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Monday Oct 08, 2018

We're Making Progress on the Issues That Matter to FPs

It seems like just yesterday we were finishing our work at the AAFP's Congress of Delegates in San Antonio. In reality, I was installed as Academy president at that event a little more than a year ago. My term as AAFP president ends this week when the COD wraps up in New Orleans.

It has been my privilege to serve the past 13 months, and I would like to provide some thoughts on the direction of our specialty and the work that remains to be done.

Several years ago, the Academy's Board of Directors focused the AAFP's strategic priorities on the four points members consistently say they need help with: payment reform, practice transformation, workforce and clinical expertise.

We made some good progress on these issues during the past year, and we have identified specific threats and opportunities to concentrate future work on.

Payment Reform

Payment reform consumed a great deal of the Academy's energy this past year, with some promising developments. A core principle guiding all our efforts is that increasing the overall spend in primary care will bring better quality and lower costs. We all are painfully aware of the current, abysmal six to eight cents of the health care dollar that currently goes to primary care. Our goal is to double that.

Some states already understand. We're working to show the whole country the wisdom of following the lead of states such as Rhode Island, where regulation has increased primary care spending to 13 percent, and Oregon, where it rose to 12 percent through legislation. Along the way, we need to make sure there's a good, uniform definition of what constitutes primary care. I think we would all agree that cost centers such as specialty pharmacy, specialty pediatrics and specialty psychiatry do not qualify.

One of my highlights from this past year was being part of the team that presented the Academy's Advanced Primary Care Alternative Payment Model (APC-APM) to the Physician-Focused Payment Technical Advisory Committee (PTAC), which evaluates alternative payment models for HHS. Through the tremendously diligent work of many within the AAFP's Practice Advancement Division, on Dec. 19, PTAC recommended the APC-APM for testing.

HHS said our model "offers promise," and the Academy has remained actively engaged with both CMS and the Center for Medicare and Medicaid Innovation to continue working toward payment models that emphasize primary care. We'll hold on to the principle that payments must support the infrastructure required to deliver the core advanced primary care functions of care management, planned care, population health, comprehensiveness, coordination, patient and caregiver engagement, access, and continuity.

Practice Transformation

One of the most crucial elements of the effort to improve advanced primary care delivery is reducing administrative burden. The average family physician handles 38 prior authorization requests each week. (That sounds like a slow week to me, but I digress.) We also spend an average of 3.9 hours each week reporting quality metrics, at a cost of $40,069 each year. On average, family physicians participate in seven or more payer networks. Thirty-seven percent of us deal with as many as 10 payers.

It compounds our difficulties to juggle seven or more prior authorization programs, utilization programs and quality metric sets. Of course, none of these are harmonized, and documentation guidelines remain arcane and meaningless to patient care.

Relief from this burden is our top advocacy issue, and there has been some movement on this front. In September of last year, CMS pledged to decrease administrative burden at the federal level through its new Patients Over Paperwork initiative. I provided comments on behalf of our members when CMS Administrator Seema Verma, M.P.H., announced the program.

Shortly after that event, CMS also announced the Meaningful Measures initiative to reduce duplicative and purely process-driven metrics. To date, this has led to the removal of roughly 25 percent of all existing quality measures -- not exactly the answer to our call for core measures sets that are uniform for all payers, but a step in the right direction.

On the other hand, we told CMS that the agency was moving in precisely the wrong direction with elements of the proposed Medicare physician fee schedule that would blend payment for levels 2-5 in the Medicare evaluation and management codes, and apply a 50 percent reduction to the lower payment of either a procedure or E/M code that's done on the same day with a -25 modifier. This could incentivize lower acuity care done in more frequent visits, which is not sustainable, patient-centric, rewarding or comprehensive, and does not move us toward value-based payment. In short, it would continue to shackle us to the fee-for-service hamster wheel that undervalues and demeans primary care.

