Primary care physicians and patients must function in a health care environment influenced by a complex web of legislation, regulation, and independent decisions of public and private payers. Navigating this complex system of public regulations and private business decisions places primary care physicians in a situation that is increasingly burdensome, overwhelming, and a significant source of physician burnout. As a result of this system, practices experience increasing operating costs, and physicians have less time for meaningful patient interactions.
The lack of standardization and/or cooperation among public and private payers is daunting, as a single family physicians frequently interacts with 10 or more payers. as the patients of family physicians are frequently represented by 10 or more payers.1 Physicians are forced to learn and navigate the rules for each payer. As a result, they spend countless hours reviewing documents, checking boxes to meet requirements for each health insurance plan, and complying with federal, state, and local regulations. These burdens are one of the main reasons independent practices close their businesses and are a leading cause of physician burnout. This all creates significant barriers to achieving the Quadruple Aim of health care—enhancing the patient experience, improving population health, reducing costs, and improving the work life of health care providers.2
The American Academy of Family Physicians (AAFP) has developed four principles of administrative simplification that represent the greatest burdens to our members. Administrative burdens, which contribute to a shortage of primary care physicians, can significantly be reduced, and patients can be ensured timely access to treatment by adhering to the following four principles:
- Prior Authorization and Step Therapy
- Quality and Performance Measurement
- Medical Supply Coverage Requirements
- Medical Record Documentation
1. Prior Authorization and Step Therapy
All physicians strive to deliver high-quality medical care efficiently. However, impeding this goal are the frequent phone calls, faxes, payer portals, and disparate processes across multiple payers that physicians and their teams must manage to follow step therapy protocols and obtain prior authorizations (PAs) from health insurers, prescription drug plans, durable medical equipment (DME) suppliers, and others. The PA and step therapy principles reflect guidance for key stakeholders based on the AAFP’s policies addressing PA and step therapy.
- PA for physicians using appropriate clinical knowledge, training, and experience should not be required.
- All public and private payers should adopt standardized digital PA processes using evidence-based criteria to promote conformity, improve timeliness, and reduce administrative burdens for physicians and patients.
- Services requiring PA must lack other more efficient and feasible methods of utilization control.
- Rules and criteria for PA determination must be evidence-based, transparent, and available to patients and the treating physician at the point of care.
- If a service or medication is denied, the reviewing entity should provide the physician with the criteria for denial. For medications, it should provide choices and notification of denial to expedite care for the patient when an approved alternative medicine is covered.
- Family physicians contracting with health plans to participate in a financial risk-sharing agreement or those with historically high approval rates should be exempt from PAs.
- Payers and pharmacy benefit managers (PBMs) should pay physicians for their time, as decided by the 2008 Merck-Medco v. Gibson court case.
- Payers should eliminate PA and step therapy protocols for effective medication management for patients with chronic disease and eliminate PA for standard and inexpensive drugs, including generic medications.
- Step therapy should not be required for patients already on a course of treatment or required to repeat step therapy protocols conducted under other benefit plans.
- PA and step therapy decisions, requests, and appeals must be processed in a timely manner, and all denials should include the clinical rationale for the adverse determination and allow physicians to provide supporting documentation when needed.
2. Quality and Performance Measurement
Quality and performance measurement has proliferated in the past 25 years, leading to significant burdens on physicians. This is especially true for primary care physicians, who are disproportionately accountable for a growing number of disease-specific process measures that fail to capture the true nature and value of comprehensive, patient-centered primary care.
The AAFP’s Vision and Principles of a Quality Measurement Strategy for Primary Care distinguish between quality and performance measurement based on how those measures are applied. Quality measurement is used by physicians, care teams, and organizations to accelerate internal clinical improvements. Performance measurement is more externally oriented and primarily used for comparative purposes, including for value-based payment programs.
- Performance measurement should focus on improving outcomes that matter most to patients and have the greatest impact on improving the health of the population, creating a better experience of care, and lowering the per capita cost of care, while also returning joy to the practice of caregiving for physicians and other clinicians.
- Performance measurement should meet the highest standards of validity and reliability, be evidence-based, and reflect variations in care consistent with appropriate professional judgment.
- Performance measurement should be practical, given the various systems and resources available across practice settings.
- Performance measurement should not evaluate the cost of care separately from quality and appropriateness.
- Performance measurement should only be relied upon when data is complete and readily available. For example, data should be derived from multiple data sources to achieve completeness, as needed, using the most efficient technologies available in a standardized manner.
- When selecting performance measures, payers should consider the burden of data collection, particularly in the aggregation of multiple measures requiring multiple data sources.
- Payers should make every effort to minimize the burden of performance measurement on primary care physicians by using standardized technologies and centralized measurement by neutral third parties.
- Methodologies used to rate or rank physicians should be transparent and readily available to physicians being measured and to patients and others accessing results.
- Payers should prioritize using measures included in the core measure sets developed through a multi-stakeholder consensus process at the federal, state, or local levels (e.g., the Core Quality Measure Collaborative) to ensure parsimony, alignment, harmonization, and the avoidance of competing quality measures.
- Performance measurement feedback to physicians should be simplified, standardized, and delivered in a timely fashion across all payers to allow for course corrections as early as possible.
- Performance measurement should be updated regularly or when new evidence is developed. As new measures are adopted, sponsoring entities should sunset measures that have become outdated or no longer provide the best measurement.
- Physicians should not be accountable for measures they have no control or authority to improve.
3. Medical Supply Coverage Requirements
Physicians should be able to efficiently order the services and supplies that patients need to manage their medical conditions. The current procedures surrounding coverage of medical supplies and services impede this goal and add no discernible value to patient care.
- The physician’s order should be sufficient. They should not have to complete multiple processes from various outside entities for patients to receive needed physical therapy, home health care, hospice care, or DME (including diabetic supplies).
- Physicians should not be required to recertify DME supplies annually for patients with chronic conditions.
- Authorization supply forms should be standardized, so physicians are not required to complete a new process every time a patient switches brands, including but not limited to diabetic supplies. In addition, processes should be standardized to allow automated electronic health record (EHR) extraction of information needed for authorization.
- Physicians should not be required to attest to the patient’s status when the service is provided by another licensed health professional (e.g., diabetic footwear).
4. Medical Record Documentation
Documentation burdens have increased dramatically, despite the adoption of EHRs, with document requirements for public and private payer programs and initiatives having escalated.
- The primary purpose of medical record documentation should be to record essential elements of the patient encounter that track patient progress over time and/or communicate that information to other physicians and clinicians.
- EHR vendors, physicians, and workflow engineers must collaborate to redesign and optimize EHR systems.
- Employers of primary care physicians should provide ample EHR training and work to reduce the documentation burden for their employed physicians.
1. Robertson-Cooper H, Neaderhiser B, Happe LE, Beveridge RA. Family physician readiness for value-based payments: does ownership status matter? Popul Health Manag. 2017;20(5):357-361.
2. Bodenheimer T, Sinsky C. From Triple Aim to Quadruple Aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573-576.
(2017 BOD) (October 2023 COD)