AAFP Leaders Talk About Next Steps in a Post-SGR World

May 06, 2015 08:54 am Chris Crawford Kansas City, Mo. –

During a recent event here, AAFP President-elect Wanda Filer, M.D., M.B.A., of York, Pa., drew enthusiastic applause when she announced that repeal of Medicare's sustainable growth rate (SGR) wouldn't have happened without Academy members' calls and emails to their congressional representatives in conjunction with all of the AAFP government relations team's hard work.

AAFP President Robert Wergin, M.D., and President-elect Wanda Filer, M.D., M.B.A., field questions from attendees during the Town Hall meeting held as part of the AAFP's 2015 Annual Leadership Forum.

Filer told attendees at a May 1 Town Hall meeting held as part of the 2015 AAFP Leadership Conference (the combined Annual Chapter Leader Forum and National Conference of Constituency Leaders) that with passage of the Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act (MACRA), family physicians now need to research which of two payment pathways they will pursue.

The Academy currently offers a resource to answer members' questions about MACRA, and Filer said the AAFP is working to compile comprehensive materials to educate members about the legislation and its requirements.

"We know (MACRA) will create some level funding for the next five years, which in and of itself is an upside," said Filer. After that, family physicians will need to decide whether to opt for payment based on the patient-centered medical home (PCMH) model or the more traditional fee-for-service model.

Story highlights
  • During the 2015 Annual Leadership Conference Town Hall meeting, AAFP President-elect Wanda Filer, M.D., M.B.A., said under the Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act, family physicians will have to decide between two payment models.
  • Graduate medical education reform is still needed, said AAFP President Robert Wergin, M.D., and the Academy has proposed a new approach that stands to add 7,000 primary care residency positions.
  • According to AAFP Board Chair Reid Blackwelder, M.D., the Board recently developed a list of characteristics that it plans to ask retail clinic operators to adhere to.

The Academy has encouraged members to investigate the transition to being a patient-centered medical home (PCMH) for years, with about 32 percent of members already having made the transition. Practices that currently are PCMHs or are planning to speed up their transition will benefit from the improved payment available through MACRA, she said.

The other option is a more traditional fee-for-service model -- a merit-based incentive payment system (MIPS) -- that will encompass many quality layers. MACRA calls for harmonization of these quality measures, however, bringing many of these programs under one roof.

"Our current prediction is payment probably will be based on your 2018 performance as they look forward to paying 2019 and 2020 dollars," Filer said. "They will look at your performance and you could see as much as a 9 percent increase in your payment, but you also risk a 9 percent decrease or anywhere in between. This presents potential predictability issues."

When asked by an audience member what PCMH certification will be needed for the MACRA program, Filer explained that first, it was important to realize that "PCMH does not equal NCQA (National Committee for Quality Assurance)," which drew applause.

"I don't think (the certification) has been delineated yet," she replied. "There appear to be multiple paths to PCMH, and we hope these paths are acceptable. Competition between companies looking to help get us PCMH-certified also isn't a bad idea."

Academy EVP and CEO Douglas Henley, M.D., said he anticipated CMS would use the Comprehensive Primary Care initiative( and its criteria to determine what constitutes an advanced primary care medical home.

What's Next on the Advocacy Front?

Marie-Elizabeth Ramas, M.D., new physician delegate of Mount Shasta, Calif., thanked the Academy for its leadership during the lengthy SGR repeal efforts and wanted to know how the organization planned to keep things rolling.

Marie-Elizabeth Ramas, M.D., asks AAFP leaders how they plan to carry the momentum of repeal of the sustainable growth rate into continued advocacy for family medicine.

"As a new physician, I was ecstatic to see Dr. Wergin shaking hands with the president during the SGR repeal ceremony," she said, referring to AAFP President Robert Wergin, M.D., of Milford, Neb., being invited to the signing ceremony President Obama held in the White House Rose Garden on April 21. "I mention this because I saw family medicine represented during that very historical day. I am trying to envision how we continue that momentum as family physicians. How can the AAFP wrangle up its members to be a noticeable presence on Capitol Hill so we can make more change?"

Wergin responded that legislators know the AAFP, and that gives family physicians a strong voice on Capitol Hill. "But the next step is getting them to know who family physicians are and the value we bring."

One megaphone currently shouting this message is the Health is Primary( campaign from Family Medicine for America's Health,( a partnership of eight family medicine organizations, including the AAFP.

AAFP Board Chair Reid Blackwelder, M.D., of Kingsport, Tenn., said, "A big part of that message is we are family physicians, not primary care physicians. We are changing our language to be more consistent in our messaging about the value of family medicine."

Need for GME Funding Reform Continues

Wergin explained to Town Hall attendees that graduate medical education (GME) reform is still needed, and the challenge has been exacerbated by some academic medical centers not prioritizing family medicine.

"So last fall, the AAFP came up with a GME proposal; we need more residency positions, but need to expand in a socially responsible way instead of just expanding 'slots,'" he said. "If we just expand slots, we'll have more transplant surgeons or cardiologists.

"Our proposal was to expand these slots in primary care certificate training only as the first training you take after your medical school rotations."

The proposal calls for adding more than 7,000 new residency positions, Wergin said, with at least half of those in a primary care specialty -- family medicine, general internal medicine or general pediatrics. The expansion would be funded in a budget-neutral manner by doing away with funding for fellowships.

Henley explained that one out of four medical students belongs to the Academy, so "we are starting to close the deal when it comes to career choice." But he added that continuing the trend of students choosing family medicine would take members' help.

"You all need to educate and inform your state legislators and challenge the medical schools and their deans in your state to be accountable to produce the workforce this nation needs -- and more and more, that's family medicine and primary care." Henley said.

Henley noted that earlier in the week, the Texas Higher Education Coordinating Board allocated $16 million( to train family physicians in Texas residency programs. No other specialties were included in the measure. "No more 'family medicine nice,'" he quipped.

Retail Clinics Come Under Scrutiny

Regarding retail clinics, Blackwelder told the crowd that the AAFP policy on these clinics doesn't encourage or endorse the concept and that they present different challenges to family medicine practices depending on their location.

"We need to stop fragmented care," he said. "We need to make sure that chronic care management happens with us, and if our patients get care somewhere else in the system, they are not doing so in an isolated fashion."

The Board recently developed a list of characteristics that it plans to ask retail clinic operators to adhere to. The list will be circulated to chapter leaders for feedback before the document is finalized and made available to members.

"We hope that retail clinics say these sound reasonable and they'd like to be part of the solution and not part of the problem," said Blackwelder. "The list of retail clinic characteristics will give you an opportunity to have the same discussion with retail clinics in your communities, as well."

Adnan Ahmed, M.D., an international medical graduate delegate from Florence, Ky., asked how the AAFP plans to encourage retail clinics to collaborate in care when they didn't collaborate when the businesses first entered the medical market.

"If you meet the medical needs your community has yourself, your patients won't need retail clinics, as they are there to fill a perceived need for additional care in your area," Blackwelder said. "But negotiating with retail clinic operations should be viewed as part of the shift to community-based care that patients have been demanding."

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