Leading the Way

Jen Hartmark-Hill, MD

Jen Hartmark-Hill, MD

One of my top priorities for staying involved in health care advocacy is to promote a better future for my students.

As a medical educator, I often ponder the uncomfortable paradox of training medical students to become “ideal” physicians, only to send them out into a far less than ideal health care system upon graduation. Preparing and educating future physicians to lead health care transformation is essential, but we who serve as educators and role models cannot stop there.

I believe we have a duty not only to provide knowledge, skills, and resource tools but also to go on ahead of our students to pave the way. 

Having been involved with state level advocacy for a number of years, my learning curve since introduction to advocacy in residency (thanks to my state AAFP chapter) has been steep, yet still I know so little. Given my minimal experience advocating at the national level, I have been contemplating the need to expand my skills. This year, I had an opportunity to attend the Family Medicine Congressional Conference in Washington, DC, through a scholarship from the Society of Teachers of Family Medicine.

Lessons Learned

At the conference, an amazing line-up of national leaders in health care policy opened my eyes to current areas of need and opportunities to educate our leaders and lawmakers. A few of the many take-home points were these:

SGR Repealed

For anyone with residual doubts regarding whether or not persistent advocacy really works, the opening statements of the Family Medicine Congressional Conference provided solid evidence of critical value. As one speaker noted, “The acronym no one need utter during this conference is ‘SGR,’” which was followed by volleys of heartfelt applause. The speaker referenced an unprecedented milestone. For the first time anyone in attendance could remember, the Damoclesian sword of devastating payment cuts embodied in the unsustainable Sustainable Growth Rate (SGR) formula was no longer hanging over our heads. Family medicine efforts, year after year, have been key to this bipartisan accomplishment. Thankfully, we can now move forward to so many other advocacy opportunities to enhance care and access for our patients.

Money Matters

The call for reform in Graduate Medical Education (GME) funding has been tolling recurrently in recent years, due to outdated funding methods that placed a choke hold on the purse strings back in the late 1990s. Many states with significant underserved patient populations have lobbied for increases in dollars to be able to train resident physicians in communities where they will then likely stay and practice. Rather than again championing a reform plan to congressional leaders, the strategy we enacted this year was to go with a strength for family physicians—evidence-based decision-making. We urged our representatives in Congress to direct the Governmental Accountability Office to issue a non-partisan report looking at locations and demographics for where yearly GME funding currently flows. Transparency in the data will allow family medicine advocates to call for accountability in federal government spending—for our leaders to use taxpayer derived funds to improve the primary care pipeline and increase patient access to care.

Advocacy in Action

 Armed with cutting edge tools and current knowledge of legislative hot topics, we left the halls of the conference for face-to-face meetings with Congressional leaders and their expert staff.  In addition to the topics mentioned above, we also had the privilege of sharing with our legislators the value of primary care, such as the fact that if a patient has a PCP, the cost of their health care tends to be about 33% lower, and risk of dying is 19% lower than those who see only a subspecialist.1 Ensuring that American citizens have access to high-quality health care and a PCP equates to growing the primary care pipeline. This message, and the fact that incentivizing medical student seniors to choose family medicine specialty training has a higher return on graduating residents staying in primary care (compared with all other specialties), was well received by the legislators with whom we spoke.

In the future, with continued education and advocacy on our parts, lawmakers will continue to consider funding new models for training physicians that bring down health care costs over time while effectively improving the health of the nation. The journey will take some time, but this experience has already hugely impacted me for the better.  I can now share these lessons learned with my students from a first-hand perspective, making me simultaneously a stronger educator and an agent of change.

My message to students and colleagues alike—get involved and stay involved. Your patients and your profession are counting on you!

Reference
  1. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health.Milbank Q 2005;83(3):457-502.

SGR Repeal and Teaching Health Center GME Extension: What Does it Mean for You?

