Family Medicine Advocacy Summit 2017

Welcome & Opening Remarks

John Meigs, Jr. MD

AAFP President

AAFP Officers

• John Meigs, Jr., MD – President

• Michael Munger, MD – President-elect

• Wanda Filer, MD, MBA – Board Chair

• Javette Orgain, MD, MPH – Speaker

• Alan Schwartzstein, MD – Vice Speaker

• Douglas E. Henley, MD – EVP/CEO

Council of Academic Family Medicine

• Mary Hall, MD – CAFM Chair

• Karen Mitchell, MD – AFMRD President

• James Jarvis, MD – AFMRD Past President

• Winston Liaw, MD, MPH – NAPCRG Research Advocacy Chair

• Beat Steiner, MD – STFM President-elect

• Joseph Gravel, MD – AFMAC Chair

Health Care Coverage

• Maintain & Expand Coverage

• Protect the Safety-Net Programs

• Stabilize the Individual Insurance Market

• Protect Patient-Centered Insurance Reforms

• Reduce Costs

• Increase Investment in Primary & Preventive Care

Teaching Health Center GME

• THCGME funds family medicine residencies

in community-based settings

• Graduates of THCs continue in primary care

and practice in underserved communities

• Unless Congress acts, the THCGME

program expires on September 30, 2017

Congressional Primary Care Caucus

• Ask: If you are not a member of the Primary Care Caucus, please join it.

• Republicans contact Perry Chappell (Rep. Rouzer) or Democrats contact Maria Costigan (Rep. Courtney) to join.

OR –

• If you are a member, thank you.

AAFP

National

Day of

Action

Introduction of Special Guests

Flora Sadri-Azarbayejani, DO

Chair, AAFP Commission on

Governmental Advocacy

Commission on Governmental Advocacy

• Flora Sadri-Azarbayejani, DO, Chair

• Julie Anderson, MD

• Domenic Casablanca, MD

• Jonathan Cook, DO

• Cheryl Dobson

• Troy Fiesinger, MD

• Andrea Gavin, MD

• Douglas Gruenbacher, MD

• Kyle Jones, MD

• Gordana Krkic, CAE

• Jesus Lizarzaburu, MD

• Tara Mertz-Hack, MD

• Dennis Salisbury, MD

• Karen Smith, MD

• Tina Tanner, MD

• Kevin Wong, MD

2017 AAFP Scholarship Winners

• Anna Balabanova, MD - Illinois

• Alexandra Gits, MD - Ohio

• Elana Curry, BS - Minnesota

• Sean McClellan, BA - Illinois

STFM New Faculty Advocacy Scholarship

• Sarah Coles, MD - Phoenix, AZ

• Kathryn Freeman, MD - St. Paul, MN

• Manasa Irwin, MD - Pittsburgh, PA

• John Nguyen, MD - Renton, WA

• Sarah Stumbar, MD, MPH - Miami, FL

AFMRD Resident Scholarships • Kristin Bendert, MD, MPH – Portland, OR

• Kathryn Calhoun, MD – Garland, TX

• Joanna Campodonico, MD, MPH – Phoenix, AZ

• Cherry Cockrell, MD – Saint Louis MO

• Mylanie Facelo, DO – Abingdon, VA

• Kirsten Gierach, DO – Appleton, WI

• Kenetra Hix, MD, MPH – Durham, NC

• Benjamin Stacy, DO – Iowa City, IA

• James Suchy, MD – Orange, CA

• Ariela Zamcheck, DO – Sleepy Hollow NY

Health Care Reform 2.0

Grace-Marie Turner

President, Galen Institute

Frederick Isasi, JD, MPH

Executive Director, Families USA

Repeal and Replace: What’s next?

Grace-Marie Turner, Galen Institute

American Academy of Family Physicians May 22, 2017

The Market Landscape

Medicaid: Primary Source of Coverage Gains

Medicaid/CHIP, 83.1%

Private Coverage,

16.9%

Effect of Individual Mandate 2015

6.5

12.7

4.3

23.5

2.3

0

5

10

15

20

25

Paid Penalty HardshipExemption

Did NotReport

TotalSubject to

Penalty

Net IncreasePrivate

Coverage

A rescue effort: Unhealthy risk pools Millions could lose coverage without congressional action

Higher costs, fewer insurers • Indiv. premiums increased 99% and

family premiums increased 140% since 2013, according to eHealth

• Insurers have requested rate hikes in Connecticut (34%) and Maryland (59%)

• If Medica leaves, 94 out of Iowa's 99 counties would have no insurer

US Counties with only one insurer

The

plan

Republican three-pronged plan

• Pass Repeal and Replace legislation

• Regulatory action First HHS rule to stabilize the market finalized in April

• Shortens the 2018 annual open enrollment period

• Expands verification of eligibility for subsidies

• Allows insurers to collect back premiums before re-enrollment

• Regular order bills that could get 60 Senate votes. First up: • Competitive Health Insurance Reform Act (H.R. 372) to eliminate anti-trust

protections for insurers

• Small Business Health Fairness Act (H.R. 1101) allowing small businesses to pool together to try to lower health insurance costs. (Hope to get some Democrats to vote yes)

Repeal and Replace

Legislation

Core provisions of the AHCA

• Repeals most ACA taxes (delays the Cadillac Tax)

• Eliminates tax penalties for the individual and employer mandates

• Protects people currently on coverage • Preserves Medicaid expansion, but eventually at

the normal federal match • Grandfathers current subsidies and provides

new tax credits to help people purchase coverage

Replace bill also … • Allows states some regulatory flexibility, including on age rating

and benefits

• Provides $138 billion to states to stabilize their individual and small group insurance markets, added help to the most needy, and extra money to protect those with pre-existing conditions

• HSA expansion

• Refundable tax credits to individuals to purchase coverage

• “Continuous coverage” requirement instead of “individual mandate”

What about pre-existing conditions? Federal protections stay in place

Under the American Health Care Act, no one will be denied coverage because of a pre-existing condition

States can waive pre-ex only if they have a safety net in place, such as a functional high risk pool

At least $138 billion in added subsidies to provide protection through premium subsidies, risk pools, etc.

Individual responsibility

No one who keeps their insurance continuously will be charged more because they are sick or get sick.

If people wait to purchase coverage when they need it, they can be charged more

If people don't buy coverage or drop their plans, they face a 30% surcharge for one year when they reenroll

And 24 million losing coverage? CBO ascribes magical powers to the individual mandate…

• 2017: Number of uninsured increases by 4 million • 2 million Medicaid beneficiaries who pay nothing for their coverage drop it • 1 million people drop their coverage in the exchanges • 1 million with job-based coverage drop out

• 2018: 14 million more uninsured. • 5 million will abandon Medicaid • 2 million will drop their employer-sponsored coverage • 6 million will leave the exchanges

• CBO says they don’t lose coverage because of the new bill but because they are no longer forced to buy insurance since the individual mandate penalty is repealed

What ‘s next?

Key Role for the States

States have new opportunities

HHS is anxious to approve waivers giving states more flexibility with insurance and Medicaid HHS is encouraging states to use a provision of existing law, “State Innovation Waivers,” to reform their health insurance markets

33

Potential State Opportunity to Reform Care: ACA Section 1332 Waivers

Gives states flexibility to restructure programs if they achieve similar coverage, access and costs

• ACA statute requires that waivers provide coverage at least as comprehensive and affordable without increasing the federal deficit

Expect HHS/CMS to be more generous and flexible with states

Few states have submitted proposals so far • Alaska reinsurance program • Hawaii alternative to SHOP exchange

HHS and White House executive actions

President Trump’s Executive Order

“…exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the Act that would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance, or makers of medical devices, products, or medications.”

How HHS Can Use That Authority

• The phrases “the Secretary shall” and “the Secretary may” occur 1,400 times in the text of the ACA

• The Obama administration made liberal use of this authority. • The Galen Institute has identified 43 provisions of law that the Obama

administration either waived, delayed or ignored

• These administrative actions affected everything from individual and corporate mandates, to cost-sharing provisions, to premium stabilization and to waivers for non-compliant plans

• The Trump administration may prove as aggressive in using its authorities to alter the ACA as its predecessor was in creating it

Grace-Marie Turner

Galen Institute

703-299-8900

[email protected]

twitter.com/GalenInstitute

facebook.com/GalenInstitute

@gracemarietweet

Subscribe to our free email alerts at www.ObamaCareWatch.org

Frederick Isasi, JD MPH

Executive Director

AAFP Family Medicine Advocacy Summit

Health Reform 2.0

FamiliesUSA.org

Families USA, a leading national

voice for health care consumers, is

dedicated to the achievement of high-

quality, affordable health care and

improved health for all. We advance

our mission through public policy

analysis, advocacy, and collaboration

with partners to promote a patient-and

community centered health system.

