Family physicians intent on improving their practices, their specialty and the health of their patients traveled to participate in the AAFP's 2017 Congress of Delegates here Sept. 11-13.
Mike Hanak, M.D., of Chicago, tells the Reference Committee on Practice Enhancement that simply asking national laboratories to share patient data with referring physicians isn't enough because, "We can ask, and they can say 'No.'"
Hundreds of physicians crowded into event meeting rooms for two and a half days of spirited discussion on dozens of resolutions assigned to five reference committees for consideration.
The Reference Committee on Practice Enhancement pondered 10 resolutions and heard testimony from family physicians -- some serving as chapter delegates or alternate delegates, and others representing themselves -- on a variety of issues that touched on payment, practice problems and patient care.
Simplifying Processes for Labs, Durable Medical Equipment
A number of resolutions touched on issues that cause great frustration for family physicians immersed in patient care.
For instance, the New Jersey AFP introduced a resolution that concerned the longstanding problems physicians have encountered in gaining access to results from clinical laboratories.
Authors noted that the sharing of such data with the patient care team reduces duplication of services, saves money and provides a measure of safety for patients.
- AAFP members who testified before the Reference Committee on Practice Enhancement during the 2017 Congress of Delegates covered a variety of topics important to practicing family physicians.
- Reference committee members heard testimony on 10 resolutions on subjects such as simplifying processes for sharing patient lab data and ordering durable medical equipment.
- Members also discussed problems with the Medicare annual wellness visit, as well as with combining medical and behavioral primary care.
During the reference committee hearing, New Jersey AFP delegate Mary Campagnolo, M.D., M.B.A., of Bordentown, said physicians send patients to labs, but the labs "don't send results to us even if patients list us as primary. We see this as an ongoing disruption to patient continuity of care."
Kathleen Saradarian, M.D., of Branchville, N.J., said, "We need more than policy. We need action. The technology exists to make this easy and seamless, but we need partners to push labs to share this information."
Pennsylvania AFP delegate Bradley Fox, M.D., of Fairview, told the reference committee he was speaking for patients. "There have been multiple times where I ordered a CMP (comprehensive metabolic panel) along with lipids, and the nephrologist already ordered it two weeks ago. The patients are getting stuck with bills insurance won't pay because of duplicative labs," said Fox.
Mike Hanak, M.D., of Chicago, said physicians in his state have the same problems, but his delegation opposed the resolution as written. "This seems like it's more of a problem of interoperability" of electronic health record systems, he said.
Ultimately, the Congress adopted a substitute resolution that asks the AAFP to support the seamless exchange of lab data between laboratories and any member of the care team when requested, to be shared through the practice's usual preferred method of receiving results at no further cost to the practice.
The topic of obtaining durable medical equipment (DME) for patients also got physicians' attention because it, too, causes disruptions in practice. A resolution introduced by the Virginia AFP sought to reduce the hassles associated with this task.
Virginia AFP delegate Jesus Lizarzaburu, M.D., of Yorktown, put it this way: "Many of us have been burned by durable medical equipment requests. It is frustrating to have patients who get knee braces that we never ordered, and then we get inundated with requests for documentation; then, when we need wheelchairs, we don't get them because there's not enough documentation.
"It is ironic, frustrating and very expensive for the system. All we want is simplification, clarification and education," he said.
Georgia AFP delegate Bruce LeClair, M.D., M.P.H., of Evans, told the committee that the requirements for DME come from contractors, not CMS. "One of the things they require is clinical notes, and they require those because there is the possibility of being audited."
LeClair said he'd been asked for six months of clinical notes for a patient who needed a catheter. That request required that he redact every other medical problem outlined in those notes. "Now, that's burdensome," he said.
Ultimately, the Congress adopted a substitute resolution asking the AAFP to, among other things, look for ways to simplify and standardize medical necessity documentation requirements for DME, and ask that physician attestation of clinical diagnosis be sufficient documentation.
The resolution also asks the AAFP to collaborate with CMS and America's Health Insurance Plans to request development of an online, accessible and up-to-date database of accredited DME suppliers for each health plan.
