Working Party - AAFP Home · Working Party Policy & Political Update ... Hope Wittenberg. Robert Hall. Overview • 2018 Mid-Term Congressional Elections • Health Care Cost •

Working PartyPolicy & Political Update

August 17, 2018Shawn Martin

Hope WittenbergRobert Hall

Overview • 2018 Mid-Term Congressional Elections

• Health Care Cost• Delivery System &

Payment Reform• Public Health, Science &

Other Disproven Activities • M&A/Consolidation• Engagement & Influence• Rural GME• VA GME

• Teaching Health Centers• Single Accreditation

System• Title VII - Appropriations

and Reauthorization• Primary Care Research• Student Documentation

Guidelines• Administrative Burden• Affordable Care Act• Direct Primary Care• Medicaid

2

2018 Mid-Term Congressional Elections

• President Trump• House of

Representatives• Senate• Governors• States• Voters

4

25%

30%

35%

40%

45%

50%

55%

60%

65%

President Trump’s overall approval rating has hovered in the low-40% range, with over 50% consistently disapproving

Donald Trump approval ratings since inauguration

Source: HuffPost Pollster, “Poll Chart: Donald Trump Approval Rating,” 2018.

52.7%

42.8%

AverageAugust 3, 2018

■ Approve ■ DisapproveHUFFPOST POLLSTER AGGREGATE

Daniel Stublen | Slide last updated on: August 9, 2018 5

Trump’s approval rating among independents has decreased since mid-July, remains very high among Republicans

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

■ Republican ■ Democrat ■ Independent

Donald Trump approval ratings by party since inauguration

Source: Gallup, 2018.

Most recent poll:August 5, 2018

GALLUP

89%

13%

First poll:Jan 29, 2017

42%

89%

7%

33%


Support for Trump is highest in Alabama and Mississippi, lowest in Massachusetts, Hawaii, and DC

Sources: Morning Consult, May 7, 2018.

MD -22%

MA -25%

RI -18%

CT -12%

DE -12%

NJ -12%

DC -57%

MORNING CONSULT; JUNE 2018; APPROVAL MINUS DISAPPROVAL

Trump net approval by state

Daniel Stublen | Slide last updated on: June 28, 2018 7

IN AUGUST OF EACH PRESIDENT’S SECOND YEAR

Gallup comparative presidential approval ratings

Trump’s approval numbers are near but slightly below most previous presidents at this point in their terms

Source: Gallup, 2018.

Daniel Stublen | Slide last updated on: August 9, 2018

4144

67

41

75

42 41

55

6765

TrumpAug. '18

ObamaAug. '10

W. BushAug. '02

ClintonAug. '94

H.W. BushAug. '90

ReaganAug. '82

CarterAug. '78

NixonAug. '70

KennedyAug. '62

EisenhowerAug. '54

8

Why Democrats Are Optimistic

• President’s approval ratings

• House of Representative map

• Women

• Supreme Court

9

Why Republicans Are Optimistic

• Senate map

• Congressional map

• Economy

• Supreme Court

10

Current House and Senate divisions

*If all members voteSources: House and Senate Clerks

Daniel Stublen | Slide last updated on: August 8, 2018

House of Representatives

Total Republicans 51

Total Democrats/Independents 49

Senate

Total Republicans 236

Total Democrats 193

Vacancies 6

11

How big of a swing? Control of the House will depend on whether Democrats can win most “Toss Up” races

ALL 2018 HOUSE RACES

Cook Political Report ratings

Source: Cook Political Report.

181

9

2

2

1

3

7

25

26

27

152

Solid Democrat

Likely Democrat

Lean Democrat

Toss Up

Lean Republican

Likely Republican

Solid Republican

Solid to Lean R (206) Toss Ups (27) Lean to Solid D (202)

218 majority line


36%

Aug. 642%

Democratsare leadingby 6 points.

Generic congressional ballot polling30-DAY MOVING AVERAGE

35%

40%

45%

30%

Jan.Nov. March May July

13

DonaldTrump Healthcare Economy andjobs Gunpolicy Immigration Foreignpolicy

30%

26%

32% 33%

25%

18%20%

23%

27%30%

20%

12%

16%18%19%

14%13%12%

Share of registered voters saying the following is a top issue:Democrats All registeredvoters Republicans

14

Large Demographic Shifts UnderwayChanges in Demographic Profile and Voting Power of White Electorate

• Whites are growing more educated, more secular, more single, and older; only the last trend is a boon to Republicans• The white share of the electorate is growing smaller; since 1980, Democratic-leaning minorities have more than doubled

*

* Numbers may not add up to 100% due to rounding

15

Women running for office in 2018

Sources: Politico, “The women candidate tracker.”

