An early morning breakfast at the AAFP's 2018 National Conference of Constituency Leaders that was billed as an update from CMS on the Quality Payment Program (QPP) turned into something quite different -- and far more meaningful to the hundreds of family physicians in attendance.
CMS' Patricia Meier, M.D., addresses a room packed with family physicians during an early morning session at the AAFP's 2018 National Conference of Constituency Leaders.
To the delight of her audience, Patricia Meier, M.D., chief medical officer for CMS' Kansas City Regional Office, decided to forgo her official QPP slide set and turned the event into a listening session.
''I came with slides, but when I look around this room, I think it's critical for me to to use this opportunity to listen to you today on things that we (CMS) can do to make life better for you," said Meier. The goal, she added, was to reduce the regulatory burden imposed on physicians and "bring back some of the joy of practicing medicine."
That statement was the first line to draw applause at the session, but certainly not the last.
For the next 40-plus minutes, family physicians lined up at two microphones to vent their frustrations with a system that has made practicing medicine challenging, to say the least.
First in line was Florida AFP Board Chair Dianna Twiggs, M.D., of Fernandina Beach. "First I want to say, as family physicians, a little piece of our soul dies every time we're lumped in with 'providers' rather than as family physicians who are board certified and trained."
- An early morning session at the AAFP 2018 National Conference of Constituency Leaders featured a Town Hall meeting followed by a listening session led by a local CMS official.
- CMS' Patricia Meier, M.D., discarded her slide set in favor of inviting physicians in the audience to tell her how CMS could make their practices less burdensome.
- Family physicians flocked to two microphones and detailed some their biggest challenges in taking care of their patients.
Regarding patient care, Twiggs said excessive documentation in electronic health records was both expensive and a waste of time. She described the endless clicking and searching in a patient's medical record just to get to the right box to record a foot exam for a patient with diabetes.
"The way we have to prove our value is incredibly burdensome," said Twiggs, and it has to change. "This doesn't improve the care I provide at all, and it costs me three to five extra minutes per patient."
The Three-Day Rule
Nick Dahl, D.O., of Washington, Ind., took to the microphone with a positive story. Dahl is employed by a medium-size hospital system and sees patients in one of its outlying clinics. He told Meier that his hospital is part of an accountable care organization (ACO) pilot that was granted an exception to a CMS rule that drives physicians nuts.
"A year ago, the ACO allowed the hospital to let physicians decide when their patients needed to be admitted to a nursing home without the three-day hospital stay. I'm here to tell you it saved hundreds of thousand of dollars," said Dahl.
He recalled an 80-year-old patient who was dwindling and had multiple medical problems. Dahl knew that a hospital admission would result in a barrage of expensive and unnecessary tests.
"I know she's depressed because her husband died last month. All she needs is a little bit of help for a week or two and some rehab, and she can go home." Relaxing that rule allows the physician who knows her to make decisions that are in her best interest, "because I know her social determinants of health," said Dahl.
The three-day rule should be rolled back nationwide, he told Meier.
New Jersey AFP President Peter Carrazzone, M.D., of North Haledon, practices in an independent group practice and said this about documenting under CMS regulations: "My issue is the amnesia that seems to happen on a yearly basis; every year we do the AWV (annual wellness visit) just to go through the 15-20 diagnoses with the patient, because every year, Medicare seems to forget the patient has had an amputation or diabetes.
These chronic conditions don't go away, and it's a big burden to make sure we document everything."
New York State AFP President-elect Marc Price, D.O., of Mechanicville, N.Y., tells CMS' Patricia Meier, M.D., during a listening session that he was pleased when his small group practice was accepted into the Comprehensive Primary Care Plus program, but says the burdens are incredible. "It's costing more money than I'm getting from CMS … and we get little direction unless we do something wrong," said Price.
Another documentation issue was raised by Kay Jacobson, M.D., clerkship director at the University of Maryland School of Medicine in Baltimore. "I send a lot of our students out to work with community preceptors, and people there were very excited about the student documentation rule change," she said.
Preceptors reacted with, "Finally, something the students can actually help me with, not just extend my day," said Jacobson. However, it is unclear what needs to be reviewed in the documentation and if the attending needs to be present while the student is taking notes.
