More than just the calendar year will end on Dec. 31. The New Year also will mark the end of the Primary Care Incentive Program (PCIP).

The PCIP, created in 2010 as part of the Patient Protection and Affordable Care Act, pays family physicians and other primary care providers bonuses equal to 10 percent of the amount Medicare paid them for primary care services if they met certain conditions. This bonus was an overdue step toward recognizing the value of primary care.

The program paid $664 million to primary care practices in 2012, but how much it will be missed depends somewhat on whom you ask. A survey of primary care physicians found that half were unaware of the program's existence.(kaiserfamilyfoundation.files.wordpress.com) Some physicians "boutique" their practices, limiting their number of Medicare patients. But many practices in rural and underserved areas can't do this, and they benefited greatly from the bonus payments. Practices with large Medicare panels certainly will feel the hit. Qualifying primary care physicians received an average of nearly $4,000 a year.

Although the AAFP and other primary care advocates fought for an extension of the program, Congress showed little interest in prolonging a bonus program based on the fee-for-service model. As we have seen in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) -- the law passed earlier this year that repealed the flawed Medicare sustainable growth rate formula -- legislators are more interested in linking increased physician payments to certain quality and performance standards.

If you haven't already, I strongly encourage you to start making yourself familiar with the alternative payment models and the merit-based incentive payment system (MIPS) described in the new law. By 2019, all physicians participating in Medicare will fall into one category or the other.

MIPS, while attempting to promote quality and added value, still is based on fee-for-service. And as we have seen, that model continues to be a popular target for spending cuts. A multi-year federal budget agreement led to a 2 percent cut to Medicare payments in 2013 and further incremental reductions for several years, and Congress allowed the Medicaid parity program -- a provision of the ACA that raised Medicaid physician payments in line with Medicare -- to expire in December 2014.

The 2016 physician fee schedule called for a modest 0.5 percent increase in the physician payment conversion rate. However, other legal mandates made even that minimal increase too tall a task for CMS because it failed to identify and adjust a required percentage of overvalued CPT codes. As a result, the Medicare physician fee schedule will see a fractional decrease in the conversion factor in 2016, rather than a half-percent increase.

What it boils down to is that alternative payment models are the path forward that will provide stability and give our practices the greatest opportunity to thrive. One-third of family physicians already are pursuing value-based payments.

The AAFP recently submitted detailed responses to 126 questions as part of a CMS request for information on how to implement new payment models associated with MACRA. Early in 2016, the Academy will be rolling out materials that will help family physicians better understand the choices, deadlines and challenges that MACRA presents. Stay tuned.

Robert Wergin, M.D., is Board Chair of the AAFP.

We're No. 1.

Again.

For the ninth straight year, "family physician" was the most highly recruited role in U.S. health care, according to national health care search firm Merritt Hawkins.

© 2015 Tiffany Matson/AAFP Residency exhibitors talk with medical students during the 2015 National Conference of Family Medicine Residents and Medical Students. The recent event in Kansas City, Mo., attracted record-setting attendance, including more than 1,200 medical students and representatives from hundreds of family medicine residency programs.

Merritt Hawkins publishes a review each year of the more than 3,100 search and consulting assignments it conducts on behalf of its clients. In its 2015 report(www.hcpro.com), the firm noted it sought to fill 734 openings in family medicine from April 1, 2014, to March 31, 2015. Internal medicine was a distant second at 237 openings. It was the ninth consecutive year that general internist ranked second behind family physician, a fact that highlights "the continued nationwide demand for primary care physicians as team-based care and the population health management model continue to proliferate," according to the report.

The report's authors noted that primary care physicians top the list of most-in-demand doctors in part because of the key role we play in patient management and care coordination. Specifically, they likened us to point guards on a basketball team. Patients need to see us first so we can coordinate their care appropriately. We can provide comprehensive care and refer patients to expensive subspecialist care only when needed. Like a point guard, family physicians see the big picture, not merely focusing on a single issue or area.

The report pointed out that primary care physicians are being rewarded for "the savings
they realize, the quality standards they achieve and for their managerial role" in newer models of care.

"That, at least, is the aspiration of these emerging models," said the report.