Hope Wittenberg

Hope Wittenberg, MA
Director, Government Relations

The long-sought-after repeal of the failed Sustainable Growth Rate (SGR) formula has finally happened. Earlier this week the Senate passed the Medicare Access and CHIP Reauthorization Act of 2015 (HR 2), which repealed SGR and extended several key programs of importance to family medicine.

Changes to Physician Payments

The bill permanently replaces the SGR formula with stable annual payment increases of 0.5% for 5 years. It also includes incentives for physicians to move into one of two value-based payment systems, based on their practice model, beginning in 2019.

Merit-Based Incentive Payment System (MIPS)

MIPS consolidates existing Medicare fee-for-service incentive programs (PQRS, Meaningful Use, and Value-based Modifier). One can think of this payment system as the default system. Payments will be based on improved performance of specific criteria, resulting in a base payment being increased or decreased up to 4% beginning in 2019, rising to up to 9% by 2022. Starting in 2026, physicians participating in the MIPS will be eligible for a 0.25% annual increase in their payments.

  • This consolidation is intended to streamline complex quality reporting measures.
  • It adds incentives for physicians to engage in clinical improvement activities (e.g., same-day appointments, care coordination, etc.).
  • It rewards physicians based on their own measured improvement, rather than through a “tournament style” system that mandates winners and losers.

Of note, the legislation includes ABFM maintenance of certification as a MIPS clinical-improvement activity.

Alternative Payment Methodology (APM)

The other method of payment is for physicians who receive a certain percentage of their revenue from alternative payment models such as patient-centered medical home and accountable care organizations. Eligible practices paid under the APM model will receive a 5% bonus on their Medicare billings for years 2019 to 2024. Starting in 2026, physicians participating in an APM qualify for a 0.75% annual increase.

  • APM provides safe harbor from the downside of MIPS assessment and most EHR meaningful use requirements.
  • It rewards movement away from the fee-for-service model and into models that reward value and outcomes rather than activity or volume.

Our hope is that both of the tracks will allow family medicine practices to garner better payment for providing improved care; however, the larger bonus payments in the alternative payment models intentionally encourage a shift from focusing on solely on patients to improved care of communities and populations. The underlying premise is that this type of payment system, in contrast to fee-for-service, will incentivize practices to achieve the triple aim of improving the health of the population, enhancing the patient outcomes and reducing costs.

Funding of Critical Programs

There were several other primary care priorities that were included in the bill that our advocacy staff and many of our members have worked very hard to achieve. The bill includes 2 years of additional funding for:

  • Children’s Health Insurance Program
  • Community health centers
  • National Health Service Corps
  • Teaching Health Center Graduate Medical Education program.

Our academic family medicine advocacy staff has been actively working for over 3 years to achieve an extension of the Teaching Health Center GME program. Its 2-year extension in this legislation provides funding for the current crop of residents—including those who just matched into these programs for the 2015–2016 academic year. Without this extension the program was at risk of running out of money. The HRSA had given notice that the per-resident amount might be reduced from its current $150,000, to as low as $70,000, depending on this year’s match and fill rates. The bill allows us some breathing room to continue to work for a more permanent solution—but we don’t have time to rest on our laurels!

Thank You CAFM Advocacy Network and Members!

Take a moment to enjoy the success! I would like to extend a very great thank you to those who advocated for this bill and the programs contained in it. Many of you answered our call and were committed to moving the process forward.  We will need to continue our advocacy efforts to move our national agenda forward. I look to your help in efforts to obtain overall graduate medical education reform, increased funding for primary care research, and better funding for primary care training under Title VII.

Advocacy is not all about national agendas, either of our specialty, or of academic family medicine. I’d also like to hear ideas about your personal advocacy journey.

What issues, causes, or problems matter to you? What do you see as your next personal advocacy cause? And when you read the summary above of what’s contained in the SGR legislation, what ideas did it stimulate in you for your advocacy agenda in the future?