Physicians need clarification on a couple of points, she said. "There is no attending in private practice who has time to sit there and watch a student dwindle through obtaining a history. Also, what is the appropriate attestation language to use?" Jacobson asked.
Time as a Limited Resource
Susan Osborne, D.O., is a solo rural physician in Floyd, Va. "I know my patients well; I spend an hour with each one. I work from nine to five and then start work on that large stack of papers," she said.
Osborne told Meier she spends way too much time on the phone with middle managers trying to get patients the medications they need. Case in point: a recent nursing home patient with a drug-resistant infection. Trying to get the antibiotic the patient needed was a struggle.
"I'm talking to a nonmedical person -- who's put me on hold for 20 minutes, hung up on me twice -- trying to explain drug-resistant infection. This is making us crazy," Osborne said. It seemed that her time "was the least important thing in the entire equation," she added.
Many FPs drew applause with their remarks at the microphone, but none more than Jeffrey Bachtel, M.D., of Tallmadge, Ohio, who is part of a Comprehensive Primary Care Plus (CPC+) practice.
"For me, the biggest burden in our practice is prior authorization for drugs," said Bachtel. He said the majority of his Medicare patients have Medicare Advantages plans -- each with a unique drug formulary that is subject to change without notice.
In fact, "Many plans now require prior authorization for generic drugs, which is absolutely the dumbest thing I've ever heard of in 34 years of practice. I'm talking about inexpensive generics that patients have been on for years that we have to beg and plead to get covered," said Bachtel.
"The medical assistant in my office is ready to quit on many days because she spends hours trying to get lisinopril approved."
Prior to a CMS presentation, AAFP leadership, from left, Speaker Alan Schwartzstein, M.D.; President Michael Munger, M.D.; Board Chair John Meigs, M.D.; President-elect John Cullen, M.D.; and EVP Douglas Henley, M.D., take questions from family physicians in a short town hall meeting. Family physicians asked about a variety of issues, including maintenance of certification, the AAFP's Advanced Primary Care Alternative Payment Model, the Merit-based Incentive Payment System and the primary care workforce.
Durable Medical Equipment
Anna McMaster, M.D., of Liberty Center, Ohio, is part of a small family practice group in Northwest Ohio that is affiliated with a larger health system in the Toledo area.
"I'm going to email you my list," she told Meier, before relating a story about unreasonable durable medical equipment (DME) requirements that involved a patient seen in McMaster's office late on a Friday afternoon with chronic obstructive pulmonary disease exacerbation and a broken aerosol machine.
"CMS would not give the DME store authorization to dispense machine," said McMaster, until the store faxed an additional form to be filled out -- at 4:30 p.m. on Friday.
"The hoops we have to jump through," she sighed. "Just believe us -- take the prescription and fill it."
Ditto for diabetic shoes, said McMaster. "Believe me, she has diabetes. She's had it for five years, and she's missing three toes. She's still missing three toes. I don't need to fill out copious notes that it hasn't changed since last year."
Rachel Carpenter, M.D., of Denver complained to Meier about a major coding headache.
"I spend way too much time trying to guess the right ICD-10 code to get certain labs and images. I get a call from a nonclinical person who says, 'We cannot cover this (osteoporosis) DEXA screen because you didn't put in the right code,' or 'We can't cover this lipid panel,' even though it's all evidence-based medicine.
"So I say, 'Which ICD-10 code would you like me to use?' And the response I get is, 'We don't know, it's just not this one.'"
Too Many Quality Measures
Dennis Salisbury, M.D., of Butte, Mont., is the chief medical officer for his group practice that is part of a small hospital system. His experience as a CPC+ practice has been good, but he pointed out a few flaws.
For instance, payers "absolutely have not lived up to their job" of helping to pay for the improved process of care. "They need to be held to task, because that was part of the deal for them," said Salisbury.
Additionally, he recommended a reduction in the number of quality measures. "I suggest letting practices choose three to five measures. Once a practice gets the process down and improves everyone's A1c, they'll say 'What's the next measure? What else can we do?'"
For her part, Meier listened well, took notes, and assured her audience that she would take all their comments back to CMS. She also invited -- in fact, encouraged -- family physicians to email her with additional comments, and even dictated her email address right from the stage.
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