Working at the national, state and

community level for over 35 years.

Families USA’s Mission and Focus Areas

FamiliesUSA.org

Roadmap of the Discussion

ACA Fact vs. Fiction

AHCA Fact vs. Fiction

What’s Next in Congress

FamiliesUSA.org

The Affordable Care Act (ACA) Led to Historic Gains in Coverage

From 2010 to 2016

20 million people gained coverage

FamiliesUSA.org

Adults Gain Coverage: Historic Drop in Uninsured

FamiliesUSA.org

Kids Gain Coverage: Historic Drop In Uninsured

FamiliesUSA.org

Gains by Demographic Group

v Sources: Urban Institute Analysis of American Community Survey data (IPUMS-USA,

University of Minnesota, www.ipums.org) for 2010 and 2015.

FamiliesUSA.org

Gaining public and private coverage, 2013-2015

http://www.cbpp.org/research/health/affordable-care-act-has-produced-

historic-gains-in-health-coverage

FamiliesUSA.org

A 50-state look at Medicaid Expansion, 2017

FamiliesUSA.org

The Affordable Care Act: Popularity

Myth: “…Americans continue to call for Obamacare’s repeal…They spoke loudly

again this November, and about 8 out of 10 favor changing Obamacare

significantly or replacing it altogether." (McConnell, op-ed for Fox News,

January 9, 2017)

Truth: • Across polls conducted by many different research firms, on average, about 50%

of Americans view the ACA favorably vs. 42% unfavorably.1

• This is particularly true since the push to repeal the ACA began in January.

• Marketplace consumers rate their coverage highly: 68% rated it “excellent” or

“good” in OE3.2

1Real Clear Politics, average of all health law polling data, 2/7-4/25/2017 2Kaiser Family Foundation, Survey of Non-Group Health Insurance Enrollees, May 2016

FamiliesUSA.org

The Affordable Care Act: Plan Choice

Myth: “[Democrats] gave us a system where choices went away.”

– Speaker Ryan, Feb 28, 2017

Truth: • 79% of marketplace consumers have a choice of marketplace issuers;

• 34 states had two or more issuers in 2017

• Within issuers, consumers have many choices of plans (PPOs, HMOs,

different levels of coverage, etc.) On average, consumers had a choice

of 30 plans in 2017;

• Marketplace consumers have more choices than most employees

Sources: Kaiser Family Foundation, “2017 Premium Changes and Insurer Participation in the ACA’s Health Insurance Marketplaces,”

October 2016 and ASPE, “Health Plan Choice and Premiums in the 2017 Health Insurance Marketplace,” October 2016.

FamiliesUSA.org

vv 79% of exchange enrollees had a choice of three or more

insurers in 2017, down from 96% in 2016.

FamiliesUSA.org

The Affordable Care Act: Marketplace Stability

Myth: “[Obamacare is on a] respirator and it’s just about ready to

implode” – President Trump, March 17, 2017

Truth: • CBO: market will remain stable in most areas under current law.1

• Uncertainty caused by the administration and Congress threaten

stability:

• Blue Cross Blue Shield announced it will participate in Knoxville, TN

marketplace, noting its improved 2017 performance. However, they stated

“Given the potential negative effects of federal legislative and/or regulatory

changes, we believe it will be necessary to price-in those downside risks.”2

1CBO, AHCA Cost Estimate, March 13, 2017 2J.D. Hickey, CEO of BlueCross of Tennessee, letter to Tennessee Commissioner Julie Mix McPeak, May 9, 2017

FamiliesUSA.org

Market is on a 5 Year Path to Stability

http://allh.us/PxUf

Truth: S&P Global Ratings: market is on a 5 year path to stability,

most insurers will break even or profit in 2018 if business

continues as usual

FamiliesUSA.org





FamiliesUSA.org

American Health Care Act (AHCA) Impact

At least 24 M lose coverage for a tax cut to the rich and

corporations… Health Tax cuts

Medicaid: - $839 B Mostly to wealthy and corporations: $604 B*

Premium and cost sharing subsidy: - $663 B

Replacement premium credits: $357 B

Patient and stability fund: $138 B

Net cut from health: $650 B Benefit to wealthy/corps: $604 B

*Excludes premium credits and medical deduction threshold

Source: Calculations from March 23 CBO score, table 2 and 3, with addition of patient and stability fund as amended

FamiliesUSA.org

http://www.taxpolicycenter.org/taxvox/dont-forget-those-tax-cuts-house-health-bill

Wealthy Benefit from Tax Cuts

FamiliesUSA.org

Under AHCA: Plans Cost More and Cover Less

AHCA cuts premium assistance, increases prices for those who

are older or have preexisting conditions, eliminates cost sharing

reductions

• A 64 year old earning $27,000 faces a $13,000 premium

increase

• 7 million people lose help that lowers deductibles and

out-of-pocket costs

FamiliesUSA.org

Cost Sharing Help at Risk

Source: http://www.cbpp.org/blog/interactive-map-cost-sharing-subsidies-at-risk-under-

house-gop-health-bill

Most Marketplace Enrollees Receive Significant Help

FamiliesUSA.org

What a single individual with income of $26,500

(175% of poverty) will pay

Age Current law AHCA

Net premium AV Net Premium AV

21 years $1700 87 $1450 65

40 years $1700 87 $2400 65

60 years $1700 87 $14,600 65

What people pay under current law and under AHCA, single individual with income of $26,500 (175% poverty) (examples without essential health benefit waivers)

Example: Current Law vs. AHCA

Source: Congressional Budget Office, AHCA cost estimate, March 23, 2017, Table 4

FamiliesUSA.org

v Lower-Income Families See Healthcare Costs Soar in House Repeal Bill*

*Families USA analysis based on 2017 national average premium for the second-least expensive silver plan adjusted to

reflect expected premium change using 5:1 age rating bands, and changes in premium tax credits. Deductible estimates

based on average 2016 deductibles for silver plans with and without cost-sharing reductions. Source: Health Insurance

Marketplace Calculator, (Washington, DC: Kaiser Family Foundation, November, 2016); Impact of Changing ACA Age Rating

Structure (Milliman, January 2017); Cost-Sharing Subsidies in Federal Marketplace Plans, 2016, (Washington, DC: Kaiser

Family Foundation, November 2015).

FamiliesUSA.org

v *Families USA analysis based on 2017 national average premium for the second-least expensive silver plan, adjusted to

reflect expected premium change using 5:1 age rating bands, and changes in premium tax credits. Source: Health Insurance

Marketplace Calculator, (Washington, DC: Kaiser Family Foundation, November, 2016); Impact of Changing ACA Age Rating

Structure (Milliman, January 2017)

Seniors’ Premiums Skyrocket under House Repeal Bill*

FamiliesUSA.org





FamiliesUSA.org

Potential Outline of Congressional Activity for 2017

FamiliesUSA.org

Three “gangs” negotiating

Cassidy (LA)

Collins (ME)

Heller (NV)

Graham (SC)

Sullivan (AK)

Capito (WV)

Manchin (WV)

Donnelly (IN)

Heitkamp (NK)

Others..

McConnell (KY)

Portman (OH)

Cornyn (TX)

Thune (SD)

Enzi (WY)

Hatch (UT)

Alexander (TN)

Cotton (AR)

Gardner (CO)

Cruz (TX)

Lee (UT)

Barrasso (WY)

Toomey (PA)

Collins (ME)

Cassidy (LA)

Capito (WV)

Isakson (GA)

Rounds (SD)

Bipartisan group Moderates, including

Cassidy and Collins

McConnell, et al.

FamiliesUSA.org

• Activate around senators - particularly the moderates and small group of

democrats negotiating - and your governor

• Time is NOW

• Go armed with concrete impact and a focused message: ask Senators

to pledge that they will oppose any bill that

• Cuts and destroys the Medicaid program

• Ends the Medicaid expansion, no matter when

• Increases the number of uninsured

• Undermines the consumer protections under the ACA

We need your help

FamiliesUSA.org

Your voices have

never been

more important!

Health Care Reform 2.0

Grace-Marie Turner

President, Galen Institute

Frederick Isasi, JD, MPH

Executive Director, Families USA

Physician-Focused & Advanced Payment Models

Jeff Micklos

Executive Director, Health Care Transformation

Task Force, Leavitt Partners

Laura Sessums, JD, MD

Director, Division of Advanced Primary Care,

Center for Medicare & Medicaid Innovation

www.hcttf.org

Health Care Transformation Task Force Patients, Payers, Providers and Purchasers

Committed to Better Value Now

Jeff Micklos

Executive Director

www.hcttf.org

Who we are: Our mission to achieve results in value-based care

The Health Care Transformation Task Force is an industry consortium that brings

together patients, payers, providers, and purchasers to align private and public sector

efforts to clear the way for a sweeping transformation of the U.S. health care system.

