AAFP Sees Equity Boost, Network Opportunities in Proposed Rule

HHS’ 2023 Notice of Benefit and Payment Parameters Draws Detailed Response

February 3, 2022, 8:50 a.m. News Staff — Health equity, administrative simplification and improved network adequacy topped the Academy’s list of concerns in guidance it recently sent HHS in response to a request for information ahead of 2023 rule-making.

“The Academy recommends HHS clarify in the final rule that the requirement for EHB benefit design to be based on clinical evidence also applies to utilization management processes, such as step therapy and prior authorization,” the letter said. “Evidence indicates that prior authorization requirements may be discriminatory and worsen health disparities. We are concerned that the unnecessary increase in prior authorization requirements, even among evidence-based, medically necessary services and medications, is creating barriers to care that disproportionately impact medically underserved patients, patients of color, those identifying as LGBTQ+ and those at risk for poor health outcomes.”

The Academy agreed with the proposed rule’s concern that benefit designs including incentives for enrollees to seek telehealth services instead of in-person services (such as waived co-pays for services provided by a telehealth vendor) could be inadvertently discriminatory. The letter called on the agency to guard against care fragmentation and worsened health outcomes by issuing a final rule that would prevent plans from steering patients away from primary care physicians in favor of direct-to-consumer telehealth companies.

The letter addressed several other elements of the proposed rule, emphasizing the following.

Network Adequacy

The Academy backed HHS’ proposal to reinstate time and distance standards in 2023, calculated at the county level and allowing for unique considerations in the qualified health plan market. “The AAFP has long supported minimum federal network adequacy standards in order to facilitate timely, equitable access to comprehensive primary care and other services,” the letter said.

However, the AAFP said that the proposed rule’s “behavioral health” standard, including both mental health and substance use disorder treatment services, was too broad.

“Without further specification, enrollees may experience challenges accessing in-network SUD treatment services,” the letter warned. “Many family physicians provide buprenorphine treatment in their practices, often serving as the only source of outpatient SUD treatment in their communities. Time and distance standards should recognize the availability of SUD treatment in primary care clinics and also acknowledge the limited capacity these practices have to take on new patients due to regulatory and other requirements.

“The AAFP recommends HHS separately monitor time and distance to both inpatient and outpatient SUD treatment services and consider implementing separate standards for SUD treatment in future rulemaking.”

The letter also strongly recommended against providing health plan issuers with credit toward time and distance standards for direct-to-consumer telehealth services.

“These types of telehealth providers cannot serve as a substitute for comprehensive, longitudinal, person-centered primary care,” the Academy wrote. “Clinicians providing telehealth services should only be included in network adequacy calculations if the clinician is also providing in-person care in the network.”

Essential Community Providers

The Academy voiced strong support for the proposed rule’s raising of the provider participation threshold from 20% to 35% of available essential community providers. ECPs serve predominantly low-income and medically underserved individuals and include family planning providers, Indian health care providers and federally qualified health centers, among others. HHS’ proposed 2023 change would require qualified health plan issuers to raise the number and geographic distribution of ECPs in their networks, where available.

“Ensuring low-income enrollees can access high-quality services at little or no cost will help improve health outcomes and advance health equity,” the Academy wrote. “The AAFP also agrees that, for plans that use tiered networks to count toward the issuer’s satisfaction of the ECP standard, ECPs must be contracted within the network tier that results in the lowest cost-sharing obligation.

“The AAFP believes that low-income consumers seeking care from ECPs should have equitable access to telehealth services,” the letter added, answering a related question in the RFI concerning virtual care and ECPs. “However, we are concerned that allowing issuers to meet ECP thresholds by replacing in-person primary care services with telehealth services could create a two-tiered system for low-income enrollees and ultimately exacerbate health inequities. We urge HHS to examine alternative options for accessible, affordable in-network services for low-income enrollees while also advancing policies to increase the number of ECPs across the country.”

Z Codes

The Academy cautioned against using penalties to increase physicians’ reporting of ICD-10 Z codes, particularly Z55-Z65, which allow physicians to report social and other factors influencing patients’ health. HHS noted in the proposed rule that more consistent use of these codes could enhance data collection on health-related social needs among marketplace enrollees, which could then inform federal policies.

The AAFP’s letter acknowledged the need for additional data on health-related social needs and social determinants of health and added that robust risk adjustment for physician payments was essential for advancing value-based care models and whole-person care.

“However, we are mindful that the collection of additional data, particularly via diagnosis coding and documentation, also introduces additional burden on physician practices,” the Academy wrote. “The AAFP suggests HHS explore ways to provide additional payment for reporting Z codes that is equitable and does not exacerbate existing disparities. For example, HHS could examine the feasibility of providing payment for screening for social determinants of health when a standardized screening tool is used in alternative payment models being tested by the Center for Medicare & Medicaid Innovation.”

The letter pointed out that some family physician practices use EHR systems that do not support the reporting of more than a certain number of diagnosis codes, sometimes preventing Z code reporting.

“HHS should develop EHR certification standards for capturing Z codes and other data related to social determinants of health,” the Academy said. “EHRs should be required to implement these standards in a manner that does not increase burden or impose additional expenses on physician practices.”