183

165

9

9

182

136

27

19

Total

House

Senate

Governor

Advanced in primariesAwaiting primaries

Alice Johnson | Slide last updated on: August 8, 2018 16

https://www.politico.com/interactives/2018/women-rule-candidate-tracker/

Democrat held seat Republican held seat

COMPETITIVE 2018 HOUSE RACES

Cook Political Report ratings

House Republicans are defending 88 competitive seats to only 14 competitive Democratic seats

Source: Cook Political Report.

*Asterisks denote incumbents not seeking reelection, seeking other office, or lost primary election

Lean Republican

AR-2 HillCA-45 WaltersFL-15 Ross*FL-16 BuchananFL-18 MastGA-6 HandelIL-13 DavisIL-14 HultgrenMT-AL GianforteNC-9 Pittenger*NC-13 BuddNE-2 BaconNJ-3 MacArthurNM-2 Pearce*OH-1 ChabotOH-12 VACANT (Tiberi)PA-1 FitzpatrickPA-16 KellyTX-23 HurdUT-4 LoveVA-2 TaylorVA-5 Garrett*WA-3 BeutlerWA-5 McMorris RodgersWI-1 Ryan*WV-3 Jenkins*

(26 GOP) PA-14 OPEN (Lamb)AZ-6 SchweikertCA-4 McClintockCA-21 ValadaoCO-3 TiptonFL-6 DeSantis*FL-25 Diaz-BalartGA-7 WoodallIN-2 WalorskiMI-1 BergmanMI-6 UptonMI-7 WalbergMO-2 WagnerNC-2 HoldingNC-8 HudsonNY-1 ZeldinNY-11 DonovanNY-24 KatkoNY-27 CollinsOH-10 TurnerOH-14 JoyceOH-15 StiversPA-10 PerrySC-1 SanfordTX-2 Poe*TX-21 Smith*TX-31 CarterWI-6 Grothman

Likely Republican

(1 Dem, 27 GOP)

MN-1 Walz*MN-8 Nolan*CA-10 DenhamCA-25 KnightCA-39 Royce*CA-48 RohrabacherCO-6 CoffmanFL-26 CurbeloIA-1 BlumIA-3 YoungIL-6 RoskamIL-12 BostKS-2 Jenkins*KS-3 YoderKY-6 BarrME-2 PoliquinMI-8 BishopMI-11 Trott*MN-2 LewisMN-3 PaulsenNJ-7 LanceNY-19 FasoNY-22 TenneyTX-7 CulbersonTX-32 SessionsVA-7 BratWA-8 Reichert*

Toss Up

(2 Dem, 25 GOP)

NH-1 Shea-Porter*NV-3 Rosen*AZ-2 McSally*CA-49 Issa*FL-27 Ros-Lehtinen*NJ-11 Frelinghuysen*PA-7 VACANT-DentPA-17 Rothfus/LambVA-10 Comstock

Lean Democrat

(2 Dem, 7 GOP)AZ-1 O’HalleranCA-7 BeraFL-7 MurphyMN-7 PetersonNH-2 KusterNJ-5 GottheimerNV-4 Kihuen*NY-25 VACANT-SlaughterPA-8 CartwrightNJ-2 LoBiondo*PA-5 VACANT-MeehanPA-6 Costello*

Likely Democrat

(9 Dem, 3 GOP)


18

Election Day

35 Legislative Days

Supreme Court Session Begins

19

Health Care Costs •

Shruthi Ashok | Slide last updated on: July 26, 2018

Per capita health care spending1980-2016

Sources: Health expenditures, Centers for Medicare & Medicaid Services.

National health care spending has increased by $3,000 per person since 1980

National health expenditures, $3,337

Personal health care, $2,834

Hospital care, $1,083

Physician and clinical services, $665

Prescription drugs, $329

Retail drug spending represents 10% of U.S. health care spending

Hospital spending makes up almost 35% of total national health expenditures

21

22

23

24

25

26

About 60 percent of all adults aged 18-64 obtain health insurance through theirworkplace.

From 2007 to 2017, the percentage of employees choosing a traditional plan fell from 85 percent to 57 percent.

