AAFP Sustains Fight to Reduce Administrative Complexity for Family Medicine
The AAFP continues efforts calling for an immediate reduction in the regulatory and administrative requirements family physicians and practices must comply with on a daily basis. These complexities range from onerous documentation guidelines to cumbersome prior authorization criteria and the unrelenting frustrations associated with electronic health records.
A 2016 study published in the Annals of Internal Medicine found that during a typical day, primary care physicians would spend 27 percent of their time on clinical activities and 49 percent on administrative activities. The authors of the study, “Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties(annals.org),” concluded that for every hour primary care physicians spends in direct patient care, they spend two hours engaged in administrative functions.
In January 2017, the AAFP published its Agenda for Regulatory and Administrative Reforms. Family physicians are concerned with the ever increasing number of administrative requirements that detract from time that would be better spent on patient care. Studies have estimated that primary care physicians spend nearly 50 percent of their time on overly cumbersome administrative tasks, such as:
- Prior Authorizations
- Performance Measures and Reporting
- Electronic Health Record Documentation
- Care Management Documentation
Prior authorizations top the list of physician complaints about administrative complexity. On January 25, 2017, the AAFP and a coalition of 16 other medical organizations called for the reform of prior authorization and utilization management requirements that bog down physicians and impede patient care. Through its "Prior Authorization and Utilization Management Reform Principles(www.ama-assn.org)," the coalition is "urging health insurers and others to apply the reform principles and streamline requirements, lengthy assessments and inconsistent rules in current prior authorization programs." The 19 principles address prior authorizations as they apply to the following areas:
- Clinical validity
- Continuity of care
- Transparency and fairness
- Timely access and administrative efficiency
- Alternatives and exemptions
In April 2017, the AAFP published a new policy on prior authorizations to support its advocacy initiatives with facts. The policy explains how prior authorizations threaten patient care by delaying or halting the continuation of timely, evidence-based care.
The AAFP continues to advocate that all payers use the primary care core measure set developed by the Core Quality Measure Collaborative. Recently, the CQMC reinitiated work to update the core set and to ensure payers are adopting it.
CMS has expressed its intent to update the documentation guidelines for evaluation and management services to better align E/M coding and documentation with the current practice of medicine and thereby reduce the associated burden. AAFP staff and representatives continue to interact with CMS and other entities to determine direction and potential solutions.
On October 26, 2017, AAFP President Michael Munger, MD, traveled to Washington, D.C., to present the AAFP’s views to a roundtable discussion hosted by Seema Verma, the administrator for the Centers for Medicare and Medicaid Services. As one of only three panelists, Dr. Munger delivered three administrative reform recommendations for consideration to CMS:
- Elimination/reduction of prior authorizations for certain drugs and supplies for established patients
- Elimination of documentation guidelines for evaluation and management codes for primary care physicians
- Repeal of the regulatory framework of the promoting interoperability (previously called Advancing Care Information) requirements under the Medicare Access and CHIP Reauthorization Act
In December 2017, the AAFP Board of Directors adopted the AAFP’s own host of principles aimed at reducing the administrative complexities weighing down doctors. The four-part "Principles for Administrative Simplification" covers prior authorization, quality measure harmonization, certification and documentation of medical services and supplies, and medical record documentation.
The AAFP’s advocacy efforts to alleviate family physicians from undue administrative complexity are ongoing, as demonstrated by recent letters to the Trump administration and CMS.
In an August 7, 2019 letter to CMS Administrator Seema Verma(6 page PDF), the AAFP offered feedback on the agency’s Patients Over Paperwork initiative. The feedback focused on several categories identified by CMS in the RFI including: reporting and documentation requirements; prior authorization procedures; policies and requirements for rural providers, clinicians and beneficiaries; beneficiary enrollment and eligibility determination; building a foundation for significant burden reduction through technology; and CMS processes for issuing regulations and policies.
In a Jan. 28, 2019 letter to Donald Rucker, MD, National Coordinator for Health IT at the Department of Health and Human Services, the AAFP writes of concerns about fundamental issues not iaddressed in the ONC’s draft report “Strategy on Reducing Regulatory and Administrative Burden Relating the the Use of Health IT and EHRs.” The AAFP is concerned that gaps in functionality to support primary care practices are widening with the additional requirements of value-based payment models. The letter urged the ONC to focus on EHR system designs centered on small tasks. The AAFP also strongly advocated the elimination of health IT utilization measures as part of the Quality Payment Program.
In a Jan. 18, 2019 letter to CMS Administrator Seema Verma, the AAFP and 10 other medical organizations wrote to express concern with the application deadline of February 19, 2019, for Accountable Care Organizations applying to participate in the Medicare Shared Savings Program beginning July 1, 2019. Due to the complexity of CMS’s new final rule for the program, many existing ACOs and those in the process of formation are still actively working to understand how they may successfully participate in the program. Additional time is needed to ensure ACOs may evaluate their options and complete the administrative and legal requirements of the application. They warned, without additional time to apply, participation in this voluntary program will suffer. The organizations urged a March 29, 2019 deadline instead.