We are committed to rapid, measurable change, both for ourselves and our country.

We aspire to have 75% of our respective businesses operating under value-based

payment arrangements by 2020.

www.hcttf.org

Our Members: Patients, Payers, Providers and Purchasers

committed to better value

www.hcttf.org

Political Landscape for Value-based Payment

• AHCA: all eyes on the Senate

• Value agenda not directly addressed in ACA repeal and replace efforts to date

• Coverage will impact private sector investment in value-based care

• Value-based payment advancement through MACRA retains bipartisan support

• CHRONIC Care Act reintroduced in the Senate

www.hcttf.org

Administrative Actions on Value-based Payment

• Continued MACRA implementation and physician focus: Quality Payment

Program or Advanced APMs?

• Next QPP proposed rule eagerly anticipated

• Focus on reduced provider burden through regulatory reform

• Center for Medicare & Medicaid Innovation “2.0”

• State-based innovation

• Mandatory vs voluntary bundled payment models

www.hcttf.org

Physician-Focused Payment Model Technical Advisory Committee

• Private stakeholders bringing physician-focused APMs forward for

consideration

• PTAC took action on a first set of proposals in April

• Anticipate refinements to the PTAC proposal process

• How CMS will proceed remains an open question

Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation


Comprehensive Primary Care Plus

(CPC+)

Transforming Primary Care in America

American Academy of Family Physicians

May 22, 2017

75

Laura L. Sessums, JD, MD, FACP


Agenda

CPC+ Model Overview 1 • Key statistics

• Geographic regions

• Multi-payer partnership

Impact of the Medicare Quality Payment Program on CPC+

2 Practice Transformation Activities and Supports

3

• Medicare financial supports

• Care delivery and health IT requirements

• Data feedback and learning support

• Alternative Payment Models (APMs)

• Timeline of potential payment adjustments


>1.76 million Medicare Beneficiaries

ROUND 2

2,891 Practice Sites

13,090 Clinicians

ROUND 1

Comprehensive Primary Care Plus

12 New Payers

Including 5 supporting

Round 1 regions

5 Years

From 2018-2022

4 New Regions

Selected based on payer

commitment to partnership

Up to 1,000 New Practices

Depending on

interest and eligibility

53 Payer Partners

58 HIT Vendor Partners

5 Years

2 Tracks

14 Regions

America’s Largest-Ever Initiative to Transform Primary Care


= Round 1 Region

= Sub-state region comprising contiguous counties

CPC+ Now Offered in 18 Regions

North Hudson/

Capital District (NY)

Northern KY (part of OH region)

New Jersey

Rhode Island

Greater Philadelphia (PA)

Hawaii

OR MT

CO

OK AR

OH

MI

TN

Greater

Kansas

City

ND

NE

LA

Greater Buffalo

(NY)

= Round 2 Region


Multi-Payer Partnership

Essential for Primary Care Reform

Multi-payer engagement is an essential

component of CPC+.

Support from any one payer covers

only a portion of a practice’s

population.

True comprehensive primary care possible

only with the support of multiple payers.

In CPC+, CMS partners with payers that

share Medicare’s commitment to

strengthening primary care in America.

Medicare

FFS

Public

employee

plans

Medicaid/

CHIP state

agencies

Medicaid/

CHIP

managed

care plans

Self-insured

businesses

Medicare

Advantage

plans

Commer-

cial

insurance

plans

CPC+

Practice


Five Functions Guide CPC+

Care Delivery Transformation

24/7 Patient Access

Patient Assignment to

Care Teams Patient Risk Stratification

Hospital/ED Discharge

Follow-Up

Coordination with

Other Providers

Patient and Family

Advisory Councils

Practice and

Payer Data Insight

Care Plans for Chronic

Disease Patients Out-of-Office Care Options

Integrated

Behavioral Health

Psychosocial

Needs Assessment

Self-Management

Support Tools

Full Care Team

Data Review

Access and Continuity Care Management Comprehensiveness

and Coordination

Patient and Caregiver

Engagement

Planned Care and

Population Health Track 1

requirements

Additional requirements

for Track 2


Three Payment Innovations Support

CPC+ Practice Transformation

Care Management Fee

(PBPM)

Performance-Based Incentive

Payment (PBPM) Payment Structure Redesign

Objective

Support augmented staffing and

training for delivering comprehensive

primary care

Reward practice performance on

utilization and quality of care

Reduce dependence on visit-based fee-

for-service to offer flexibility in care

setting

Track 1 $15 average $2.50 opportunity N/A

(Medicare FFS)

Track 2

$28 average; including

$100 to support patients with complex

needs

$4.00 opportunity

Payment enhanced 10%;

split roughly 50/50 between

upfront “Comprehensive Primary Care

Payment” and reduced FFS claims

CPC+ practices also in the Medicare Shared Savings Program participate in their ACO’s

shared savings/loss arrangement INSTEAD of receiving CPC+ incentive payments.


Track 2 Reimbursement Redesign

Offers Flexibility in Care Delivery

Designed to Promote Population Health Beyond Office Visits

Traditional practice paid only

through FFS; must see patients in

office to receive reimbursement

CPC+ Track 2 practice paid roughly half of FFS payments

upfront in “Comprehensive Primary Care Payment” (CPCP) to

give clinicians more flexibility in how/where they deliver care

CPCP

Reduced

FFS


Health IT Vendors CPC+ Practices

Both CPC+ Tracks require

use of certified health IT.

Health IT vendor partners are

invited to participate in relevant

learning activities with

practices and payers.

Track 2 practices apply with a

letter of support from their

health IT vendor(s) committing

to facilitate the development of

advanced health IT capabilities.

Health IT vendors supporting

Track 2 practices must sign a

Memorandum of Understanding

(MOU) with CMS.

Engaging Health IT Vendors in CPC+


Required Health IT

Functionalities in CPC+ Track 2

Empanel patients to the

practice site care team

Screen for social and community

support needs and link the identified

need(s) to practice identified resources

Produce and display eCQM

results at the practice level to

support continuous feedback

Risk stratify the practice site

patient population

Establish patient focused care

plans to guide care management

Document and track patient

reported outcomes

Health IT vendor partners commit to supporting Track 2 Practices in

developing these advanced functionalities across the five years of CPC+.


Centralized and Aligned

Comprehensive Data Feedback

• Quarterly list of Medicare FFS

beneficiaries attributed, by risk tier

• Quarterly financial support amounts

• Performance on Electronic Clinical

Quality Measures and CAHPS surveys,

compared to other practices

• Quarterly report on care delivery

requirements, compared to other practices

• Practice budget requirement analysis

Quality Data Attribution/Payment Data

Cost and Utilization Data Care Delivery Assessment

Multi-Payer Aligned

Data Feedback

• Expenditures: professional services,

inpatient, outpatient, SNFs, etc.

• Utilization: inpatient, 30-day readmission,

ED utilization

Resource: CPC+ Practice Portal Online tool for reporting, feedback, and assessment on practice progress


Many Opportunities for Learning,

Collaboration, and Support

Web-based platform for

CPC+ stakeholders to

share ideas, resources,

and strategies for practice

transformation.

National Learning Community

• Cross-region collaboration

• Live and on-demand learning opportunities: action

groups, webinars, affinity groups, office hours

• Durable written products: Implementation Guide,

newsletters, FAQs, case studies/spotlights

• Annual Stakeholder Meeting

Regional Learning Networks

• Virtual and in-person learning sessions

• Outreach to and support for practices

• Clinical and administrative leadership engagement

• Payer and health IT vendor engagement

• Alignment with regional reform

Learning Communities


Merit-based Incentive Payment System

(MIPS) Eligible Clinician in a

MIPS APM

Qualifying APM Participant (QP) in an

Advanced APM

CPC+ Payment for 2017 Under the

Medicare Quality Payment Program

In addition to CPC+ Payments and your

physician fee schedule reimbursement, CMS

will make a lump sum payment that is equal

to 5% of the payments for your Part B

professional services one year prior.

CPC+ is Both an Advanced APM and a MIPS APM; Participating

Practitioners Receive MIPS Exemption or Special Scoring.

Of all your Medicare patients eligible for

CPC+, 25% of Medicare Part B professional

services payments or 20% of Medicare Part

B patients seen by your CPC+ Practice are

attributed to CPC+.

You are exempt from MIPS reporting

and scoring.

In addition to CPC+ Payments, CMS will

adjust your physician fee schedule

payments during the payment year based on

your MIPS final score two years prior.

