2008: The Year in Review

2008 could well have been called the year of the patient-centered medical home, or PCMH. As increasing numbers of organizations, government agencies and officials, and private entities acknowledged the burgeoning U.S. health care crisis, the PCMH gained increasing prominence. From the halls of Congress, to privately funded think-tanks, to insurers, the cry became, "Turn the focus back to primary care." That cry prompted the Academy and its primary care partners to redouble their efforts to push the PCMH, along with one of its key components -- payment for managing the medical home -- as the solution to the crisis.

Late in 2007, the Council of State Governments, or CSG, urged its members to implement and fund PCMH pilot projects. At its annual meeting, the CSG approved a resolution that encourages states to implement and fund pilot programs to demonstrate the quality, safety, value and effectiveness of the PCMH. Several states, including Indiana and Pennsylvania, subsequently launched statewide health care programs that focus on primary care.

The PCMH also played a role at the federal level when the presidential candidates included some of its tenets in their health care platforms. President-elect Barack Obama subsequently announced that health care reform would play a large role in the beginning days of his administration because of the effects of rising health care costs on the weakening economy.

In February 2008, the National Committee for Quality Assurance introduced its Physician Practice Connections -- Patient-Centered Medical Home program, and then in April, TransforMED concluded its National Demonstration Project, which was designed to test the PCMH model. TransforMED also launched its online Medical Home Implementation Quotient program to help family medicine practices working to become medical homes measure their progress.

By mid-October, the PCMH momentum was evident during a stakeholders' meeting of the Patient-Centered Primary Care Collaborative. The group, which only had 30 attendees at its first meeting two years ago, hosted more than 350 attendees at its Oct. 17 meeting.

Arguably, the crowning achievement came in November, however, when the AMA House of Delegates voted to endorse the Joint Principles of the Patient-Centered Medical Home developed by the AAFP, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association, thus throwing the support of the entire house of medicine behind the PCMH model.

Once again in 2008, family physicians were faced with the threat of reduced payment levels, forcing AAFP members and their patients to rally behind efforts to overcome threatened cuts to physician Medicare payment.

The year began with the Academy on the front lines in the battle involving physician payment cuts mandated under the sustainable growth rate formula. Although Congress once again acted at the last minute to replace a scheduled 10.1 percent pay cut with a 0.5 percent pay increase, the Academy was outraged that the reprieve was only for six months.

Support to find a fix was intense, particularly after the Academy launched a grass-roots campaign in February to stop the cut then scheduled for June. Members and their patients phoned, e-mailed and met in person with their legislators to inform them about the consequences of cutting Medicare payment rates.

The lobbying intensified in June and early July when President Bush vetoed passage of a final physician payment bill that included provisions to replace the payment cuts with a 0.5 percent increase for the remainder of 2008 and a 1.1 percent increase in 2009. Legislators, however, rallied to the side of physicians and patients by overturning the veto after a prolonged battle. The 18-month fix is expected to give legislators time to fix the flawed Medicare payment formula.

2008 also was the year when CMS' Physician Quality Reporting Initiative, or PQRI, was supposed to begin reaping benefits for physicians who had participated in the program in 2007; however, errors and problems dogged the program throughout 2008, and the year ended with CMS promising to do better in the future.

The agency offered a glimpse into the progress of the PQRI program in March when it released preliminary data that indicated "more than half of the participating professionals … appear to be on track to receive bonuses."

However, a September study released by the Medical Group Management Association indicated that physicians were struggling with the PQRI program. The study found that physicians were frustrated with the administrative burdens of the PQRI, the time it took to get feedback on data submitted, and the absence of data that would help improve patient outcomes.

Ongoing complaints about the program led to a December meeting between CMS Acting Administrator Kerry Weems and AAFP Board Chair Jim King, M.D. King wanted to know why thousands of physicians who participated in the program did not receive a promised Medicare bonus payment of 1.5 percent.

CMS officials acknowledged that there were problems with the program, but they also pointed out that many of the problems occurred before claims ever reached CMS. King said he recognized this fact, but he encouraged CMS officials to work on fixing every part of the system.

The AAFP has pledged to continue working with CMS to resolve problems with the PQRI program, and, in return, CMS has said it is "committed to a successful PQRI program," and has promised to "reduce or eliminate" issues causing physician frustration.

Electronic health records, or EHRs, also played a big role in 2008, mostly because of efforts to reform the health care system.

Near the end of 2007, legislation was introduced in Congress that proposed using financial incentives and disincentives to encourage the adoption of electronic prescribing under Medicare. Provisions from those proposals eventually were included in a larger Medicare legislative package passed in early 2008.

