AAFP Leaders Answer Member Questions on the AAFP and Health Care Reform Legislation

The recently passed federal health care reform legislation was the topic of the day at a town hall meeting and a question-and-answer session with the AAFP's elected leaders during the Annual Leadership Forum/National Conference of Special Constituencies, here on April 30. AAFP members, seeking answers about what health care reform means for their patients and their practice, engaged Academy leaders with a series of questions on how the bill will affect them.

AAFP President Lori Heim, M.D., of Vass, N.C., started off the town hall meeting by telling attendees that the AAFP Board of Directors evaluated the health care reform legislation in light of the principles and policies set out by the AAFP Congress of Delegates. Although the Academy supported the final health care reform legislation, said Heim, it didn't necessarily meet all of the Academy's needs. But "we got what we were most vested in," she said. The bill will increase the number of patients who are covered by insurance by 32 million.

"Some aspects (of the bill) will continue to need attention from the Academy," she added. And as the bill is interpreted through various state and federal agencies, the AAFP will be working with those agencies to craft the regulations. "The devil is in the details," said Heim, adding the health care reform bill provides a platform to build upon.

Audience members, however, expressed concern about the threshold set out in the bill that limits bonus payments for primary care services to practices that are providing certain primary care codes for 60 percent or more of their Medicare billings.

"That is one of the most frustrating parts of the bill," said Heim. The AAFP actively lobbied against the thresholds because "many physicians -- particularly rural, full-scope physicians -- will not meet the criteria."

AAFP Board Chair Ted Epperly, M.D., of Boise, Idaho, chimed in that the Academy will be actively working to expand the primary care payment codes that will be included in the 60 percent criteria.

In response to a question regarding how soon FPs on the front lines will see changes and benefits from the health care reform bill, particularly in terms of administrative simplification, Heim noted that the main impact of the bill comes in 2014. But work will be getting underway on some aspects of the bill beginning this year.

For example, the AAFP wants to ensure that an FP is included as a member of the workforce commission called for in the bill. In addition, "we are working to include the AAFP's principles for the patient-centered medical home (PCMH) in the demonstration projects promulgated in the bill," said Heim. "You probably won’t see the results in your office for awhile, but we’re beginning to build toward the workforce that is needed" for health care reform to succeed.

Another audience member pointed out that many AAFP members are irritated by the Academy's support of the health care reform bill. He asked what the Academy plans to do going forward to deal with members who are unhappy with the organization's stance on the legislation.

According to Heim, only a few members have cancelled their membership citing the Academy's stance on the reform bill. She acknowledged, however, that the issue became very divisive for the AAFP, as well as for the rest of the country. But, said Heim, "the Academy was nonpartisan on (the reform bill)." Board members evaluated the legislation based on the policies and principles set out by the Congress of Delegates.

She added that the Academy will continue to work on Medicare payment rates and tort reform, two areas that were not addressed in the final bill.

"It's a very polarizing issue," said Epperly, particularly because there has been no substantial reform of the health care system in the United States since 1965. But, he pointed out, the AAFP represents more than its stance on health care reform. The AAFP also does a lot with practice enhancement, education and health of the public, said Epperly.

Terence Cahill, M.D., of Blue Earth, Minn., noted that with the increasing acceptance of the patient-centered medical home as a model of care, many providers are insisting that they can provide a medical home. "When are we going to acknowledge the medical home can only be provided in primary care?" asked Cahill.

It's not so much about saying who can and cannot provide a medical home, said Heim. The key is to insist that everyone has to meet the same criteria. The AAFP's Joint Principles of the Patient-Centered Medical Home (3-page PDF; About PDFs) say that anyone can be a PCMH, as long as they are providing the same level of services. If you can provide that same level, said Heim, then you should get the recognition as a PCMH.

And that's the stumbling block for many other entities wanting to be a PCMH, said AAFP President-elect Roland Goertz, M.D., of Waco, Texas. "It is absolutely a primary-care centered model," he said. In addition, it's not about the individual health care provider; it is about a practice and the team providing care. When you apply the criteria equally across the board, "I doubt that many (sub)specialists would qualify to be a PCMH," said Goertz. They need to prove that they can provide increased and improved care at a better cost, and many of subspecialists will not be able to show those results, he added.

The issue came up again during the question-and-answer session with the Board members, when an audience member specifically asked about the growing influence of physician extenders, such as nurse practitioners and physician assistants. What is the future of these professions and how should we interact with them as their influence grows, she asked.

Epperly said that the Academy and members have to be proactive in this situation. "Educationally, there is no equivalent between family physicians and extenders," he said. But we still need to be collaborative with these professions so they can help provide a PCMH. However, "The Academy has been clear that the criteria of the PCMH must be met," regardless of who is providing the medical home.

Goertz added that there seems to be a public perception that some care is better than no care, and extenders have been very shrewd about how they have leveraged this perception. However, he noted, if the government wants to maintain quality health care, extenders cannot just seek to expand their scope politically, they have to do it educationally.

And that's an example of why the Academy has to engage with extender organizations and stay at the table. We cannot just walk away, or our viewpoint will not be represented, said Goertz.

The upshot, said AAFP EVP Douglas Henley, M.D., -- as was stated in the Future of Family Medicine report -- is that unless the system changes and unless the specialty changes, the future of family medicine will be untenable. "The system is now changing so that it values the importance of primary care," he said. "But are (family physicians) changing? Are we redesigning practices to be PCMHs. That is the challenge to the profession."