NCSC Delegates Press for Stronger Advocacy on Payment

Delegates to the 2008 National Conference of Special Constituencies, or NCSC, urged the Academy to step up its advocacy efforts with government agencies, third-party payers and other private-sector stakeholders to ensure family physicians get their fair share of the reimbursement pie. That message came through adoption of resolutions on a range of payment issues.

Vaccine administration was an especially hot topic at the May 1-3 meeting, with special constituency chapter representatives fielding a pair of resolutions on the issue. The first of these called for the AAFP to expand its current advocacy efforts "to include working with governmental and private payers and pharmaceutical firms to ensure payments for vaccines reflect the actual cost of providing them, particularly with regard to new, more expensive vaccines."

Rebecca Moran, M.D., a women physician constituency representative from Phoenix and co-author of the resolution, testified May 2 before the Reference Committee on Practice Enhancement. Moran told committee members that her practice's recent brush with insolvency could be traced in part to her and her partners' efforts to ensure eligible patients received the new human papillomavirus vaccine, Gardasil.

"When we did the analysis," Moran explained, "we found it was costing us $140 (per dose) for the vaccine, and we were only getting paid an average of $122 (per dose)." In the case of one insurer, she added, payment was only $93 per dose.

"If something doesn't change," Moran said, "I'm afraid there will be many patients not able to get this beneficial vaccine."

According to Moran, part of the answer is to ensure all stakeholders are at the table when discussing vaccine price and payment issues. That means drawing vaccine manufacturers into Academy discussions with government and private payers about closing existing gaps between what physicians are paid to administer vaccines versus the actual cost of giving them.

A second resolution took a slightly difference tack, calling on the AAFP to advocate that all vaccines recommended by the CDC's Advisory Committee on Immunization Practices "be reimbursed in a financially sustainable manner to encourage all family physicians to administer recommended immunizations to all appropriate populations."

"Family physicians are bold champions of immunizations and other preventive services," said resolution co-author Stacy Taylor, M.D., a gay, lesbian, bisexual and transgender constituency representative from Torrington, Conn., in her testimony to the reference committee. But every day, she noted, it grows increasingly difficult to maintain that momentum in the face of inadequate reimbursement.

Testimony on the two measures overall was supportive. In an attempt to accommodate the concepts embodied in both, the reference committee fielded a substitute resolution during the May 2 delegates' business session. That resolution called on the AAFP to "broaden existing policy to include working with governmental and private payers to ensure that the administration of immunizations recommended by the Advisory Committee on Immunization Practices be reimbursed in an adequate manner to encourage all family physicians to administer recommended immunizations to all appropriate populations."

Some delegates, however, objected to the substitute, saying it didn't address the need to make sure vaccine makers fully understand the relationship between product pricing, the actual cost of administering those products and payment for immunization services.

In the end, delegates adopted both the reference committee's substitute resolution and an additional amendment directing the AAFP to work with vaccine makers and others in the pharmaceutical industry "to reduce the cost of newer, more expensive vaccines."

The practice enhancement reference committee also combined two payment-related measures into one substitute resolution. Reference committee testimony on the first resolution focused on mental health services provided by family physicians and other primary care physicians.

That resolution's authors contended that in the context of caring for "the whole patient," family physicians often encounter and manage psychiatric morbidity in their patients. Yet when a mental health diagnosis, such as depression or anxiety, is listed as the initial diagnosis along with sometimes multiple physiological conditions, such as hypertension and coronary artery disease, insurers fail to "provide fair and agreed-upon payment for all medical conditions submitted."

The Academy should address this inequity through its private advocacy efforts, the authors asserted, to ensure that all diagnoses -- in whatever sequence they appear on billing sheets -- are "separately considered and paid fairly."

The authors of the second resolution went straight to the heart of interspecialty payment variations, urging the Academy to advocate to CMS and other third-party payers "equal payment for the diagnosis and treatment of medical conditions and procedures performed by family physicians" compared with other medical specialists and subspecialists.

"If I remove a sebaceous cyst and a surgeon removes a sebaceous cyst, they get paid more than I do," said Kiran Khanolkar, M.D., of Keokuk, Iowa, a special constituency representative to the AAFP Congress of Delegates. "I don't know why that is, when we're both doing the same thing."

That difference, according to resolution co-author Paul Sucgang, D.O., of Los Angeles, can run on the order of $50 to $60 for the same endoscopic procedure depending on who performs it -- an FP versus a gastroenterologist.

The committee fielded a substitute resolution to conference delegates -- which they adopted on the consent calendar -- that the Academy would bring its advocacy efforts with CMS and other third-party payers to bear "to provide equal payment for diagnosis and treatment of medical/mental health conditions and procedures performed by family physicians, as compared with subspecialty care for the same CPT and/or ICD-9 codes."