In a Dec. 28, 2018 letter to CMS Administrator Seema Verma, the AAFP opened by expressing appreciation for CMS' support for primary care in recent years and outlined avenues for the agency to explore fair payment to primary care physicians who provide health care services to Medicare patients. The letter also focused on changes to documentation and payment related to evaluation and management services, noting the opportunity for physicians to rely on relevant information already in the medical record for established patients -- a decision that will allow family physicians to focus their documentation on what has changed since the last visit … and avoid re-recording certain elements just for the sake of meeting outdated documentation guidelines.
In an Oct. 25, 2018 letter to Daniel Levinson, Inspector General for the Department of Health and Human Services, the AAFP once again urges OIG and CMS to ensure policies do not hinder family physicians’ ability to transform their practices and ensure the flexibility to collaborate with other physicians and health care professionals to provide team-based, patient-centered care that incorporates new technologies and focuses on reducing the total cost of care. The AAFP advocates for the creation of a simple decision tree with clear safe harbors for medical practices to help determine if collaboration will trigger OIG or other scrutiny and if further costly compliance analyses may be needed.
In an Oct. 17, 2018 letter to Donald Rucker, MD, National Coordinator for Health IT at the Department of Health and Human Services, the AAFP addresses ongoing concerns regarding interoperability, usability and certification testing of certified electronic health record technology (CEHRT) products. The AAFP points out that interoperability tasks work "only with customization and substantial effort during implementation and use -- which can contribute to physician/provider dissatisfaction and burnout, especially if it involves a task related to either the critical window of the physician-patient interaction at point of care, or a high-frequency task." The AAFP warned ONC against overtaxing physicians with requests for feedback about recordkeeping systems, as they are already heavily burdened while using the EHR and that burden needs to be decreased, not amplified.
In an October 15, 2018 letter to CMS Administrator Seema Verma, the AAFP detailed what it likes and what it would like changed in CMS' proposed rule titled "Medicare Program; Medicare Shared Savings Program; Accountable Care Organizations -- Pathways to Success" that was published in the Aug. 17 Federal Register. The AAFP responded with suggestions on how to improve its proposed rule on ACOs through reporting harmonization and administrative simplification. The AAFP also urged CMS to delay implementation of all proposed policies until Jan. 1, 2020, and pushed CMS to create additional pathways for participation by small and rural practices.
In a Sept. 15, 2018 letter to CMS Administrator Seema Verma, the AAFP highlighted four high-level items for the agency’s consideration in the 2019 proposed Medicare Physician Fee Schedule. They are: 1. Alternative payment models for primary care; 2. Priority proposals in the 2019 fee schedule; 3. Impact on Medicare beneficiaries; and 4. Impact on small and solo physician practices. The AAFP also urged CMS to work with Congress to eliminate deductible and co-insurance requirements for chronic care management codes to foster greater utilization of the codes and improve care coordination for high-need patients. The AAFP also urged a reduction in documentation requirements for these codes.
In an August 22, 2018 letter to CMS Administrator Seema Verma, the AAFP urges CMS to ensure that Stark Law provisions do not hinder family physicians’ ability to transform their practices and collaborate with other physicians and health care professionals to provide team-based, patient-centered care that incorporates new technologies and focuses on reducing the total cost of care. Overall, CMS must make available clear safe harbors for advanced primary-care models, covering operational and financial arrangements as well as physician practice and flexibility.
In an August 6, 2018 sign-on letter to Donald Rucker, MD, at the Office of the National Coordination for Health Information Technology, and Daniel Levinson, at the Department of Health and Human Services, the AAFP and 13 other medical groups urge the administration to step up efforts to implement critical provisions of the 20th Century Cures Act that prevent information blocking caused by health IT products and the developers of the products. Information blocking is a risk to patient safety and a significant contributor to the high costs and waste that currently plague the U.S. health care system.
In an April 23, 2018 letter to CMS Administrator, Seema Verma, the AAFP offered further input on questions asked by CMS during the “Documentation Guidelines and Burden Reduction” listening session held on March 21, 2018. The AAFP calls for the documentation guidelines to be eliminated for codes 99211-99215 and 99201-99205 for primary care physicians for all three domains: history, physical exam, and medical decision making.
In an April 16, 2018 sign-on letter to CMS Administrator Seema Verma, more than 40 medical organizations urged CMS to reduce the MIPS quality measure reporting period to a minimum of 90 consecutive days rather than a full calendar year. Implementation of a 90-day minimum reporting period would give physicians and group practices greater flexibility to incorporate the first-year MIPS feedback into their 2018 performance and be consistent with CMS' efforts to reduce the burden on physicians and truly put patients over paperwork.
