At the 2018 Congress of Delegates (COD) held here from Oct. 8-10, family physicians who participated in the Reference Committee on Practice Enhancement hearing discussed a number of high-priority topics that affect their practices.
Indiana alternate delegate Risheet Patel, M.D., of Indianapolis, testifies during the 2018 Congress of Delegates about a resolution that describes member difficulties with Healthcare Effectiveness and Data Information Set (HEDIS) audits. He tells members of the Reference Committee on Practice Enhancement that some FPs in his state who have undergone HEDIS audits have been asked to provide information from as long as four years ago. Delegates adopted a substitute resolution directing the AAFP to advocate that HEDIS audits by Medicaid and their managed care plans be reduced or eliminated.
During the COD business session on Tuesday, delegates decided how to dispense with each resolution -- with significant input and recommendations from the reference committee's official report.
Some resolutions were adopted as written; others underwent revisions and were presented as substitute resolutions. Six resolutions were referred to the AAFP Board of Directors for further consideration and one was reaffirmed as current policy.
Harnessing Big Data
A resolution introduced by the Colorado and Arizona chapters dealt with the issue of all-payer claims databases (APCD) and their application to family physicians and their practices.
Colorado alternate delegate Tamaan Osbourne-Roberts, M.D., of Denver, authored the resolution and opened the dialogue by disclosing that he is the chief medical officer for the organization that runs Colorado's APCD.
"I am clearly going to be a fan of big health data -- not because it's cool, not because it gives me a job -- but because it has the power to revolutionize what we do," he said. "Claims data, when it comes to quality metrics and payment, in looking at those in big huge population health ways, is incredibly powerful -- and incredibly powerful for family medicine."
- During the AAFP's 2018 Congress of Delegates, the Reference Committee on Practice Enhancement tackled topics ranging from claims data to credentialing.
- One resolution family physicians discussed at length was states' establishment of all pay claims databases as a critical step in increasing the primary care spend rate.
- Another resolution dealt with some payers' refusal to accept physicians' supplemental data in value-based contract situations, which can result in inaccurate payer records and a loss of shared savings and lower payments.
Osbourne-Roberts said his organization looked at all primary care provided in various settings -- urgent care, as well as free-standing and hospital-based emergency departments -- and found that Colorado could save hundreds of millions of dollars every year if all the primary care emergency services being sent to the emergency department went instead to primary care clinics.
"We proved it numerically and we proved it unequivocally, and you can imagine what type of an argument that makes to policymakers," said Osbourne-Roberts.
"The one thing that continues to be really apparent is that whenever you look at primary care relative to our 'partialist' colleagues, you really begin to see that transparency helps physicians in general. But primary care physicians, in particular, stand out above the pack as a solution to a variety of different problems," he added.
Kansas delegate Douglas Gruenbacher, M.D., of Quinter, expressed strong support for the resolution and said work to increase the primary care spend was just beginning in his state.
"We are grateful for those states that have paved the way by giving us model legislation," said Gruenbacher. He noted that establishing an APCD was a critical first step in pursuit of increasing the primary care spend.
"We have to measure the baseline before we can understand whether our work will effect change. The more we understand the details, the more we can advocate for increasing the primary care spend," he said.
Oregon delegate Glenn Rodriguez, M.D., of Milwaukie, testified that his state already passed legislation that required a percentage of medical spending to go to primary care. "We're actually working to implement that," he said.
One of the key issues that's come up is having the infrastructure necessary to do that, and the APCD is a critical piece. "We have struggled and gotten national headlines for some of our big IT projects that have failed spectacularly; this is a critical infrastructure piece to implement the AAFP's Advanced Primary Care Alternative Payment Model(38 page PDF)," said Rodriguez.
Vermont alternate delegate Allan Ramsay, M.D., of Essex Junction, said his state developed an APCD more than 10 years ago that's been used for regulatory authority over insurance rates, as well as for hospital budgets.
"The primary care spend rate cannot be determined without an all-payer claims database, but we need to know how to deal with the unaudited voluntary reports from payers to that database," he said.
The Congress voted to adopt the resolution, which directs the AAFP to study APCDs and their application to family physicians, including how they can
- assist family physicians in clinical practice,
- demonstrate the value of family medicine and
- help to quantify the overall current spend on family medicine.
Valuing Supplemental Data
Connecticut alternate delegate Robert Carr, M.D., of Bethel, said his chapter introduced a resolution pertaining to use of supplemental data in value-based contracts as a followup to a similar resolution submitted during the 2017 COD.
District of Columbia delegate and chapter President Kandie Tate, M.D., of Havre De Grace, Md., provides testimony on prior authorizations. Because of her employment status, she sees things differently than do many of her colleagues. "What I see is a lot of improper medications being sent from the highest (drug) tier as opposed to the generic. I see a lot of MRIs where there has been no X-ray or explanation for why it's being ordered," said Tate. A resolution asking for physicians to be paid to complete prior authorizations was referred to the AAFP Board for further consideration.
