It’s been a busy holiday season. Our states PCMH pilot project with Medicaid is proceeding nicely in Kearney and Lexington. Your AAFP continues to meet with policy makers and insurance companies to continue to work on payment reform. They keep coming back with there is no way to increase premiums. We don’t message that we are asking for a larger pie but instead adequate payment for the value we bring to their customers and our patients. Our message is if this is done and primary care is supported the efficiency produced does not require a larger pie. The pilot projects utilizing the Patient Centered Medical Home concept of care have uniformly shown higher quality and lower costs. Our value has to be recognized more than with words only but with payment. But what is our responsibility in regards to better payment? Barbara Sarfield’s data was clear that a family physician having a relationship with their patient and providing comprehensive care brings this savings about. We need to continue to provide all the services that we are trained to provide. This comprehensiveness is one of the major qualities that separates us from the mid levels that claim they can provide independent care. I believe we should economically encentivise hopital practice in Urban practices. Many of my urban colleagues have given up hospital work primarily for economic reasons. This undermines our comprehensiveness and creates possible errors in transitions of care. Shift working hospitalist transferring care to the true primary care physicians create potential communication errors. Eight page ER visits that you can’t really determined what the patient was seen or treated for may meet the billing criteria but doesn’t do much for patient care. Transfers of care from me to me I believe reduces errors and perhaps re-admissions. My suggestion would be to add a modifier to primary care physicians who qualify for hospital care to make it economically feasible to continue to follow our patients when they are the most vulnerable. Again Dr Starfield demonstrated a lower mortality rate, higher quality measures and less cost just having a primary physcian follow the patient during their inpatient stay at UCSF Hospital no matter what their diagnosis. Wow! There has never been a better time to be a family physician than now. Our value is obvious and now we should be reimbursed appropriately. We can’t be replaced by noncomprhensive less trained midlevels. Our time is now.

Onward! 

Sorry about the lapse between writings. What a busy but wonderful summer. By the way congratulations to David Hoelting, Pender NE for being selected as Nebraska Family Physician of the Year. An honor well deserved. Our summer board meeting of the AAFP took place in Banff Alberta Canada. What a beautiful place. The board and staff still stay busy with our big focus on payment reform and scope of practice of Nurse Practioners. Roland Goertz MD our president is still actively participating in discussions on NPs being part of a physician led health care team. Their leadership is very aggressively seeking independent practice and quote a lot of data of questionable accuracy. One quote was that a NP working with physician oversight have higher costs and lower quality. The Robert Grahm Center is working on data and evidence based studies on this. We stay committed to our policy that NP’s remain part of a physician led team. Another hot topic is “Distressed State Chapters”. This will be part of our town hall meeting at the Congress of Delegates meeting Sept. 11 in Orlando. Distressed states refer to states where private insurers reimbursement rates have fallen below Medicare rates making it difficult for private Family Physicians to survive economically. The Grahm Center is again sorting out the facts so your board can come up with a strategy quickly to aid those areas. The letter the Board recieved was from the New Jersey Chapter highlighting their issues. The RUC remains a hot topic but our task force to revalue cognitive E & M code has met and made progress. I’m optimistic we can come up with a new payment system for these cognitive codes and cut them out of the CMS reimbursement pie for fairer reimbursement. There was an article in NEJM questioning the cost saviings of primary care but it used both medicare part A & B and included ER and Urgent care physicians as part of their data. The Grahm center again is putting together a response to the article. The AMA RUC committee has until March 2012 to repond to our request for better representation on the committee for primary care. Stay tuned. Our annual scientific assembly is just around the corner and I’m excited to see how Mark Butler MD will enjoy his first Congress of Delegates meeting as our new Alternate Delegate. He will represent us well and I’m sure he’ll find it to be a huge growth experience professionally More to come. Onward!

