AAFP Leaders Address Members' Health Care Reform Questions During Telephone Town Hall Meetings

Two successive telephone town hall call-in meetings on Aug. 31 gave Academy leaders a chance to answer dozens of questions from AAFP members about the Academy's positions on several key health care reform issues, including the public plan option, Medicare payment reform and the patient-centered medical home.

"Over the past five months or so, health care reform has been going through a lot of transformation. We've kind of gotten away from the policy stage ... into the political stage," said AAFP President Ted Epperly, M.D., of Boise, Idaho, in the lead-in to the first call-in meeting. Along with that stage, he added, "comes a lot of anger, a lot of fear, a lot of confusion, a lot of ideology." Thus, Epperly said, the Academy decided the telephone town hall meetings would offer an opportunity for AAFP leaders to openly and honestly answer members' questions about health care reform and the Academy's role.

Epperly was joined on the calls by AAFP Board Chair Jim King, M.D., of Selmer, Tenn.; President-elect Lori Heim, M.D., of Vass, N.C.; and EVP Doug Henley, M.D., who moderated the meetings. More than 250 AAFP members called in during the first town hall call at 8 p.m. E.D.T., and another 230 called in during the second call at 10 p.m. E.D.T. Many more members e-mailed questions in advance.

One area of concern for members was the Academy's qualified support for legislation introduced recently in the House that includes a public plan option. The public plan option has emerged as one of the most contentious issues during the ongoing debate about health care reform. Although the Academy has expressed support for the House bill, it has laid out a number of guidelines that must be met by any public plan option the AAFP would fully back.

During the first call-in meeting, King said the AAFP "does not require a public plan option to support health care reform in its present form." If Congress decides to include a public plan option, said King, the AAFP would support it based on whether the Academy's guidelines were met.

For example, participation by physicians and patients in a public plan has to be voluntary, said King. Any public plan also has to be able to function on its own, cannot be an extension of Medicare and cannot use Medicare's payment rates.

Any public plan option also must operate on a level playing field with private plans, said King, adding that health care reform bills pending in the House and Senate meet those criteria.

"We are going to be watching very closely to make sure there are no changes in (the legislation)," he said.

AAFP members also raised questions about the cost of the health care reform legislation during the town hall meetings. For example, several asked if enactment of health care reform measures would actually slow health care costs and whether the measures would achieve budget-neutrality.

"The ultimate answer to bending the cost curve is primary care," said Epperly. "That is exactly the value (FPs) bring to the system. That is what President Obama and Congress have recognized. It is why primary care and family medicine are ... at the epicenter of health care reform in this country."

In addition, there is a cost for inaction, said Epperly. "Medicare is already projected to be insolvent in 2017," he noted, so "we have about 10 years to get this right."

Health care reform is "an investment in the future," said Epperly. He and the other AAFP leaders applauded primary care provisions contained in health care reform legislation introduced in both the House and Senate. For example, both bills have provisions for rapid and widespread testing of the patient-centered medical home. The House bill would promote the medical home from a demonstration to a pilot project, making it easier to expand the medical home model if it is judged successful.

"The things that are in these bills are the same things we are trying to get into other bills -- enhanced payment for primary care, better pay for family physicians and more people who have health insurance," said King.

Nevertheless, AAFP leaders told participants, they have concerns about certain provisions in the House and Senate legislation. For example, the AAFP has called for a 25 percent increase in fee-for-service payments for primary care physicians, an amount that is needed to sustain primary care practices and increase the primary care physician workforce. But the House and Senate bills would provide only a 5 percent payment increase for fee-for-service payments for primary care physicians, Epperly said.

In addition, although the bills would reform graduate medical education to promote primary care, those reforms do not go far enough, Epperly said.

The AAFP also opposes the creation of an independent Medicare advisory committee, or IMAC, a body that would oversee Medicare. "It doesn't meet the basic principles we have put forth," said Epperly.

Instead, the Academy might be able to support a strengthened and expanded Medicare Payment Advisory Committee, or MedPAC, as an alternative to the IMAC. MedPAC currently advises Congress on Medicare payment issues, and the Academy has proposed that the committee include consumer and primary care physician representation.

Another area of concern for members was the lack of tort reform in the pending legislation.

Heim agreed that this omission is a disappointing development, adding that an amendment has been included in the House Energy and Commerce Committee bill that pays states to "implement some alternative medical liability loss." However, although the AAFP has long supported major tort reform, including caps on noneconomic damages awards, those caps are not going to be in this bill, said Heim. The AAFP is pushing for alternatives, she said, "such as liability laws, special health courts, things that would limit expert witnesses."

The patient-centered medical home and the number of uninsured in the United States were two other areas of concern for members.

For example, Craig Gage, M.D., of Tampa, Fla., asked how the patient-centered medical home was different from the gatekeeper model used by managed care companies in the late 1980s and early 1990s.

King noted that there were fundamental differences. "One was 'gate closed'; the other is 'gate opened,'" he said. The gatekeeper model sought to save money while trying to keep people away from different subspecialists' offices, whereas "the patient-centered medical home is a portal to get you into the system to make sure every patient gets the right care from the right physician at the right place for the right reasons," said King.

Robert Wergin, M.D., of Milford, Neb., said he recently attended a town hall health care meeting with a Republican congressional representative who said the number of uninsured in this country is much lower than the oft-cited 47 million.

Epperly said the U.S. Census Bureau puts the number of uninsured at 47 million, which is the number used by the Academy. He acknowledged, however, that based on U.S. Census Bureau data, 10 million of those 47 million are illegal immigrants; another 10 million are people who have chosen not to carry insurance.

Is the AAFP too close to Democrats during this health care reform process? asked another member.

"Four years ago, we were told we were too close to Republicans because they happened to be the ones in control of Congress and the White House," said King. In actuality, he added, the AAFP is meeting with the lawmakers and staff members who are making decisions and writing the bills. Those include Democrats, Republicans, liberals and conservatives, he noted.

"Now is the time to try and get (health care reform) right," said Epperly, and the AAFP is "going to stay at the table and we are going to advocate and advocate and advocate for our members, our patients and for a better health care system."