Growing Influence of Primary Care Recognized at Congressional Conference

Changes in Payment Models, Training Reforms Focus of FMCC

May 17, 2013 05:15 pm James Arvantes Washington –

AAFP President Jeff Cain, M.D., right, talks with Rep. Joe Heck, D.O., R-Nev., shortly before Heck addresses the 2013 Family Medicine Congressional Conference.

This year's Family Medicine Congressional Conference (FMCC) took place amid growing optimism that Congress finally would succeed in repealing and replacing the sustainable growth rate (SGR) formula with a Medicare payment system that would better recognize and reward physicians who provide primary care services.

"Congress and the administration are really engaged in dialogue to move beyond the SGR," said family physician Jason Dees, D.O., who introduced a plenary session on primary care payment and valuation at the FMCC on May 14. "And we all know that is essential for the health of our practices."

Dees cited the move toward a Medicare payment fix as an example of the AAFP's lobbying and advocacy work paying off. "Today, as we make this progress, we have to look at what is coming next," he said when introducing a panel on physician payment and valuation.

Story highlights
  • This year's Family Medicine Congressional Conference (FMCC) focused on attaining adequate payment for primary care, including efforts to create separate evaluation and management codes for primary care physicians.
  • Speakers at the conference also described congressional attempts to repeal and replace the sustainable growth rate this year.
  • In addition, FMCC participants addressed workforce issues, including the need to train more primary care residents in community-based settings.

The Congressional Budget Office (CBO) recently said the cost of repealing the SGR fell to $138 billion, a decrease of $107 billion from a previous CBO score. The agency further refined that estimate on May 15 by adding $1 billion, which still is far less than previous estimates, raising renewed hopes that Congress will repeal the SGR this year.

Congress still will have to find offsets in the budget to pay for an SGR fix, regardless of the cost, according to Julius Hobson Jr., a senior policy adviser for the Polsinelli law firm and one of the panel speakers. This will be difficult to achieve in the current budgetary environment, said Hobson. However, he added, Congress started to address the SGR early this year, fueling optimism that lawmakers would repeal the formula before the end of the year.

Sen. Max Baucus, D-Mont., chair of the Senate Committee on Finance, and Sen. Orrin Hatch, R-Utah, the senior Republican member of the committee, recently sent a letter to the AAFP and other physician organizations asking for suggestions and input on how to develop a "more viable alternative to the SGR that will provide stability for physician reimbursement and lay the necessary foundation for a performance-based payment system."

In the House, the Ways and Means and the Energy and Commerce committees have developed a joint draft outline that would repeal and replace the SGR with a payment system that would move Medicare from a volume-based to a value-based purchaser of health care services.

The House proposal is made up of three stages:

  • a period of stable payment updates,
  • an additional variable rate based on quality-of-care measures, and
  • efficiency bonuses for physicians who perform well in both quality and efficiency.

Hobson, however, expressed concerns about using quality-of-care measures. Risk-adjusted mechanisms have to be in place to assess the health of patients and determine whether physicians actually are meeting the quality measurements, said Hobson. Family medicine and other physician specialties should be allowed to develop measurements for their particular practice areas, he added.

FMCC Draws Record Number of AAFP Members

Nearly 250 family physicians, residents and students attended this year's Family Medicine Congressional Conference (FMCC) on May 14 and 15, making this year's event the most heavily attended FMCC conference ever.

"We hope this is a sign of continued commitment for family medicine on Capitol Hill," said Marc Price, D.O., from Mechanicville, N.Y., who provided opening remarks at the conference.

In addition, this is the first year three members of Congress, all of whom are physicians, addressed the FMCC. Each provided conference attendees with medical perspectives on the work of Congress.

Rep. Joe Heck, D.O., R-Nev., and Rep. William Cassidy, M.D., R-La., provided insights into physician payment issues currently before Congress, and Rep. Ami Bera, M.D., D-Calif., shared views on the importance of physician involvement in the legislative process.

Recognizing Value

Despite efforts to move from a volume-based to a value-based health care system, fee-for-service will remain in place for the foreseeable future, according to Fauzea Hussain, vice president of reimbursement and product commercialization for Avalere Health LLC, a health care policy and research firm.

"We are still going to be living in a fee-for-service world, so we have to continue to look at ways of adjusting the fee-for-service system to appropriately recognize and pay for primary care services," said Hussain, who addressed efforts to improve the valuation of primary care.

The AAFP is leading an effort to create new evaluation and management (E/M) codes for primary care to better reflect the care and services provided by primary care physicians. As part of this effort, the AAFP has partnered with Avalere Health.

"We began working with the Academy last year and essentially proposed to validate our hypothesis that visits to primary care physicians as described by the evaluation and management code are more complex and deserve preferential payment than those billed by (sub)specialists," said Hussain.

Moreover, the use of the same E/M codes for primary care physicians and subspecialists "shortchanges primary care physicians in economic terms because a single set of relative value units and payment level are assigned to it," said Hussain.

This has particular importance for primary care physicians because they rely more on E/M codes to describe and bill for their work, according to Hussain. For example, office-based E/M services represent 55 percent of total relative value unit-based Medicare payments to family physicians but only 17 percent of Medicare payments to (sub)specialists, he said.

"One of the benefits of being in primary care is you have a really robust set of guidelines and quality metrics," said Hussain. "The downside of that is when you are looking at programs that are incorporating these measures. The (metrics) tend to be heavy on measures that are burdensome to primary care providers."

Physician Workforce

The need for physician workforce reform also played a prominent role during this year's FMCC. Speakers addressed the Teaching Health Center Graduate Medical Education, (THCGME) program, an initiative passed as part of the 2010 health care reform law that provides graduate medical education (GME) money directly to community-based ambulatory care centers instead of teaching hospitals.

"This is very different from the way that Medicare pays for our traditional residency programs," said Frederick Chen, M.D., M.P.H., chief of family medicine at the Harborview Medical Center in Seattle. "For Medicare GME, the sponsoring institution is almost always the teaching hospital."

The goal of the program is to boost the number of primary care residents who train out in the community where most primary care is practiced and delivered. According to Chen and other speakers, the program has led to the creation of 37 successful teaching health centers during the past few years, the majority of which are family medicine residencies.

However, the THCGME program is set to expire in 2015 unless it is reauthorized and funded. Joseph Gravel Jr., M.D., residency director of the Lawrence Family Medicine Residency Program in Massachusetts, described the THCGME program as a "paradigm shift," saying it is a model that is important to family medicine.

"There is no shortage of money going to residency programs," said Gravel. "It is just very maldistributed, just like physicians are."