Advocacy for family physicians was at the forefront of the AAFP's activities during 2006. The Academy fought hard on physician payment issues, met with private insurers to ensure they were aware of FPs' concerns and worked to increase the national visibility of the concepts outlined in the Future of Family Medicine Project report. Those advocacy efforts met with success as CMS increased payments for evaluation and management codes, insurers backed off of some programs that were hurting FPs, and the idea of a medical home found acceptance within the public and private sectors.
2006: The Year in Review
By News Staff
1/4/2007
Public Sector Advocacy
Medicare physician payment was a hot topic among FPs in 2006. The year began with a 5 percent pay cut. Then, in January, Congress reinstated 2005 payment levels. During the next 10 months, lawmakers wrangled about whether to allow 2007 to begin with yet another scheduled 5 percent reduction. In the end, legislators froze 2007 Medicare payments at 2006 levels and added a 1.5 percent incentive increase -- to begin in July 2007 -- for physicians who participate in a new quality reporting program.
Throughout 2006, AAFP members and staff maintained a steady drumbeat of support for discarding the sustainable growth rate, or SGR, on which Medicare physician payment is based. Members hammered home the "Fix it Now!" message when they took part in an AAFP-sponsored rally on Capitol Hill in September. Thousands of members contacted their U.S. representatives and senators to urge action on a permanent solution to the continuing problem of Medicare physician payment. Despite promises to resolve the issue before -- and then, as time passed, immediately after -- midterm elections, Congress ended the year the way it had started: with a continuing resolution that temporarily prevents the 5 percent payment cut scheduled for 2007. With the Democrats in control of both the U.S. House and Senate in the 110th Congress, chances may improve for passage of legislation that would permanently resolve Medicare payment formula issues.
Family physicians fared better with CMS when the agency updated relative value units, or RVUs. As a result of ongoing pressure from the AAFP and its primary care colleagues, CMS effected updates for CPT codes 99213 and 99214. As of Jan. 1, code 99213 increased by $6.83, or 13 percent, and code 99214 rose by $7.58, or 9 percent. When accounting for all the proposed changes in work components of RVUs (both increases in E/M services and decreases in other services done by FPs) and budget neutrality adjustments, CMS estimated the impact on Medicare-allowed charges to family medicine would be a 5 percent increase in 2007. Only three other specialties did better.
2006 also was the inaugural year for the Medicare Part D prescription drug plan, and it got off to a rocky start as family physicians attempted to sort through dozens of plan formularies to resolve an onslaught of patients' and pharmacists' questions about denied claims, unexpected and unaffordable copayments, and plans that demanded immediate prescription changes despite a federally mandated, 30-day grace period on requiring prior authorization for certain prescriptions. The Academy quickly moved to post a Medicare Part D Web page that provides a complaint form for CMS and links to CMS. In September, the AAFP Congress of Delegates asked the Academy to advocate simplification of the Part D program.
Throughout 2006, AAFP members and staff maintained a steady drumbeat of support for discarding the sustainable growth rate, or SGR, on which Medicare physician payment is based. Members hammered home the "Fix it Now!" message when they took part in an AAFP-sponsored rally on Capitol Hill in September. Thousands of members contacted their U.S. representatives and senators to urge action on a permanent solution to the continuing problem of Medicare physician payment. Despite promises to resolve the issue before -- and then, as time passed, immediately after -- midterm elections, Congress ended the year the way it had started: with a continuing resolution that temporarily prevents the 5 percent payment cut scheduled for 2007. With the Democrats in control of both the U.S. House and Senate in the 110th Congress, chances may improve for passage of legislation that would permanently resolve Medicare payment formula issues.
Family physicians fared better with CMS when the agency updated relative value units, or RVUs. As a result of ongoing pressure from the AAFP and its primary care colleagues, CMS effected updates for CPT codes 99213 and 99214. As of Jan. 1, code 99213 increased by $6.83, or 13 percent, and code 99214 rose by $7.58, or 9 percent. When accounting for all the proposed changes in work components of RVUs (both increases in E/M services and decreases in other services done by FPs) and budget neutrality adjustments, CMS estimated the impact on Medicare-allowed charges to family medicine would be a 5 percent increase in 2007. Only three other specialties did better.
2006 also was the inaugural year for the Medicare Part D prescription drug plan, and it got off to a rocky start as family physicians attempted to sort through dozens of plan formularies to resolve an onslaught of patients' and pharmacists' questions about denied claims, unexpected and unaffordable copayments, and plans that demanded immediate prescription changes despite a federally mandated, 30-day grace period on requiring prior authorization for certain prescriptions. The Academy quickly moved to post a Medicare Part D Web page that provides a complaint form for CMS and links to CMS. In September, the AAFP Congress of Delegates asked the Academy to advocate simplification of the Part D program.