"In systems where volume/fee-for service still prevails," the report added, "primary care physicians remain the keys to patient referrals and revenue generation." In fact, a 2014 Merritt Hawkins survey found that family physicians generate, on average, more than $2 million a year for their affiliated hospitals.

I don't know about you, but I'd rather be a point guard who is looked to as the leader of a health care team than as a mere referral factory.

"Regardless of which model is in place (or a hybrid of the two) primary care physicians are the drivers of cost, quality and reimbursement and therefore remain in acute demand," the report said.

And that brings us to income.

For the jobs Merritt Hawkins sought to fill, family physicians had an average starting salary of $198,000. Overall, according to the firm, family physician income has increased more than 11 percent since its 2010-11 survey.

Meanwhile, a recent report by the Medical Group Management Association(www.medpagetoday.com) (MGMA) that was based on a survey of nearly 70,000 physicians reported a median salary of $227,883 for family physicians who provide maternity care and $221,419 for family physicians who do not. MGMA reported a median salary of $241,273 for primary care physicians, which was an increase of 3.56 percent compared with the previous year's figure. The same report found that median pay for subspecialists rose 2.39 percent to $411,852.

So although primary care physician income still lags behind that of our subspecialty colleagues, it is increasing at a faster rate. Since 2012, primary care physicians' income increased 9 percent, while subspecialist pay increased 3.9 percent during the same period, according to MGMA.

Part of the reason for the change is the shift to value-based contracts. According to MGMA, 11 percent of primary care payments came from value-based contracts in 2014, up from 3 percent in 2012. Halee Fischer-Wright, M.D., a pediatrician and MGMA’s chief executive officer, said in a recent interview with Forbes(www.forbes.com) that the figure could grow to more than 30 percent within three years.

It's worth noting that Merritt Hawkins reported decreasing incomes for the positions it sought to fill in several subspecialties. Otolaryngology was down 10.2 percent, physiatry dropped 13.8 percent, urology lost 18.3 percent, and noninvasive cardiology declined a whopping 34.2 percent. OB/Gyn (-4.2 percent), general surgery (-4.2 percent), hematology (-7.2 percent) and pulmonology (-7.5 percent) also saw declines.

Our country has a critical need for primary care physicians. To convince more medical students to pick primary care, that payment gap will have to continue to shrink.

Emily Briggs, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.

Editor's note: During the AAFP's Scientific Assembly in San Diego, a panel discussion on practice transformation generated far more questions than the panelists could answer in the time allotted. This is the sixth post in an occasional series that will attempt to address the issues members raised -- including questions regarding accountable care organizations -- during the panel.

I recently attended a payment forum where family physicians expressed their frustrations with the existing health care system, as well as their hopes for the future. We discussed the need to repeal and replace the sustainable growth rate formula, payment for telemedicine and much more.

For every success story these FPs shared, there were others who talked about the challenges we face in primary care. It was a mix of dreams of the future and realities of the present.

One of those realities was the potential for change posed by accountable care organizations (ACOs). One physician grabbed the audience's attention by talking about his ACO, a group of about 40 physicians in Austin, Texas, that has negotiated a 5 percent positive payment differential with BlueCross and BlueShield.

Several physicians, in fact, talked of positive experiences with ACOs, which allow family physicians and other health care professionals to band together to pool data, develop best practices and make policy decisions that improve quality and reduce costs, and, ultimately allow them to negotiate contracts with the power of a larger group.

They didn't need to convince me. I'm the medical director and board chair of a fledgling ACO that received its charter from CMS in December. So far, we have nearly three dozen practices and about 50 physicians (mostly family physicians) on board.

CMS is encouraging ACO development by offering shared savings bonuses to participating practices. Those short-term incentives can invigorate and strengthen family medicine practices. But in the long run, ACOs will need to look beyond Medicare to thrive.

My ACO has already signed a three-year contract with Aetna that will pay fee-for-service, plus incentives for quality outcomes and cost savings as well as fees to cover the cost of administering the ACO. We're also in talks with two other large private payers with the goal of negotiating similar deals.

A representative of one of those payers told me his company sees itself transitioning from a traditional insurance model to a business based more on health maintenance. That revolutionary statement indicates that payers understand that fee-for-service is not the concept our future will be based on. Are we finally are on the verge of payment reform in this country?

