A recent White House executive order meant to bolster Medicare includes some good ideas -- but it also contains a poison pill that would jeopardize high-quality, team-based primary care, the Academy warned the administration in an Oct. 11 letter.
"The AAFP opposes recommendations included in the executive order that seek to eliminate supervision requirements and create parity in payments between physicians and nonphysician providers," said the letter,(2 page PDF) which was sent in response to an Oct. 3 order titled "Protecting and Improving Medicare for Our Nation's Seniors."(www.whitehouse.gov)
"We strongly disagree that greater collaboration can be achieved through independent practice for nonphysicians," the Academy wrote. "Furthermore, creating equity in payments would not only disincentivize team-based care, it would facilitate increases in volume of low-value care by nonphysicians."
The correspondence was sent to President Donald Trump, with HHS Secretary Alex Azar and CMS Administrator Seema Verma, M.P.H, copied, and was signed by Board Chair John Cullen, M.D., of Valdez, Alaska.
In conjunction with that letter, the AAFP issued a memo to its members(6 page PDF) about the political context and potential impact of the order.
- The Academy recently objected to elements of a White House executive order regarding Medicare that are inconsistent with AAFP policy on coding and payment.
- "The AAFP opposes recommendations included in the executive order that seek to eliminate supervision requirements and create parity in payments between physicians and nonphysician providers," said the Academy in an Oct. 11 letter to the White House.
- "The AAFP shares your desire to take accelerated steps to reduce the administrative burden placed on family physicians participating in the Medicare program," the letter added.
Noting that the president announced his order in express opposition to the Medicare for All Act of 2019(www.congress.gov) -- legislation, Trump said Oct. 3, that "would destroy our current Medicare program" -- the memo outlined the AAFP's reactions to each of the proposed policies in the order, several of which the Academy supports.
The memo also reiterated the AAFP's forceful opposition to a section titled "Enabling Providers to Spend More Time With Patients," which directs that "items and services provided by clinicians, including physicians, physician assistants and nurse practitioners, are appropriately reimbursed in accordance with the work performed rather than the clinician's occupation."
The AAFP's memo called this segment of the order vague, confusing and inconsistent with Academy policy on coding and payment. During any subsequent rulemaking process, the Academy -- in keeping with its longstanding guidelines on the supervision of certified nurse midwives, nurse practitioners and physician assistants -- said it "opposes the independent practice of nonphysician providers and equity in payment for those who may have independent practice authority under state law."
The response is in line with the Academy's vigilance on scope-of-practice issues.
In September, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy Shawn Martin wrote in an In the Trenches blog post, "It is a demonstrable fact that every physician, regardless of specialty, has successfully achieved significantly more hours of didactic and clinical education than every nonphysician provider."
Prompting approval from the Academy, on the other hand, were the order's approach to reforms aimed at administrative complexity, site-neutral payments and network adequacy.
"It is well documented that the complexity and costs of complying with current administrative requirements in the Medicare program are having a profoundly negative impact on the economic viability of family medicine practices, distracting physicians from patient care, creating patient safety hazards and destroying physicians' professional satisfaction," the Academy told the White House.
And the letter pointed out that "the AAFP shares your desire to take accelerated steps to reduce the administrative burden placed on family physicians participating in the Medicare program."
The Academy also noted its appreciation of the administration's "continued commitment to creating site-neutral parity in payments for health care services."
"Policies that provide differential payments based solely on the site where services are provided are not warranted," the letter said.
And the Academy praised the order's aim to improve patient access to physicians.
"The fluidity of Medicare Advantage networks, coupled with the one-sided, insurance-dominated contracting process, should be evaluated and reformed," the letter said. "All family physicians should be considered in-network for all MA plans unless there are extraordinary reasons for exclusion."
The letter advised against prioritizing Medicare Advantage over the traditional Medicare program.
"Despite the rapid growth of the MA program, a majority of seniors continue to reside in areas where an MA plan is not available," the AAFP said. "To ensure equity in access and affordability for all seniors, it is imperative that the traditional Medicare program be preserved and improved."
Likewise, the Academy expressed concern about the order's possible expansion of direct contracting beyond primary care.
"Allowing seniors the ability to individually navigate the health care system -- negotiating their own terms with hospitals, long-term care, physicians, etc. -- would create tremendous challenges and likely would not produce improvements in quality and cost," the letter cautioned.
Noting that the executive order directs HHS to study, develop and propose policies that achieve its directives across separate 180-day and one-year deadlines, the Academy's memo reminded members that the order does not have the effect of law. Rather, it's a set of proposals that must comply with the rulemaking process.
"We have already initiated conversations with the administration via the White House and HHS, and we will continue this engagement in the weeks and months ahead as we work to shape the policies in a manner that is beneficial to family medicine," the memo said.
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