AAFP, Other Primary Care Groups Urge Changes in Implementation of Incentive Program

November 02, 2010 05:40 pm News Staff

The nation's leading primary care organizations have called on CMS to implement the Medicare Primary Care Incentive Program, or PCIP, in a way that does not exclude a significant number of primary care physicians from participating in the program. The Medicare PCIP provides for a 10 percent bonus for primary care services.

According to the Patient Protection and Affordable Care Act, Medicare will start paying certain primary care physicians -- those whose primary care billings comprise at least 60 percent of their total Medicare-allowed charges -- a 10 percent bonus for the primary care services they provide. The Medicare bonus will be in effect from January 2011 to December 2015 and will be paid quarterly.

The AAFP, along with the American College of Physicians, the American Osteopathic Association and the National Rural Health Association, have sent a joint letter to CMS telling the agency that its proposed implementation of the program will "preclude a significant number of primary care physicians who are providing comprehensive and longitudinal care from receiving the 2011 incentive payment." Primary care physicians in rural areas are likely to be the most adversely affected, according to the letter.

The AAFP and the other organizations identified barriers that would prevent these primary care physicians from receiving the bonus. "The proposal includes all Medicare Part B charges in the allowed charge denominator -- out of which at least 60 percent of charges must be derived from designated primary care services," the coalition letter says. Therefore, the letter adds, physicians who maintain an in-office laboratory to provide timely testing, for example, would be less likely to qualify for the bonus.

In addition, the proposal puts rural primary care physicians at a disadvantage because they typically provide a broad range of services, say the organizations. They point to a paper(www.graham-center.org) from the AAFP's Robert Graham Center that discusses the fact that rural primary care physicians often perform minor procedures, such as aspirations, joint injections and skin lesion removals, in addition to providing inpatient and emergency care. These services and procedures fall outside the realm of specified primary care services that are part of the PCIP, so it likely will be difficult for rural physicians to meet the 60 percent threshold needed to qualify for the incentive.

Moreover, the PCIP proposal penalizes all primary care physicians who treat hospitalized patients, according to the letter. "Following a patient in the hospital setting provides continuity of care and is a hallmark of traditional primary care practice," the letter says. Although the hospitalist movement has reduced the number of hospital visits made by the patient's primary care physician, say the organizations, a significant number of primary care physicians still make such visits.

The letter further points out that beneficiaries in urban areas are more likely to receive inpatient care from a hospitalist, again leaving rural primary care physicians disproportionately harmed by criteria that characterize hospital care as inconsistent with primary care, the letter says.

All this, the organizations note, is in spite of the fact that, using data from the American Board of Family Medicine and the Dartmouth Atlas, the Graham Center found a strong association between a broader scope of practice in primary care and reduced Medicare costs.

The organizations have urged CMS to take the following actions:

  • establish the denominator as charges derived only from Medicare Physician Fee Schedule professional services;
  • count hospital evaluation and management, or E/M, services as designated primary care services, which would allow the associated allowed charges of these services to count as part of the 60 percent minimum allowed charges threshold;
  • expand the list of primary care services for physicians in rural areas to include emergency department E/M services and some minor procedures; and
  • allow rural primary care physicians whose Medicare-allowed charges from inpatient and emergency services are under a certain threshold (e.g., 50 percent) to qualify for the PCIP.

"Our recommendations are consistent with those contained in the official comment letters submitted by our respective organizations prior to the Aug. 24 public comment deadline," the letter states. "This letter -- and the recommendations it contains -- is not meant to substitute for each organization's previously submitted recommendations."

Rather, the letter's recommendations are intended to highlight that primary care and rural organizations are united in their concern that the PCIP program will fail to meet its intended goal of boosting support for primary care physicians if CMS finalizes its proposed implementation of the program. Moreover, says the letter, the recommendations demonstrate that the AAFP and these other primary care organizations are united regarding the type of modifications CMS needs to make in the final rule.