AAFP's presence on Capitol Hill grew as FamMedPAC, the Academy's federal political action committee, stepped up its activities. With more than $387,600 in member donations, FamMedPAC has given a total of $189,500 to current lawmakers and candidates for federal offices who meet certain criteria: support of AAFP's legislative and regulatory initiatives, membership on legislative committees or assignment to committees important to Academy goals. The activity has raised the profile of family medicine and primary care on Capitol Hill and enabled Academy members and leaders to attend more than 100 events at which physician payment, health care policy, medical homes and access to care were discussed.
Despite a slew of activity urging U.S. senators to end debate on medical liability reform, an effort in early May to bring the Medical Care Access Protection Act of 2006 to a floor vote failed. The Senate vote came after more than a month of intense AAFP activism, including an all-member e-mail, Academy member meetings with Sen. Majority leader Bill Frist, M.D., R-Tenn., and meetings between AAFP's then-President Larry Fields, M.D., of Flatwoods, Ky., and several legislators and their aides. If the bill had passed, the legislation would have limited medical liability noneconomic damages to a total cap of $750,000. Political analysts say prospects for passing a medical liability reform bill in the 110th Congress are dim, given the Democratic control of both the U.S. House and Senate. In the meantime, states have taken up the cause. In 2006, 36 state legislatures introduced and nine states passed laws that affect medical liability, including issues such as excluding apologies from evidence in malpractice litigation, providing assistance with buying or paying for medical liability insurance, setting noneconomic damages, and establishing rules for medical liability insurance companies.
As more Americans agitated for action on reining in spiraling health insurance costs and the burgeoning number of uninsured people in 2006, state legislators grappled with improving access to care at a reasonable cost. Many sought the counsel of family medicine and found merit in many aspects of the Future of Family Medicine Project report. With the active support of the Massachusetts AFP, Massachusetts implemented a law establishing universal access to health care through mandatory insurance coverage. The Louisiana Health Care Redesign Collaborative (PDF file: 67 pages / 655 KB. More about PDFs.) looked to family medicine for input into developing a primary care-focused plan for providing community-based medical homes to New Orleanians and, in the future, residents throughout the state. Transparency in health plans' contracts with physicians made solid inroads when the Colorado legislature -- with instrumental support from Colorado family physicians -- passed S.B. 198, a bill that would have required standardized health plan contracts with physicians. Although then-Gov. Bill Owens vetoed the 2006 bill, newly elected Gov. Bill Ritter has indicated he would sign similar legislation if it were brought before him.
Despite a slew of activity urging U.S. senators to end debate on medical liability reform, an effort in early May to bring the Medical Care Access Protection Act of 2006 to a floor vote failed. The Senate vote came after more than a month of intense AAFP activism, including an all-member e-mail, Academy member meetings with Sen. Majority leader Bill Frist, M.D., R-Tenn., and meetings between AAFP's then-President Larry Fields, M.D., of Flatwoods, Ky., and several legislators and their aides. If the bill had passed, the legislation would have limited medical liability noneconomic damages to a total cap of $750,000. Political analysts say prospects for passing a medical liability reform bill in the 110th Congress are dim, given the Democratic control of both the U.S. House and Senate. In the meantime, states have taken up the cause. In 2006, 36 state legislatures introduced and nine states passed laws that affect medical liability, including issues such as excluding apologies from evidence in malpractice litigation, providing assistance with buying or paying for medical liability insurance, setting noneconomic damages, and establishing rules for medical liability insurance companies.
As more Americans agitated for action on reining in spiraling health insurance costs and the burgeoning number of uninsured people in 2006, state legislators grappled with improving access to care at a reasonable cost. Many sought the counsel of family medicine and found merit in many aspects of the Future of Family Medicine Project report. With the active support of the Massachusetts AFP, Massachusetts implemented a law establishing universal access to health care through mandatory insurance coverage. The Louisiana Health Care Redesign Collaborative (PDF file: 67 pages / 655 KB. More about PDFs.) looked to family medicine for input into developing a primary care-focused plan for providing community-based medical homes to New Orleanians and, in the future, residents throughout the state. Transparency in health plans' contracts with physicians made solid inroads when the Colorado legislature -- with instrumental support from Colorado family physicians -- passed S.B. 198, a bill that would have required standardized health plan contracts with physicians. Although then-Gov. Bill Owens vetoed the 2006 bill, newly elected Gov. Bill Ritter has indicated he would sign similar legislation if it were brought before him.