Over the same period, the percentage opting for a plan with a higher deductible rose from 15 percent to 44 percent.

Higher-educated and more affluent employees are most likely to skip the traditional plan for a higher deductible with an HSA.

27

Percentage of adults aged 18-64 with employment-based health insurance, by type of coverage

25%

50%

Traditional health plan

High-deductible health plan, with HSA

’07 ’08 ’09 ’10 ’11 ’12 ’13 ’14 ’15 ’16 ’17

High-deductible health plan, no HSA

11%4%0%

100%

85%

75%

25% (+131%)19% (+350%)

57%–33%since ’07

Note: Totals do not sum to 100 percent because of independent rounding.

28

poverty level or less

138%-250% FPL 60.6% 27.2% 12.2

250%-400% FPL 58.1% 26.1% 15.8

400%+ FPL 55.5% 22.6% 22.0

Type of coverage by family income, 2017AMONG ADULTS AGED 18-64 WITH EMPLOYMENT-BASED PLAN

138% of federal


59.9% 32.2% 7.9

TRADITIONAL PLAN HDHP, NO HSAHDHP+ HSA

29

Type of coverage by educational attainment, 2017AMONG ADULTS AGED 18-64 WITH EMPLOYMENT-BASED PLAN

HS diplomaor GED

Some college

Bachelor’s degree or higher

Less than HS

59.5% 27.1% 13.5

57.6% 25.8% 16.7

54.3% 21.8% 23.9

61.1%


28.2% 10.7

TRADITIONAL PLAN HDHP, NO HSAHDHP+ HSA

30

Delivery System & Payment Reform

• Advanced Primary Care Alternative Payment Model (APC-APM)

• Direct Primary Care

• 2019 Physician Fee Schedule

• 2019 Accountable Care Organizations

Advanced Primary Care Alternative Payment Model (APC-APM)

32

2019 Medicare Physician Fee Schedule Includes MACRA QPP Changes

• On July 12, 2018, CMS released a proposed rule on 2019 Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Medicare Part B– Combines the 2019 Medicare Physician Fee Schedule and

MACRA’s Quality Payment Program changes and updates

• Comments are due September 10, 2018

The AAFP policy team is reviewing the proposed rule for impacts on family medicine and drafting comments for Board approval.

33

https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-14985.pdf

Key MPFS Provisions for Family Medicine

Medicare Physician Fee Schedule

• Updates to Conversion Factor• Changes to E/M Payment & Documentation• Payments for Telehealth• Other Updates Impacting Family Physicians

• Updates to RVUs, GPCIs• Physician payment for administering new biologics• Identifies potentially mis-valued services• Updates to Appropriate Use Criteria (AUC) program• Potential episode payment for SUD treatment• Changes to MSSP quality measures

MACRA QPP

•Updates to MIPS•Performance Categories and Scoring• Promoting Interoperability Category• Low-Volume Threshold

•Advanced APMs • Increases CEHRT Threshold to 75%•Maintains 8% revenue-based nominal risk standard•Refines Other-Payer Advanced APM determination process for

multi-year arrangements•Medicare Advantage Qualifying Payment Arrangement Incentive

Demonstration (MAQI)

34

Proposed Restructuring of E/M Payment Levels• Collapse Payment for E/M Services

– Blended, single payment for new patient office visits levels 2 - 5 (99202 - 99205) – Blended, single payment for existing patient office visits level 2 - 5 (99212 - 99215)

Level

Current Payment for Est. Patient

Proposed

Payment1 $22 $242 $45

$933 $744 $1095 $148

Level

Current Payment for New Patient

Proposed Payment

1 $45 $442 $76

$1353 $1104 $1675 $172

35

Proposed E/M Payment Changes • Multiple Procedure Payment Reduction

– 50% reduction on lower paid service when physicians report E/M service and certain procedures on the same date

• New Codes for Add-on Payments to Office Visits– Specific specialties ($9)

• Allergy/Immunology, Cardiology, Endocrinology, Hematology/Oncology, Interventional Pain Management-Centered Care, Neurology, Obstetrics/Gynecology, Otolaryngology, Rheumatology, Urology

– Primary care physicians ($5) – definition TBD– 30-minute prolonged E/M visit ($67)

36

Proposed Changes to E/M Documentation• Expand documentation of history and exam to focus on changes since last visit or

pertinent issues

• Allow physicians to review and verify certain information in the medical record that is entered by ancillary staff or beneficiary, rather than re-entering

