September 24, 2019 03:56 pm David Mitchell Philadelphia – Hundreds of AAFP members from all 50 states; Washington, D.C.; U.S. territories; member constituency groups; medical students and residents; and the uniformed services gathered here for the 2019 Congress of Delegates to discuss resolutions on a wide range of issues that affect family physicians and their patients.
AAFP President John Cullen, M.D., of Valdez, Alaska; Board Chair Michael Munger, M.D., of Overland Park, Kan.; President-elect Gary LeRoy, M.D., of Dayton, Ohio; and EVP and CEO Douglas Henley, M.D., spoke with members for more than 90 minutes. One of the most frequent topics raised was administrative burden, which Henley said has replaced payment as the top concern of a majority of family physicians in recent years, according to the Academy's annual Member Satisfaction Survey.
It's not always clear, however, specifically what is meant by that term because it has been used to refer to documentation demands, prior authorization requirements and more. Henley said an AAFP staff team is taking a deep dive into the issue to better understand the problems members face.
Henley also pointed to the AAFP's health IT innovation project that was announced last fall. He said the Academy intends to engage and influence developers of artificial intelligence and machine learning products to develop virtual scribes, tools that can simplify the prior authorization process, and technology that allows a practice to easily extract and report performance data from EHRs.
AAFP members raised issues of high priority to family medicine at a standing-room-only Town Hall meeting on Sept. 22.
In response to a question about the burden of prior authorization, AAFP President John Cullen, M.D., said he recently told legislators that "the whole process was completely out of control and needs to be fixed."
Board Chair Michael Munger, M.D., described how he has pressed CMS to double its spending on primary care.
Henley said there are "serious efforts afoot" and interest from CMS, Congress and other physician organizations to eliminate unnecessary prior authorizations, especially those related to things like generic medications.
"I think there is hope on the horizon," he said.
Daron Gersch, M.D., of Albany, Minn., urged the Academy to advocate for "patient-centered measures versus number-centered measures."
"If I take someone's A1c from 15 to 9, I'm a great doctor because I've reduced his heart attack risk," he said, "not a crappy doctor because I didn't get him below 8."
Henley agreed and pointed out that the Academy is a member of the Core Quality Measures Collaborative, which aims to reduce administrative burden and costs by reducing variability in measures.
"There's too many measures and no harmonization or alignment of those measures across payers, which is absolutely ridiculous," Henley said.
According to some estimates, administrative costs account for more than 30% of health care spending. Andrea DeSantis, D.O., of Charlotte, N.C., asked what the Academy is doing about the significant amount of health care dollars being funneled through "for-profit companies that never talk to, touch or see patients."
Cullen drew a collective groan from the audience when he led into an answer by saying that a payer had told his practice to submit a prior authorization request for a hydrochlorothiazide prescription. That common diuretic has been on the market since 1959.
Cullen said he recently testified before the House Small Business Committee about the harms caused by prior authorization and other administrative burdens.
"What I told them was the whole process was completely out of control and needs to be fixed," he said. "It's costing us enormous amounts of money. It's not in any way benefiting patients. It's an internal thing going on between insurance companies and pharmacy benefit managers."
Munger highlighted some positive elements of the 2020 Medicare physician fee schedule that CMS proposed in late July, including a 12% increase in payment for evaluation and management codes and simplified billing and coding requirements for E/M services. However, neither of those improvements will take effect until 2021 unless CMS makes changes in its final rule, which is expected to be issued in November.
"We're really strongly encouraging them to move these forward now and not wait until 2021," said Munger, noting that the Academy had responded to CMS with a 61-page letter.
"We recognize that each and every one of you -- especially our members in small and solo practices -- are on the thinnest of margins. Even though this isn't the ultimate end game, you need a lifeline and you need it now."
Munger said the Academy also is having ongoing communication with CMS about alternative payment models. The agency announced two new payment models in April -- Primary Care First and Direct Contracting.
Munger said Primary Care First is "built on many of the principles" of the AAFP's Advanced Primary Care Alternative Payment Model, which HHS' Physician Payment Model Technical Advisory Committee recommended for testing more than a year ago.
However, Munger said that without some modifications and improvements, the new alternative payment models introduced by CMS don't represent significant investments in primary care.
"We don't see a reason, even with Primary Care First, that they can't launch our model as well," Munger said. "We're going to continue to message that and make that case."
Munger said Medicare allocates less than 5% of its total spend on primary care, compared to 12% to 16% in many other nations that are "giving high-quality care, bending the curve in terms of utilization and costs," and enjoying better population health.
Cullen said Academy leaders have met with CMS on this topic, and he shared with the agency evidence that having more primary care physicians per capita increases a community's life expectancy and reduces costs.
"So, I just recommended that they pay us double what they're paying us now," he said.
AAFP officers fielded multiple questions related to single-payer models. Munger pointed to a policy the Academy adopted last year that aims to ensure health care coverage for all Americans through a primary care-based health system.
He said the Academy has engaged health care consulting firms on both sides of the aisle in Washington, D.C., and both firms said the AAFP's policy has the organization well positioned for potential changes.
"The most important thing about our policy is we didn't carve out any one system right now," he said. "We understand there isn't one system at this point that has emerged as the answer. It allows us to have flexibility for whatever does move forward, whatever system, systems or combination of approaches that will allow us to hit our principles -- meaningful coverage for all in a system grounded in primary care. We're going to be there and ready to go."
James Gill, M.D., M.P.H., of Wilmington, Del., expressed concern regarding a recent report that said a declining percentage of U.S. children are receiving care from family physicians.
"I'm afraid pediatric care is going to go the same way OB has gone, where it's a niche thing a small percentage of family physicians do," he said.
LeRoy said family physicians have to be bold and push back when they are asked to give up things they are trained to do.
"It's called family medicine for a reason," he said. "That includes children. For us to divorce ourselves from that component of the family makes no sense."
Cullen said nearly 20 percent of AAFP members practice in rural areas, and those physicians provide the vast majority of care for children in their communities.
"Part of the problem is we are letting ourselves get defined by other entities about what our scope should be," he said. "We have to actively fight against that, and that's true with OB and pediatrics. There are so many things -- like emergency medicine -- that are in our purview. I worry a great deal that other entities are creating this box that's getting smaller and smaller, and we have to blow the walls right off."
The officers also fielded questions about workforce and the need for more family physicians in rural and underserved areas.
"Get medical students to your clinic," said Cullen, who invites students to stay at his home when they rotate at his clinic in Alaska. "We need to get med students out of med schools because of what they're being told: They're too smart for family medicine or there's no future in it. As I've said, that's complete 'bulshytt,'"
Cullen said the country needs more residency slots for family medicine, particularly in rural and underserved areas. He said it was imperative for Congress to reauthorize funding for the Teaching Health Center Graduate Medical Education program, which will expire this month unless Congress reauthorizes it. The AAFP is encouraging members to add their voices to the reauthorization effort using the Academy's Speak Out tool.
In addition, the AAFP launched an initiative this summer to address issues in rural health care, including access, an alarming number of hospital closings, and disparities in maternal and infant mortality rates.
"Both parties very interested in this topic," Cullen said. "Rural medicine is hot right now."
Cullen said when he testified at a Senate Finance Committee hearing on payment, many of the legislators' questions were about rural health care.
"That was great for me," he said. "It wasn't as good for the oncologist on my right who started calling herself a rural oncologist."