The United States spends twice as much on health care as other developed countries but gets worse outcomes. During a Town Hall meeting here Oct. 7 before the Congress of Delegates (COD) opened, AAFP leaders said they are working to increase primary care's share of this investment, which would reduce overall costs and improve outcomes.
AAFP Board Chair John Meigs, M.D., talks about the AAFP's work during a Town Hall meeting. AAFP EVP and CEO Douglas Henley, M.D., left, also spoke during the meeting Oct. 7 in New Orleans.
"We have to increase the current paltry 6 to 8 percent primary care spend," said Academy President Michael Munger, M.D., of Overland Park, Kan. "We have to at least double that to be consistent with what other highly efficient, well-organized systems around the world are spending."
President-elect John Cullen, M.D., of Valdez, Alaska, added that studies have shown that every $1 spent on primary care saves $13 for the overall health system.
A handful of states are already moving toward this goal of greater primary care investment. Oregon, for example, has passed legislation that will boost primary care spending to 12 percent. Glenn Rodriguez, M.D., a delegate from Milwaukie, Ore., said the legislation was successful for two reasons: unified support for the bill across specialties, and the leadership of family physician and state Sen. Elizabeth Steiner Hayward, M.D., of Portland.
Delaware recently passed legislation that requires private payers -- who had been paying 65 to 85 percent of Medicare rates -- to reimburse primary care physicians at rates at least equal to those of Medicare. Delaware delegate James Gill, M.D., M.P.H., of Wilmington, said the Delaware AFP and other primary care groups supported the bill, but he added that it passed, in part, because subspecialist leaders from the state's medical society also supported the legislation. He asked whether such collaboration is possible on the national level.
Delegate James Gill, M.D., M.P.H., of Wilmington, Del., speaks about reimbursement during the Oct. 7 Town Hall meeting. Gill talked about payment reform efforts in his state.
AAFP EVP and CEO Douglas Henley, M.D., said the Academy is working on the issue with a wide range of organizations, including commercial and public payers, as well as employers. Henley said one important step in such efforts will be working collaboratively to define what qualifies as primary care and what does not.
Cullen pointed out that Rhode Island also is moving in the direction of more sensible primary care investment, with plans to devote roughly 13 percent of the state's health care dollars to primary care. The move, he said, will help improve physician retention.
"This works," he said. "It's something we need to do."
Michigan delegate Chris Bush, M.D., of Riverview, questioned whether the AAFP's goal of increasing primary care payment would come at the expense of other specialties.
In a country that spends $3.6 trillion a year on health care, Henley said, primary care payment could easily be increased without "robbing Peter to pay Paul."
"There's plenty of money in health care," he added, pointing out that as much as 30 percent of health care costs are spent on treatments that are "unnecessary, duplicative and don't improve outcomes."
Henley said the key is to put more focus on prevention and eliminating waste.
Payment Part II
Munger said the Academy continues its efforts related to the Advanced Primary Care Alternative Payment model,(38 page PDF) which the AAFP presented to the Physician-Focused Payment Technical Advisory Committee in December. The committee recommended the model to HHS for testing, and the agency responded in June.
"Although it didn't say it should move forward for testing or implementation, it did note that reform in payment for primary care was essential and needs to be looked at," Munger said. "We weren't told no, and we weren't told yes -- yet -- so since that time, we have been actively engaged with CMS, as well as the Center for Medicare & Medicaid Innovation."
Truly Meaningful Measures?
Eugene Newmier, D.O., a delegate from Cambridge, Md., said he no longer sees patients in hospitals or nursing homes and sees fewer patients in his clinic because of demands related to administrative burdens. He asked what the AAFP is doing to address that problem.
The AAFP has ongoing communications about administrative burdens with CMS and private payers. Munger said the Meaningful Measures initiative CMS launched last year has eliminated about 25 percent of existing quality measures. He also pointed out the AAFP is advocating for the adoption of the standardized measures the Academy helped develop as a member of the Core Quality Measures Collaborative.
Harshini Jayasuriya, M.D., a member constituency alternate delegate from Holt, Mich., asks a question during the Town Hall meeting. AAFP leaders answered members' questions during the 90-minute session in New Orleans.
The 2019 Medicare physician fee schedule proposed by CMS includes provisions to reduce documentation requirements, but the proposal has several serious flaws related to payment, including a 50 percent payment reduction for certain services provided in conjunction with an evaluation and management code using CPT modifier 25.
"We know that doesn't work for primary care," said Board Chair John Meigs, M.D., of Centreville, Ala., "and we have pushed back hard."
The Academy last month sent CMS 92 pages of suggestions on how to improve the proposal.
Meanwhile, Cullen -- who chaired the AAFP's task force on continuing certification -- said he expects changes will be made to that process, which is commonly cited as a burden by members.
Primary Care-based Health System
Henley urged delegates to adopt a board report(622 KB PDF) that presents a framework for moving to a health care system based on primary care. The report, which was influenced by feedback from 30 constituent chapters, would update the Academy's longstanding policy of affordable health care for all and would make it consistent with policy adopted last year that states that health care is a basic human right.
A More Diverse Future
AAFP officers were asked what the Academy is doing to diversify its leadership. Meigs pointed out that the National Conference of Constituency Leaders has provided leadership training and a policy platform for women; minorities; new physicians; international medical graduates; and LGBT physicians or physician allies for more than two decades.
"It has had a definite impact on leadership at the state chapter level, and those folks are making their way into the COD," he said. "It takes time, and candidates have to run. If candidates don't run, they can't be elected. You have four white men sitting up here. It won't be too many more years before it won't be that way."
Delegates will select leaders for several positions this week during COD.
Harshini Jayasuriya, M.D., a member constituency alternate delegate from Holt, Mich., asked for an example of ways the AAFP is being proactive.
Meigs said the Board of Directors approved a special project last week intended to engage the artificial intelligence community. The 42-month project aims to let organizations in that field know what primary care physicians need rather than waiting for companies to develop and market products they think primary care needs.
Meigs said the technology has the potential to expand primary care.
"It's not that machines can replace us, but they can expand the capabilities of what you can do in a primary care office," he said.
Virginia delegate Jesus Lizarzaburu, M.D., of Grafton, asked whether the AAFP's Speak Out tool could be expanded so patients also could make their voices heard through the Academy.
"Patients have asked how they can help," he said. "Those are the times I wish I could get them involved, and they'd do it. Legislators listen to us, but they'll listen a lot more to a greater number of patients."
Cullen said the Academy is in the process of revamping its website, and that the idea might be "a possibility."
Meigs will transition off the Board when COD concludes Oct. 10. When speaker Alan Schwartzstein, M.D., of Oregon, Wis., pointed out that Meigs was wrapping up a decade of service on the Board, members in the packed ballroom gave him a standing ovation.
"I'm sure you're all glad I'm about gone," quipped Meigs, who also has served as vice speaker, speaker, president-elect and president.
2018 Congress of Delegates: Day One(wakelet.com)