• Removal of duplicative requirements for teaching physicians on notations that may have previously been included in the medical records by residents or medical team members

• Allow physicians a choice in documentation for E/M visits:– 1995 or 1997 guidelines, OR– Medical decision-making, OR – Time

37

Impact Analysis

2019 Medicare Physician Fee Schedule

Evaluation & Management Codes

Distribution of New Patient Visits by Specialty

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00%

99201

99202

99203

99204

99205

Distribution of New Patient Visits

SPC Distribution PC Distribution FM Distribution

39

Distribution of Existing Patient Visits by Specialty

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00%

99211

99212

99213

99214

99215

Distribution of Existing Patient Visits

SPC Distribution PC Distribution FM Distribution

40

Utilization of New Patient CodesFamily Medicine 2012 to 2016

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

2012 2013 2014 2015 2016

Utilization of New Patient Codes

99201 99202 99203 99204 99205

41

Utilization of Existing Patient CodesFamily Medicine

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

2012 2013 2014 2015 2016

Utilization of Existing Patient Codes

99211 99212 99213 99214 99215

42

Trend 2012 to 2021Existing Patient Codes for Family Medicine

Percentages99211 99212 99213 99214 99215

2012 2.88% 3.46% 47.06% 43.73% 2.88%2013 2.69% 3.19% 46.14% 45.27% 2.72%2014 2.30% 2.79% 44.87% 47.35% 2.68%2015 2.08% 2.42% 43.69% 49.14% 2.67%2016 1.90% 2.21% 42.39% 50.80% 2.72%2017 41.22% 52.57%2018 40.05% 54.34%2019 38.88% 56.11%2020 37.71% 57.88%2021 36.54% 59.65%

43

• Between 2012 – 2016 utilization of 99214 increased, on average, 1.77% annually.

• At current trend, a 99214 code will be used in 60% of visits to a family physician by 2021 (next 5 years).

• Between 2012 – 2016 utilization of 99213 decreased, on average, 1.17% annually.

Trend 2012 to 2021Existing Patients Codes for Family Medicine

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

2012 2013 2014 2015 2016 2017 2018 2019 2020 2021

Trend: Existing Patients

99213 99214

44

Impact Analysis – 2019

45

Medicare FFS Beneficiaries (300) 99211 99212 99213 99214 99215 TotalPercentage 1.92 2.1 38.88 56.11 3.21Number 6 6 117 168 10

2018 Values 22.00$ 45.00$ 74.00$ 109.00$ 148.00$

Total Payment at 2018 Values 132.00$ 270.00$ 8,658.00$ 18,312.00$ 1,480.00$ 28,852.00$

Total Payments at Proposed $93 115.20$ 558.00$ 10,881.00$ 15,624.00$ 930.00$ 28,108.20$ Net change from 2018 16.80$ (288.00)$ (2,223.00)$ 2,688.00$ 550.00$ 743.80$

Total Payments at Proposed $98 115.20$ 588.00$ 11,466.00$ 16,464.00$ 980.00$ 29,613.20$ Net change from 2018 16.80$ (318.00)$ (2,808.00)$ 1,848.00$ 500.00$ (761.20)$

Type of Visit - 2019

Impact Analysis – 2021

46

Medicare FFS Beneficiaries (300) 99211 99212 99213 99214 99215 TotalPercentage 1.92 2.1 36.54 59.65 3.21Number 6 6 110 179 10

2018 Values 22.00$ 45.00$ 74.00$ 109.00$ 148.00$

Total Payment at 2016 Values 132.00$ 270.00$ 8,140.00$ 19,511.00$ 1,480.00$ 29,533.00$

Total Payments at Proposed $93 115.20$ 558.00$ 10,230.00$ 16,647.00$ 930.00$ 28,480.20$ Net change from 2018 16.80$ (288.00)$ (2,090.00)$ 2,864.00$ 550.00$ 1,052.80$

Total Payments at Proposed $98 115.20$ 588.00$ 10,780.00$ 17,542.00$ 980.00$ 30,005.20$ Net change from 2018 16.80$ (318.00)$ (2,640.00)$ 1,969.00$ 500.00$ (472.20)$

Type of Visit - 2021

Key Takeaways• Directionally appropriate – technically flawed • The E&M proposal is net-neutral for most family physicians• The MPPR policy is a problem and would result in major cuts• The total package is net-negative for many if not most• Proposal upends progress towards comprehensive primary care

