FPs Key to Improving Access and Equity, Academy Tells CMS

Detailed Recommendations Come Ahead of PHE Wind-down

Dec. 7, 2022, 8:48 a.m. News Staff — CMS’ recent invitation to health care stakeholders to help the agency improve efficiency and equity offered the Academy a prime opportunity to champion family physicians’ crucial role in public health. In a detailed response to the agency, the AAFP called for stronger investment in primary care, greater commitment to administrative simplification and swift movement to plug the gaps in CMS’ “road map” for the end of the COVID-19 public health emergency.

The letter further reiterated advocacy calling for improved prior authorization, step therapy and other plan requirements. “While the administrative burden of prior authorizations cannot be meaningfully reduced without comprehensive reform to reduce the volume of requests, the AAFP supports efforts to implement electronic prior authorization as a meaningful first step to streamlining the process.

“Low Medicare physician payment rates are another major challenge family physicians are currently facing,” the Academy added, prefacing recommendations centered on payment.

To accelerate and smooth the transition from fee-for-service medicine to value-based care — a goal shared by HHS and the Academy — the letter urged

• investment in community-based primary care, including additional alternative payment models;
• implementation of “a stable suite of multipayer APMs that are appropriate for practices with varying levels of experience taking on financial risk and assist practices to transition to more advanced APMs over time”; and
• coordination across Medicare, Medicaid, CHIP, marketplace plans and commercial payers to harmonize requirements and quality measures.

“Aligning models across payers and embedding equity as a shared aim, regardless of the patient population, will foster greater physician participation and resource practices more efficiently to ensure all patients receive high quality, affordable, patient-centered care,” the letter said. “The AAFP urges HHS to increase APM participation opportunities, align models across payers and ensure physicians caring for rural and underserved populations can successfully participate in APMs.”

COVID-19 Waivers and Flexibilities

Answering a section of the request for information about waivers, flexibilities and other policies related to the COVID-19 public health emergency, the Academy again urged implementation of a “transparent, intentional and equity-focused approach to ending the PHE and unwinding its associated policy changes.”

Specifically, the letter said permanent telehealth coverage and payment policies should

• ensure coverage and access to audio/video and audio-only telehealth services for all beneficiaries, regardless of location;
• include guardrails to ensure care continuity and quality by encouraging the use of telehealth with a patient’s usual primary care physician or another trusted care relationship; and
• enable patients, in consultation with their trusted primary care physician, to determine the most appropriate modality of care for each encounter.

The Academy repeated a call to regulators to “ensure timely, equitable access to COVID-19 vaccines, testing and treatment across payers and programs.”

“CMS must also provide physicians, beneficiaries, and other stakeholders with at least 60 days of notice before transitioning the purchase of COVID-19 vaccine supplies, testing or therapeutics on to physician practices or beneficiaries,” the letter added. “Finally, we urge CMS to ensure that payment rates for vaccine products and vaccine administration are adequate once the PHE ends or the federal government transfers the vaccines to the commercial market.”

Health Care Access

CMS asked for comment on the challenges and barriers patients face across its programs, in which some 145 million individuals are enrolled. The Academy’s response repeated recent advocacy asking the agency to

• increase Medicaid payment rates and reduce administrative complexity to ensure that Medicaid beneficiaries have access to a robust network of physicians delivering timely, comprehensive care; 
• strengthen federal oversight and monitoring of Medicaid managed care plans;
• support the integration of behavioral health care into primary care settings, including via risk-adjusted alternative payment models;
• approve postpartum coverage extensions and other measures advancing reproductive health coverage; and
• limit potential coverage disruptions for Medicaid beneficiaries following the end of the PHE.

The Academy realized a Medicare win in October when CMS finalized a rule shortening the gap between Medicare enrollment and the commencement of coverage for many beneficiaries, and increasing the number and scope of Medicare special enrollment periods.

Health Equity

Responding to the RFI’s questions on how to eliminate health disparities, including individual and community-level burdens that impair access to comprehensive, high-quality care, the AAFP made several recommendations, including

• robust patient data collection;
• oversight and monitoring of enrollment denials under Medicaid, Medicare, state-based exchanges and other payers;
• culturally sensitive care, such as HHS’ National Standards for Culturally and Linguistically Appropriate Services in Health and Heath Care initiative;
• network adequacy that takes into account accessible medical equipment for individuals with disabilities as well as language and translation accessibility; and
• artificial intelligence and machine learning policies that correct for systemic algorithmic discrimination and emphasize live clinical judgment.