National reforms needed to avoid ‘many small, independent practices in a state of financial ruin’

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Primary care is undervalued and overburdened across the United States, but there are measures that could help, said the leader of the American Academy of Family Physicians (AAFP).

Steven Furr, MD, FAAFP, the academy’s president, offered his solutions this month in testimony presented to the House Committee on Energy & Commerce.

Prescription drug changes, prior authorization requirements, various sets of quality measures, and inadequate compensation are smothering doctors forced to cut their time caring for actual patients, Furr said.

“Primary care physicians consistently report that they are being asked to do more with less – and it’s having a profound impact on our health care workforce and on patient access,” he said in his written testimony.

Steven Furr, MD, FAAFP
_{American Academy of Family Physicians}

While the situation appears bleak for American primary care, Congress could act on legislation that could help, Furr said. He outlined some of AAFP’s suggested remedies for the committee’s Subcommittee on Health in the hearing “What’s the Prognosis? Examining Medicare Proposals to Improve Patient Access to Care & Minimize Red Tape for Doctors.”

Billing code assistance

AAFP, along with at least 36 other physician, health care and patient-advocacy organizations, are endorsing the add-on billing code known as G2211, currently proposed by the U.S. Centers for Medicare & Medicaid Services.

Family medicine and internal medicine visits are complex, involving multiple conditions and coordination of care across a large team, but physicians are not reimbursed at scale. The code would “better recognize the inherent resource costs clinicians incur when longitudinally managing a patient’s overall health or treating a patient’s single, serious or complex chronic condition,” Furr said.

Prices going up

Currently, physician reimbursement is the only system in Medicare that does not get a yearly update for inflation.

“There is a significant discrepancy between what it costs to run a physician practice and the actual payment we receive, placing many small, independent practices in a state of financial ruin that leaves them with virtually no options other than to be acquired by a health system or payer, or close their doors entirely,” Furr said. AAFP has endorsed House Resolution 2474, the “Strengthening Medicare for Patients and Providers Act,” which would allow an inflationary update to physician payments based on the Medicare Economic Index.

Price vs. place

AAFP supports eliminating geographic adjustments in the Medicare Physician Fee Schedule (PFS), except for incentives for specific policy goals. Those include encouraging physicians to practice in underserved areas, instead of penalizing them with lower reimbursement, Furr said.

“If we want to do a better job of recruiting and retaining rural physicians, this is one place to start,” he said. “Patient care provided in a rural area should not be valued less by Medicare than physician work provided elsewhere.”

MIPS

Medicare’s Merit-based Incentive Payment System (MIPS) aimed to help physicians move to alternative payment models (APMs) by measuring their performance. But cutting the Medicare PFS has inhibited practices from investments to move into APMs, and is unfair for small and rural practices, Furr said.

It needs serious reform, he said. AAFP also endorses Congress granting a five-year extension to the Quality Payment Program’s Small, Underserved, and Rural practices support program that expired in 2022, Furr added.

Prior authorizations

Physicians know well the administrative complexity – and delays in patient care – created by prior authorization requirements in Medicare Advantage and other insurers, Furr said. AAFP supports the “Improving Seniors’ Timely Access to Care Act,” which has long had bipartisan support in Congress.

Congress should mandate greater oversight on prior authorization management by CMS and state Medicaid plans, he said.

Drug coverage

When insurers change coverage of various medications, they don’t explain why to physicians who are helping patients manage health conditions. They also require step therapy, or “fail first,” requiring patients to try insurer-preferred drugs prior to the one prescribed by physicians, Furr said.

Those practices can be disastrous for patients who have been using medications for years, and a time-consuming headache for doctors. Furr called it “the single greatest administrative burden I’m facing.”

AAFP supports a CMS proposal for MA plans to use electronic systems to query patients’ drug formularies in real time at the point of care, Furr said. The entire process needs streamlining and more transparency, he said.

Get shots in arms

Congress should pass legislation requiring Medicare Part B coverage of all vaccines recommended by the Advisory Committee on Immunization Practices of the U.S. Centers for Disease Control and Prevention. Currently those are split between outpatient care and prescription drug coverage, which prevents primary care physicians from delivering recommended vaccines in their offices, Furr said.

He noted the nation spends $27 billion a year on four vaccine-preventable illnesses in adults aged 50 years or older: influenza, pertussis, pneumococcal pneumonia, and shingles.

Performance standards

Tracking various quality and performance standards with data from multiple sources “is a logistical nightmare,” focused on finances with little benefit to patient health or cost reduction, Furr said. The nation would benefit from a standardized universal set of quality and performance measures focused on outcomes and cost reduction, he said.