Private Sector Advocacy
The Academy took the offense with some of the country's largest private insurers in 2006. Executives from a number of companies met with AAFP leaders and staff at AAFP headquarters in Leawood, Kan., for across-the-table discussions on issues important to FPs. Successes included UnitedHealthcare's decision to drop support for benefit tiering, Aetna's modification of an existing policy to begin paying for two E/M codes on the same day, Blue Cross Blue Shield of Ohio's announcement that it would discontinue its blended-rate policy, and Humana's call to establish a higher copay for patients seeking care at a retail health clinic versus a physician's office. In addition, beginning Feb. 1, the Academy gave members a means to report insurance company hassles via an online health plan complaint form.
In August, corporate giant IBM sat down with the Academy to discuss how to build a quality-driven affordable health care system based on primary care. Fields called the meeting a "watershed moment." The momentum continued into November when representatives from IBM, the Academy, the American College of Physicians and some of the nation's largest employers gathered to discuss how to put together a model primary-care product that employers could buy for their employees. In December, AAFP EVP Douglas Henley, M.D., joined executives from five corporations and other corporate leaders at a National Press Club event during which a Web-based framework called "Dossia" was introduced to the nation. The system would allow patients to build and maintain their own portable personal health records.
Retail health clinics, such as MinuteClinic and Take Care, continued to garner much interest from consumers and employers looking for convenient health care services in 2006. In June, the Academy approved a list of desired attributes that it identified as critical to the patient care offered by such clinics. According to the AAFP, retail health care should include a defined scope of service, incorporate evidence-based medicine, utilize a referral system directing patients to physician practices and implement an electronic health record, or EHR, system that communicates information to the patient's medical home.
The Academy stood up for family physicians when scope-of-practice issues threatened late in 2005 and in 2006. In December 2005, the AAFP responded to a legal opinion written by the American College of Gastroenterology that attempted to limit endoscopy privileges only to board-certified gastroenterologists. In its own legal opinion, AAFP cautioned that excluding FPs from conducting such procedures could violate antitrust laws. In April, AAFP News Now reported on the Academy's participation in the Scope of Practice Partnership, a coalition of national medical specialty organizations and state medical societies that would develop a clearinghouse of information about nonphysician providers. In May, the Academy backed the Ohio AFP on a scope-of-practice issue involving FPs' qualifications to administer nerve conduction studies.
In August, corporate giant IBM sat down with the Academy to discuss how to build a quality-driven affordable health care system based on primary care. Fields called the meeting a "watershed moment." The momentum continued into November when representatives from IBM, the Academy, the American College of Physicians and some of the nation's largest employers gathered to discuss how to put together a model primary-care product that employers could buy for their employees. In December, AAFP EVP Douglas Henley, M.D., joined executives from five corporations and other corporate leaders at a National Press Club event during which a Web-based framework called "Dossia" was introduced to the nation. The system would allow patients to build and maintain their own portable personal health records.
Retail health clinics, such as MinuteClinic and Take Care, continued to garner much interest from consumers and employers looking for convenient health care services in 2006. In June, the Academy approved a list of desired attributes that it identified as critical to the patient care offered by such clinics. According to the AAFP, retail health care should include a defined scope of service, incorporate evidence-based medicine, utilize a referral system directing patients to physician practices and implement an electronic health record, or EHR, system that communicates information to the patient's medical home.
The Academy stood up for family physicians when scope-of-practice issues threatened late in 2005 and in 2006. In December 2005, the AAFP responded to a legal opinion written by the American College of Gastroenterology that attempted to limit endoscopy privileges only to board-certified gastroenterologists. In its own legal opinion, AAFP cautioned that excluding FPs from conducting such procedures could violate antitrust laws. In April, AAFP News Now reported on the Academy's participation in the Scope of Practice Partnership, a coalition of national medical specialty organizations and state medical societies that would develop a clearinghouse of information about nonphysician providers. In May, the Academy backed the Ohio AFP on a scope-of-practice issue involving FPs' qualifications to administer nerve conduction studies.
In April, TransforMED, a division of the Academy focused on transformative practice redesign, announced the launch of a national demonstration project designed to move family medicine practices to an innovative, patient-centered practice model dubbed the "TransforMED model of care." Thirty-six practices were chosen from hundreds of applicants to participate in the two-year pilot. June brought the first meeting of 18 of those practices. "You're embarking on a journey," EVP Douglas Henley, M.D., told the group. In December, the Commonwealth Fund awarded grants totaling nearly $264,000 to the University of Texas Health Sciences Center at San Antonio for use in the TransforMED demonstration project. The money was designated to fund TransforMED's research team as it evaluates how ongoing practice redesign would affect patient-centered care in the demonstration project practices.
