Miriam E. Tucker

October 22, 2014

WASHINGTON — Resolutions passed at the American Academy of Family Physicians Congress of Delegates aim to fix some of the most vexing barriers family physicians confront in providing care to their patients, including prior authorization, electronic health record incompatibility, and lack of reimbursement for hospital consulting.

"We are acting to realize the benefits of practice transformation and to ensure that care provided by primary care physicians meets the needs of our individual patients," Reference Committee on Practice Enhancement Chair Kurtis S. Elward, MD, a family physician in Charlottesville, Virginia, told Medscape Medical News. The steps we're taking for the future with regard to electronic health records, new payment models, and insurance design all follow a path that's going to get us to better care and more efficient care."

The three topics Dr Elward highlighted were among a total of nine resolutions addressed by the Practice Enhancement Committee. His committee is just one of five AAFP reference committees that proposed and discussed a series of resolutions on Monday; the entire Congress then voted on the resolutions on Tuesday.

Prior Authorization

The resolution "Request the American Academy of Family Physicians to Work With Insurers to Reduce the Administrative Burden for Medication Prior Authorization" was adopted by the Congress attendees. This resolution asks AAFP to collaborate with the American Medical Association, America's health insurance plans, and other stakeholders to work toward standardization of the prior authorization process across managed care plans and to develop and support model state-level legislation to implement best practices for such standardization.

Prior authorization is a major frustration among family physicians, Dr Elward told Medscape Medical News.

"We wanted to address the issue of administrative burden for prior authorizations. It's one of the biggest headaches that patients face, because there are so many ways of doing it across the board. There are forms that need to be filled out before forms can be filled out.... A lot of prior authorization setups are really based on what's beneficial to the insurer."

E. Mark Watts, MD, alternate delegate from Virginia, the chapter that sponsored the resolution, testified that his practice of six physicians spends an estimated $6000 to $7000 in staff time annually just to acquire prior authorizations. "We aren't asking for a one-size-fits-all type of process. We are asking for AAFP to help us identify the parameters that work best in states around the country," he said.

Brian Bachelder, MD, delegate from Ohio, said that in his office of four physicians and one nurse practitioner, one employee works full-time on prior authorizations, adding, "There's just plain too much of this going on."

He noted that even generic medications now often require prior authorization, and that insurance companies appear to be using the process merely to track utilization. "They always say yes, but all they want to do is track...so they're transferring their problem of tracking to us. This is becoming much broader in its implications, and it's only going to get worse. We need to put our foot down someplace, so we're asking AAFP to help us do that nationally."

Electronic Health Records

The "Electronic Health Records" resolution was referred to the AAFP Board of Directors for further consideration, signifying the complexity of the problem. The resolution had called for AAFP to encourage federal policymakers and CMS to "create significant and compelling incentives and disincentives for all electronic health record (EHR) vendors to enhance their current EHR's" in specific ways, including enabling interoperability, adopting a standard format for patient health information, creating a user-friendly interface, and providing capacity to facilitate chronic disease management.

Leonard M. Finn, MD, delegate from Massachusetts and author of the resolution, asked the audience of more than 100 people, "How many of you are happy with your electronic medical record?" About four or five audience members raised their hands.

He said that in over a decade since they came out, "Electronic medical records still fail to help us do what we want them to do to provide care for our patients. No bank, no airline system would tolerate the quality of the software that we have to work with. In particular, interoperability and standard formats for patient health information should have been present when EHRs first came on the market."

Dr Elward told Medscape Medical News, "It was very evident that that resolution tapped into a lot of frustration and addressed a lot of the challenges we have in using EHRs in ways that will really be patient-centered and user-friendly."

He added, "A lot of family physicians have been good citizens in signing onto EHRs with the promise that these would be able to exchange information and manage patients more easily, and that promise has not been kept. One thing this resolution is going to do is give direction to our academy board that we need these problems fixed, and there need to be some creative solutions to bring vendors and bring the federal government to the table to fix these problems and fulfil the promise."

Hospital Consulting Reimbursement

The "Family Medicine Is a Specialty" resolution was adopted by the Congress attendees. This resolution asks that AAFP work with CMS and private payers to recognize ambulatory family physicians as specialists for the purposes of consulting on their hospitalized patients and to allow for payment when a consultation is requested from the hospitalist or another physician, even if she or he is also a family physician.

Alternate Arizona delegate Andrew Carroll, MD, who authored the resolution, explained that because he provides ambulatory and hospital care as well as goes on house calls, his patients' utilization is lower than that of family physicians who do not provide care across settings.

"What I'm trying to do is get more family medicine physicians involved in all phases of patient care," he said, adding that even if the in-hospital care is not 24/7, at least family physicians should be paid for consulting and for 2- to 3-day follow-up after discharge.

"A lot of times the hospitalist won't even bother to call us and let us know the patient was discharged, and then the patient shows up in our office and we have no idea what happened to them."

Moreover, he continued, "[c]urrently, CMS only pays for consultations outside of the hospitalists' speciality, so if the hospitalist is a family physician, you might not get paid for providing consultation."

"If we're involved from the beginning to the very end, not only will we provide the comprehensive care that our patients want and need, but will also reduce costs," Dr Carroll said.

Dr Elward told Medscape Medical News, "It's a personal physician with knowledge and history and experience communicating with the in-hospital physicians to make sure that their plan is successful. We're asking that there be some reasonable reimbursement for it. We believe it would decrease costs, decrease duplicative care, extra testing, and help ensure that the patients' transition back to home is as successful as it can be."

But New Jersey delegate Mary F. Campagnolo, MD, sees it differently. "I think this is not the way to solve the problem. If the Academy focuses on a shared savings models, or value-based models of clinical integration, where family physicians are the leaders in those organizations, and models the money for the work will come to us...I think that would be a better way to solve [the problem] than setting up new consultation fees."

However, Massachusetts delegate Dennis M. Dimitri, MD, pointed out that many family physicians are already checking on their hospitalized patients. "Many [family physicians] are doing this pro bono.... They do it because it's the right thing to do, because it's helpful for their patients, but I think it's only fair that they get paid for this work as well."

Other Resolutions

Other adopted resolutions from the Committee on Practice Enhancement included encouraging CMS to begin covering the cost of the adult tetanus-diphtheria-pertussis booster vaccine and its administration under Medicare Part B, and calling for a new Medicare chronic care management fee. A resolution to study the impact of price transparency on the quality of rural healthcare was referred back to the Board of Directors for further study.

One resolution that was not adopted would have given special recognition to physicians who do not accept pharmaceutical detailing or samples. Many delegates felt that this would imply that those physicians who do accept detailing ― often to provide free samples to patients who cannot afford medications ― were doing something wrong. One delegate pointed out that physicians who seek such recognition can do so at www.pharmedout.org.

Dr Elward has disclosed no relevant financial relationships.

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