Family physicians care deeply about their specialty and their patients, and that's why each year about this time, hundreds of physicians gather together to participate in the AAFP Congress of Delegates.
Jaividhya Dasarathy, M.D., of Cleveland, Ohio, a Member Constituency delegate, tells the Reference Committee on Practice Enhancement that her residency program has a strong inpatient training program. Even so, after completing their training, "many residents have trouble getting privileges and end up practicing only outpatient care."
At this year's COD, which ran from Sept. 23-25, family physicians spent long hours discussing the merits of various proposals put forth as resolutions in five separate reference committees. Many rose to testify before their peers as designated chapter delegates or alternate delegates and sometimes on their own behalf.
The Reference Committee on Practice Enhancement dealt with a variety of issues that ranged from acupuncture to hospital care. After reviewing reference committee recommendations, delegates voted whether to adopt resolutions as written, adopt substitution resolutions or refer resolutions to the AAFP Board of Directors for further consideration.
This year, a resolution on use of EHRs as a condition of participation in accountable care organizations was the only item not adopted.
What follows is a snapshot of this reference committee's work.
- The AAFP's Reference Committee on Practice Enhancement discussed a number of important topics at the 2019 Congress of Delegates.
- Delegates and alternate delegates adopted resolutions and substitute resolutions related to privileging, credentialing, scope of practice and use of acupuncture to treat chronic pain.
- The COD also adopted a substitute resolution that called on the AAFP to engage with the AARP to educate that body about the role of family physicians in providing quality and cost-effective patient care.
Hospital Care, Scope
The New Jersey chapter introduced a resolution intended to help independent physicians gain hospital privileges in an era when hospitals tend to hire hospitalists and intensivists to care for patients.
New Jersey delegate Mary Campagnolo, M.D., M.B.A., of Bordentown, N.J., told of a chapter member who had been closed out of his hospital system despite residency training, ample qualifications and experience. "This is one of those examples where people talk about blowing the top off the box; we need to stand up against organizations who are trying to narrow our scope," she said.
Alicia Jacobs, M.D., of Colchester, Vt., an alternate delegate, supported the measure but preferred to broaden the resolution with by referring to "qualified" rather than "independent" family physicians. "We have employed family doctors who are working in integrated hospitalist systems but face multiple barriers because they are really hybrid doctors who work both in the medical home and in hospital. They face barriers trying to integrate with the hospitalist system," she said.
Jose David, M.D., of Albany, N.Y., speaking on his own behalf, said hospitals in his area make it difficult to see hospitalized patients. "They're making it so restrictive for family physicians who've been there for a long time," he told the reference committee.
Ultimately, the Congress voted to adopt a substitute resolution that asked the AAFP to collaborate with The Joint Commission(www.jointcommission.org) and other organizations to create policy that would have hospitals remove undue barriers and restriction of privileges to hospitals and intensive care units for qualified family physicians who practice hospital medicine.
Health Plans and Hospital Privileges
Another resolution introduced by the New Jersey chapter asked the AAFP to intervene and create a policy that would restrict health plans from having the authority to credential physicians.
Kathleen Saradarian, M.D., an independent solo physician from Branchville, N.J., testified that she brought this resolution to her academy this year after being dropped from an insurance plan because she had the "wrong" privileges at the "wrong" hospital. "I just saw this as the tip of the iceberg and something we should address before it snowballs," she said.
Utah delegate Kirsten Stoesser, M.D., of Salt Lake City, spoke in support of the resolution. "Many family physician faculty are not doing hospital care and are doing outpatient care only. It doesn't make any sense to have hospitals determining whether those physicians can be credentialed when the hospitals are hardly interacting with them," she said.
California alternate delegate Lee Ralph, M.D., of San Diego, also spoke in favor of the proposal. He testified that several California AFP members reported that they were not allowed to participate in an insurance plan and care for their patients. "It's archaic to tie insurance privileging to medical staff credentialing," he said.