Greetings!   Another month has passed and our NAFP meeting is just around the corner.  Lori Heim MD our current board chair and Jeff Cain MD a third year board member will be at our meeting.  Jeff will be lecturing and Lori will be installing our newly elected officers.  I’m sure either one would be glad to answer any questions you might have regarding the Accountable Care Act.  They are both experts on the politics involved and have a lot of insight as to the upcoming political battles.  Lori particularly, as board chair, has been in Washington a great deal these past two years and has the inside scoop.  Don Berwick MD the director nominee for CMS, has had his nomination held up in committee and it appears he may not even get a hearing purely on political grounds.  He has a tremendous CV and was a practicing pediatrician who has a wealth of knowledge on health care policy particularly as it pertains to primary care.  He has been criticized by the Republicans as being unqualified but if you bother to read about his background and experience I really can’t imagine a better qualified individual.  He is truly a friend of primary care and understands it has to be the base of any health care reform.  I’m not sure what qualified individual would want to put himself through the political approval process and be subjected to untrue and critical comments of your character and background.  I don’t believe any candidate nominated by Obama in this highly polarized political environment could get through the approval process.  We as a board have signed on to a letter of support for Dr. Berwick’s nomination.

Secondly there has been a lot of activity regarding criticism of the RUC which is group set up by the AMA to revise and review our CPT methodology for payment of services for Medicare.  All the private insurers follow their recommendations as well.  The group is heavily represented by specialist (26 out of 29) resulting in the current system that emphasizes procedures over cognitive care in terms of payment.  There is a group of primary care Doctors who have advocated resigning from the RUC committee. Also there has been recent chatter about suing the RUC.  They have even started a website called getoutoftherucnow.com.  There will be a lot of activity regarding this issue in the coming weeks and I’m sure it will come up at our ALF meeting in May.

I continue to be amazed at how efficient and hard working our NAFP and AAFP staff are.  Our national academy staff and leadership is undergoing some reorganization with the assistance of Accenture, a consultant to nonprofit organizations, to become a more efficient and lean organization.  I believe we will be in a better position to support our membership and prepare for the upcoming challenges of health care reform.  Speaking of our membership, we just surpassed the 97,000 mark this past year.  The more family physicians we represent the louder our collective voice.  I believe together we are stronger than apart.  As Benjamin Franklin said “We all hang together or most assuredly we will hang apart”.  More to come later.  Onward.

Time marches on and it is almost March already.  Our Spring ALF meeting is just around the corner and is always a unique conference with “out of the box” speakers.  Health care reform is still a hot topic and no one knows yet how it may change with a new Congress.  I will update you later on that front in that there is a board meeting and cluster meeting of the commissions of our AAFP next week.  The topics to be addressed are:  Health Care Reform with the changes in the House of Representatives, Accountable Care Organizations update, and a variety of other pertinent topics on payment reform.  More to come.

I did want to address and inform you of an issue related to health care reform and rural health clinics.  Our state has 130 rural health clinics currently.  Part of the stimulus package President Obama passed was HITECH which was a grant program to stimulate practices to implement an Electronic Health Record system.  One of the issues with small and rural practices is the capital costs of implementing an EHR.  This program was to offer cash incentives over a five or six year period to offset the costs of such a system.  Our rural health clinics are just the size and composition that the program was targeting.  Almost the “Poster Child” of the program.  You qualify for the program by either a Medicaid route or a Medicare route based on your office billing as a percentage of your whole practice.  The Medicaid stimulus was around 63,750 dollars and the Medicare stimulus was about 44,000 dollars.  Unfortunately most rural practices won’t qualify under the Medicaid requirements but would qualify under Medicare requirements.  The law as it was written qualified a practice by the percentage of HCFA 1500 form billings to Medicare.  Rural health clinics bill with a different form UB 92 which falls under Medicare part A, not Medicare Part B which is the requirement to qualify for the stimulus package.  This effectively disqualifies all the rural health clinics from qualifying for the stimulus under the Medicare criteria.  Since most or all rural health clinics won’t qualify by the Medicaid criteria it effectively closes the door on these clinics to get assistance financially to implement an EHR.  I believe this was an oversight by the lawmakers, not understanding how rural health clinics bill for outpatient clinic services.