– Incentivizes churn– Not patient-centered

• Disconnect documentation and coding – focus on documentation

47

Public Health, Science & Other Disproven Activities

•

4423 60 76 99 166

Opioid prescriptions per 100 residents, by congressional districtBOTTOM FIFTH TOP FIFTH

AL-04166 prescriptionsper 100 residents

49

The maternal death rate in most developed nations has been flat or declining, but it’s on the rise in the USRates of maternal mortality per 100,000 livebirths, 1990 to 2015

Paige Wulff | Slide last updated on: August 6, 2018

Sources: “Global, regional, and national levels of maternal mortality, 1990 – 2015: a systematic analysis for the Global Burden of Disease Study 2015,” The Lancet, October 8, 2016.

5.0

10.0

15.0

20.0

25.0

1990 2000 2015

Germany

U.S.France

Japan

England

Canada

26.4

Mergers/Acquisitions & Consolidation

•

•

Engagement & Influence

KEY FINDING #1

AAFP Continues to be One of the Most Effective Associations in Washington

53

Source: Ballast Research survey and analysis. Interview verbatims edited slightly for clarity.

In the 2018 Study of Most Prominent Associations, AAFP Retained the #2 Overall Spot

35

55

75

Washington Policy Brand

The Washington Policy Brand Index is a combination of scores on the four distinct measures of an organization’s long-term policy reputation: Respect, Consideration, Influence, and Sharing.

AAFPPhysician Association Peers

Health Care Trade Associations

Other Associations Studied

AAFP (2nd / 48)

54


And AAFP Outperforms Other Prominent Associations in Washington in Almost All Advocacy Activities Studied

All Advocacy Activities StudiedAAFP Compared to Average of All Associations Studied

+8.9 +8.2

+7.7

+5.5 +3.2+1.6 +0.8

-0.3

-1.4+ 2.6

40

65

90Association Average

AAFP

55


AAFP’s Views are More Likely to Be Sought Out Than Any Other Association Studied

25

45

65

Sharing

Survey Question: “How likely are you to seek out or share the organization’s opinion on an issue?”


Health Care Trade Associations


AAFP (1st / 48)

56


AAFP Works to Find Middle Ground on Tough Policy Issues

35

55

75

Compromise

Survey Question: “The organization negotiates for consensus and is open to making reasonable trade-offs on tough issues.”



AAFP(2nd / 48)

Top Performers

57

Academic Family Medicine Issues Update

58

Academic Family

Medicine Issues

Rural GME

VA GME

Teaching Health Centers

Single Accreditation System

Title VII - Appropriations and Reauthorization

Primary Care Research

Student Documentation Guidelines

59

Wins Continued Efforts Needed

Rural GME – Comprehensive Bill Introduced

VA GME – New authority to pay outside VA linoleum

Student Documentaton changes supported by CMS

THC Reauthorization AHRQ Appropriations Increase and Report

Language Title VII appropriations Increase

Move from Introduction to Enactment in future Congress

Regulatory Implementation

Some issues still to be included; decisions changed

Move to Permanence

Regulatory Implementation Regulatory Implementation

It’s Been a Very Good Year!60

Rural GME

4 Key Issues:

1. Rotator Issue

2. Critical Access Hospitals

3. Rural Training Track (lifting of CAP)

4. Per Resident Payment

61

CAFM COUNCIL OF ACADEMIC FAMILY MEDICINE

S. 3014 Introduced

Rural Physician Workforce Production Act of 2018 Senator Cory Gardner (R-CO) Lead Sponsor Cosponsored by Senators Cindy Hyde-Smith (R-MS) and Jon Testor

(D-MT) Coalition of Organizations Supporting bill: CAFM, AAFP, NRHA,

AACOM, Working on Budget Neutrality Impact – needed to gain more support. Possible use of Unused Residency slots in next iteration to defray cost

impact of bill

62


Veterans GME: Good news for a change Our goal: improve uptake by family medicine, especially in rural areas, by

allowing payment for training “off the VA linoleum.” MISSION Act enacted into law June 6. Creates Pilot program to establish new

medical residency programs at covered facilities, including VA facilities, a facility operated by an Indian tribe or tribal organization, an Indian Health Service facility, a FQHC, or a DOD facility. Implementation: Advocating with VA to try to include rural FM residency sites.