• You are a physician, PA, NP, or CNS

• You have more than one year of Medicare Part

B participation (or opted in)

• You bill over $30,000 to Medicare and care for

over 100 Medicare patients annually

• You are not a QP in an Advanced APM

You need only report the Advancing Care

Information category to MIPS.

Eligibility

Reporting

Payment

OR


Magnitude of MIPS Payment

Adjustments Changes Over Time

2019 2020 2021 2018 2017

0% 0% +/-

4%

+/-

5%

+/-

7%

5% 5% 5%

MIPS Eligible

Clinicians

Qualifying APM

Participants

Higher maximum

opportunity in MIPS

In 2019, MIPS payment adjustment

based on 2017 performance

In 2019, QP status based on 2017 performance;

5% lump sum bonus based on 2018 services

CPC+ participants in MIPS receive a special

“APM Scoring Standard” for their MIPS adjustments


Interested in CPC+?

Visit https://innovation.cms.gov/initiatives/

Comprehensive-Primary-Care-Plus

to learn more and apply.

Practice Applications due July 13, 2017

Contact [email protected]

1-877-309-6114

https://innovation.cms.gov/initiatives/Comprehensive-Primary-Care-Plus









mailto:[email protected]

www.hcttf.org

Physicians and Accountable Care Organizations: the Basics

• Accountable Care Organizations are groups of doctors, hospitals, and

other health care providers, who come together voluntarily to give

coordinated high quality care to the patients they serve.

• Key operational and financial components of an ACO:

• Financial Structures:

• Type of financial risk: one sided (upside only) v. two-sided (upside and

downside)

• Benchmarks: Spending targets against which savings is determined.

• Sharing rates/performance payment limits:

• Minimum savings rates/minimum loss rates/limits: applicability depends on

type of financial risk

www.hcttf.org

Physicians and Accountable Care Organizations: the Basics

• Key operational and financial components of an ACO:

• Beneficiaries and Data Reports

• Patient assignment: prospective or retrospective

• Minimum beneficiary number

• Quality reporting

• Quality measures, EHR usage, and patient satisfaction

• Waivers

• Regulatory waivers to help facilitate effective operations (telehealth,

SNF 3-day, home bound, primary care co-pay)

www.hcttf.org

Physicians and ACOs: Medicare’s Options

• Multiple Medicare ACO options:

• Medicare Shared Savings Program Tracks 1, 2, and 3.

• NEW ACO 1+ model (to be implemented for 2018).

• “Next Gen” (formerly the Pioneer ACO)

• The different ACO options are broadly defined by the level of downside risk

that the ACO must undertake.

• Upside-only vs two-sided risk

• System intended to create Incentives for move toward two-sided risk

models. Higher levels of risk create potential for higher returns.

www.hcttf.org

The Purpose of ACO 1+ Model

• A new two-sided risk model which qualifies participating physicians for

Advanced APM status, resulting in a 5% payment bonus instead of the

QPP’s +4/-4 payment formula.

• The parameters for two-sided risk are less onerous than more mature

models like MSSP Tracks 2 & 3 and Next Gen ACO.

• Recognizes there is a big leap between MSSP Track 1 and existing two-

sided risk models, and provides a more reasonable step to keep

organizations moving toward full population health/capitated type models.

Health Care Transformation Task Force

www.hcttf.org

Jeff Micklos

Executive Director

[email protected]

http://www.hcttf.org/


Physician-Focused & Advanced Payment Models

Jeff Micklos

Executive Director, Health Care Transformation

Task Force, Leavitt Partners

Laura Sessums, JD, MD

Director, Division of Advanced Primary Care,


Teaching Health Centers

Dan Renberg, JD

DC Representative, American Association of

Teaching Health Center

Roxanne Fahrenwald, MD

Faculty, RiverStone Health/Montana Teaching

Health Center

Teaching Health Centers History and Promise

Roxanne Fahrenwald MD

Montana Family Medicine Residency

RiverStone Health Center

Billings Montana

Pipeline Needs

•How many of you are recruiting family physicians for your practice?

•How many of you have all the doctors you need at your site?

•How many of you would like to hire a family physician trained to be efficient and resource sensitive?

Community Health Centers and Family Medicine

Partners in Care

• Co-evolved and emerged from the social justice movement in the 1960s

• Began to expand their participation as primary care education sites in 2010 with Teaching Health Center movement and funding

The emergence of our specialty

• 2011 was the 40th Anniversary of Family Medicine

• Our specialty grew out of a movement to reclaim general practice medicine in an era of increasing specialization and fragmentation of health care delivery which began accelerating after WW2

• Medicine was becoming specialized even at the primary care level

• There was also a growing sense of loss • of connection with the patient and their family, • of the gift of a continuous relationship between a physician

and a patient • of someone able to connect and integrate care delivery

What is Family Medicine all about?

• Wholeness – biopsychosocial model

• Physicians trained in breadth and depth of care

• Care across the life span

• Care in the context of family and community

Birth of Family Medicine 1965-66

• Folsom Report: every American should have a personal physician to ensure the integration and continuity of all medical services

• Millis Report: focused on GME – Family Practice should be a board-certified specialty

• Willard Report: Board oversight of FM residency

• ABFP established 1969

• First residency: 1970

• Now 480+ residencies and over 94,000 family physicians practicing – AAFP has around 120,000 total members

Community Health Centers

• 2010 was the 45th Anniversary of the CHC program

• Growing alongside our new specialty was another health care movement, designed to bring care to the impoverished and underserved of the nation

International Roots South Africa in 1940-50s

• A group of physicians, nurses and community organizers started a “community health center” model to counter the health consequences of apartheid

• They defined their responsibility as:

• Care of the individual patient

• The health of entire target populations

• Merging the fragmented disciplines of medical care, epidemiology and public health

Medical Students Can Drive Change

• Jack Geiger was a visiting medical student in 1957 on an international elective in South Africa and was exposed to this model

• He considered it only as a unique solution to that unique third world circumstance … but….

Civil Rights Movement

• During the civil rights protests in the south and the voter

registration drive in Mississippi in 1964, the Medical Committee For Human Rights brought hundreds of physicians, nurses, psychologists and social workers to Mississippi to assist and protect civil rights workers

• They saw devastating poverty, shocking infant mortality rates and virtually complete lack of access to then-segregated medical care

Birth of the CHC in the US 1965

• Dr. Geiger was in Mississippi with them - he had seen a model that worked

• Proposal was brought to Office Of Economic Opportunity Happening together: • 1965 -- first two health centers opened -- in a Boston public

housing project and in Bolivar County, Mississippi • 1965 -- the commissions on generalist health care were

convened to seek solutions to shrinking access to primary health care in the country

Community Health Center Growth

• Soon there were four more health centers: Denver, LA, Chicago, South Bronx

• Now over 10,400 CHC sites delivering health care, serving nearly 24 million people annually

• The vast majority of CHC physicians are family physicians

• We provide health care to all, in every sense

CHC and Family Medicine Children of the 60s Solutions for Today

• The two systems – one providing the setting and one the workforce – grew up together with similar missions and goals

• The integration of residency training in Community Health Centers has been slow but steady and logical, The recent designation of THCs recognizes that

• As family medicine and CHCs enter their 50’s together, we still share the larger overarching goal of healthcare for all

Teaching Health Center • Movement initially called Educational Health Centers

• Grew out of strategic planning session in mid 2000’s at University of Washington to explore and support this model of training

• There were some successful residencies in health centers – few, but the model appeared ideal in many ways

• Teaching Health Center funding first was part of ACA for a 5 year pilot beginning 2010

• Highly successful tho accreditation/ recruiting barriers slowed startup • Funded at $150K per resident per year, directly to health center • Reauthorized with MACRA, CHIP, CHCs bundle in 2016 for 2 years

• But fixed total allocation resulted in per-capita lower funding level, initially $95K but as programs cut back resident number, increased to around $116K

• Ends with this federal fiscal year

Our personal success story so far……

• Montana Family Medicine Residency and RiverStone Health Center

• Began as 6-6-6 residency in 1995, expanded with THC funding, now 8-8-8

• Patient access grew from pre-residency base of 7000 visits per year to current over 60,000 visits per year

• 70% of 108 graduates practice in Montana and over 40% have gone to health centers or other safety net sites to practice

• One resident “line” (1-1-1) currently is temporarily internally funded (hoped to switch to THC funding if program grew – it did not)

• One resident “line” on THC funding – total 3 residents

• 16 on traditional CMS funding – 2 over cap supported by hospitals

• If THC funding stops, we will reduce one to two residents per year

Problems

• Two year appropriation cycle

• Three year Family Medicine residency timeline • Plus front end recruiting and match cycle

