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Tuesday Jan 08, 2019

No Margin, No Mission: Better Physician Pay = Better Patient Care

"Had to have high, high hopes for a living."
Panic! at the Disco

[figures standing on stacks of coins]

Happy New Year! I hope everyone had a nice holiday season and you were able to relax and enjoy some time with family and friends. I had a great holiday, but I am sad to report that the University of Oklahoma's Football Season of Destiny came up short of its goal. Disappointing, but I am encouraged by the fact that pitchers and catchers report to spring training in less than 40 days.

Speaking of seasons starting, the 116th Congress convened last week. The first day of a new Congress is always fun, with new members and their families enjoying their first few days of official Washington. The good spirits likely will fade quickly, however, given the fact that this Congress brings a return to divided government, with Republicans controlling the White House and Senate and Democrats controlling the House of Representatives. Divided government has produced surprising outcomes in the past, so we will see how the next two years progress. This I can promise you: The AAFP will do its work in a bipartisan manner, and we will be positioned to advance the policy goals of family medicine.

In my previous two posts, I outlined two policy goals aligned with our strategic objectives related to workforce, health care coverage and expanding access to primary care. In this post, I want to take a deeper dive into our strategic objective regarding payment reform.

I understand there are mixed emotions associated with our heavy emphasis on payment reform, and that some members feel a focus on payment for physicians appears to be parochial and a distraction from patients and their health care needs. But consider this: Payment is the engine that drives patient-centered care, and if we want better care for patients, then we need better payment systems for primary care physicians. No margin, no mission. Our nation's inadequate investment in primary care is a root cause of our expensive, fragmented health care system, and the AAFP is committed to changing this dynamic.

The Academy's work on payment reform is built on two themes and six functions. The two themes are increasing the overall investment in primary care and transitioning primary care from legacy fee-for-service systems to primary care-focused alternative payment models. These are the six functions we're focused on:

  • The Medicare Access and CHIP Reauthorization Act (MACRA) -- By now, everyone is familiar with the Quality Payment Program(qpp.cms.gov) (QPP) that was created by MACRA. The QPP has two tracks, the Merit-based Incentive Payment System (MIPS) and the Alternative Payment Models (APMs) track, which includes Advanced APMs. Each of these pathways represents a complicated collection of payment and performance criteria that impacts every physician who provides care to Medicare patients.

    The AAFP has actively worked with CMS for the past several years to shape the QPP. The Academy has provided more than 500 pages of commentary to CMS since MACRA was enacted in 2015. In many cases, CMS listened and implemented our recommendations. The most notable policies we have impacted have been those that provide exemptions and bonus payments for small physician practices.

    The AAFP has extensive resources on MACRA. If you are looking for a starting point, check out the 2018 MIPS Playbook. It is by far the best source for determining how to manage the QPP in your practice. Another good information source is FPM's MACRA and value-based payment resources.

  • Advanced Alternative Payment Models -- One of the AAFP's primary goals in the payment reform strategic objective is to transition family medicine practices from the legacy fee-for-service payment model to delivery and payment models that better align and support advanced primary care practices. I have written extensively about the AAFP's work on APMs,(38 page PDF) accountable care organizations and direct primary care (DPC), so I will save some space and not cover those topics in this post.

  • Independent practices -- The preservation and promotion of independent family medicine practices is a priority issue for the AAFP and a focus of much of our advocacy work over the past several years. Although many may suggest that consolidation is the future, there is evidence that the presence of high-functioning independent physician practices may be a better path forward.

    In 2018, the AAFP joined with a small group of key collaborators to form the Partnership to Empower Physician-led Care(physiciansforvalue.org) (PEPC). This coalition promotes the value of independent physician practices and their contributions to a value-based health care system. The PEPC has a membership category for individual physicians, and I encourage you to join us in this effort.

    The AAFP's work on DPC is also an important component of our advocacy efforts on behalf of independent family medicine practices. The AAFP has been a driving force behind the acceptance and growth of the DPC movement during the past five years, and we will continue to provide resources to members and policymakers on this practice model. The AAFP has a comprehensive set of DPC resources and, if you have a DPC practice or are interested in the DPC model, we invite you to join us at the DPC Summit(www.dpcsummit.org) June 28-30 in Chicago.

  • Inputs and values -- This is an area of our policy and advocacy work that doesn't get broad promotion but is incredibly important and disproportionately impactful on our overall payment reform efforts. Let's call it the behind-the-curtain work. Most people are familiar with CPT codes and relative value units (RVUs), but you may not be aware of the process by which CPT codes are developed and RVUs are determined. The AAFP, through the tireless work of several family physicians and our professional staff, are active in our efforts to inform and influence the CPT Editorial Panel and the AMA/Specialty Society Relative Value Scale Update Committee (RUC).

    The CPT and RUC work is tedious and technical, but it also is essential. There is no doubt that the value of primary care is undervalued and likely has been devalued by the RUC process during the past 20 years. There also is no doubt that the CPT process has created a monstrosity of documentation requirements that have led to angst and anger among physicians. Both are issues we are taking on, and both are problems we plan to solve -- either through the official process or through other avenues. More to come on these efforts, but much of our work in 2019 will focus on correcting historical wrongs with respect to the values of evaluation and management (E/M) codes.

  • Health services research – The AAFP, primarily through the Robert Graham Center for Policy Studies in Family Medicine and Primary Care(www.graham-center.org) and the AAFP National Research Network (NRN), initiate and participate in a large number of research projects that look at a variety of policy and practice issues and their impact on primary care, patients, the health system, etc. This research informs our advocacy efforts and, more importantly, produces information that confirms and quantifies the value of family medicine. If you aren't familiar with the Graham Center and NRN, I encourage you to spend a little time browsing their research papers. You will be impressed and informed by their good work.

  • Evaluation -- The evaluation of payment models and methodologies is an important part of our work on payment reform. It is important to understand the true impact of changes in payment policy on both you and your practice and on the patients you care for. Again, the Graham Center is a primary source for this work inside the AAFP, but we also rely on our experts in the Academy's Division of Practice Advancement to model payment proposals and evaluate their impact on family physicians. Our evaluation work was a primary reason that CMS decided not to implement its ill-advised proposed E/M payment changes this year. The AAFP's ability to show, via data and modeling, the negative impact of that proposal was extremely influential.

As I noted in the opening of this post, payment formulas and methodologies are the engine that drives our health care system. If you care about quality and equitable care for patients, you should care about the payment formulas that make that possible (or impossible).

As the U.S. medical system transitions to value-based payment models, the AAFP is committed to supporting you and your practice through advocacy, information and tools. We have curated resources to help you make iterative changes in your practice that will result in better payment and, ultimately, better care for your patients. Watch your email for updates during the next several months, and visit that page of curated resources frequently for updates and to learn about steps you can take now to create sustained revenue sources for your practice to prepare you for success in value-based care.

Posted at 06:00AM Jan 08, 2019 by Shawn Martin

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ABOUT THE AUTHOR



Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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