in physicians' practice costs.

"Higher payments for primary care will not be effective if built upon a crumbling foundation of negative Medicare payment updates for as far as the eye can see," the letter said.

The organizations also addressed the patient-centered medical home, or PCMH, saying, for example, that a final health care reform bill should include the House's proposal to fund a Medicare pilot test of two versions of the PCMH: an independent practice model and a community-based model.

"We recommend that the patient eligibility threshold for the independent practice model be changed from the sickest 50 percent of patients with the more inclusive threshold of 'one or more chronic conditions,'" the letter said.

The organizations also recommend expanding existing programs and creating new ones to recruit, train and retrain primary care physicians; increasing graduate medical education residency programs in primary care; and reducing barriers that prevent training in community-based residency programs.