Two positive internal policy changes within VA Allow facility sharing and partnerships between the VA and its educational affiliates. Allow for joint recruitment of VA faculty. Residency faculty could become a part-time VA

faculty and serve as such in the shared facility.

63


THC Reauthorized Feb 9, 2018

Implementation Issues:

What will the PRA be? $150K for last year and this (AYs 17-18 and 18-19)

New Competition – for AY19-20) Expected in the Fall

How many new Programs? Unknown (3-10?)

Priority for New Programs Serving HPSA or Medically underserved community, or Located in a rural area (Non-metropolitan statistical area)

Next Step – Permanence?

64

Title VII – Primary Care AHRQ

FY 18 – increase of $10 m (to $48.9)

FY 19 – Committee-passed bills House – level funding Senate – level funding Expected Senate Floor action any day

now

FY 18 – increase of $10 m (to $334 m)

FY 19 - level funding

Appropriations65


AHRQ Issues s

FY 18 – Report Language for Study -$1 M study to study health services and primary care research supported by Federal agencies since fiscal year 2012

Study to identify: Research gaps and areas for consolidation Better coordination between federal agencies

FY 19 – effort to gain funding for Center for Primary Care Research; failing that, report language to prioritize Center

FY19 – AHRQ Guideline Clearinghouse victim of prior year budget cuts Funding to support AHRQ's National Guideline Clearinghouse (NGC) ended on July 16, 2018. AHRQ is exploring options to support the NGC in the future.

Potential loss of funding from PCORI if not reauthorized by FY 2020; AFMAC discussing involvement in PCORI reauthorization

66


New Rural Residency Expansion Program

FY 18 Appropriations contained $15 M for new programs TA funding opportunity published – due Aug 22. RFP for residencies: Expected to be published just after Labor Day Expected due date – Nov. 30th

67


Rural Residency Key Provisions

Funds will support planning and development costs – to achieve ACGME accreditation

Encourages HRSA to support rural hospitals, medical schools, and community-based ambulatory settings with rural designation along with a consortia of urban and rural partnerships.

Can’t just be aspirational – need to show sustainability through funding from: Medicare, Medicaid, state line items, private funders

Programs already in creation phase ok to apply until ACGME accreditation.

68


Student Documentation Guidelines

CMS changed its guidance to allow preceptors to use student documentation for billing purposes in February.Outstanding Issues for Continued Effort: Inclusion of: NP/PA students NP/PA preceptors

Clarity that a resident can use student documentation as well, generally, and with Primary Care Exception

Working with HRSA Advisory Ctmes to send letters of support to HHS/CMS Will include comments in response to Medicare Fee Schedule proposed rule

69


Medicare Fee Schedule Proposed Rule

Many questions regarding proposed coding changes impact/applicability to teaching physician rule – including the primary care exception

70

Administrative Burden & Regulatory Relief

•

72

37 Prior Authorizations / WeekAMA Survey of Physicians

73

Solution: Decrease Burden of Prior Authorizations

• Standardize the format for all payers• Allow automation in the EHR• Eliminate PA’s for

– Generic Medications– Durable Medical Equipment– Supplies– Renewal for an ongoing chronic condition

• Pay for the time involved in completing the PA

74

Solution: Streamline Quality Reporting

• Family Physicians indicate they may have 10 or more payers that require different quality reporting requirements– Need standardization– Core measure sets adopted by all payers

• Core Quality Measures Collaborative• Feedback report should be standardized for all payers• When a new measure is added, old measures should be

eliminated

75

Solution: Change the Primary Care Payment Model

Blended model with emphasis on overall population care and focus on quality rather than volume of office visits

76

Affordable Care Act •

78

79

80

16.7

12.0

17.2

16.3

17.5

16.1

18.2

13.3

10.510.4

10.7

02

46

810

1214

1618

20

1972

1974

1976

1978

1980

1982

1983

1984

1986

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

*

Source: CDC/NCHS, National Health Interview Survey, reported in http://www.cdc.gov/nchs/health_policy/trends_hc_1968_2011.htm#table01and https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201805.pdf.

Uninsured Rate Among the Nonelderly Population, 1972-2017

Share of population uninsured:

http://www.cdc.gov/nchs/health_policy/trends_hc_1968_2011.htm#table01

https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201805.pdf

Direct Primary Care: Federal Overview• Americans with Health Savings Accounts (HSAs) (21.8 million as of

January 2017) are not permitted to enroll in Direct Primary Care practices.