Medicare Annual Wellness Visits
Georgia AFP alternate delegate Beulette Hooks, M.D., of Midland, introduced a resolution the delegation submitted that deals with issues related to the Medicare annual wellness visit.
She noted the AAFP's ongoing efforts to resolve the problem, but said many physicians still report that when they offer patients the annual wellness visit, they discover it has been performed by someone else.
"We don't have the information on what (that party) did or said, and so we just want to be sure our patients see us (their family physicians) to get their annual wellness visit," said Hooks.
Oregon AFP alternate delegate Elizabeth Powers, M.D., of Enterprise, says the small payment her practice receives for providing behavioral care -- $2 per member per month -- is not enough to support any part of that program by itself.
Texas AFP delegate Douglas Curran, M.D., of Athens, described the "nightmare" of trying to explain to his older patients that the person who came to visit them at their house could have been trying to take advantage of them.
"It's very confusing for the patients," said Curran. And when that visit results in labs being drawn, "I get none of that information," he added.
The Congress adopted a substitute resolution directing the AAFP to, among other things, ask public service agencies and appropriate membership organizations to help educate Medicare-eligible individuals about the importance of the annual wellness visit being performed in the patient's primary care setting, and to support legislation and regulations that direct beneficiaries to their primary care physician or physician designee for these exams.
Medical and Behavioral Primary Care
The Arizona AFP introduced a resolution that addresses the need for more behavioral health services for patients in the context of developing the medical-behavioral primary care model.
Arizona AFP delegate Andrew Carroll, M.D., of Chandler, told the reference committee that the resolution aimed to get CMS "to recognize other health care specialists in the behavioral space" and called doing so "the future of primary care delivery."
In Arizona, that would be a licensed professional counselor (LPC) or other behavioral specialist, said Carroll. Unfortunately, CMS only recognizes and allows doctors of psychology to deliver and get paid for these services within the Medicare system.
Texas AFP alternate delegate Troy Fiesinger, M.D., of Sugar Land, said LPCs were already embedded in practices in Texas. "I've used embedded LPCs, and it's a great help to our patients; they get better care. The biggest barrier in Texas is paying LPCs for the work they're already doing," he said.
Oregon AFP alternate delegate Elizabeth Powers, M.D., of Enterprise, also spoke in favor of the resolution.
"In Oregon, we have focused a lot of energy and resources on patient-centered primary care transformation, and a lot of that focus has been on medical and behavioral health integration. But we have not been able to achieve everything because of the regulatory requirements," said Powers.
"We do have some support on the part of our coordinated care organizations for that care provided within the medical home setting," she added. For instance, "In my practice, we get $2 per member per month for the provision of behavioral health services within the medical home." But that's not nearly enough to cover the cost of providing such services, said Powers.
The resolution asked the AAFP to, among other things, urge CMS to expand the types of licensed behavioral health professionals that can be credentialed by CMS to provide services to Medicare beneficiaries and to urge payers to include payment for such services as part of a patient's medical benefits.
The reference committee recommended referral to the Board, and the Congress agreed.
The Congress voted on additional resolutions that were discussed before the reference committee.
Delegates adopted a substitute resolution that covers the responsibilities of commercial and government insurers related to shared savings payments to family physicians.
They also referred to the Board of Directors
- a resolution that would reduce administrative burden by limiting the addition of performance metrics,
- a substitute resolution asking for incremental pay increases for small practices that participate in any quality improvement activities outside of the Merit-based Incentive Payment System,
- a resolution allowing physician assistants to perform face-to-face exams for hospice recertification with appropriate physician oversight or collaboration, and
- a substitute resolution emphasizing direct clinical care in health care spending.
A full accounting of the work of the 2017 Congress of Delegates is available online, where AAFP members can read reports from all five reference committees in their entirety.
Related AAFP News Coverage
2017 Congress of Delegates
Delegates Choose New AAFP Leaders
2017 Congress of Delegates: Day Three(storify.com)