• AAFP to CMS: Medicare Rules Must Cut Burden, Empower FPs

    Academy Advises Agency on Changes to Medicare Advantage, Part D

    April 16, 2020 09:16 am News Staff – As CMS considers new rules for the Medicare Advantage and Medicare Part D programs, the AAFP has advised the agency to focus on changes that make it easier for family physicians to care for their patients.

    physician and patient discussing care

    Specifically, the Academy said in an April 6 letter to CMS Administrator Seema Verma, M.P.H., that new rules should reduce prior authorization and other burdens that take time from patient care, prioritize team-based care led by primary care physicians and support physician-patient decision-making with greater transparency and patient education.

    The letter, signed by Board Chair John Cullen, M.D., of Valdez, Alaska, was sent in response to a proposed rule published in the Feb. 18 Federal Register.

    Administrative Burden

    Family physicians cite administrative burden as one of their top concerns, so the AAFP devoted much of the letter to outlining steps CMS should take to cut down on the time physicians spend on documentation and phone calls that do not directly involve patient care.

    One of the most frustrating of these time sinks is prior authorization, which keeps physicians from seeing more patients, threatens patient care and all too often leads to denials that are overturned on appeal.

    "Uncertainty as to whether the care recommended by your physician can be received, and if so, when it can be, is extremely stressful for patients," the Academy wrote. "For a physician, having to delay treatment until a health plan makes a prior authorization determination can be an administrative hassle and, more importantly, can potentially lead to worsening patient health outcomes."

    Citing a 2018 audit report from the HHS Office of Inspector General, the letter pointed out that Medicare Advantage plans overturn 75% of their own prior authorization and payment denials when beneficiaries or their health care professionals appeal.

    The AAFP advised CMS to make three changes:

    • Measure prior authorization approval rates by service and set a standard for when prior authorization should no longer be required, such as when the service is routinely approved more than 90% of the time.
    • Measure the rate of successful denial appeals and establish a threshold for when this rate is excessive.
    • When prior authorization is called for, require that a decision be made within 24 hours for urgent care and within 48 hours for nonurgent care.


    The Academy supported changes that CMS proposed to improve quality measurement, with an emphasis on reducing the burden on physicians by using automatic data extraction and aligning measurements with those identified by the Core Quality Measures Collaborative. 

    "Measure burden must be kept low, as physicians are the ones who bear the ultimate burden of data submission when data abstraction is required," the AAFP wrote.

    In response to a proposal for two new process measures -- one on follow-up after ER visits for patients with multiple chronic conditions and the other on transitions of care -- the letter acknowledged that this data may improve patient care but added the important caveat that it will require timely notification from the ER.

    Finally, the Academy supported CMS' proposal to make the Medicare Star Rating System more stable and predictable by reducing the influence of outlying data points and increasing the weight of patient experience and access measures.

    Physician-led Health Teams

    CMS proposed improving network adequacy for Medicare Advantage plans by reducing the percentage of beneficiaries who must live within a plan's maximum time and distance standards from 90% to 85% and encouraging use of telehealth.

    This might work if plans are carefully monitored, the AAFP wrote, but a better approach would be to simply allow all family physicians to participate in any Medicare Advantage plan they wanted to, absent an extraordinary reason for exclusion.

    "Primary care capacity should be the focal point of network adequacy, and CMS should examine the percentages of family physicians and other primary care physicians participating in rural areas," the letter added.

    And it's crucial that plans' physician-to-beneficiary ratios count only physicians, not nurse practitioners or physician assistants, the Academy wrote, "because listing these providers creates the illusion that there is more access to physicians."

    "Family physicians are particularly qualified to lead the health care team," the letter continued, "because they possess the skills, training, experience, knowledge and leadership needed to provide comprehensive medical care, health maintenance and preventive services for a range of medical and behavioral health issues."

    Patient Transparency

    The AAFP supported proposals that would require Part D plans to offer up-to-date, patient-specific information on prescription drug costs and to educate beneficiaries about opioid risks, alternatives and disposal.

    The requirements regarding opioids would help prevent and treat opioid overuse, the letter said.

    Regarding the information on drug costs, which would take effect on Jan. 1, 2022, the AAFP noted that easy access to plans' formularies and benefit data would allow for more effective shared decision-making between physicians and patients.

    "Improving access to cost, quality and population health management information related to services furnished to their patients by other providers will enable family physicians and their patients to make better-informed decisions that consider both cost and quality."