In talking to some of my colleagues both locally and on the board of directors they thought the costs of an EHR would be covered by the Medicare cost report which is reflected on the UB 92 form rural health clinics use to bill with.  This is partially true but you only receive the cost reimbursement to the degree you see Medicare patients.  This would amount to 30% to 35% of your costs of implementing an EHR depending on your percentage of Medicare billing.  Also depending on the format of your rural health clinic (independent vs. hospital owned) there is a cap on the amount of expenses you can report.  This again would reduce the percentage of the costs to implement an electronic health record.  In essence then while you get part of the expense covered it is just part of the total expense.  I believe this serves as a barrier to implementing an EHR which was the intent of the bill.  Senator Ben Nelson has written a letter on behalf of the rural health clinics in our state and rural health clinics across the United States to recommend a legislative fix to this oversight.  Rural health clinics are a critical part of health care delivery in the rural areas of not only Nebraska but all of the United States.  I would hope this important program could be retooled to qualify these clinics under the Medicare criteria.  I’ll keep you informed.  Onward! 

Bob’s Babblings

My first AAFP Board of directors meeting is officially in the bank. What a great group of individuals we have to lead us as family physicians into the future. I know this will be a wonderful growth experience for me personally and I know I’m going to become a lot better with computers before I’m done.

Your AAFP staff were key players in getting initially a one month patch to the SGR calculation for Medicare payments to prevent the 23% reduction that was scheduled to take place January first. Your Washington staff additionally contributed in obtaining a one year “fix” to the SGR to buy us time to do additional work on payment reform. Job well done Kevin Burke, Rosie Sweeney and their staff.

As a follow up to the Robert Wood Johnson commission and their contribution to the IOM (Institute of Medicine) report on the future of nursing, our current president Roland Goertz MD, MBA pointed out the emphasis the report placed on APRNs and their licensure. Our aafp.org website has a link to our official position on APRNs and PAs and the importance of physician extenders working as part of a physician directed team. It clarifies some of the educational differences between MDs and APRNs and the variability of educational experiences of APRNs in obtaining their certification. Dr Goertz pointed out in his testimony the “standard training and standard certifications’ of competencies” that is embedded in physicians training. Physicians have over 14,000 hours of clinical experience compared to about 1,000 hours of clinical experience in a Nurse Practitioner’s education. For independent practice and first contact care this could prove to be an important difference.

Your Board of directors are still looking and working on non-dues revenue sources so that we can continue to provide the full scope of valuable services to our members at a reasonable cost. Many ideas were brought forward and I will communicate them to you through the blog as they become more mature. Communication to our members and our chapters is going to be a large focus of the AAFP and your board in the coming year to keep you abreast of the rapid changes that are occurring in this era of health care reform and how it may affect you and your practice situation. As I have mentioned before, payment reform in terms of how you are paid will continue to be a focus of your academy. It’s important to all of us to have the value of what we bring to our health care system be recognized in payment systems. This may narrow the discrepancy of income between family physicians and our specialty colleagues. This as well may increase student interest to ensure we have enough family physicians to care for the citizens of our nation. I would refer you to the COGME report that addresses this issue and the changes in income it will take to remove this as a consideration in specialty choice for medical students.

My first Board of Directors experience only confirms what I already knew, we are in good hands with the competent professional leadership in our academy. We are always open to suggestions though and I am more than happy to serve as your voice to the board of your AAFP. More to come on Meaningful use and rural health clinics and ACOs. Onward!

Wow! It has been over a month since my election to the Board of Directors of the AAFP. I really can’t express my gratitude and appreciation to our NAFP staff and all of you for your support. My official first board meeting is December 7 through 12.

 Your Academy has been very active and was successful in patching the SGR (sustainable growth rate) adjustment for the month of December. Medicare would have cut physician fees by 23% if no remedy had been proposed and passed. Our Washington staff is working to offer a three-five year fix to the SGR until a permanent payment reform policy can be passed.

The IOM (Institute of Medicine) referred their report on workforce issues and it was heavily weighted towards APRN’s as being part of the solution to our primary care manpower shortage. They recommend nurses work to the “full extent of their licensure”. Our AAFP positions and comments to the panel were that we are supportive of physician extensions, both PA’s and NP’s as being part of a physician-led team in the patient-centered medical home concept of healthcare delivery.

I am excited and committed to represent all of you, no matter what form your practice takes and to keep you informed of the challenges we face as family physicians in this era of healthcare reform. I’m only an email away (rwergin@gmail.com) for your comments or concerns.

 More to come. Onward!