2014 Congress of Delegates

FPs Highlight Practice Concerns That Affect Patient Care, Payment

October 24, 2014 01:49 pm Sheri Porter Washington –

Gretchen Dickson, M.D., tells the reference committee that prior authorizations negatively affect family physicians across the country. "This issue inhibits our ability to take care of our patients," she said.

It's that time of year when the AAFP's Congress of Delegates convenes to debate issues important to family physicians and their patients. The 2014 Congress, in session here from Oct. 20-22, was no different.

The Reference Committee on Practice Enhancement worked at a fast clip to address a plethora of resolutions that ranged from ensuring patients get the drugs they need to seeing that family physicians get paid appropriately for the care they provide.

One resolution that drew impassioned testimony asked the AAFP to work with stakeholders to standardize the prior authorization process for medications.

Resolution author and Virginia alternate delegate E. Mark Watts, M.D., of Vinton, told the reference committee that work related to obtaining prior authorizations costs his practice between $6,000 and $7,000 a year.

Story Highlights
  • During the AAFP's 2014 Congress of Delegates, family physicians engaged in healthy debate about issues that affect patient care and payment.
  • Physicians were particularly vocal about the work associated with securing prior authorizations for patient medications.
  • Issues surrounding the use of electronic health records also touched a nerve with family physicians.

Kansas alternate delegate Gretchen Dickson, M.D., M.B.A., of Wichita, shared Watts' chagrin. "We surveyed our members and asked an opened-ended question about their biggest practice issues and expected a potpourri of answers, but 47 percent said 'Fix prior authorization,'" Dickson told the reference committee.

Ohio alternate delegate Brian Bachelder, M.D., of Akron, said his practice is swamped with prior authorization work. "We have four docs, one nurse practitioner and one full-time staff member who only does prior authorizations. There's plain too much of this going on. If the insurance company can save three cents, they want to change a patient's medication," said Bachelder.

Janet Hurley, M.D., of Whitehouse, Texas, testified that it can take as long as 30 minutes to fill out a single prior authorization form. "Rigorous cost reductions have to occur," she acknowledged, "but we should be able to simplify the process."

As a sitting board member of Blue Cross Blue Shield of Kansas City, Missouri delegate Lawrence Rues, M.D., of Kansas City, offered an interesting perspective.

"If one drug company is offering a rebate, that's often why the insurance company wants to switch a patient to that drug," he testified, adding that insurers are not always sensitive to the extra work created on the physician's end.

Delegates readily adopted the resolution during the Oct. 21 business session.

Another measure asked the AAFP to work with the AMA, CMS and TRICARE to require that all health plans "cover insulin delivery devices at the same tier as vial and syringe insulin injections."

Mississippi delegate Timothy Alford, M.D., of Kosciusko, pointed out the irony of the situation by saying, "You are denied the medication because of the device that delivers it."

Andrew Carroll, M.D., turns to his colleagues in the reference committee to drive home his point that hospital care is part of the comprehensive care family physicians are trained to provide to their patients.

The system needs to "stop 'siloing' drug costs and treat the bucket of money as a whole," said Texas delegate Erica Swegler, M.D., of Austin, in her testimony. "Allow us to treat our patients," she added.

The reference committee recommended that the issue be referred to the Board, but during the business session, Alford urged quicker action. "There is nothing less useful than insulin on the shelf," he said.

After replacing the term "delivery devices" with "pens," delegates adopted the amended measure.

The committee also heard vigorous debate on a resolution that asked the AAFP to work with CMS to, among other thing, recognize family physicians in ambulatory practice settings as specialists when it comes to hospital consultations.

Arizona alternate delegate Andrew Carroll, M.D., of Chandler, told the reference committee that most of the hospital care in his community is provided by hospitalists. "We (the Arizona chapter) want more family physicians involved in the care of their patients from the moment they are admitted to the hospital," said Chandler.

It's important for family physicians to be paid for hospital consultations, Massachusetts delegate Dennis Dimitri, M.D., of Worcester, asserted. "Some of us still go to the hospital, see our patients, and have input as to what is going on with them," he said, adding that some FPs do so without compensation "because it is the right thing to do."

In the end, delegates adopted a substitute measure that simply deleted a clause referring to materials not yet produced.

Among resolutions referred to the AAFP Board of Directors was an item regarding the negative impact of health insurers' price transparency policies on small rural hospitals.

"I don't want to tweak the current (health IT) system, I want to blow it up," says Cecil Bennett, M.D., in reference committee testimony. "The current system is harmful to our patients."

Resolution author and Kentucky alternate delegate Richard Miles, M.D., of Russell Springs, testified about instances in which an insurance company sent a patient to a hospital other than the one the patient preferred. "Is this a concerted effort to close small hospitals?" he asked. "We want a level playing field, and we want to know what insurance companies are paying hospitals; you can't have cost transparency if there isn't trust all around."

Bachelder called it "cost-shifting" and said his patients sometimes didn't follow through on medical tests he'd ordered for them because of the distance they were asked to travel to a hospital.

"We are the state that has 40 percent of our population and family physicians living and working in rural environments," said Swegler. "We need to get inside the 'black box' of insurers and hospital costs."

Another resolution referred to the Board involved electronic health records (EHRs), a topic so hot it had members lining up at the microphones during the reference committee.

The resolution asked the AAFP to work with CMS and policymakers to create incentives -- and disincentives -- to compel EHR vendors to work on issues such as universal interoperability

"These systems weren't designed for us (physicians) at all. We're checking boxes instead of developing a relationship with our patients," said Alaska delegate Paul Davis, M.D., of Anchorage.

Vermont delegate Andrea Regan, M.D., of Hinesburg, said health IT vendors should work collaboratively. "Vendors need to focus on a few things they do well rather than a lot of things they do terribly," she said. "It cost my practice $22,000 to $27,000 to change systems; if we blow up the system (as some delegates suggest), we will bear the cost."

A third measure delegates referred explored issues related to high-deductible health plans.

Resolution author and New Jersey alternate delegate Mary Campagnolo, M.D., of Bordentown, said many of her patients with high-deductible plans didn't seem to understand they were responsible for some hefty out-of-pocket costs.

"That leaves us to be a cash-based business, providing care with no compensation," she said, adding that both consumers and lawmakers need to be educated about the pros and cons of such plans.

"There's a lot to learn on the physician and the patient side," said Justin Bartos III, M.D., of North Richland Hills, Texas, and physicians could make informational handouts available in their practices.

Health savings accounts (HSAs) help fill the gap, said Guam delegate William Weare, M.D, of Inarajan. In fact, Weare said he favors patients having both a high-deductible plans and an HSA. "So an individual would have backup in the form of an HSA to cover (high-dollar) expenses," he explained.

But Cecil Bennett, M.D., of Atlanta, didn't let consumers off so easily. "Patients choose the cheapest plan and often know what they're doing. Patients make decisions willingly," he told the committee.

Related AAFP News Coverage
2014 Congress of Delegates
AAFP Delegates Debate Issues Past, Present and Future

New AAFP Leaders Announced at Congress of Delegates

GME, Payment Reform Take Center Stage at Town Hall Meeting
Family Medicine for America's Health Also Highlighted


Additional Resources
Storify: Congress of Delegates: Day One(storify.com)

Storify: Congress of Delegates: Day Two(storify.com)