"More primary care" became the rallying cry in 2010 as the federal government moved forward on health care reform. And the AAFP was at the table, making sure family physician concerns were being heard. Although the Academy didn't get everything it wanted in the final bill, there were some real gains for family physicians in the bill's provisions.
AAFP President Lori Heim tells a House appropriations subcommittee during her May 12 testimony that health care reform and investments in the primary care physician workforce are linked.
President Obama started the year off by calling for passage of a health care reform bill during his January State of the Union address. And the AAFP was solidly behind those efforts.
The Academy has supported health care coverage for everyone for more than 20 years, said (then) AAFP President Lori Heim, M.D., of Vass, N.C., in response to the president's comments.
"We must provide health care coverage to people who cannot afford it or who have been turned away due to pre-existing conditions," Heim said. "We must end the fragmentation of care; the duplication of tests and services; and the disregard for chronic disease management, prevention and wellness care in favor of medical intervention."
Although the final bill, which is known as the Patient Protection and Affordable Care Act, did not contain certain provisions the AAFP supported (e.g., a permanent fix for the sustainable growth rate, or SGR, formula and medical liability reform), it did mark the start of a U.S. health care system that meets Americans' needs, said Heim.
Heim pointed out during an April 30 town hall meeting at the AAFP's Annual Leadership Forum/National Conference of Special Constituencies that the AAFP Board of Directors evaluated the legislation in light of the principles and policies set out by the AAFP Congress of Delegates. The final legislation didn't necessarily meet all of the Academy's needs, said Heim, but, "We got what we were most vested in."
"Some aspects (of the bill) will continue to need attention from the Academy," she added. And, as the bill is interpreted through various state and federal agencies, the AAFP will continue to work with those agencies to craft regulations.
Passage of the bill represents only a starting point, Heim noted during a Capitol Hill rally on March 22, the day before President Obama signed it into law. "There is some great language in the bill, but there is much that needs to be improved," she told more than 300 physicians during the rally, which was sponsored by Doctors for America.
President Obama signs a major health care reform bill into law during a White House ceremony on March 23.
"It is the implementation of (health care reform) that (family physicians) have to be intimately involved with," said Heim, adding "We are the ones who know how this system should work. We are the ones who have all of the stories about the patients. We know the programs that need to be modified."
And as the government began looking at ways of implementing the provisions of the Patient Protection and Affordable Care Act, the AAFP sprang into action, asking that some provisions be modified and repeatedly pointing out that health care reform would not be possible unless the government was willing to invest in primary care.
"Despite the consensus that good primary care is essential for genuine health care reform, 65 million Americans -- about one in five -- live in a primary care shortage area," Heim told the House Appropriations Subcommittee on Labor, HHS, Education and Related Agencies during a May 12 hearing. She urged the committee to provide more funds for primary care training programs to meet the future need for primary care services.
AAFP leaders also met with CMS Administrator Donald Berwick, M.D., to emphasize the importance of primary care as a foundation for provisions in the Affordable Care Act. They stressed to Berwick that although the new law provides a 10 percent Medicare bonus for physicians whose primary care services comprise 60 percent of their total Medicare services, that threshold is too high. In subsequent letters to the agency, the AAFP pointed out that the 60 percent threshold would eliminate many rural physicians, who often are called on to perform services not designated as primary care simply because they are the only physician available.
AAFP President-elect Roland Goertz, M.D., M.B.A., left, and other representatives from the medical community listen carefully as President Obama calls on Congress to vote on his health care plan.
The Academy's efforts were rewarded when CMS changed implementation rules for the Medicare Primary Care Incentive Program to allow approximately 20 percent more family physicians to qualify for the bonus program.
"This is incredibly good news and further confirmation that our issues are being heard and responded to," said AAFP President Roland Goertz, M.D., M.B.A., of Waco, Texas. "We have been telling everyone who would listen how wrong the message would be to family physicians who provide comprehensive family medicine services -- often in the most needy areas -- if they do not qualify."