• ACGME Accreditation requirements state: IV.N.2. the Sponsoring Institution must allow residents/fellows already in an affected ACGME-accredited program(s) to complete their education at the Sponsoring Institution, or assist them in enrolling in (an)other ACGME-accredited program(s) in which they can continue their education. (Core)

• Hard to make a three year commitment to a resident with two years of funding, and to program resources when funding occurs at varying levels

Community Health Centers view

• Conjunction of stressors for health centers • THC funding uncertainty • Many are AOA programs that need to make accreditation change to ACGME • Funding cliff for CHCs coincide with THC funding cycle this year • NHSC funding is in same boat – key recruitment advantage for many CHCs • Medicaid/ACA uncertainty with potential funding impact on clinical revenues

• CHCs do not have deep pockets – operate generally with tiny margins

• CHC primary funded mission is service not education

• HOWEVER have increasingly embraced education as pipeline started to

produce results and demand increased – THC funding a top NACHC ask too

Attrition already starting

• 741 currently in training at all sites • Up from 689 last year

• BUT – that obscures the decline

• This total number reflects continued growth from newer programs, however 33 spots have been cut this year across 8 different residencies, and 30 more were cut the previous year in 6 residencies

• These programs are NOT taking new resident classes, and are ramping down

• Reasons: decreased funding level below cost to sustain, uncertain duration of funding vs length of training commitment

The MUST ASK • Teaching Health Centers funding must continue

• They expand the number of primary care doctors being trained

• They train primary care doctors in resource sensitive care

• They expand access to patients

• Current funding stops this year Sept 30th

• CMS funding is capped– there is no other funding option

• Funding must return to the equivalent of the well-researched 2010 level of $150K per resident per year – current ask is $157K (only a 5% increase since 2010 level )

• Funding needs to be institutionalized and continuous and not subject to 2 year appropriation cycle to insure stability of programs

Sustained funding will maintain a specific focus on primary care physician education

Sustained funding will help provide access to patients

Sustained funding will continue to produce family physicians for America

Together we will make the world a better place

Teaching Health Centers

Dan Renberg, JD

DC Representative, American Association of

Teaching Health Center

Roxanne Fahrenwald, MD

Faculty, RiverStone Health/Montana Teaching

Health Center

Media Perspective

Mary Ellen McIntire

Reporter, Morning Consult

Family Medicine Political Action

Committee Update

Jason Dees, DO, FAAFP Mark Cribben, JD

Chair, FamMedPAC Board of Directors Director, FamMedPAC

St. Louis, MO Washington, DC

The ONLY political organization that promotes family medicine.

Elect candidates to the U.S. Congress who support AAFP’s

legislative goals and objectives.

Since 2005, FamMedPAC raised and contributed over $5

million to more than 400 candidates.

FamMedPAC contributed a record amount in the 2016 election cycle!

2016 Election Cycle Campaign Contributions

$1,020,200 To 154 Candidates

(New Record!)

56 % Democrats, 44 % Republicans

(90% won!)

The 2016 election-cycle saw FamMedPAC receive

record support from AAFP members!

2016 Election Cycle Fundraising

$975,000 received from 3,576 AAFP Members

(New Record!)

If every AAFP member contributed $100, we would have more than $10 million–FamMedPAC would be the largest medical PAC in the country.

2016 PAC Total

American Society of Anesthesiologists $3,991,211

American Assn of Orthopaedic Surgeons $3,537,000

American College of Radiology $2,771,947

American College of Emergency Physicians $2,096,014

American Academy of Dermatology $1,592,839

American Academy of Ophthalmology $1,445,856

American College of Surgeons $1,246,808

The American College of Ob-Gyns $1,200,000

American Academy of Family Physicians $ 975,145

American Osteopathic Association $ 812,375

Trial Lawyers $3.68 million

Who Can Give to FamMedPAC?

AAFP Staff – Including Chapter Staff! Active Members of AAFP

Life Members of AAFP Resident Members of AAFP

Student Members of AAFP

* Not allowed to give: Foreign Nationals and Non-members

AAFP DUES PAYMENTS MAY NOT BE USED FOR POLITICAL CONTRIBUTIONS,

ONLY DONATIONS TO FamMedPAC CAN BE USED FOR THIS PURPOSE

2016 FamMedPAC Chapter Awards

Small Chapter: Montana $10,574.00

Medium Chapter: Oklahoma $10,844.00

Large Chapter: Massachusetts $16,146.00

Extra-Large Chapter: California $35,530.00

Chairman's Award (Club George Percentage):

South Dakota 4.66%

Presented each year at NCCL/ACLF

Visit www.fammedpac.org

to learn more and to

contribute today!

http://www.fammedpac.org/

Immunizations

Amy Pisani, MS

Executive Director, Every Child by Two

Sarah Despres

Director, Government Relations, Health Programs,

Pew Charitable Trusts

A M Y P I S A N I , M S

E X E C UT I V E DI R E C T O

R 2 0 2 - 2 7 7 - 7 5 8 7

A M Y P @ E C B T . O R G

Our Mission is to… Protect families and individuals from vaccine-preventable diseases by

raising awareness of the critical need for timely immunizations for people of all ages; increasing the public’s understanding of the benefits

of vaccines; increasing confidence in the safety of vaccines; ensuring that all families have access to life-saving vaccines; and advocating for

policies that support timely vaccination.

25 Years of Dedicated Effort ECBT Cofounders Rosalynn Carter & Betty Bumpers

-ECBT founders helped pass laws in each state mandating proof of vaccination for school entry -Traveled the nation building coalitions in every state to support Iz efforts -Instrumental in attaining federal and support for vaccines

Every Child By Two’s Expanded Mission Launch

Every Child By Two’s Expanded Mission Launch

Vaccinate Your Family: Grandparent Toolkit

• Pertussis Video/Motion graphic

• FAQ for Grandparents

• 5 Tips to Soothe a Fussy Baby

• A Health and Safety Checklist for

Grandparents

• Questions to Ask a Health Care Provider

• Baby Shower Ideas

• A Pledge to Protect the Baby

ECBT’s Priorities

Educate the public about the importance of timely immunizations for people of all ages and the safety of vaccines. Collaborate with partners at national, state and local levels (e.g., CDC, AAP, USDA, National

WIC Association, AAFP, State and Local Immunization Programs, and Immunization Coalitions)

Serve as a source of accurate immunization information to the media

Keep healthcare providers and public health partners up-to-date on the latest immunization information, and assist vaccine advocates in their immunization education, vaccine promotion, and policy efforts. o Exhibit at conferences for healthcare providers and bloggers

o Disseminate ECBT News and Daily News Clips to immunization advocates to help them keep up -to-date on immunization-related news and to assist them in being proactive when workingwith their local media outlets.

o Provide strategies and resources for vaccine advocates to use when trying to educate the public or patients about vaccines.

Advocate for pro-immunization policies at the state and federal level

History of Vaccine Hesitancy

• Original study (of 12 children) claiming vaccine-autism link was conducted by British researcher Andrew Wakefield. Published in The Lancet in 1998.

• Dr. Robert Sears, a pediatrician, promotes his “alternative“ vaccine schedule for parents.

• Dozens of studies found no link between the MMR vaccine (or any other vaccine) and autism. http://www.vaccinateyourfamily.org/news/research/

• In 2010, the General Medical Council in U.K. determined Wakefield faked his data; performed unnecessary medical procedures on the children in his study; and was paid by lawyers who wanted to file lawsuits against vaccine manufacturers. Andrew Wakefield stripped of his medical license due to “ethical lapses” and “unprofessional conduct”. In 2010, The Lancet retracted Wakefield’s research paper

• In January 2011, the British Medical Journal published in-depth investigation of Wakefield and his research, and called his 1998 study an "elaborate fraud.“

http://www.vaccinateyourfamily.org/news/research/

























Past Events Garnering Anti-vaccine Publicity

• Numerous Larry King Live, Oprah and The Doctors appearances by Jenny McCarthy and others associated with Generation Rescue (Jenny becomes spokesperson for Gen Rescue)

• Hannah Poling press conference falsely reported that the federal govt. conceded Hannah’s autism was vaccine-induced – however autism like symptoms are not autism!