Carr said the Connecticut AFP continues to receive member complaints about payers with whom physicians have value-based contracts; specifically, reports from those payers telling physicians there are gaps in care for some patients.
"You go into the chart and see that you have evidence to show patients have had those things (hemoglobin A1c testing, colonoscopy, diabetic eye exam), and you try to submit that data to the payers to correct the reports.
"Some payers are not willing to accept it," said Carr.
"For many of our members, this results in significant financial difficulties -- either in meeting quality metric thresholds or losing a great deal of money in terms of shared savings or other financial remuneration," he added.
Despite all the AAFP's work, "It seems like there is not a lot of forward motion on the part of the payers," said Carr.
Texas alternate delegate and chapter President Janet Hurley, M.D., of Whitehouse, said, "It is well known that claims data is inherently inaccurate, and that claims data plus EMR (electronic medical record) data is far superior."
Hurley helps negotiate with value-based plans. "Our Blue Cross Blue Shield provider specifically asked us to exclude some of the self-reported data because it was difficult for them," she said.
"The self-reported data was accurate, and we were meeting their HEDIS (Healthcare Effectiveness and Data Information Set)(www.ncqa.org) requirements. It was a little frustrating not to be able to include those metrics in our contracting. It's very clear that supplemental data is essential in order to make sure that what we're being graded on is accurate and fair."
Missouri alternate delegate Kate Lichtenberg, D.O., M.P.H., of Kirkwood, told the reference committee that she works for Anthem Blue Cross Blue Shield in Missouri.
"Absolutely, claims data alone is not going to cut it, and I've been advocating for five and a half years that we need to collect it (supplemental data) for our commercial population."
Lichtenberg cautioned her fellow family physicians that even though she could take their supplemental data today, "It's going to sit on my desk because I have no way to input it to actually close those gaps. It will take three to five years before I have a system up and running."
Member constituency alternate delegate Harshini Jayasuriya, M.D., of Holt, Mich., agreed that technology has not kept up with the need. "When we're talking about 130 EMRs and they are feeding into our health information hub -- essentially, that's the equivalent of speaking 130 different languages," she said.
Jayasuriya explained that the hub information goes back into the EMR, which converts it into nonextractable data. "It comes back in a format that's not compatible with our current EMR system. There are limitations in our current systems and just the way coding works," she said.
The delegates adopted a substitute resolution that asks the AAFP to
- create educational materials for payers and physicians on topics related to claims data,
- increase public visibility on the issue,
- ramp up advocacy to payers that do not currently accept supplemental data,
- develop model language regarding the acceptance of supplemental data in value-based contracts, and
- enhance advocacy efforts on the federal level for legislation to mandate acceptance of supplemental data in value-based arrangements.
Easing the Credentialing Process
Hurley led off discussion on a resolution about credentialing.
"We have individuals doing some moonlighting -- and other individuals who are trying to work locum tenens. I think we can recognize that it would be a valuable service to our solo and small-group practices to be able to take a week off, and yet getting a locums person to come in and be credentialed is sometimes a pretty challenging experience," said Hurley.
"If we have an individual who has already been credentialed properly through the various channels, it would seem as though some of that work should not have to be repeated over and over again."
Jayasuriya said, "I have recently accepted three part-time positions in Michigan … It took between three to nine months to be credentialed for each position." She called the credentialing period "lengthy" and said it was most cumbersome for larger organizations.
The delegates adopted a substitute resolution that asks the AAFP to take a resolution to the AMA House of Delegates asking that body to streamline and standardize the credentialing process.
A number of resolutions were referred to the AAFP Board of Directors for further discussion.
The Board will consider resolutions or substitute resolutions asking the AAFP to
- develop a policy to promote the appropriate compensation of physician for oversight of nurse practitioners and physician assistants;
- work with various organizations to develop primary care modifiers to help increase primary care payment, which would in turn boost the number of medical students choosing family medicine;
- engage with appropriate organizations to classify all primary care evaluation and management serves as preventive, thereby ensuring that they are covered without a patient copay or deductible;
- work with outside groups to ensure that primary care physicians receive adequate payment for providing mental health care services;
- advocate on behalf of family physicians for appropriate payment for the work done to complete prior authorizations; and
- urge CMS to redesign documentation requirements that take into account historical relative risk to ensure that family physician payment is based on the severity of a patient's illness rather than a physician's ability to document.
Another resolution asks the AAFP to work with CMS to ensure that the Medicare annual wellness visit is undertaken only by family physicians and general internists; the Congress voted to reaffirm that advocacy on this issue will continue to be a high priority for the AAFP.
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