• Academy Gives HHS Comprehensive Guidance on Primary Care

    Advice Gets Specific on Payment, Administrative Simplification, More

    Aug. 3, 2022, 7:11 p.m. News Staff — In new guidance sent to HHS, the Academy called for a number of regulatory actions to improve patient access to comprehensive primary care, strengthen the primary care pipeline and reduce family physicians’ administrative complexity.

    Index finger pressing red "comprehensive solutions" button on computer keyboard

    The department should “use its authority to significantly increase our nation’s investment in PC, improve patients’ access to and connections with PC, grow and diversify the PC workforce and address the administrative requirements that drive care delays and physician burnout,” said the AAFP in its July 27 letter.

    The Academy was responding to a request for information on the HHS Initiative to Strengthen Primary Care, published June 27 in the Federal Register. The letter was sent to HHS Secretary Xavier Becerra and signed by AAFP Board Chair Ada Stewart, M.D., of Columbia, S.C.

    Addressing Underinvestment

    The Academy urged increased primary care spending while noting that “fee-for-service, the dominant model of physician payment, fails to support PC by consistently underinvesting in PC services.” 

    “Across payers, including both public and private insurance, PC spending in the United States amounts to approximately 5% to 8% of all health spending, with an even lower percentage in Medicare, compared to approximately 14% of all health spending in most high-income nations,” the letter said. “The negative impact of underinvestment is exacerbated by the fact that FFS payment models such as the Medicare physician payment system have failed to keep up with the pace of inflation, even while Medicare payments for hospitals, nursing facilities, hospital outpatient departments and surgery centers continue to benefit from annual updates. These low payment rates contribute to PC workforce shortages and worsen beneficiaries’ equitable, timely access to care.”

    A July AAFP executive summary of the 2023 Medicare physician fee schedule voiced similar concern about fee-for-service family physician payment lagging inflation.

    Story Highlights

    Administrative Simplification

    The Academy characterized fee-for-service financing of primary care as a “piecemeal” approach that undervalues primary care’s whole-person, longitudinal model while adding excessive paperwork.

    “Across payers, physicians must document several unique screening codes,” the letter said, including those for vaccine administration, other preventive services and several additional components typical of comprehensive primary care, “even though these services are all foundational parts of PC.

    “In addition to being administratively burdensome, this approach encourages carve-outs for behavioral health, telehealth and other services that are more accessible and effective when they are integrated and coordinated within the PC medical home,” the letter added. Fee-for-service “also undervalues the component parts of PC, like care management and integrated behavioral health, and therefore fails to account for the complexity of PC.”

    To work toward administrative simplification while addressing payment issues, the Academy asked HHS to “examine opportunities to more comprehensively finance PC in FFS.”

    The Academy also repeated its support for HHS’ streamlining of prior authorization while asking that the agency’s electronic prior authorization rule be broadened to include Medicare Advantage plans and swiftly finalized.

    “Comprehensive PA reform is needed to reduce the volume of PA and ensure patients’ timely access to care, including clear guidelines for PA requirements and timely responses from insurance plans.”

    Value-based Care

    To boost investment in primary care — and fair payment for family physicians — HHS should accelerate the transition to value-based models of primary care, the letter said.

    “Alternative payment models provide PC practices with additional flexibility and financial stability, which practices leverage to hire additional staff (e.g., social workers, behavioral health professionals) and provide advanced PC services not paid for under FFS,” the Academy wrote. “Unfortunately, a dearth of PC models and the inadequacy of FFS payment rates are undermining the transition to value-based care.

    “Because most APMs are designed based on FFS payment rates, modernizing FFS payment for PC is one essential strategy for support physicians’ transition into value-based care. The AAFP also recommends implementing a stable suite of multipayer APMs that are appropriate for practices with varying levels of experience taking on financial risk and assisting practices to transition to more advanced APMs over time.

    “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,” the Academy said.


    “To address the shortage and maldistribution of physicians, the AAFP has advocated for the federal government to align physician training with workforce needs,” the letter said. “Medicare graduate medical education slots should be targeted specifically toward hospitals and programs in areas and specialties of need, including by considering those with a proven track record of training physicians who ultimately practice in physician shortage areas. We encourage HHS to collect, analyze and publish data on how federal GME positions are aligned with national workforce needs.”

    Noting the Academy’s longtime advocacy for the Teaching Health Center GME program, the letter added that HHS should establish and support new teaching health centers and expand existing ones, “both through federal funding and by removing burdensome regulatory requirements.”

    Primary Care Access and Coverage

    “The AAFP is strongly supportive of expanding coverage and payment of telehealth services,” the letter said. “Across programs, we urge HHS to support the provision of telehealth services that are provided by beneficiaries’ usual source of care and integrated within the medical home. HHS should not allow health plans across programs to count telehealth services provided by direct-to-consumer telehealth companies toward meeting minimum federal access standards for PC.”

    The AAFP’s call for a “coordinated, whole-of-government approach” to strengthening U.S. primary care urged a number of other actions, including

    • increased primary care availability and connectivity for Medicare, Medicaid, CHIP and Patient Protection and Affordable Care Act marketplace enrollees;
    • reinstated and stronger federal access standards for Medicaid managed care alongside enhanced federal monitoring and oversight of Medicaid beneficiaries’ access to care
    • enforcement of existing Medicaid reporting regulations;
    • continued strong support for community health centers;
    • Center for Medicare and Medicaid Innovation–created APMs that better support federally qualified health centers, rural health clinics and other safety nets;
    • HHS using its authority “to remove cost and other barriers to accessing recommended PC services”;
    • expanded funding for programs diversifying the physician workforce, such as the Health Resources and Services Administration’s Health Careers Opportunity Program and Centers of Excellence; and
    • improved information sharing with primary care physicians from hospitals, subspecialists and other care team members.