• Omnibus Autism Proceeding – In 2009 & 2010 A special vaccine court ruled on a series of cases examining whether vaccines can contribute to or cause autism. They examined both the MMR vaccine and thimerosal-containing vaccines and concluded in both cases that there is no link to autism. http://www.vaccinateyourbaby.org/safe/autism/omnibus_proceedings.cfm

http://www.vaccinateyourbaby.or/























Recent Vaccine Skepticism in News

• Prior to the Inauguration, Robert Kennedy Jr. met with President-elect Trump & Vice President Pence at Trump Tower – discussed disproven theory that thimerosal in vaccines causes autism & that govt. involved in conspiracy

• Kennedy claims Trump requested he chair a new commission on “vaccine safety and scientific integrity.” Trump team declines to comment, no contact with RFK since

• RFK Jr interviewed by Don Imus 04/18/17

• RFK Jr appears on Fox News 04/20/17

Press Conference – Hill Briefing on Vaccine Safety

Robert F. Kennedy Jr. and actor Robert DeNiro were featured at a press conference in DC in February 2017 making allegations about the dangers of thimerosal in vaccines and calling for a new “Vaccine Safety Commission”

Of Note: DeNiro was a no-show at the Congressional Briefing and few were in attendance.

AAP RESPONDS

• On January 10, after Kennedy meets with President-elect Trump, AAP issues a statement declaring vaccines are safe, vaccines are effective, vaccines save lives.

• On February 7, AAP sends a

letter to President Trump signed by over 350 other national and State organizations that expresses unequivocal support for the safety of vaccines.

• Slide credit: Patrick Johnson, AAP

Other Federal Issues

• Oversight & Government Reform Committee investigation of the CDC Whistleblower allegations:

• Background materials available on the www.ECBT.org website

• http://www.ecbt.org/images/articles/Whistleblower_QA012017_updated3-6-17.pdf

• http://www.ecbt.org/images/articles/Vaccine_Safety_and_African_American_Children.pdf

• Anti-vaccine rally/hill visits hosted by Revolution for Truth

http://www.ECBT.org/











http://www.ecbt.org/images/articles/Whistleblower_QA012017_updated3





















































http://www.ecbt.org/images/articles/Vaccine_Safety_and_African_American_Children.pdf





































































Congressional Support for Vaccines Evident in February Dear Colleague Letter - Drafted by ECBT

Disease Outbreaks Still Occur in the U.S.

• In the past three years 904 Americans were diagnosed with highly contagious measles, 2017 cases compiling in Minnesota (this month 58 cases, 600 exposures).

• Pertussis (which is particularly deadly to infants) was diagnosed in more than 67,000 people from 2013-2016

• Each year, more than 200,000 individuals are hospitalized and 3,000 - 49,000 deaths occur from influenza-related complications.

• 20,000 children under 5 y.o. are hospitalized every year and approx. 100 die as a result of the flu.

Congressional Update: ECBT Sign on Letter – 4,500 signatures on letter to congress regarding vaccine funding/ACA Repeal

Legislative & Public Education

State of the ImmUnion Program Social Media

State of the ImmUnion Program Infographics

State of the ImmUnion Report to Legislators

• Cost of Preventable Disease Cases

• Additional policy/safety resources http://www.vaccinateyourfamily.org /baby- and-child/protect/state-of-the-immunion

http://www.vaccinateyourfamily.org/




























Synopsis of key

challenges to

maintaining

and increasing

vaccination

rates

Solutions for

policymakers

State Iz. Data

http://www.vaccinateyourfamily.org /baby- and-child/protect/state-of-the-immunion





























http://www.vaccinateyourfamily.org/baby- and-child/protect/state-of-the-immunion

http://www.vaccinateyourfamily.org/baby-

































State of the ImmUnion Report

▪ Sent to members of congress/media on the eve of the Trump address to congress in February

▪ Overview of Success of Vaccines/Cost Savings

▪ Visual of Map highlighting outbreaks

▪ Sections on progress in childhood, adolescent, adult, maternal vax

▪ Challenges, links to CDC and AAP maps with vaccine rates

▪ Vaccine Safety Talking Points, Resources (including AIM website)

▪ Asks – support vax funding base, support vax services when modifying Affordable Care Act, general support for vaccines and their safety

State of the ImmUnion Report – Resources Toolkit

Please visit our website to read full report and download the social media graphics toolkit: http://www.vaccinateyourfamily.org /baby-and- child/protect/state-of-the-immunion




























Outlook: Federal Appointees

• Assistant Secretary for Health – nominee, Dr. Bret Giroir, infectious disease expert, history of bioterror and pandemic preparedeness

• Still awaiting nominees for Surgeon General, Asst. Secretary of Preparedness and Response, and CDC

• Secretary of Health Tom Price, supported meningitis mandates in GA

ECBT Letter to Congress Requesting Questions on Vaccine Position during HHS Secretary Price’s Nomination Hearings

Letter signed by 90+ orgs. Three members of congress asked vax questions during hearing; several more requested written responses

FDA Commissioner – strong on vaccine science

“It is settled science that vaccines do not cause autism, and policy should move on accordingly, Scott Gottlieb, MD, said Wednesday at his Senate confirmation hearing for FDA commissioner.”

• "This is one of the most exhaustively studied questions in scientific history," Gottlieb said at the hearing before the Senate Health, Education, Labor, and Pensions (HELP) Committee. "I think we need to come to the point where we can accept 'No' for an answer, and come to the conclusion that there is no causal link between vaccinations and autism."

• Gottlieb, a hospitalist and former FDA official, said he is well

known for speaking truth to power. • https://www.medpagetoday.com/washington-watch/fdageneral/64383

http://www.medpagetoday.com/washington-watch/fdageneral/64383













































What do we know about public attitudes toward, government, science, and vaccines?

According to data from the Pew research center, trust in government is at historic lows.

However, according to a Pew study from October, 2016, there is still a lot of trust in medical scientists.

And Pew surveys have also found that while younger parents express more skepticism about vaccines, most people do believe in immunization.

21st Century Cures Act – Included Provisions on Vaccines

•• ECBT spearheaded the inclusion of a critical provision within the 21st Century Cures Act that will provide coverage for damages through the National Vaccine Injury Compensation Program for any live-born child who mmaayy hhaavvee iinnccuurrrreedd hhaarrmm ffrroomm aa vvaacccciinnee ggiivveenn iinn vviittrroo..

•• ECBT also worked with partners include and refine additional vaccine provisions within the bill aimed at ensuring vaccine innovation.

Federal Funding for Vaccines

• Unfortunately, the House version of the American Healthcare Act (AHCA) eliminates some key provisions that will undermine vaccination programs remain in the bill. First dollar coverage of vaccines, which ensures that families will be vaccinated without deductibles or copays, is at risk of being eliminated for some populations. Also, there is no planned replacement for the Prevention and Public Health Fund which under the Affordable Care Act provided 45% of immunization infrastructure and program funding.

Federal Funding for Vaccines

• In good news, the Fiscal Year (FY) 2017 budget was passed by Congress

• The 317 Program received a small reduction (approx. $4 million) in FY 2017

• The House funded the 317 Program at $560,000,000, which was the Administration's request, and the Senate funded the 317 Program at $610,000,000.

• The conference level of $606,792,000 for FY 2017 is a good outcome considering the cuts rendered to other health programs

The bad news is that we expect deep cuts to public health funding in the president's budget and even though Congressional leadership have said they will do their own budget, we expect a fairly austere climate for non defense discretionary funding.

Please Help Us Keep You Informed & Share Your Voice:

• ECBT Reaches Over 11 Million Individuals Annually With Social Media

Messaging/Materials

• ECBT Daily News Clips/Monthly Top 5/Week in Review – email us at [email protected]

• Guest Post on ECBT’s Shot of Prevention www.shotofprevention.com

• Like Us on Facebook: Facebook/VaccinateYourFamily

• Follow us on Twitter: EveryChildBy2 & ShotofPrev

• Contact: Amy Pisani [email protected]














http://www.shotofprevention.com/
































Immunizations

Amy Pisani, MS

Executive Director, Every Child by Two

Sarah Despres

Director, Government Relations, Health Programs,

Pew Charitable Trusts

Presentation of Congressional Asks

and Role Playing Exercise

Robert T. Hall, JD, MPAff

Director, AAFP Government Relations

Walk-Through:

Packets and Logistics

Hill Visit Basics • Greeting (2-3 min)

• Introduction (1-2 min)

• Personal Story (2-3 min)

• Supporting Information (1-2 min)

• Asks (2-4 min)

• Closing (1-2 min)

Total meeting time goal: Around 10-15 minutes!

Health Care Coverage

• Maintain & Expand Coverage

• Protect the Safety-Net Programs

• Stabilize the Individual Insurance Market

• Protect Patient-Centered Insurance Reforms

• Reduce Costs

• Increase Investment in Primary & Preventive Care

Teaching Health Center GME

• THCGME funds family medicine residencies

in community-based settings

• Graduates of THCs continue in primary care

and practice in underserved communities

• Unless Congress acts, the THCGME

program expires on September 30, 2017

Congressional Primary Care Caucus

House of Representatives Only

• Ask: If you are not a member of the Primary Care Caucus, please join it.

