AAFP Fights to Make Payment System Favorable for FPs

February 29, 2016 02:47 pm News Staff

Hard to believe it's been nearly one year since the Medicare Access and CHIP Reauthorization Act (MACRA) was enacted in April 2015 to effectively replace the disastrous Medicare sustainable growth rate formula.


In the ensuing months, CMS has been developing various pieces of a giant puzzle that eventually will guide how physicians are paid.

As this work progresses on many fronts, family physicians will begin to have a better understanding of phrases like episode groups, resource use measures, alternative payment models, composite performance score and merit-based incentive payment system.

With a spirt of anticipation and cooperation, the AAFP recently responded to a request for information from CMS regarding the future role of episode groups in resource use measurement(www.cms.gov).

In a Feb. 11 letter(6 page PDF) to CMS Acting Administrator Andy Slavitt, the AAFP provided detailed recommendations on more than a dozen questions posed by the agency -- with an eye toward family physicians' best interests at every turn.

Story Highlights
  • The AAFP recently responded to a request for information from CMS on payment system questions related to episodes of care and resource use measurement.
  • The questions are just part of a push by CMS to develop new measurements and methods of physician payment following enactment in April 2015 of the Medicare Access and CHIP Reauthorization Act.
  • AAFP Board Chair Robert Wergin, M.D., focused his attention on areas that strongly impact family physicians such as care management and coordination services.

For example, regarding a question about using episodes of care to measure spending and resource utilization, AAFP Board Chair Robert Wergin, M.D., of Milford, Neb., suggested an approach that "initially begins with only two episode conditions such as urinary tract infections or some of the respiratory conditions.

"Family physicians commonly see these conditions in the outpatient setting, are the first line of care delivery and have better control over these costs," he said.

Wergin also urged CMS to refine payment to encourage care management and coordination services that family physicians so often provide.

"As primary care physicians take on more responsibility for total cost of care and episode groups, payment for primary care needs to become more global and comprehensive," said Wergin.

"Additionally, prior authorization, paperwork associated with justification of clinical decisions, and other hassles intended to control utilization need to be discontinued as they add administrative burden without improving patient care."

Indeed, the heavy yoke of administrative burden was a point Wergin hammered home more than half a dozen times in the letter.

When it came to addressing care coordination and measuring resource use, Wergin took a stance firmly in primary care's corner. "With better coordination of services, some costs may increase in primary care in order to reduce more expensive, downstream costs and resource utilization.

"Primary care should not be penalized for increased resource use (e.g. more office visits) if the care coordination efforts are reducing unnecessary emergency department visits and admissions that occur downstream," he said.

Wergin noted that care coordination "will be ever more important among all members of the care team" as physicians strive to conserve Medicare resources.

"If all members of the care team are preforming the task of coordination, it would not be fair to attribute that activity only to the primary care physician when measuring resource use," added Wergin.

To ensure that CMS doesn't overlook the AAFP's top concerns, Wergin listed them in the body of the introductory letter. Specifically, he urged CMS to

  • use a slow, phased-in approach to implementing episode groups as a form of resource measurement,
  • ensure family physicians have access to subspecialist quality performance outcomes to enable informed decisions when considering patient referrals and
  • refrain from allowing an increase in upfront, primary care costs -- which ultimately serve to reduce more expensive downstream costs -- to negatively impact how family physicians are evaluated.

After considering all stakeholder feedback, CMS expects to have a draft list of care episode and patient condition groups, and applicable codes, available for public viewing by early November.

Related AAFP News Coverage
In the Trenches blog: Maximizing MACRA for Family Medicine

CMS Request for Information
AAFP Expends Huge Effort to Shape New Payment System


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Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)