• In The Trenches

    Three AAFP Presidents, One Message: Stabilize Primary Care

    October 26, 2021, 1:15 p.m. — This country’s battle for pandemic recovery is also a fight for family medicine — one the Academy again this week forcefully takes to the Hill.

    Capitol building on cloudy day

    Across a flurry of virtual meetings on Oct. 27 and 28, your Academy presidents are speaking directly to members of Congress and their staff to advocate for three top priorities: telehealth flexibility beyond the COVID-19 public health emergency, adequate Medicare payments for primary care and improved high-deductible health plan coverage for primary care patients.

    Delivering these messages are AAFP Board Chair and immediate past president Ada Stewart, M.D., of Columbia., S.C.; President Sterling Ransone, M.D., of Deltaville, Va.; and President-elect Tochi Iroku-Malize, M.D., M.P.H., M.B.A., of Long Island, N.Y.

    Their agendas include sit-downs with the offices of House Speaker Nancy Pelosi, D-Calif.; Senate Minority Leader Mitch McConnell, R-Ky.; House Minority Leader Kevin McCarthy, R-Calif.; Sen. Mark Warner, D-Va.; Sen. Lindsey Graham, R-S.C.; Sen. Kirsten Gillibrand, D-N.Y.; Rep. Andrew Garbarino, R-N.Y., and others.

    Lawmakers have heard from us a lot lately. Roaring in the background of Wednesday and Thursday’s conversations is Congress’ ongoing negotiations toward implementing the Build Back Better Plan, elements of which the Academy strongly supports. Earlier this month, Ransone testified before a Senate subcommittee about telehealth, expanding on the Academy’s detailed remarks to the Senate Finance Committee this past May. We continue to call for legislation that extends temporary Medicare telehealth flexibilities for at least one year beyond the COVID-19 public health emergency to preserve patients’ access to care and that cements telehealth as an important modality of care (one that can’t and shouldn’t replace true longitudinal in-person primary care).

    As for high-deductible health plans, we’ve pushed a long time now to close the coverage gaps they’ve led to, and we’re doing it again this week.

    Last year’s Coronavirus Aid, Relief and Economic Security Act temporarily allowed high-deductible health plans to cover telehealth services pre-deductible, in response to the COVID-19 pandemic. Without new legislation, that flexibility will expire at the end of 2021. To avoid this cliff, the Academy is backing the recently introduced Primary and Virtual Care Affordability Act (H.R. 5541). It’s legislation that would increase access to primary care in person as well as virtually — a welcome upgrade when family physicians are working to vaccinate their communities, keep patients out of the hospital and restore routine and preventive services to their panels.

    I encourage you to join the Academy’s Speak Out campaign and ask your legislators to co-sponsor the Primary and Virtual Care Affordability Act.

    The Academy is also using these 10-plus meetings to alert Congress to issues likely to arise from the 2022 Medicare physician fee schedule and Quality Payment Program final rule — I talked about the proposed rule in this space last month — which is expected any day.

    What’s going to come up (again) is budget neutrality. As I said last year, when long-overdue raises for family physicians had come under threat, that statutory pinch — which precludes CMS from increasing payment in any area of the fee schedule without cutting it somewhere else — is ruinous. The requirement is still there, necessitating, at minimum, the same last-minute intervention that Congress made last year.

    At the end of 2020, Congress enacted legislation to increase the conversion factor in the Medicare physician fee schedule by 3.75% to provide relief to physicians hammered by the pandemic. That reprieve will expire at the end of the year.

    That’s why more than 100 medical and specialty societies, including the AMA, the American College of Surgeons and the American College of Radiology, called on Congress this past summer to again waive the budget-neutrality requirement, this time for at least two years.

    We, along with every one of the AAFP’s co-signatories on that letter, need Congress to pass equitable short-term relief from Medicare’s budget-neutrality requirement. And then we — all of us — need lawmakers to develop a truly sustainable solution for updating physician payment annually.

    They should consider at last ending the budget-neutrality rule, a zealous anti-inflation gesture that has edged into harm. Since its inception, the rule has contributed to the conversion factor getting absolutely lapped by inflation. Today, the factor is only about 50% of what it would be had it correctly been indexed to general inflation over the past 20 years. At the same time, the cost of running a medical practice has increased 37% over the past two decades while, adjusted for inflation in practice costs, Medicare physician pay declined 22% from 2001 to 2020.

    A powerful corrective is in the proposed fee schedule: CMS’ proposed update to clinical labor pricing to reflect up-to-date U.S. Bureau of Labor Statistics wage data, the first such change in nearly 20 years. As I told you in September, the AAFP not only favors this idea; we want it to be implemented in full ASAP.

    Naturally, some of the Academy’s peers in the house of medicine disagree. But neither primary care physicians nor their patients can afford to see this can continue to get kicked down the road. Budget neutrality’s painful byproducts are now being further exacerbated by a pandemic that has led to temporary practice closures, reduced visit volume and increased spending on personal protective equipment and other unbudgeted measures.

    Primary care staffing shortages are an urgent problem in need of serious solutions. This counts as one. Inadequate payment for clinical labor impedes AAFP member physicians’ ability to pay their nurses and medical assistants adequately, leading recruitment and retention to suffer and holding hostage the future of the specialty.

    Incrementalism here just won’t do.

    Stephanie Quinn is senior vice president of advocacy, practice advancement and policy.


    Stephanie Quinn, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.  Read author bio »


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