• Republicans contact Perry Chappell (Rep. Rouzer) or Democrats contact Maria Costigan (Rep. Courtney) to join.

OR

• If you are a member, thank you.

Role Play #1

“I'm New”

or

“I Don't Know Anything About Health”

Role Play #2

“I Agree”

or

“Preaching To The Choir”

Role Play #3

"I Agree, but…"

Role Play #4

"That Is Not My Position" Or "I Disagree"

(Politely)

Role Play #5

"Don't Call Us, We'll Call You"

Follow-Up • Fill out your Feedback Form and get it to AAFP

• Send a thank you letter / email to the legislator & staff, summarizing your conversation & any commitments

• Follow up & provide any additional information that was requested (as soon as you can)

• Remember the “Five P’s” – Politely Persistent Physicians Persuade Politicians

• Coordinate with AAFP staff about any next steps

Breakout Sessions

• Primary Care Policy Research – Grand Ballroom

• Direct Primary Care – Springwood

• Telemedicine – Sagamore Hill

• Lobbying 201 – Executive Room

Primary Care Policy Research: An Update from The Robert Graham Center

Primary Care Function: Measuring what

Matters in an Age of Uncertainty Andrew Bazemore, MD MPH

22 May 2017—FMAS meeting, Washington DC

Measuring what Matters in Primary

Care and an Age of Uncertainty

Andrew Bazemore, MD, MPH Director, Robert Graham Center

April 2017

But the reality is, through a health care lens,

our differences couldn’t be any more stark

U.S. spends nearly 2X the OECD avg % GDP

2017: 18.3%; rising to nearly 20% by 2025

Starfield: Expenditures vs Primary Care Score

UNITED STATES

AUSBEL

GERCAN

DKFIN

NTH

SPA

SWE UK

FRA

JAP

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000

0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2

worse Primary Care Score better

Per

Cap

ita

Hea

lth

Car

e

Exp

end

itu

res

2000

Adapted with permission from Starfield B. Policy relevant determinants of health: an

international perspective. Health Policy 2002;60:201-21.

United

States

AUS

BELGER

CANFIN

SPSWE

UK

0

1

2

3

4

5

6

7

8

9

10

0 1 2 3 4 5 6 7 8 9 10 11 12

better------Primary care score ranking-------worse

Hea

lth

care

Ou

tco

mes

Ran

k* NTH/DK

Starfield also defined the nature &

impact of Primary Care’s via 4 Cs

1st Contact, Comprehensive, Coordinated

Continuous

There is now good evidence, from a variety of studies at national, state,

regional, local, and individual levels that good primary care is associated with better health outcomes (on average),

lower costs (robustly and consistently), and greater equity in health

And as we move into an age of

measurement and quantification, will we

do any better?

These things we know:

Primary Care is Complex

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Onediagnosis

Twodiagnosis

Threediagnosis

Fourdiagnosis

Primary care

Speciality Care

And remains the main platform of care, even for

Complex Chronic Illness

% of all Visits for Top 14 Chronic Diseases by Cost to Primary Care

% of all Visits for Top 14 Chronic Diseases by Cost to Specialists

Remember… in US, 70% of physicians are specialists

Breadth & Aspirational definitions of primary care

• 1978, Declaration of Alma-Alta: Primary Health Care should be ‘the central function and main focus’ of a nation’s health system, in which it: – addresses the main health problems in the community,

providing promotive, preventive, curative and rehabilitative services accordingly

• 1996, Institute of Medicine: “…the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs”

• 2004: Future of Family Medicine: FM is defined by its comprehensive ‘Basket of Services’

Existential Moment for Family Physicians

• 2004, US: Future of Family Medicine says FM is defined by its comprehensive ‘Basket of Services’

• Yet, 2004-2014, many elements (e.g. Maternity/Obstetrical/Pediatric/ Inpatient care) are waning in practice

• What will define a US Family Physician going forward, and does scope matter?

Can we measure something like

Comprehensiveness? And does it

matter?

Perhaps the least studied of PC characteristics

2-3 (vs. 0-1)

4 (vs. 0-1)

5-6 (vs. 0-1)

7+ (vs. 0-1)

Com

pre

hen

sive

nes

s

.2 .3 .4 .5 .6 .7 .8 .9 1 1.1 1.2 1.3Odds Ratio

Hospitalizations (OR)

2-3 (vs. 0-1)

4 (vs. 0-1)

5-6 (vs. 0-1)

7+ (vs. 0-1)

Com

pre

hen

sive

nes

s

-30 -20 -10 0 10Percent Change

ln(Part A & B Expenses)

2-3 (vs. 0-1)

4 (vs. 0-1)

5-6 (vs. 0-1)

7+ (vs. 0-1)

Com

pre

hen

sive

nes

s

-30 -20 -10 0 10Percent Change

ln(Part B Expenses)

Bottom line: Comprehensiveness can be measured, &

using any of 3 measures, increasing comprehensiveness was associated with fewer Hospitalization and Lower Overall

Costs of Care Among Medicare Beneficiaries, Adjusted for Patient and

Physician Characteristics

What about Continuity? • Has a variety of definitions

• Previous measures are of patient continuity with their single physician, not physician-level

• Little thinking about continuity in a measurement paradigm

• Or how physician-level continuity impacts outcomes.

What about Training?

• $15 billion dollar public investment in GME

(residency) training annually

• Is anyone measuring it? Is it

measureable? Does it matter?

• Imprinting Studies

Bottom line#1: Training in places emphasizing primary care not only impacts likelihood of practice in areas

where we need doctors, it influences primary care behaviors

Comprehensiveness of Practicing PCPs by their Training

Institution’s % Graduates Practicing Rurally

ICD-9 BETOS

% Graduates Practicing Rurally →

<--Lowest Highest -->

<--Lowest Highest -->

Co

mp

reh

ensi

ven

ess

→

Bottom line:

Training in places emphasizing primary care not only impacts likelihood of practice in areas

where we need doctors, it influences primary care behaviors

Bottom line: Training in high cost areas is

associated with downstream high cost care, and similarly,

Training in low cost areas is associated with downstream low

cost care

What does all this mean?

• First contact, comprehensive, continuous, coordinated generalism is under siege

• One of many many countervailing forces was fee for service payment that favored a narrowing of scope of practice?

• We are entering an age of Value-based payment, where measurable outcomes are increasingly emphasized


• But measurement doesn’t necessarily

equal improvement, particularly if it doesn’t

emphasize or capture key elements of the

Primary Care function which Starfield

demonstrated to be the path to higher

quality, lower costs, and greater equity


• The 4Cs are measurable, and meaningful

• Paths forward: Further work developing

them as measures, or accepting that we’ll

never fully capture their essence absent

alternative payment models?

And finally

• Primary Care is increasingly a Team sport-

and individual 4C performance may be

less relevant than before

• We need to better understand how to

measure and assess outcomes of Practice

and Team-level 4Cs

Thanks!

For Questions & Comments:

Andrew Bazemore

[email protected]

Update on Primary Care Costs &

Payments Winston Liaw, MD MPH


How have ACOs affected the delivery of primary care?

How can we improve the ACO program to better support primary care?

What does the future hold for primary care’s role in ACOs?

146

243

353

404

460

0

50

100

150

200

250

300

350

400

450

500

2012 2013 2014 2015 2016

Next Generation

Pioneer

Medicare Shared SavingsProgram

Growth in the Accountable Care Organization Program, 2012-2016

Relative Frequency Histogram of Accountable

Care Organization Savings Rates

0

0.02

0.04

0.06

0.08

0.1

0.12

-13 -10 -7 -4 0 3 6 9 13

Pro

port

ion

Of the 333 ACOs, 28% shared in savings

Successful accountable care organizations had

higher benchmarks

$11,178

$10,207

$9,600

$9,800

$10,000

$10,200

$10,400

$10,600

$10,800

$11,000

$11,200

$11,400

Successful Not Successful

“It’s hard to achieve savings, if, like Dartmouth,

you are a low-cost provider to begin with.”

“It is easier for a person who runs a mile in 12

minutes to reduce the time to 10 minutes than for a

five-minute miler to break the four-minute barrier.”

Paying for improvement rather than achievement

Successful Not

Successful

p-value

6.5% -1.7% <.001

2.0 1.8 0.004

770.9 782.0 0.057

177.3 170.4 0.040

46.5% 41.1% 0.036

Shared Saving Tract (%) Savings Only

(Track 1)

97.8% 99.6% 0.130

Savings And Losses

(Track 2)

2.2% 0.40%

85.8 90.4 0.019

Region (%) North East 14.4% 25.3% 0.035

South 65.6% 39.0% <.001

Midwest 21.1% 22.8% 0.741

West 6.7% 21.2% 0.002

Quality Score

Characteristics

Saving Rate (%)

ACO Age (Years)

Follow up within 30 days of discharge (per 1,000)

Physicians in Primary Care (%)

Hospital Readmissions (per 1,000)

ACO Characteristics, by Success

Thanks!