Jennifer Sparks, M.D., of Cambridge, Mass., president of the Massachusetts AFP, spoke in favor of the measure. "There is a great risk of hospitalist programs and hospital-acquired practices edging out the competition in terms of solo physicians being able to practice medicine" with insurers available in their local area, she said.
Ryan Kauffman, M.D., an alternate delegate from Bellefontaine, Ohio, testifies in support of a resolution calling for health insurers to cover acupuncture for chronic pain control. He says only physicians should order the procedure but that anyone who's trained in acupuncture can provide the actual treatment.
The Congress adopted a substitute resolution that asked the AAFP to create a policy against health insurance company privileging of physicians based solely on their hospital privileges and hospital credentials. The resolution also directed the AAFP to engage with major health insurance companies to develop methods to credential physicians that do not depend on hospital privileges.
AARP Involvement in APRN Initiatives
Another resolution addressed collaborative initiatives between the AARP and advanced practice registered nurse organizations. The resolution, offered by the West Virginia chapter, noted that the AARP funds a Campaign for Action initiative that is focused on strengthening nursing on multiple fronts.
Kentucky alternate delegate Patricia Swiney, M.D., of Paris, gave the reference committee some background on what is happening in her state. "Kentucky is one of those states that has been very hard hit because of the AARP's support of nurses and nurse practitioners. When APRNs were trying to gain independent prescribing and independent practice, they were supported by the AARP," she said.
In fact, Swiney said, on the day legislation that gave APRNs the ability to do those things was signed into law, the AARP paid to bring busloads of nurse practitioners to town to witness the governor's signing.
"Every chapter in here has to remember that your patients are bombarded by the AARP magazine" with information on that topic, she added.
Texas delegate Linda Siy, M.D., of Bedford, also testified in support of the resolution. "We are one of those states that have come into conflict with the AARP representative who came to present at one of our meetings. I've never seen our members so engaged and almost riotous at that meeting.
"I think it's imperative that we continue to engage with the AARP because clearly there is a lot of education that needed to be done regarding the role of family physicians," she said.
The Congress voted to adopt a substitute resolution that calls on the AAFP to develop strategies to engage the AARP that would promote the role of family medicine in the provision of quality and cost-effective patient care.
Acupuncture Treatment for Pain
The New Jersey AFP introduced a resolution that made the case for health insurance coverage for acupuncture treatment for chronic pain.
Montana delegate Janice Gomersall, M.D., of Missoula, spoke in support of the measure. She told the reference committee that she gave up full-spectrum family practice to see patients through the Department of Veterans Affairs.
"The VA approves of the use of acupuncture as well as chiropractic care … They're trying to decrease the use of opiates by having acupuncture available free to veterans," said Gomersall.
Megan Mahowald, M.D., of Spring Lake, N.C., an alternate delegate for the Member Constituency, said clinicians other than physicians can provide acupuncture.
"If we limit this to physicians, we limit the number of people who could potentially provide pain relief in areas where there may not be access to physicians. In the military, we have medics who do this, we have residents and nurse practitioners who do it; this provides a broad spectrum of care to patients in need," said Mahowald.
Mary Krebs, M.D., of Xenia, Ohio, testified on her own behalf. She spoke in favor of physicians having the sole right to order acupuncture, regardless of who provides the procedure. "We as the AAFP are in favor of physician-led care, and all patients deserve a physician to make sure this is the right thing for them," she said.
After additional testimony on Sept. 25, the Congress adopted an amended substitute resolution that asked the AAFP to create policy to support insurance coverage of acupuncture for pain control when ordered by a licensed physician or licensed collaborating advanced clinician on the physician's practice team.
The COD also referred two items to the AAFP Board of Directors.
A resolution introduced by the Virginia chapter discussed ways to reduce the administrative burden placed on physicians by chain pharmacies -- including the misuse of medical refill frequency. In suggesting referral, the reference committee noted the complexity of the issue and the Congress agreed.
A second resolution dealt with the issue of nonphysician participation in family physician credentialing and privileging decisions. After much debate on the Congress floor, delegates and alternate delegates voted to refer an amended substitute resolution to the Board.
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