• Jan. 2017: Bipartisan Primary Care Enhancement Act introduced in both House and Senate. The bill (1) allows patients with HSAs to enroll in DPC, and (2) allows patients to use HSA dollars to pay the membership fees.

• July 19, 2018: House Ways and Means marks up revised version of the Primary Care Enhancement Act. (4 Dems crossed party lines).

• July 25, 2018: House passes (by vote of 277-142) H.R. 6199, which contains the modified Primary Care Enhancement Act as Sec. 3.

82

Direct Primary Care: Federal Overview (cont’d)Modifications to Primary Care Enhancement Act in H.R. 6199(1) Limited to services provided by a family physician, general

internist, pediatrician, or geriatrician(2) Limits monthly subscription fee to $150 per person / $300 per

family (3) Defines primary care by exclusion, carving out:

(a) procedures requiring general anesthesia, (b) Rx drugs excluding vaccines, and (c) lab services not typically administered in an ambulatory

setting.

83

Direct Primary Care: Federal Overview (cont’d)

• AAFP position on Primary Care Enhancement Act– support as introduced; neutral after modifications– DPC Coalition “strongly supports” the bill as

modified.• Challenges for Passage before 2019

– JCT: $1.8b less revenue over 10-year window– less momentum behind HSA reforms in the Senate

84

Direct Primary Care: State Overview

85

Medicaid Section 1115 Waivers• In January 2018, CMS Administrator Seema Verma encouraged

states to submit plans to establish Medicaid work requirements.– Eleven states have submitted Section 1115 waivers to implement

work requirements for able-bodied adults.– Most proposals require individuals to work 80 hours/month.– Exemptions included for pregnant women, primary caregivers,

students, the disabled, those under 18 or over 65.– Additional eligibility restrictions have been proposed, including

the elimination of retroactive eligibility, additional cost sharing, and citizenship verification.

86

Medicaid Section 1115 Waivers

As of August 8, 2018; Kaiser Family Foundation

87

Work Requirements

• CMS approved work requirements waivers in Kentucky, Indiana, Arkansas, and New Hampshire.

• Kentucky’s work requirements have been blocked by the courts

• Arkansas sued on Monday

Approved and Pending Work Requirements by State

88

AAFP’s Policy ReputationAAFP Involvement• In December 2017, AAFP joined five other primary care physician

groups in releasing a series of joint principles through which to evaluate Section 1115 waivers:• Maintain affordability protections and oppose time limits • Maintain/strengthen benefits• Oppose barriers to eligibility, including work requirements• Maintain access to all providers, including women’s health

services• Limit cost- or risk-shifting to families or physicians and promote

innovative models of health care delivery• Strengthen waiver transparency and engagement

89

AAFP’s Policy ReputationAAFP Involvement• The AAFP’s Center for State Policy has worked with the following

state chapters to comment on waivers in opposition to work requirements and other provisions to limit Medicaid coverage:• Alabama• Arizona • Florida• Kansas• Ohio

• Plan on continued engagement with state chapters, as well as states and HHS, as new waivers are submitted for federal approval.

90

Prescription Drug Pricing• 2017 – AAFP joined the Campaign for Sustainable Rx Prices

• Bipartisan agreement – Lower costs = Higher Competition– No one-size-fits-all solution– Delivery system = highly complex

• Major drug pricing proposals– Reducing costs – Medicare Part D negotiation, value-based

contracting, Medicaid generic drug rebate – Increasing access to generic drugs – REMS, anti-trust practices– Promoting transparency – drug hikes, pharm benefit managers

91

Prescription Drug Policy Proposals• Transparency

• Parity – Required pricing and R&D costs disclosure

• HHS annual report • Continued assessment of Direct-to-Consumer

advertising requirements• Value

• Expand treatment and effectiveness research• Require comparisons with existing products• Expand value-Based pricing availability• Require innovative payment and incentive

structures that promote value

• Competition• Reduce backlog of generic

applications• Foster competition for branded drugs• Curb misuse of REMS• Strengthen post-market surveillance• Target exclusivity protections• Increase pay for delay oversight• Shorten exclusivity period for biologics• Target orphan drug incentives

92

Documents

Working Party - AAFP Home · Working Party Policy & Political Update ... Hope Wittenberg. Robert Hall. Overview • 2018 Mid-Term Congressional Elections • Health Care Cost •