Although the Academy had strong hopes that the final health care reform legislation would at least attempt to fix the SGR, leaders and members alike were bitterly disappointed that the SGR was not addressed in the legislation. And that disappointment only grew during 2010 as Congress passed short-term patch after short-term patch.
Although the Patient Protection and Affordable Care Act is a federal law, much of its implementation will happen at the state level, and this is creating an opportunity for family physicians to work with state governments on how to enact various provisions of the law.
In many states, family physicians will have the ability to influence implementation of health care reform by engaging newly created committees that are focused on how to put health care reform provisions into place, according to Robin Richardson, M.S., the AAFP's state government affairs analyst. "This is the time for family physicians to step forward and tell lawmakers what they want to see in their state," said Richardson.
Even former CMS Administrator Mark McClellan, M.D., Ph.D., considers the Affordable Care Act to be an opportunity for family physicians to play a major role in implementing health care reform on the state level. McClellan, who gave the keynote address at the 2010 AAFP State Legislative Conference in November, said, "There are some opportunities that we have not had before to make care better and to do it in a way that really reflects primary care and family practice leadership."
Mary Takach, R.N., M.P.H., a program manager for the National Academy of State Health Policy in Portland, Maine, who also spoke during the State Legislative Conference, echoed McClellan's message. She noted that states are pushing ahead with primary care initiatives -- including medical home projects -- a trend that is not likely to abate regardless of what happens with federal health care reform efforts.
"Know what your states are doing around medical home initiatives, know what they are requiring for recognition," Takach told attendees at the conference. "If you have not aligned your own practices with your state medical home initiatives, you probably want to do that. Your payment, particularly for Medicaid patients, is going to hinge on whether you are recognized (as a medical home)."
Congress approved a temporary SGR payment patch at the end of 2009 that extended the Medicare physician payment rate until March. But AAFP members were angered and frustrated as Congress continued to pass 30-day extension after 30-day extension, often missing the deadline and letting the cuts go into effect.
The Academy was outraged at Congress' lack of action. "The AAFP is deeply angered at congressional failure to avert the mandated 21.2 percent Medicare physician pay cut," said Heim. "This inaction -- in the face of virtually universal calls by the medical community and advocates for Medicare beneficiaries -- has put elderly and disabled patients at risk of losing access to care and imposed potentially devastating fiscal hardship on physicians."
The ongoing gamesmanship surrounding the SGR finally led the AAFP to issue a letter censuring Congress' efforts. "This month-to-month uncertainty about (physician) Medicare payments is disruptive and interferes with (physicians') ability to provide reliable, enduring health care, especially for patients with chronic disease conditions," said (then) AAFP Board Chair Ted Epperly, M.D., of Boise, Idaho, in the letter.
When Congress failed once again to stop the Medicare payment cut from going into effect on June 1, the AAFP Executive Committee decided that if Congress could not provide a permanent fix for the SGR forumula, then the AAFP would not support any legislation that provides a temporary payment patch, unless the legislation were to include a primary care payment differential and extend at least through Dec. 31, 2012.
"The political gamesmanship must end," said Heim. "A comprehensive and stable Medicare payment system must be put in place. The time to begin that process is now."
Calling the SGR formula "untenable," Heim further declared, "If a permanent fix is not possible, then it needs to be at least a longer-term fix that gives physicians stability."
In late December, Congress finally passed a yearlong payment patch, which should give them time to find a permanent fix or at least craft a longer-term patch.
"Today's vote will temporarily end the series of short-term patches that have plagued doctors and their patients throughout 2010," said AAFP President Goertz of the Dec. 9 vote. "It is, however, only one step toward a permanent solution to the flawed sustainable growth rate formula that threatens deep Medicare payment cuts and the financial viability of primary care physician practices."
Goertz vowed that the AAFP would continue to work with and pressure Congress to find a solution to the SGR, or at the very least work together to put an SGR patch in place for three to five years to allow payment reform demonstrations enough time to produce the evidence that should underlie any permanent replacement to the current poorly structured formula.