Reform Update: AAFP criticized for participation on AMA's RUC

The American Academy of Family Physicians is catching some heat for its participation on the American Medical Association Specialty Society Relative Value Scale Update Committee, or RUC.

Dr. Paul Fischer, founder of the 27-phyisician, Augusta, Ga.-based Center for Primary Care, said he dropped his AAFP membership over the issue. He said the AAFP is more interested in keeping its seat on the RUC than it is in narrowing the payment gap between primary-care and specialist physicians.

“They have been politically timid in promoting member interests,” Fischer said. “We're sitting at the table, but we're getting more of nothing.”

Dr. Jeffrey Cain, AAFP president, said Fischer is not alone in his opinion. “There are members of the academy, and even within our Congress of Delegates, that said the most appropriate thing for us to do was to walk away from the RUC,” Cain said. “Paul is not the only family doctor in the U.S. who thinks the RUC has been over reimbursing procedural specialists and undervaluing cognitive specialists.”

There have been growing calls to reform the Medicare payment-setting process by critics who say specialty physicians should not have so much power to set their own payment rates and that specialty control has set payments too high for specialty procedures and too low for primary and cognitive care services. But there's no indication Congress plans to take action.

Fischer, who unsuccessfully sued the CMS to stop it from relying on the RUC, argued that the panel is the reason for the payment divide and for overvaluing certain procedures which has led to their overuse.

“There are codes that are clearly over-reimbursed—all you have to do is look at the ones that are increasing in volume, that's where all the money is,” Fischer said. “If people couldn't make any money off unnecessary back surgeries, people would stop doing it.”

In contrast, he noted, “No one is going to jail for too many well-child visits.”

Cain said the AAFP has decided to keep its seat on the RUC and to work within it and outside of it to improve primary-care compensation. To this end, he said the AAFP is supporting legislation introduced by Rep. Jim McDermott (D-Wash.) to create an additional payment advisory committee that would have open meetings and would publish the minutes of those meetings.

McDermott said an aim of his bill was to address “the lack of transparency and fairness” in setting the Medicare fees.

Three different organizations are vying in the growing area of accrediting patient-centered medical homes, which were given a boost by the healthcare reform law. And that competition is likely to heat up now that the CMS has proposed to pay primary-care physicians for non face-to-face care management based in part on medical home accreditation.

In its proposal to pay primary-care physicians for non face-to-face care-management activities, the CMS solicited public comment on whether third-party recognition as a patient-centered medical home could serve as proof that a practice was up to the task of providing these care-coordination services.

Medical home certification programs may have started as a marketing tool to help practices differentiate themselves from their competitors, but their importance has been elevated as some payers have boosted reimbursement to practices that have earned some level of third-party recognition.

Having recognized 5,770 practices as medical homes, the National Committee for Quality Assurance operates the largest of these programs. One way other organizations, such as the Joint Commission and the Accreditation Association for Ambulatory Health Care, have sought to differentiate themselves is to include onsite visits as part of their recognition process.

If third-party medical home recognition becomes part of a CMS payment process for care-management services, the stakes will be raised even higher.

The AAAHC, which has accredited 226 practices as medical homes and is based in Skokie, Ill., believes the value of onsite accreditation-survey visits will be raised as well.

“We believe the only reliable indicator for validation of patient-centered care is through the on-site visit process,” said Mona Sweeney, the AAAHC's assistant director of accreditation services. “AAAHC on-site survey and our accreditation and certification processes are not only thorough but are a reliable evaluation of an organization's ability to deliver care as a medical home.”

AAAHC also argues that lawmakers and regulators will find more value in onsite surveys.

“The purpose of the on-site survey is to have peer reviewers observe the culture, the dynamics and the quality of care in action,” she said. “Conducting patient, provider and staff interviews in addition to the in-depth review of written policies, clinical records, provider credentialing and privileging—all of these provide evidence of the best practices we expect from an accreditable organization.”

Sarah Thomas, vice president of public policy and communications for the Washington-based NCQA, said “a growing body of evidence” has shown that the NCQA's program can reduce cost while improving patient access and satisfaction.

“We encouraged CMS to accept NCQA recognition and are pleased that the proposed rule asks about this,” Thomas said. “Our program requires rigorous documentation on how practices meet our standards, and includes an audit process. We have considered site visits but it is not clear that they would lead to more accurate assessment.”

Amy Gibson, chief operating officer for the Patient-Centered Primary Care Collaborative, a coalition of 1,000 stakeholders advocating for medical homes, said her organization has not taken a position on this issue. “We don't advocate one as better than the other,” she said. “We certainly want practices to be rewarded for the things that they are doing.”

As the healthcare system prepares for a huge arrival of newly insured patients in 2014, more evidence comes from Massachusetts indicating that coverage does not equal access.

The Massachusetts Medical Society surveyed 1,137 physician offices covering seven medical specialties and asked about wait times for new patients, percentages of doctors accepting new patients and physician acceptance of Medicare and the MassHealth Medicaid government insurance.

While waits to see family physicians dropped 13.3%, to 39 days from 45, wait times to see an internist grew 13.6%, to 50 days from 44. Waits for pediatric visits dropped 7.4%, to 25 days from 27. Wait times for specialists remained stable, though the wait to see a gastroenterologist decreased 11 days and the wait to see an orthopedic surgeon increased six days.

Primary-care physicians also reported decreased acceptance of new patients. According to the 9th annual MMS survey, the percentage of pediatricians seeing new patients dropped to 70% from 72%. For internists the figure decreased to 45% from 51%. For family physicians it increased slightly, to 51% from 50%.

“Our latest survey once again points out a critical characteristic of healthcare in the commonwealth,” Dr. Ronald Dunlap, MMS president, said in a news release. “While we've achieved success in securing insurance coverage for nearly all of our residents, coverage doesn't guarantee access to care. The concern is that limited and delayed access can lead to undesirable results, as people will seek more costly care at emergency rooms, delay care too long or not seek care at all.”

The survey was conducted via telephone between Feb. 28 and April 15.

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