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Dr. Davis Mirvis, UTHSC

With reimbursement methods still screaming for reform, the American Academy of Family Physicians (AAFP) has taken the cry a step further by actually putting their thoughts to paper.

The AAFP has numerous principles to consider when devising a new payment plan and has taken those to top officials.

Some of the AAFP principles include more pay for physician cognitive skills relative to procedural skills, for case management services and for preventive care and health maintenance services.

Additional principles include:

• While quality care, access to care and positive health outcomes are the primary goals, the doctor/patient partnership must be preserved.

• Payment must be based on continuing care and should encourage outpatient treatment rather than institutional settings.

• It should not be based on physician training or location of the services.

In May, AAFP president Dr. Rick Kellerman testified before the House Ways and Means Subcommittee on Health in Washington DC, on the importance of payment reform and the coordination of care.

“Care coordination cuts down on medical costs,” Kellerman said. “The subcommittee considered different thoughts and will be making recommendations to the House Committee. The AAFP has also talked to Medicare and different insurance companies about the medical home concept. Research has shown that quality of care is better, costs are better controlled and patients are more satisfied with that concept.”

Dr. Davis Mirvis, department of preventive medicine, University of Tennessee Health Science Center, has done tremendous research on health systems, health policies, managed care and the issues physicians face.

“Some of the AAFP principles I agree with and some I don’t,” Mirvis said. “It gets back to basic economics that you get what you pay for and what the incentives are. Procedures are paid at a higher rate than a usual doctor office visit, but prevention should be more valued than it is and reimbursed at a higher rate to encourage people to do it. Some of the other issues are more complicated, like individual physicians retaining the right to make their own charges. That gets into issues of physician autonomy and the whole issue of individual physicians trying to charge whatever they think they deserve. That’s how it used to be and is why we have managed care and contracting for servicing now. The free market might work for buying television sets, but doesn’t work that way in medicine. It’s not life threatening if you get a set that isn’t as good a quality as another one. Some doctors are now opting out of plans and are charging upfront for operations. That’s OK for them, but there will be a lot of people who can’t get their operations if everyone does it.”

Dr. Charles Ball, president of the Tennessee Academy of Family Physicians and medical director of Maury Regional Hospital in Columbia, said family physicians strongly support the new payment reform principles adopted by the AAFP.

“Historically, there has been a bias in payment for procedural skills as compared to cognitive skills and interventions,” Ball explained. “Payment reform needs to assess all aspects of patient care, including cognitive, procedural, and preventative. The AAFP has developed a paper entitled, The Future of Family Medicine, which outlines requirements for comprehensive continuous patient care. Foremost in this paper is the need for every citizen to have a medical home to insure this complete medical care. It also includes the need for skills and technology that family physicians will need to achieve these goals, and the recognition that appropriate payment must be accomplished to support quality patient care.”

Kellerman said one of the biggest flies in the ointment is the way Medicare uses the Relative Value Scale to compare services in which, for example, an appendectomy is equivalent to a certain number of office visits.

“The SGR formula problem is that it links physician fees with increases in the gross domestic product of the United States. That doesn’t correlate with overhead costs of medical services that have increased,” Kellerman said. “The prices of toys and cars go up 1 to 2 percent each year. Overhead costs in medical offices go up 5 to 10 percent. Physician payments are not keeping up. With the way the formula works now, we’ll see a 10 percent cut in physician fees next year.”

Ball agreed that family physicians, in a broad sense, cross so many specialty lines; payment for equal services should be equitable regardless of provider.

“For example, there are family physicians that perform gastrointestinal endoscopy procedures identical to gastroenterologists, but payment may be unequal solely based on specialty training,” said Ball. “Family physicians also provide the bulk of mental health services in this country, but are often excluded by third party payers due to carve out policies for behavioral health.”

Kellerman said poor reimbursement was also the reason students going into family medicine declined 50 percent in the last 10 years.

“The incentives are misaligned,” said Kellerman. “The pay is not as good in primary care practices, the work is long and hard and right out of medical school, students owe over $100,000 in loans. But I feel optimistic. In the last year, we’ve seen a better understanding of the medical home concept that will change the way physicians are reimbursed. I think policymakers are starting to wake up and understand this. The process of change takes a long time.”

As for Mirvis, he said he had his own ideas of how it should work.

“My own personal bias is a single payer system because 20 to 30 percent now is going toward administration, because they’re so many different plans out there and each has their own rules. Administration for all of that is huge. The AAFP is complicated. But it’s a good discussion for doctors to put these ideas on the table,” Mirvis said.

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