2013 Congress of Delegates

AAFP Delegates Wrestle With Needs of Older Physicians, Rural Practices

September 25, 2013 05:30 pm Cindy Borgmeyer San Diego –

Delegates to the 2013 Congress of Delegates here voted Sept. 24 to safeguard access to quality health care for all by investigating how best to serve the interests of the nation's older family physicians, as well as those in solo or small practices, especially in rural areas.

Maryland delegate Adebowale Prest, M.D., of Hebron, expresses concern about the potential cost of a resolution asking the AAFP to study electronic health record implementation and patient-centered medical home transformation to determine how to help struggling physicians overcome these challenges.

A resolution jointly submitted by seven AAFP chapters -- many of which encompass significant populations of medically underserved patients -- asked the Academy to encourage CMS to "institute a waiver of penalties to all one- or two-physician private practices whose principals are aged 60 or older."

In testimony before the Reference Committee on Advocacy Sept. 23, AAFP members came down on both sides of the issue. Those who supported the measure pointed to the fact that older family physicians -- many of whom are the only health care professionals practicing in rural locations -- face added challenges in implementing electronic health record (EHR) systems.

"I worry a lot about older physicians going through this transition," said Alaska delegate John Cullen, M.D., of Valdez, noting that communities in remote areas of his state can ill afford to lose physicians for any reason.

In his testimony, Nebraska delegate David Hoelting, M.D., of Pender, contended that incentives offered by CMS for physicians who achieve meaningful use of their EHRs -- a key part of the patient-centered medical home (PCMH) transformation process -- don't necessarily cover the costs associated with implementing such systems.

Story Highlights
  • AAFP members at this year's Congress of Delegates passionately debated some potentially controversial issues.
  • A call for penalty waivers for older physicians struggling with health information technology adoption drew spirited debate, as did a resolution on a possible "score card" showing legislators' voting records.
  • The Board of Directors was asked to take a closer look at three resolutions on OTC status for oral contraceptives.

Hoelting cited a May 27 American Medical News article(www.amednews.com) that put the average cost per physician to adopt, implement and upgrade a certified EHR at $54,000 -- plus $10,000 in annual maintenance costs -- based on CMS data. Additional investments needed to facilitate certain functionalities required by CMS, such as purchasing lab interfaces that allow test results to be reviewed electronically, can cost physicians thousands of dollars more.

Many older physicians simply won't remain in practice long enough to recoup these costs through CMS' EHR meaningful use incentive programs, which offer a maximum of $44,000 over five years for physicians who attest to meaningful use as part of the Medicare incentive program and $63,750 over six years for those who attest under Medicaid, said Hoelting.

Others, however, objected to what they said amounted to older physicians getting a "pass" on implementing EHRs in their practices. Physicians who are 60 or older shouldn't be held to a lower standard of care, one speaker observed. Other physicians also face challenges in adopting this technology, and a move to exempt only certain physicians from penalties levied on those who don't implement EHRs could create a "slippery slope" that might sidetrack the progress already made.

"The Academy has been pushing for EHRs for 15 years," said Florida delegate Dennis Saver, M.D., of Vero Beach. "We should not go back. However, as an Academy, we should help individual physicians get over the (EHR) hump."

In its report, the reference committee focused on concerns that granting waivers to one group of physicians would, indeed, create a slippery slope. The report also pointed to the fact that "the transformation mandate was given 10 years ago and that practices have known about it for some time." Finally, reference committee members noted that the AAFP has and continues to advocate on behalf of physicians making such practice transformations and recommended that delegates not adopt the resolution.

Acknowledging the obstacles to creating an AAFP "health policy report card" that would detail legislators' voting records, Maryland delegate Howard Wilson, M.D., of Bowie, tells his colleagues, "I believe the task is difficult, but it's doable."

During the Sept. 24 business session, Alaska delegate Marin Granholm, M.D., of Anchorage, offered an amendment in the form of a substitute resolution that sought to take into account much of the previous day's testimony. That measure called for the AAFP to "study EMR (electronic medical record) adoption and PCMH transformation by family physicians who may face additional barriers to change, including, but not limited to, age, practice size and rural location, and determine the best ways to assist them in staying in practice."

"I think we want to make sure that the key idea here that goes forward is our concern that older members of our Academy may be struggling in making some of these transitions, and we have real fear of losing people who may be the sole providers for their communities," Granholm said of the amended measure. "I want to see that we pay attention to this and do all we can to keep them in practice."

Pointing to the complexities of the issue, however, some delegates pressed for referral to the Board of Directors. Maryland delegate Adebowale Prest, M.D., of Hebron, was among those who took this stance, voicing concerns about the uncertain fiscal note attached to conducting the research called for in the amended resolution.

Resident delegate Andrew Lutzkanin, M.D., of Ephrata, Pa., however, pointed out that referral would do nothing but send the measure along the same path of information-gathering, deliberation and decision-making that adoption would.

Connecticut delegate Drew Edwards, M.D., of Prospect, voices his trepidation about some women being able to afford higher costs for oral contraceptive pills should they become available OTC.

In the end, delegates voted to both accept the amended language and adopt the amended resolution.

Among other items considered during the advocacy reference committee hearing was a resolution asking the AAFP to establish a "health policy report card" that smaller chapters, especially, could use to gauge federal legislators' voting records on issues of interest to family physicians. Testimony focused largely on the expense that such an endeavor would incur, as well as on the difficulty understanding all the nuances involved in lawmakers' voting decisions.

After all, observed North Carolina delegate Mott Blair IV, M.D., of Wallace, "As you all know, in politics, today's enemy may be your friend tomorrow."

Drawing from her personal experience, Oregon state Sen. Elizabeth Steiner, M.D., of Portland, seconded that sentiment in the following day's business session, assuring her fellow family physicians that "Score cards don't help" when it comes to interacting with lawmakers. "Personal relationships are what matter," she said.

Moreover, added some opponents, chapters always have the option of contacting staff within the AAFP's Government Relations Division or FamMedPAC for this type of information. But that's not always practical for smaller chapters, which may have few -- sometimes not even one -- full-time staff members to tackle such tasks, said Delaware delegate James Gill, M.D., M.P.H., of Newark. "I think the reference committee recognized that the information could be useful, and they said that in their report," he said. The question is, "How do we put this together in a way that's informative but not divisive?"

Delegates eventually accepted the reference committee's recommendation to not adopt the resolution.

Other measures considered included three resolutions calling for OTC access to oral contraceptives, including one asking the AAFP to press for coverage of these medications by both public and private insurers. After wide-ranging debate, delegates voted to refer all three resolutions to the Board.

Two resolutions involving the civil marriage stance the Academy adopted last year -- one calling for a "neutral position" on the issue and the other seeking to expand the AAFP's official nondiscrimination policy to include "marital preference" rather than to "target support to any specific institution" -- were not adopted by the delegates.