From the President

The Battle for Better Pay Continues

March 25, 2011 05:35 pm Roland Goertz, M.D., M.B.A.

When it comes to improving payment for family physicians, we made incremental but significant progress last year and hope to make even more headway this year. But many members still ask me, Why isn't it happening faster? Can't the Academy do more to help my practice reach firm financial ground?

[Roland Goertz, M.D., MBA, FAAFP]

AAFP President Roland Goertz, M.D., M.B.A.

If you've felt the same concerns, I understand your frustration. We all yearn for appropriate rewards for what we do. Our payment problems have built up over time, and it will take time to correct them -- especially given today's political wrangling over the federal deficit and a focus on "cost cutting." We'll keep fighting, but improvements will likely continue to come increment by increment, at least for now. The good news is that increments do add up.

I'm reminded of a quote often attributed to the late Everett Dirksen, R-Ill., Senate minority leader from 1959 to 1969: "A billion here, a billion there, pretty soon it adds up to real money." That's what we must attain -- the "real money" of being paid appropriately for the work we do.

2010 Successes -- and Averting Disaster

AAFP resources are finite, so we direct most of our payment efforts to where they can make the biggest difference. And that means focusing primarily on Medicare and Medicaid. Historically, when Medicare makes a change, the commercial market eventually follows.

In 2010, our most protracted battle was fending off the biggest threat to physician solvency -- the looming 25 percent Medicare pay cut caused by the sustainable growth rate, or SGR, formula. Along with others in organized medicine, we kept up constant pressure to avoid the cut and fix the SGR, convincing Congress to act five times to pass payment patches. Four patches were short-term, but the fifth, passed in December, gives us a yearlong reprieve from a cut, although without a pay increase. The patch also gives Congress time to consider a longer-term solution.

Although the SGR battle likely was our biggest challenge, we also had clear victories such as these:

  • Incentive payment for primary care only. This 10 percent bonus is relatively modest, but it's also enormously important because it shows the government's intent to support primary care. CMS included regulations for the bonus last July in its preliminary Medicare physician payment rule for 2011, the first rule to implement provisions of the Patient Protection and Affordable Care Act. The Academy always analyzes this preliminary rule and sends CMS a detailed comment letter about what works and what doesn't for family physicians. Our analysis showed that the bonus regulations didn't go far enough: Only 59 percent of FPs would likely meet the eligibility criteria. In the letter to CMS, we proposed changes to boost the percentage of qualifying FPs to about 80 percent, and we also met with CMS Administrator Donald Berwick, M.D., to press our case. We were very pleased when CMS incorporated our proposals in the final rule.
  • Shortage area bonus. The health care reform law also makes it clear that FPs practicing in health professional shortage areas, or HPSAs, may receive both the 10 percent primary care bonus noted above and another 10 percent bonus under the HPSA physician bonus program. The AAFP supported this provision of the law.
  • Axed consultation codes. CMS, of its own volition, announced it would stop paying for CPT codes for consultation services and would redistribute the relative values from those services to services FPs commonly perform. Others in organized medicine fought back because their members often used those higher-paying consultation codes. We urged CMS to stick to its guns, and it did -- resulting in yet another payment bump for you in the codes you use most often and also helping primary care in the long run.
  • Medicaid payment boost. Since the stinginess of Medicaid payments in many states is a huge issue for us, the AAFP strongly supported the health care reform law's requirement for parity between Medicare and Medicaid payments for primary care services. Here in Texas, Medicaid, in recent years, has paid about 68 percent of what Medicare pays. Since my center cares for many Medicaid patients, this provision should provide a welcome financial boost. You may get one as well, depending on the size of your state's Medicare-Medicaid gap. It's worth noting that the federal government will pick up the cost of this parity requirement for the two years of its commitment, so it won't burden states whose budgets are in difficult straits. The Academy is hoping this will be made permanent.
  • Reprocessed claims. Last December, CMS was still dragging its feet on reworking a slew of Medicare claims originally processed before the Affordable Care Act passed with provisions retroactive to Jan. 1, 2010. With other medical groups, we sent a letter telling CMS it was high time to make good on the money they owed doctors. It worked: CMS ordered its Medicare contractors to reprocess the claims and pay you the money you're due.

The Continuing Fight

In 2011, improved payment continues as one of our top priorities. I recently joined several other AAFP leaders on Capitol Hill for meetings with House leaders, new House members and their staffs. We gave them an earful about our payment concerns! I was elated to hear the chair of the Ways and Means Subcommittee on Health, Rep. Wally Herger, R-Calif., say he understood the issues we're facing.

I flew back to Washington just a few weeks later, speaking at a briefing for staff of new members of Congress that was convened by the Partnership for Primary Care Workforce. More than 30 congressional staff attended, most staying to the very end. I told them that the data show an incredibly strong correlation between increased numbers of primary care physicians and slower growth in costs and higher quality of care, and I decried the income disparities between primary care and non-primary care physicians.

But the cost containment and deficit reduction climate in Congress makes our fight even more difficult this year. Every increase considered for us will have to be balanced by cuts somewhere else. However, we have a trump card: We're presenting policymakers with the only substantial model shown to bend the cost curve: the patient-centered medical home. No one else has proposed a viable alternative.

Just as critical this year is our work on the regulatory side. Right now, CMS and other agencies are pulling together the preliminary Medicare physician payment rule for 2012 and myriad regulations to implement the health care reform law.

After health care reform passed, we decided on a bold new tactic regarding the rule-making process. The Academy hired a new staff member whose entire job consists of tracking the broad sweep of health regulations and getting the Academy inserted in early discussions to help shape the rules as they're formulated. It's a very aggressive posture, but we don't want to miss any opportunity to get family doctors taken care of before the rules are published for comment.

Seizing Our Advantage

I'd like to close with my hope that all of us -- conservative, liberal and in between -- can look past our own political viewpoints and seize our opportunity to keep improving the circumstances for the specialty we love. If we're going to get the payment and workforce changes that need to happen, all of us have to band together to keep raising awareness -- all the way up to the president -- about what we family physicians can do to create a better health care system. This has to occur no matter who's in power, the Republicans or the Democrats.

President George W. Bush, a fellow Texan, has a ranch just 20 miles from where I sit. When he was in the Oval Office, I did my best to raise his awareness. I knew health care was an important issue to him when he was Texas' governor, but when he was president, it was not a primary focus, so I never could get through all the layers around him.

Now, because the current administration has made health care an issue they're staking their future on, we are getting through. They are paying attention. I've heard the president speak extemporaneously about family doctors, so I know we're reaching the highest level.

Even with the current divisiveness in Washington, when I go there, I sense a growing awareness of the importance of family medicine that crosses ideological lines. Congress and the administration increasingly realize that we are best suited to provide care and serve as the patient's advocate in a redesigned system. They actively seek our input, calling the Academy about opportunities to comment and get engaged. We are in the best position we've had in years to improve our future.

Here's the bottom line: Whoever is president is president, and if the president is inclined to support family medicine's agenda, then a decision has to be made on whether or not to take advantage of that inclination. The future for family medicine, and for our patients' care, without the changes we seek is not very bright, so how could we, in good conscience, not take advantage of the current situation and push for a health system based on family medicine?

I hope you'll become a warrior in Washington for our specialty, regardless of your political viewpoint. Try to develop a relationship with your legislators, especially if they're new and need to learn about family medicine and our issues. If you're already engaged in this effort, I hope you'll keep it up.

We can continue to make progress for family medicine and our patients. Let's work together to make it happen.