By July 2008, HHS was ready with some of the details of the new e-prescribing program created by that Medicare legislation. The program initially will use incentive bonuses to coax physicians into using e-prescribing. The bonuses eventually will be phased out, however, in favor of penalties on physicians and other prescribers who have not adopted e-prescribing. (Then) AAFP President Jim King, M.D., noted that although the AAFP supports e-prescribing, a number of barriers have to be removed before family physicians can embrace the technology fully.

A ban on faxed prescriptions that was scheduled to take effect on Jan. 1, 2009, was expected to set back efforts to incorporate e-prescribing into physician practices. After urging from the AAFP and others, however, CMS announced in November that it would move the deadline for banning computer-generated faxes of prescriptions to pharmacies to 2012, thus giving physician practices more time to fully integrate e-prescribing.

HHS also rolled out its national EHR demonstration project in 2008. Physicians participating in the program will receive bonus payments for investing in and using EHR systems, gathering and reporting quality data to CMS, and delivering high-quality health care to patients based on national standards. Bonuses will be paid based on how well physicians use their EHR systems to manage patient care, said HHS Secretary Michael Leavitt.

New York City also jumped on the EHR bandwagon with a program that was expected to equip more than 1,000 primary care physician offices with EHRs by the end of 2008. The city provided software, maintenance and support services, and system training to participating physicians. Physicians in the program agreed to supply their own computer and Internet connections and to contribute $4,000 to a technical assistance fund.

After several years of dealing with influenza vaccination shortages and delays, 2008 was the year of the Haemophilus influenzae type b, or Hib, vaccine shortage.

The shortage got its start late in 2007 when Merck & Co. Inc. recalled several lots of two of its Hib vaccine products -- PedvaxHIB and COMVAX -- because of a potential for contamination. Merck suspended production of its Hib conjugate vaccines, leading to an Hib vaccine shortage. The CDC subsequently released interim immunization recommendations calling for temporary deferral of the routine Hib vaccine booster dose administered at age 12-15 months, except for children in certain high-risk groups.

Although Merck had expected to resume Hib vaccine distribution in late 2008, in October, the company announced that distribution would be delayed until mid-2009. This led the CDC to reinforce its recommendation on temporary deferral of the vaccine booster dose in most children. The agency also stepped up its surveillance for Hib disease, and has asked physicians to contact their local health departments when invasive H. influenzae disease is suspected.

After several years of shortages and distribution miscues, the relative abundance in the influenza vaccine supply for the 2008-09 season led to increased efforts to get the public vaccinated.

The AAFP, along with the CDC's Advisory Committee on Immunization Practices, or ACIP, and the American Academy of Pediatrics released a recommendation to expand annual influenza immunizations to include all children ages 6 months to 18 years by the 2009-10 flu season. In addition, the groups called for greater vaccine coverage among health care workers.

The question of vaccination coverage arose again when outbreaks of measles were reported in several states during the year. Most of the cases were associated with importation of the virus from foreign countries, and the CDC noted that nearly all had occurred in individuals who had not been vaccinated against the disease or whose vaccination status was unknown or undocumented.

By the end of July, the number of measles cases had reached 131, the highest year-to-date number of cases since 1996. According to an update in the Aug. 22 Morbidity and Mortality Weekly Report, "This increase was not the result of a greater number of imported cases, but was the result of greater viral transmission after importation into the United States."

In January, many doctors were left scratching their heads about what to do for parents demanding medication for their young children with coughs and colds after the FDA issued a health advisory recommending that over-the-counter, or OTC, cough and cold medications no longer be used in infants and children younger than 2 years of age. The FDA based its recommendation on a review of published studies on the overall efficacy of OTC cough and cold medications, as well as on safety information gleaned from decades of widespread use.

In October, the Consumer Healthcare Products Association, or CHPA, a not-for-profit association representing the manufacturers of OTC medications and nutritional supplements, added its voice to the issue. The CHPA announced that its member companies would voluntarily change the labeling of OTC cough and cold products to indicate the medications should not be used in children younger than age 4.

Although first raised in 2006, the doctor of nursing practice, or DNP, issue exploded this year after an article on the designation appeared in the Wall Street Journal and the National Board of Medical Examiners, or NBME, announced it would work with the Council for the Advancement of Comprehensive Care to develop and administer the first certification examination for DNP graduates.

In June, members of the AMA House of Delegates made it clear that although they would welcome DNPs as members of the medical team, physicians still need to take the lead.

Delegates adopted a resolution calling for new AMA policy that stipulates that DNPs "must practice as part of a medical team under the supervision of a licensed physician who has final authority and responsibility for the patient."

At its interim meeting in November, the AMA house further directed the AMA to develop model state legislation designed to avoid any perception that DNPs are equivalent in training to doctors of medicine or doctors of osteopathy.

Meanwhile, a meeting between the AAFP and the NBME in September resulted in official acknowledgment from the NBME that a new certification examination for candidates for the DNP degree is in no way equivalent to exams for physician licensure.