Technology
The Academy supported the Certification Commission for Healthcare Information Technology, or CCHIT, and its mission to create a mechanism for certifying health IT products. In April, Steven Waldren, M.D., then-assistant director of AAFP's Center for Health Information Technology, was appointed co-chair of CCHIT's ambulatory EHR functionality work group. In late April, CCHIT announced the launch of its certification program for ambulatory EHR products. In July, the names of the first 18 products to receive CCHIT's seal of approval were announced. "This is the center of the universe on health IT today," said HHS Secretary Mike Leavitt at the press event.
The Academy also continued its strong support of the continuity-of-care record, or CCR, standard and applauded ASTM International, the standard-setting organization that developed the CCR record standard, when the standard was published. "The CCR is now a full-fledged standard, and it's time for family physicians to push their EHR vendors to become CCR-compliant," said Waldren after the January announcement. In August, AAFP News Now reported that FPs could benefit from health information technology final rules published by CMS and HHS that created exceptions and safe harbors to key federal fraud and abuse laws for arrangements involving the donation of certain health IT technology and services. Also in August, President Bush signed an executive order requiring federal agencies to use certified, interoperable health IT products when such products are available.
Clinical Issues
The Academy's Influenza Vaccine Task Force finalized its report to the AAFP Board of Directors in late January. In March, the AAFP Board approved the task force's recommendations, which included a directive to continue working with manufacturers and distributors "to ensure family physicians receive the influenza vaccine necessary to meet their patients' needs in a timely manner." That work has continued as, despite a record-high total number of annual influenza vaccine doses produced for the 2006-07 season, miscues again plagued the U.S. influenza vaccine distribution system, leaving some AAFP members with only a portion or none of their influenza vaccine orders when patients began seeking vaccine in September and October. Accordingly, subsequent vaccine supply discussions by Academy staff and leaders have focused on distributors, culminating in a December meeting with top officials from distributor Henry Schein, which serves thousands of AAFP members.
Federal health officials also attempted to address vaccine delay problems. To help raise awareness of the need to continue vaccinating throughout November and beyond, HHS, including the CDC, and the National Influenza Vaccine Summit, in which the AAFP is a partner, sponsored the first National Influenza Vaccination Week, which was held Nov. 27-Dec. 3. The event offered a valuable reminder, according to AAFP President Rick Kellerman, M.D., of Wichita, Kan. "In a family physician's office, every day is influenza vaccination day," said Kellerman. "Physicians should encourage influenza vaccination as vigorously in December and January -- if not more so -- as they do in October. Every year, influenza vaccine goes unused at the end of the vaccination season, yet millions of people remain unvaccinated."
In October, the Academy issued a revised Recommended Adult Immunization Schedule that features several changes, including routinely giving some patients the human papillomavirus, or HPV, vaccine approved earlier this year. An AAFP Provisional Recommendations for the Use of Quadrivalent HPV Vaccine document approved in September call for routine HPV vaccination of females ages 11 to 12.
In November, AAFP Board Chair Larry Fields, M.D., approved a provisional immunization recommendation that adults 60 and older receive a single dose of varicella zoster vaccine, regardless of whether they report a previous episode of herpes zoster. The recommendation is intended to prevent development of herpes zoster, commonly known as shingles, and post-herpetic neuralgia in this population.
Federal health officials also attempted to address vaccine delay problems. To help raise awareness of the need to continue vaccinating throughout November and beyond, HHS, including the CDC, and the National Influenza Vaccine Summit, in which the AAFP is a partner, sponsored the first National Influenza Vaccination Week, which was held Nov. 27-Dec. 3. The event offered a valuable reminder, according to AAFP President Rick Kellerman, M.D., of Wichita, Kan. "In a family physician's office, every day is influenza vaccination day," said Kellerman. "Physicians should encourage influenza vaccination as vigorously in December and January -- if not more so -- as they do in October. Every year, influenza vaccine goes unused at the end of the vaccination season, yet millions of people remain unvaccinated."
In October, the Academy issued a revised Recommended Adult Immunization Schedule that features several changes, including routinely giving some patients the human papillomavirus, or HPV, vaccine approved earlier this year. An AAFP Provisional Recommendations for the Use of Quadrivalent HPV Vaccine document approved in September call for routine HPV vaccination of females ages 11 to 12.
