• In The Trenches

    You Earned That Raise; Here's How to Keep It

    "It's business. Leave your emotions at the door."
    -- Jordan Belfort in
    The Wolf of Wall Street

    You Earned It, You Keep It words in 3d letters surrounded by piles or stacks of hundred dollar bills to symbolize your revenue, profits or wages protected from taxes and fees

    On Nov. 1, CMS published the final rule establishing physician compensation levels for 2020 via the Medicare physician fee schedule. The final rule implements several hard-fought victories for family physicians, including an increase in values for evaluation and management codes, the establishment of an add-on code for care provided to complex patients and substantial changes to the documentation guidelines. In total, the increased value for E&M codes, along with the add-on codes for complex patients, equate to a 12% increase in payments for primary care physicians participating in Medicare, starting in 2021.

    Due to statutory budget-neutrality provisions, CMS must decrease payments for other codes in the fee schedule in order to finance these increases for primary care.

    Do you see where I am going here?

    Some other physician specialties, specifically those that are in the upper echelon of physician salaries and on the negative end of this new payment policy, are not amused that CMS would reduce values of their codes to increase payments for primary care -- despite volumes of evidence that support such action.  

    There are efforts underway to pressure CMS to reverse course and not implement the payment policies in 2021 as proposed. In fact, during the recent AMA Interim Meeting, an official AMA representative stated, "We are hoping what has been finalized will not be the final policy implemented in 2021."

    Game on.

    We need your help to impress upon Congress and the administration that the changes made in the 2020 Medicare Physician Fee Schedule are appropriate, supported by research, and will result in better access and better quality of care for Medicare beneficiaries. The AAFP is aggressively making this argument. On Oct. 31, the AAFP sent a letter to all 535 Members of the House and Senate urging them to protect the investments made in primary care by supporting the provisions in the CMS final rule. Then, on Nov. 22, AAFP President Gary LeRoy, M.D., joined American College of Physicians President Robert McLean, M.D., in writing an op-ed for Stat making the same arguments. The voices of opposition will only grow louder, so it is important that we create a narrative that supports these important policies.

    Here is my challenge to each of you. At some point this week, you will need a break from your family and friends -- we all will. When that time comes, sit down at your computer and click this link to send a letter to your representative and your two senators urging them to support better care for patients by increasing the overall investment in primary care in the Medicare program. Ask them to protect the primary care investments made in the 2020 Medicare physician fee schedule. It will take your mind off the stupid comment your second cousin made and, more importantly, it will benefit your practice and your patients.

    The E&M increases and primary care add-on codes I have described are an important step toward appropriate compensation for family physicians. However, there is much more that needs to be done to truly shift our health care system from an episodic, specialty-driven system to a primary care system. This pursuit of driving innovation in family medicine and primary care delivery and payment consumes large portions of my days, and the AAFP recognizes that the health of individuals and the stability of our health care system start with a robust, well-trained, well-financed primary care foundation.

    On a recent flight, I had an opportunity to read the November/December issue of Annals of Family Medicine, which includes two important articles that show trends in patient utilization patterns within the current health care system before and after enactment of the Patient Protection and Affordable Care Act -- care delivery patterns and utilization patterns of primary care services. The articles are "The Ecology of Medical Care Before and After the Affordable Care Act: Trends From 2002 to 2016" and "National Trends in Primary Care Visit Use and Practice Capabilities, 2008-2015."  

    I encourage you to read both articles. If you are pressed for time, read the accompanying editorial by Donald Pathman, M.D., M.P.H., "Changes in Rates and Content of Primary Care Visits Within an Evolving Health Care System."  

    The studies outlined in the two articles include findings that are both positive and negative for family medicine. But beyond the emotional responses the articles will stimulate, they also paint a clear picture of a changing landscape for family medicine. The following are my four key takeaways from the articles with supporting findings:

    The frequency of visits to primary care physicians are decreasing. Authors of the first study found that primary care and dental care visits decreased from 2002 to 2016, as did hospitalizations, with the greatest decrease among elderly patients and those who reported fair or poor health. The monthly number of patients who were in contact with a primary care physician fell significantly, by 1.2 patients per 1,000. Authors of the second study reported a decrease of 37 million primary care visits over the eight years they examined, with the per capita visit rate falling by 20%.

    Visits to primary care physicians are becoming more complex. The second study found that primary care physicians addressed more diagnoses and medications during visits (0.3 and 0.82 more, on average, respectively), and provided more preventive services (0.24 more, on average) -- and the duration of those visits increased by 2.4 minutes from 2008 to 2015.

    Primary care practices are changing to incorporate more non-face-to-face modalities. The second study also found an increase in the number of primary care physicians who used EHRs (+44.3%), email consults (+9.6%), secure messaging (+60.9%) and after-hours appointments (+8.6%), as well as a decrease in the number who used phone consults (-9.7%).

    Increasing out-of-pocket costs appear to be impacting patient behavior and likely influencing their engagements with primary care. The first study found that patients with higher income had greater rates of contact with physicians (overall and specialty) and dentists, while those with lower income had more hospitalizations, as well as more ER and home health visits. The second study noted that a decline in primary care visits may reflect "rising financial barriers and use of alternative venues."

    As I said, these findings raise reasons to be concerned, but they also point to more comprehensive primary care services being offered during face-to-face encounters accompanied by the growing use of technology to interact with patients between visits. This is positive. The authors of the "National Trends" article summarized the situation extremely well: "Our findings suggest the need to recognize and remunerate PCPs adequately for increasingly complex work and mitigate the potential for PCP burnout, through strategies such as adequate reimbursement for non-visit-based care and further support of these delivery models."

    This brings me full circle to my Thanksgiving assignment outlined above. Sometime during the next five days, take five minutes and send letters to your elected officials urging them to support the increased investment in primary care as proposed by CMS.

    Happy Thanksgiving!

    Shawn Martin is senior vice president of advocacy, practice advancement and policy.


    The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.