In a March 14, 2018, letter to CMS Administrator, Seema Verma, the AAFP praises the agency for its recently announced MyHealthEData initiative, which is designed to empower patients through greater control and portability of their health care data. However, the AAFP objects to placing responsibility for the adoption of interoperable systems on physician practices, insisting the creation of standardized interoperable systems should instead be the responsibility of vendors.
In a March 7, 2018 letter to David Shulkin, MD, Secretary of the Department of Veterans Affairs, the AAFP advocates that payment to participating physicians in the Civilian Health and Medical Program of the VA must be at or above Medicare levels to be effective in promoting access to primary care services for veterans, spouses, children, survivors and certain eligible caregivers. The AAFP also strongly encouraged a proposed plan requiring that prior authorizations be justified in terms of factors such as administrative cost and workflow complexity, eliminating prior authorizations in some cases, and adopting a standardized prior authorization form.
In a February 27, 2018 letter to Demetrios Kouzoukas, Principal Deputy Administrator and Director, Center for Medicare, Centers for Medicare & Medicaid Services, the AAFP calls for CMS to go beyond “merely reminding and encouraging” Medicare Advantage insurers about the multiple, inconsistent and time-consuming preauthorization requirements imposed by MA plans, prescription drug plans and durable medical equipment suppliers. Instead, the AAFP says CMS should require and enforce preauthorization principles that are transparent and consistent across all plans.
In a February 7, 2018 letter to CMS Administrator, Seema Verma, and Don Rucker, MD, Office of the National Coordinator for Health Information Technology, the AAFP urges CMS and ONC to alleviate unneeded regulatory complexities related to health information technology. Doing so would guide physicians closer to achieving the Quadruple Aim of enhancing patient experience, improving population health, reducing costs, and improving the work life of clinicians and staff.
In an October 19, 2017 letter from the AAFP to John R. Graham, Acting Assistant Secretary of the U.S. Department of Health and Human Services, the AAFP provided guidance for the agency’s draft strategic plan for 2018-2022. The AAFP used the bulk of its seven-page letter to respond to an objective for the first goal that touches on the need to reduce administrative regulatory and operations burdens. The AAFP argued that the final strategic plan "must specifically address" the need to reduce those complexities for practicing physicians.
In a June 8, 2017 letter from the AAFP to CMS Administrator, Seema Verma, the AAFP weighed in on the 2018 Hospital Inpatient Prospective Payment proposed rule as published in the April 28 Federal Register. The AAFP expressed a mixture of praise and concern regarding the alignment and simplification of various reporting requirements, as well as ongoing concerns about the readiness of 2015 edition certified EHR technology for 2018 reporting. In addition, the AAFP reminded CMS that the Medicare Access and CHIP Reauthorization Act was intended to simplify Medicare payment, quality improvement and performance measurement programs, rather than introduce new and cumbersome administrative requirements for physicians that do not improve patient care.
In a May 11, 2017 joint letter to CMS Administrator, Seema Verma, the AAFP and a long list of other medical specialty organizations expressed concerns over the agency’s planned enactment of the Social Security Number Removal Initiative. While supportive of the need to protect seniors from identity theft, the signatories called for the change to be made through the traditional notice and comment rulemaking process so that valuable industry feedback may be considered. In addition, the signatories asked that CMS develop a mechanism for providers to quickly and securely access Medicare beneficiary identification numbers to avoid back-office billing headaches and disruptions in access to care for patients.
In an April 26, 2017 letter from the AAFP to CMS Administrator, Seema Verma, the AAFP notes its support of President Trump’s executive order, Reducing Regulation and Controlling Regulatory Costs, but calls for CMS to step back and reconsider the current approaches to the Medicare Access and CHIP reauthorization Act of 2015 (MACRA), which we view as overly complex and burdensome to physicians.
On March 21, 2017, the AAFP and nearly 90 other medical organizations sent a letter to CMS Administrator, Seema Verma, calling for the agency to establish a strategy to relieve the electronic health record documentation burden. The letter also called on CMS to create a hardship exemption for physicians who attempted to report PQRS in 2016 but were unsuccessful due to the complexity of the reporting requirements and the significant number of measures that were required.
A January 31, 2017, letter from the AAFP to President Trump cites research demonstrating how family physicians face a regulatory burden that is unmatched among the various medical disciplines.
A December 16, 2016, letter from the AAFP to acting CMS Administrator, Andy Slavitt, expresses concern about patient relationship categories and related coding documentation required under the Medicare Access and CHIP Reauthorization Act. The requirement will significantly increase the administrative complexity that Medicare participating physicians already experience.