In November, AAFP Board Chair Larry Fields, M.D., approved a provisional immunization recommendation that adults 60 and older receive a single dose of varicella zoster vaccine, regardless of whether they report a previous episode of herpes zoster. The recommendation is intended to prevent development of herpes zoster, commonly known as shingles, and post-herpetic neuralgia in this population.
Education
Physician recruiting companies and workforce analysts documented continued, strong demand for family physicians, confirming what the AAFP already knew: that America must bolster the number of family physicians. The Academy's Family Physician Workforce Reform report, (PDF file: 12 pages / 123 KB. More about PDFs.) presented Sept. 25 to the Congress of Delegates, calls for a family physician workforce of at least 139,521 by 2020. To achieve that target, 3,725 family physicians will need to be graduated by Accreditation Council for Graduate Medical Education-accredited family medicine residencies, and 714 by American Osteopathic Association-accredited residencies each year. In November, the American Medical Student Association endorsed the workforce reform report and commended the Academy for its leadership in addressing primary care workforce issues.
Family medicine residencies grappled with significant reductions in their Title VII funding this year while the AAFP Division of Government Relations worked to bring fiscal year 2007 funding back up to 2005 levels. Section 747 of Title VII of the Public Health Service Act, which supports family medicine training, had been slashed from $88 million in 2005 to $41 million in 2006. A funding increase seemed possible in June, when the Senate added $7 billion to the labor/health and human services appropriations bill, a move that held promise for increasing federal support for Section 747 of Title VII. But the attempt fell victim to defense spending legislation. In the end, Title VII joined other appropriations proposals in a continuing resolution, which temporarily maintains government spending for 2007 at 2006 levels. The result: Title VII will operate with $41 million, at least until the continuing resolution expires in February.
The American Board of Family Medicine, or ABFM, and the American Board of Emergency Medicine in March adopted guidelines (PDF file: 6 pages / 32.1 KB. More about PDFs.) that allow hospitals and other residency sponsors with accredited programs in family medicine and emergency medicine to offer combined residency training that leads to dual board certification. Dual family and emergency medicine residency training is a resource for residents who plan to practice in rural areas, where family physicians often staff emergency departments. Moreover, the dual residency approval will help preserve family physicians' role in emergency departments, ensure medical coverage of EDs in underserved areas and address emergency medicine's desire for board-certified ED directors, according to medical education officials.
A new project -- dubbed Preparing the Personal Physician for Practice, or P4 -- will lay the groundwork for restructuring family medicine residency training, thanks to more than $1.7 million in pledges from the ABFM Foundation and Association of Family Medicine Residency Directors. TransforMED will oversee the six-year project. Ten to 20 family medicine residency programs will participate by launching demonstration projects that include program innovations in length, structure, source and content, and place of training, as well as in measurement of competency. Residency program selection is scheduled for January, and selected programs may initiate their projects as early as June.
Family medicine residencies grappled with significant reductions in their Title VII funding this year while the AAFP Division of Government Relations worked to bring fiscal year 2007 funding back up to 2005 levels. Section 747 of Title VII of the Public Health Service Act, which supports family medicine training, had been slashed from $88 million in 2005 to $41 million in 2006. A funding increase seemed possible in June, when the Senate added $7 billion to the labor/health and human services appropriations bill, a move that held promise for increasing federal support for Section 747 of Title VII. But the attempt fell victim to defense spending legislation. In the end, Title VII joined other appropriations proposals in a continuing resolution, which temporarily maintains government spending for 2007 at 2006 levels. The result: Title VII will operate with $41 million, at least until the continuing resolution expires in February.
The American Board of Family Medicine, or ABFM, and the American Board of Emergency Medicine in March adopted guidelines (PDF file: 6 pages / 32.1 KB. More about PDFs.) that allow hospitals and other residency sponsors with accredited programs in family medicine and emergency medicine to offer combined residency training that leads to dual board certification. Dual family and emergency medicine residency training is a resource for residents who plan to practice in rural areas, where family physicians often staff emergency departments. Moreover, the dual residency approval will help preserve family physicians' role in emergency departments, ensure medical coverage of EDs in underserved areas and address emergency medicine's desire for board-certified ED directors, according to medical education officials.
A new project -- dubbed Preparing the Personal Physician for Practice, or P4 -- will lay the groundwork for restructuring family medicine residency training, thanks to more than $1.7 million in pledges from the ABFM Foundation and Association of Family Medicine Residency Directors. TransforMED will oversee the six-year project. Ten to 20 family medicine residency programs will participate by launching demonstration projects that include program innovations in length, structure, source and content, and place of training, as well as in measurement of competency. Residency program selection is scheduled for January, and selected programs may initiate their projects as early as June.