Winston Liaw

[email protected]

What Proportion of US General

Internists are Hospitalists? Douglas Kamerow, MD


Background/Context

• Use of inpatient-only MDs, “hospitalists,” has been increasing in the US, based on survey data (Soc.Hosp.Med.)

• Now ~44,000 US hospitalists (SHM, 2014)

• Most (80-85%) hospitalists are general internists

• About 15 million stays, half of inpatient costs are paid by Medicare (2011)

Kuo, et al, NEJM 2009: Bi-modal

Primary Care Visits, 2008 • Almost 1/3 of 2008

primary care visits were to general internists (GIM)

• What will happen to those patients if there are fewer primary care internists?

• And what about new patients, since ACA?

FP/GP 45%

PD 24%

GIM 31%

Source:

Design

• Using 2012-2014 Medicare billing data

• Around 70,000 general internists billed at least 100 E&M codes annually in 2012-2014

• MDs placed in deciles by inpatient E&M billing proportion

• Separately, using AMA Masterfile, internists and family physicians were stratified by med school class and % hospitalist (≥90% inpatient billing) to look at trends

Results: 20121-2014 Data

2012

2013

2014

Hospitalist (≥90% inpatient billing)

28%

30%

32%

Mix (11-89% inpatient billing)

30%

27%

24%

Only outpatient (≤10% inpatient billing)

42%

43%

44%

Results: 2001, 2006 vs. 2012-14

2013 Results: Stratified by Med School Class

Conclusions

• An increasing proportion of general internists are becoming hospitalists (this trend may be leveling off)

• This will likely diminish the supply of general internists serving as primary care physicians, exacerbating the shortage of primary care clinicians

• To come: analyses of churn and replacement

Thanks!


Doug Kamerow

[email protected]

Bright Spot in Care Management

Megan Coffman Policy Research Administrator


Definition of Care Management • “A team-based, patient-centered approach designed to assist patients and their

support systems in managing medical conditions more effectively.”

– Care coordination: Organizing patient care—both information and activities—with the patient, family, and all care providers in a coordinated fashion with the patient, placing the patient’s care wishes at the center of the activities.1

– Self-management support: Helping patients cope with all aspects of their illness when they are outside of the health care system.

– Patient outreach: Reaching out to patients, and caregivers, before, after, and in between health care visits by phone, mail, electronically, or in person.

CareMore

GRACE Model

InterMed

John Hopkins Medicare Advantage Plan

Policy Opportunities to Expand

Effective Care Management • Incentives for the use of risk stratification to identify high need, high risk patients.

• Coordination by primary care for each managed patient.

• Incentives for the use of care management teams that include appropriate personnel,

including a Registered Nurse, Social Worker and/ or a CHW working closely with

clinical staff.

• Align different payment system and benefits dually eligible individuals and patients

with multiple chronic conditions through the use of value based capitated payment.

• Flexibility in payment and coverage to enable providers to treat patients at the most

appropriate site of care and to offer additional benefits as needed to meet care goals.

Thanks


Megan Coffman

[email protected]

• 140 Larry A. Green Visiting Scholars

• 16 Robert L. Phillips Policy Fellows -Fellowship now funded by HRSA, fellows serve as SME’s for Bureau of Primary Care

-Alums are leaders and innovators in PC (e.g. AHRQ Medical Director,

Your comments and questions welcomed!

Thoughts from a Physician,

Member of Congress

Rep. Ami Bera, MD (D-CA)

State Delegation Planning

Breakout Sessions

1) Lobbying 201 2) Telemedicine

Lobbying 201

http://greatergood.berkeley.edu/article/item/how_stories_change_brain

http://nyti.ms/1arRTCx

http://nyti.ms/1DJrdri

E: [email protected] P: 571.308.9539

www.keyadvocacy.com

Family Medicine Advocacy Summit 2017

Thank You for Participating in the Family Medicine Advocacy Summit 2017

BUT Am Org of Nurse Executives (100 in May)

Am Diabetes Assn (150 in March)

Air Line Pilots Assn (150 in June)

SHRM in March (500 in March)

Alzheimer’s Assn (1,300 in March)


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Keep Up the Momentum Back Home

• Engaging in DC is important – build a relationship by being active back home

• Start planning NOW for the next meeting with your MoC back home

• There are no limits on how often you may engage with your MoC’s office


www.keyadvocacy.com


The Most Successful Advocacy Efforts Use Diverse Advocacy Strategies

E-mail campaigns

Phone calls from VIPs

Constituent visits

Town hall meetings

Congressional Management Foundation

PAC Activities

Letters to the Editor


www.keyadvocacy.com

• Lobbying and Policy Change: Who Wins, Who Loses and Why

• Authors followed 98 issues from 1998 to 2002. Of the 98 issues reviewed, “the side with more lobbyists, more PAC donations, bigger organizational budgets and more members won only half the time”

• “A better predictor of success …was the support of …high-level congressional and government officials and …party leaders and the president”

• Leadership changes (1998, 2014 & 2015)

• “Change Elections” can swing majorities in Congress & party control of White House

Why Be an Advocate Back Home?


www.keyadvocacy.com

Town Halls, Community Events or Create Your Own



www.keyadvocacy.com



…San Antonio Hispanic Chamber of Commerce met with Congressman Lamar Smith, 21st Congressional District. He provided a few sentences on his legislative initiatives before taking questions from the audience. I provided a few talking points on Employment Verification, specifically I-9's...

…stated that he is introducing a Bill next Tuesday that would address SHRM's concerns. Thinks we should be pleased. After the meeting, I gave him a copy of the Employment Verification Paper you prepared. He briefly reviewed it, and placed it in his coat pocket. He stated he knew I-9's were not working...

…Congressman Smith was surprised to see a SHRM Affiliate Chapter in San Antonio...


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• Town Hall meetings & Tele-town Halls

• Letters to the Editor & Op-Eds

• Scheduled office hours

• Community Events elected officials attend (county & state fairs, parades, picnics, etc.)

• PAC Events

• Create your own: “Congressional Coffees”, “Lunch with a Legislator”, “Learn from a Legislator”


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Building Relationships: Giving Instead of Asking


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Don’t Discount or Forget About District Staff


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David Lusk, Founder

Key Advocacy

[email protected]

571-308-9539

www.keyadvocacy.com

Telehealth / Telemedicine the not too distant

Steven E. Waldren, MD, MS May 22, 2017

2

DefinitionsTelemedicine - the practice of medicine using technology to deliver care at a distance, over a telecommunications infrastructure, between a patient at an originating (spoke) site and a physician, or other practitioner licensed to practice medicine, at a distant (hub) site.

Telehealth - a broad collection of electronic and telecommunications technologies and services that support at-a-distance healthcare delivery and services. Telehealth technologies and tactics support virtual medical, health and education services.

3

Source: http://www.aafp.org/about/policies/all/telemedicine.html

http://www.aafp.org/about/policies/all/telemedicine.html

Adoption• Telemedicine and telehealth have been growing

at a greater than linear rate for the last few years. • Emergence of direct to consumer, telemedicine

only offerings have seen exponential growth • Private practice adoption in family medicine is

growing but was only 15% in 2015 Robert Graham Center study

4

Key Challenges & Issues• Practice adoption

• Training / Education • Reimbursement • Capital & operational costs • Potential liability issues

• Complexity of regulations and payment rules • Disruption of continuity of care

5

Potential Role in Care• Improved access • Improved continuity of care • Improved care coordination • Reduced cost of care delivery • Patient convenience

6

Payment Policy

7

Fee for Service Value Based Payment

Regulations• State based laws

• Licensure • Payment policy

• Medicare payment policy

8

Source: https://imlcc.org/

Interstate Medical Licensure Compact

https://imlcc.org/

AAFP Telehealth Activities• Recently revised telehealth policy

http://www.aafp.org/about/policies/all/telemedicine.html • Advocacy issues

• Support of continuity of care and care coordination • Appropriateness of telemedicine delivery • Adequate payment

• Telehealth Member Interest Group (MIG) • Collaboration with National Telemedicine Resource Centers

http://www.telehealthresourcecenter.org/ • Development of educational resources in telehealth • Exploring potential new products and services in telehealth • FMX - CME Presentation and Office of the Future

9

http://www.aafp.org/about/policies/all/telemedicine.html

http://www.telehealthresourcecenter.org/

Health & Medicine

Family Medicine Advocacy Summit 2017