AAFP Works to Resolve Members' Practice Management Issues in 2010

In 2009, family physicians learned that the American Recovery and Reinvestment Act would provide bonuses for physician practices that incorporated the "meaningful use" of electronic health records, or EHRs. However, physicians and the AAFP were left scratching their heads about just what was meant by meaningful use. In 2010, the federal government set about defining the term.

CMS began by issuing a proposed rule that outlined provisions governing EHR incentive programs, including the definition of meaningful use of health information technology, or health IT. The AAFP immediately started examining the proposed rule to evaluate its effect on family physicians.

At the same time CMS issued its proposed rule on the EHR incentive programs, the Office of the National Coordinator for Health Information Technology, or ONC, issued its own interim final regulations that set initial standards, implementation specifications and certification criteria for EHR technology.

The ONC emphasized the importance the government places on the use of health IT when it announced plans to establish a nationwide network of regional extension centers to help health care providers adopt health IT systems. According to Joshua Seidman, Ph.D., acting director of the Meaningful Use Division, Office of the Provider Adoption Support at the ONC, the regional extension centers are designed to help about 1,000-2,000 physicians and initially will focus on primary care practices.

Shortly after, HHS announced a proposed rule to establish certification programs to test EHR systems. Specifically, the proposal called for establishment of a temporary certification program that eventually would be replaced by a permanent program.

In the meantime, the AAFP weighed in on CMS' proposed rule that defined meaningful use. In a letter to CMS Acting Administrator Charlene Frizzera, the Academy called for significant modifications to the rule. "We believe that certain aspects in the details of these regulations are unworkable, excessive or redundant and will actually impede the very goals of the legislation," said (then) AAFP Board Chair Ted Epperly, M.D., of Boise, Idaho.

Specifically, the AAFP asked for modifications in the incentive program to allow partial incentives, parity between Medicare and Medicaid programs, modifications in calculations of meaningful use measures, and incentives for team-based care.

Epperly noted that he was "greatly concerned about the capacity for many eligible providers, especially those in small and medium practices, to achieve all of the required criteria by 2011 and 2012."

But when the final rules on meaningful use and certification criteria for EHRs were released in July, the AAFP was pleased to find that some of its concerns had been addressed. For example, CMS modified the rule to increase physician participation by offering partial incentives. "CMS has addressed the Academy's biggest concerns, and many of the changes they have made will benefit family physicians," said Steven Waldren, M.D., director of the AAFP's Center for Health IT.

However, he noted that the meaningful use rule still will require significant effort to implement. CMS' aggressive timeline for the implementation of meaningful use could be a challenge for family physicians, he said.

FPs also learned that although some provisions of the Patient Protection and Affordable Care Act -- which became law in March -- provide practice management opportunities, the law also creates opportunities for other health care providers to try to increase their respective scopes of practice. The Academy maintains that this type of "mission creep" is not in the best interests of patients.

In February, the AAFP Board of Directors revised the Academy's retail health clinic policy in response to ongoing expansions in scope of services offered by these clinics. "The AAFP revised its policy because some clinics are expanding their scope of service beyond what the Academy thinks is appropriate," said (then) AAFP President Lori Heim, M.D., of Vass, N.C.

The Academy noted in its revised policy that it does not endorse retail health clinics and believes they could interfere with the medical home model of care. However, the AAFP acknowledged that some members have established successful working relationships with these clinics. "When our members decide to work with retail health clinics, the AAFP strongly recommends that they do so in a manner consistent with the attributes listed in our policy because ensuring the patient's best interest and good health is the ultimate goal," said Heim.

Attempts by advanced practice nurses to expand their scope of practice also led to Academy protests in 2010. In August, the Academy was forced to demand that the National Board of Medical Examiners cease equating physicians with graduates of programs in clinical advanced-practice nursing and graduates of physician assistant master's programs based on their scopes and depths of practice.

The AAFP Congress of Delegates was concerned enough about the issue to call for a study comparing the practices of primary care physicians and nurse practitioners. Specifically, delegates adopted a resolution calling on the Academy to fund a Robert Graham Center study to evaluate the quality of existing studies that compare the two groups of health care providers, including in terms of health care outcomes and cost-effectiveness of care provided.

"We're in competition nose-to-nose with independent nurse practitioners," said delegate John Cullen, M.D., of Valdez, Alaska. "In states like mine, nurse practitioners can hang their own shingles with very little clinical experience, and the public doesn't understand that."

Those fears proved to be well-founded when the Institute of Medicine, or IOM, released an October report that calls for a greater nursing role in the health care system. The report, The Future of Nursing: Leading Change, Advancing Health, calls for eliminating scope-of-practice barriers and allowing advanced practice nurses to practice to the full extent of their education and training.

Although the Academy agrees that nurses should practice to the fullest extent of their nursing training, said AAFP President Roland Goertz, M.D., M.B.A., of Waco, Texas, the basic educational preparation for the largest proportion of registered nurses in the United States is an associate's degree. The IOM report calls for increased training for nurses, but it lacks recommendations about standard training or standard certification of competencies, said Goertz. In addition, he noted, the report is woefully inadequate in the area of patient safety.

The other challenge for family physicians that emerged from the health care reform legislation was the promulgation of accountable care organizations, or ACOs.

Knowing that this model of care was being looked at in a number of the health care reform proposals on Capitol Hill at the time, the AAFP proactively adopted Accountable Care Organization Principles late in 2009.

"The foundation of an ACO is primary care and the patient-centered medical home," said (then) AAFP Director Kenneth Bertka, M.D., of Holland, Ohio, chair of the AAFP's ACO Task Force. He noted that the concept could be loosely defined as a primary care-based collaboration of health care professionals and health care facilities that accept joint responsibility and accountability for the quality and cost of care provided to a defined patient population.

Confusion about the definition of an ACO continued to reign in the medical establishment, however. In September, AAFP delegates asked the Academy to further clarify and expand on physicians' role in ACOs by adopting a substitute resolution that asks the AAFP to "take a leadership position in educating members in various practice settings about the formation of ACOs" and "encourage and facilitate strong family physician leadership in ACO development and governance."

In November, the AMA House of Delegates also adopted principles regarding the establishment and operation of ACOs at its interim meeting. The AMA's ACO principles set forth guidance on what constitutes an ACO and list various features that should be incorporated into such agreements, noting, in particular, that they must be physician-led, allow flexibility in payment mechanisms and be completely voluntary. The principles also note that interoperable health information technology and electronic health record systems are key to the success of ACOs.

Then in November, the AAFP joined with the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association to release the Joint Principles for Accountable Care Organizations (3-page PDF; About PDFs). According to Heim, it was important that the four primary care organizations articulate a shared vision of ACOs. "You have all four organizations coming together to develop policy, and that sends a very strong message to the government and to other payers about what they need to be aware of as they roll out these accountable care organizations," said Heim.