Your AAFP sent a strong message opposing this, not only through our 92-page response letter but also in communications to CMS during the past several weeks, many of which I participated in.


Closely tied to the delivery of advanced primary care is the need for a robust workforce that meets the needs of our patients. An aggressive goal has been set to increase the percentage of U.S. medical school graduates matching in family medicine to 25 percent by 2030. This 25 by 2030 initiative, a result of the Family Medicine for America's Health project, will be a joint effort by all of the "family of family medicine" organizations. This is a critical piece of the overall viability of our specialty and the ability to deliver high-quality, cost-efficient care to our country.

An equally large threat to our workforce is physician burnout, which is increasingly being seen among medical students and residents, not just those in practice. It will obviously jeopardize our efforts related to 25 by 2030 if we can't make significant progress on this for our members and our specialty.

I spoke about the issue at the Academy's first Family Physician Health and Well-being Conference in Naples, Fla., this past April. More than 500 physicians attended, which was encouraging, but also saddening when I listened to the stories being told.

Members are finding help in the AAFP's Physician Health First resources, and there is no doubt that resilience and mindfulness are important parts of the solution to this epidemic. But until the drivers of burnout are corrected, we are only putting our finger in the proverbial dike. We will continue our all-out effort to address this crisis.

Because one driver of physician burnout is continuing certification, the AAFP Board formed a task force to examine the issue in the summer of 2017. This spring, the Board adopted the task force's recommendations, including a policy that states that certification "should not be used as an absolute requirement for decisions involving licensure, employment, payment, credentialing or privileging" and a guideline that establishes principles for the evaluation of family medicine specialty certifying boards.

In addition, in March, I provided comments to the Vision for the Future Commission of the American Board of Medical Specialties and Council of Medical Specialty Societies. This commission is charged with reviewing and understanding continuing certification within the context of the practice of medicine.

I emphasized that it is critical that certifying boards consider physicians -- not just the public -- as key stakeholders in the overall process. That process must be meaningful and enhance patient care, and it must not be an added burden. Finally, we must have alternatives to the high-stakes, proctored exam for ongoing certification.

More recently, I participated in the ABFM strategic planning session in Lexington, Ky. Twenty stakeholders were invited to the session, many of them members of the Academy. It was a chance for us to participate in the process of considering changes to ensure certification is meaningful and relevant. I believe we are seeing improvements in aspects of continuing certification, such as the ability to now satisfy some requirements by attesting to quality and process improvement initiatives that many of us already are doing in our practices.

Clinical Expertise

The AAFP continues to speak out on attempts to intrude on the patient-physician relationship. Standing with our colleagues from the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the American College of Physicians, we issued joint principles to protect the patient-physician relationship and keep external interference out of the clinic and out of the practice of medicine. These principles

  • support participation of any qualified provider in federal- and state-funded programs;
  • protect coverage for essential health benefits, such as maternity care and women's preventative services, including contraception;
  • support the continued funding of evidence-based federal programs, including Title X; and
  • reject government restrictions on information our patients receive from us.

We must fight to protect our ethical obligation to help our patients make choices consistent with good medical practice.

This year, the Academy also rolled out several resources related to the social determinants of health as part of The EveryONE project. We understand the critical role these social determinants play for our patients and communities. A person's ZIP code is a more powerful determinant of health than one's genetic code. Our Center for Diversity and Health Equity continues to support these efforts.

This past year has been an incredible journey, with experiences and events I never could have imagined. In my travels, I met many people in all walks of life. Invariably, the conversations would turn to "What do you do for a living?" I've never felt more pride than when I replied, "I am a family physician, and I represent family physicians across this country."

From the bottom of my heart, I want to thank you for the opportunity, privilege and tremendous blessing to represent us, our specialty and this incredible organization.

Michael Munger, M.D., is president of the AAFP. He transitions to the role of Board chair on Oct. 10.

Posted at 04:33PM Oct 08, 2018 by Michael Munger, M.D.

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