We grew up with a health care system that had hospitals at the center of our medical communities, but that paradigm is about to shift radically, with primary care becoming the center of the health care delivery universe and hospitals becoming the satellites that orbit medical homes.

People resist change, especially when it doesn't benefit them. Health care and payment reform stand to benefit both primary care physicians and our patients. The need to change has been obvious for decades, but progress previously had been checked by political roadblocks. For the first time in my career, this shift is realistically achievable, and I'm doing my best to make the ACO model work.

So how does a family physician become the head of an ACO? There's no class or training that I'm aware of, so I did a lot of reading and networking and attended relevant conferences.

Maybe you don't want to run an ACO but you're interested in joining one and aren't sure how to get started. I was fortunate that in 2000, my small, rural practice joined an independent practice association, which became the basis of our ACO. Given that my experience might be the exception rather than the rule, I would suggest you look for a physician-owned and -operated ACO. If there are none in your area, look for an ACO that has primary care-led governance built into its operations. If other parties are in positions of authority, that ACO might not share your goals or want the kind of change you hope to be part of.

The patient-centered medical home (PCMH) was another topic discussed at the payment forum, and it's a vital part of the plans for our ACO. Our goal is for all the participating practices to achieve National Committee for Quality Assurance (NCQA) PCMH recognition within the next 12 months.

There has been a lot of concern from small practices about the cost and time needed to achieve PCMH recognition, but it can be done. My two-physician practice achieved Level 2 recognition by working together with other small practices in my area, and we have submitted paperwork for Level 3. Blue Cross and Blue Shield has pledged to provide a 5 percent positive payment differential for practices in our group that achieve Level 3 recognition.

There seems to be little question that fee-for-service is going to become a smaller and smaller part of how primary care physicians get paid in the future. We need to look at all the options available -- whether that be an ACO, direct primary care or something else -- and choose the best opportunity for our individual practices.

Finally, if you are interested in learning more about ACOs, or connecting with AAFP members who are participating in -- or leading -- ACO initiatives, you will be pleased to know that there are a number of family physicians interested in forming an ACO member interest group. At our most recent meeting, the AAFP Board of Directors approved the formation of member interest groups as a way to define, recognize and engage groups of AAFP active members who have shared professional interests. These groups will provide a forum for such members to have a voice in the development of Academy development.

If you are interested in participating in the formation of an ACO member interest group, contact AAFP delivery systems strategist Joe Grundy.

Lloyd Van Winkle, M.D., is a member of the AAFP Board of Directors.

Implementation of the Patient Protection and Affordable Care Act (ACA) has created several challenges in our offices and to patient work flow. For instance, does your practice have a system in place to verify patients' insurance coverage at each appointment? If not, you may need to update your office's check-in procedures.

Under rules issued by CMS, certain consumers now have a 90-day grace period to pay outstanding insurance premiums before insurers can drop their coverage. The CMS rule requires insurers to pay outstanding physician charges during the first 30 days of this grace period. However, if a consumer fails to make a payment to the insurer within the 90-day period and his or her coverage is dropped, insurers will not be required to pay for claims incurred during the last 60 days of the grace period.

That means physicians could be left to work directly with patients to collect payment for services provided during those final 60 days.

The rule, which took effect Jan. 1, applies only to consumers who purchase subsidized coverage through the ACA's health insurance marketplace. The Academy has developed an FAQ to address questions family physicians may have about the new rule.

As of Jan. 24, roughly 3 million people had enrolled(www.hhs.gov) in private insurance through federal and state marketplaces since October. People making between 100 and 400 percent of the federal poverty level(aspe.hhs.gov) can qualify for the premium tax credit health insurance subsidy. The Congressional Budget Office has estimated(aspe.hhs.gov) that 7 million people will enroll through the marketplaces before the March 31 deadline, and 86 percent of those, or 6 million, would qualify for assistance.

Although those 6 million patients represent only 2 percent of the U.S. population, the new rule presents a challenge for those of us who care for this group of patients. Again, it will important to verify eligibility for patients who have coverage through an exchange plan at every visit.

It's not yet clear how the new rule affects physicians in states with prompt pay laws. Physicians should consult with their chapters about laws and regulations in their states.

Robert Wergin, M.D., is President-elect of the AAFP.