AAFP Engages Senate on Amendment to Health Care Reform Legislation

As the Senate moves closer to passing comprehensive health care reform legislation, the AAFP has sent a letter to Senate members (5-page PDF; About PDFs) that both praises and raises issues with a so-called manager's amendment that makes key changes to existing provisions in the Senate's health care reform bill.

In the letter, AAFP Board Chair Ted Epperly, M.D., of Boise, Idaho, described the manager's amendment as "generally a positive addition to major legislation that is the result of a great deal of work by the U.S. Senate and its excellent staff." Overall, Epperly's letter reiterates the Academy's support for various provisions of the Patient Protection and Affordable Care Act (at the THOMAS Web site, type "H.R. 3590" in the search box after selecting "Bill Number"), without supporting the legislation outright.

"We greatly appreciate several features of this legislation, especially the provisions to extend health insurance coverage to as much as 94 percent of the American nonelderly population," said Epperly. "Extending coverage to as many people as possible is a basic provision of the AAFP's Health Care for All policy, and it is an essential part of health reform."

Epperly also said the AAFP applauds the legislation's 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 longer than 90 days.

The legislation no longer contains a 0.5 percent increase in the Medicare physician payment rate for 2010 originally intended to give Congress time to work on a more permanent solution to reductions called for under the sustainable growth rate formula. In the meantime, the president has signed into law a bill containing a two-month payment patch, blocking any payment reductions from going into effect on Jan. 1.

"We know that the Senate understands that family physicians, and indeed all physicians, support a permanent fix to this long-term problem and strongly urge and expect the Senate to address this issue before the February 28, 2010, deadline," Epperly said. "Continued delay only makes fixing the formula more costly."

The manager's amendment also removes the budget neutrality adjustment that would have offset half of the cost of the bonus payments for primary care and general surgery. Although the AAFP is "pleased with this change," according to Epperly, "We believe that the better use of primary care physicians will generate savings in all parts of Medicare and those savings ought to support the primary care physician payment."

Epperly praised the legislation's provision of a 10 percent bonus payment for five years for physicians who provide more than 60 percent primary care health services, calling it "a critically important step toward signaling to medical students that the federal government is committed to investing in primary care." But he said the provision should be strengthened "if it is going to accomplish the task of encouraging more talented medical students to choose 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. In addition, the eligibility threshold should be a more realistic 50 percent of a physician's services in primary care."

Epperly also called on the Senate to equalize Medicaid payment rates for primary care services nationwide with those of Medicare.

"This is probably one of the most important steps that Congress can take to support those physicians who currently provide primary care services and encourage medical student choice of primary specialties," he said.

The Senate legislation provides support for the patient-centered medical home, or PCMH, by establishing Medicaid PCMH demonstration projects and by creating a Center for Innovation at CMS to test the medical home model in Medicare. Both provisions, however, are too limited, said Epperly.

The Medicaid demonstration, for example, is restricted to patients with chronic conditions, and the language regarding the Medicare innovation center gives preference to demonstrations of medical homes for "high-need individuals."

"The medical home is particularly effective in providing the prevention and wellness health care that much of the legislation attempts to promote. We believe the medical home is especially helpful in preventing chronic diseases, as well as managing the chronic diseases that do emerge," said Epperly.

"We would strongly recommend the elimination of the limitations on the medical home demonstrations in both Medicare and Medicaid so that physicians can provide the best possible care to all of their patients," he said.

Epperly praised the amendment's addition of language that would allow health plans to provide coverage through a qualified primary care medical home in the new health insurance exchange, as well as its call for grants to networks that coordinate care for low-income populations.

Among other workforce-related innovations, the Senate legislation seeks to test effective primary care residency training methods by establishing a teaching health center program to train primary care residents in nonhospital settings, a provision that Epperly said could be a "valuable mechanism."

However, he stressed, "It is imperative that the funding for the teaching health centers not be drawn from funds that support Title VII health professions grants," and he urged that both programs be adequately funded.

Epperly also praised a provision in the amendment that would establish a grant program to help medical schools recruit students most likely to practice medicine in underserved rural communities and provide rural-focused training and experience, with the goal of increasing the number of medical school graduates willing to practice in these communities.

Other provisions of the manager's amendment also drew the AAFP's support, said Epperly, including a provision that provides funding for states to experiment with alternative dispute resolution systems.