ACP pleased with affordable coverage for all Americans, expresses concern regarding several provisions

American College of PhysiciansDec 5 2009

Letter to Senate leaders supports key policies on coverage; primary care, prevention and wellness; and delivery and payment system reforms; seeks modifications of several areas of concern

The American College of Physicians (ACP) today sent a letter to Senate leaders sharing the College's views on key issues in H.R. 3590, the Patient Protection and Affordable Care Act.

"We commend the Senate for approving a motion to proceed to debate this legislation, which includes important and essential reforms that overall are consistent with ACP policy to expand coverage and reverse a shortage of primary care physicians," Joseph W. Stubbs, MD, FACP, president of ACP, said in the letter. "Although there is much in this bill that is consistent with these goals and ACP policy, we also have significant concerns regarding several provisions and urge you to consider amending the legislation to address these issues prior to Senate passage of the bill."

ACP highlighted its support for the bill's provisions to expand coverage to almost all legal residents in the United States, calling this one of the organization's "highest priorities." ACP also expressed support for provisions to reform payments to support the value of care provided by primary care physicians, to accelerate testing of innovative payment and delivery models, and to increase the training of primary care physicians.

Specific ACP recommendations included:

• Sustainable Growth Rate: Enactment of a permanent repeal of the flawed SGR formula and replace it with a new payment system that will provide positive and predictable payment updates for physicians and a higher growth target, and update, for primary care and preventive services.

• Patient-Centered Medical Home: ACP expressed support for several provisions in the bill to support patient-centered care in a medical home, but asked the Senate to provide specific funding for a Medicare Medical Home pilot, instead of leaving it to a new Center on Innovation to decide if such a program would be funded.

• Improved Payments for Primary Care Services: ACP supported the intent of a proposal to increase Medicare payments to primary care physicians but advised the Senate leadership that it was "essential" that the provision be modified so as to not exclude most primary care internists. The Senate bill, by narrowly defining primary care services as excluding hospital visits, would exclude most primary care internists, particularly those in rural areas, who provide care to their patients in both the office and hospital setting-a hallmark of comprehensive primary care. ACP proposed that the Senate add hospital visits to the designated primary care services and allow any primary care physician to qualify if 50 percent of their total Medicare billings were for office, hospital, nursing, and other visits. ACP also urged that the Senate make the primary care bonus "permanent" instead of allowing it to expire after five years. It also cautioned the Senate not to make changes, in response to concerns from other groups, which would have the effect of lowering or diluting the primary care bonus.

• Also, the Senate bill, unlike the House legislation, does not have any provisions to increase payments to primary care physicians under the Medicaid program. ACP strongly urged inclusion of a provision in the final bill that increases Medicaid payments to primary care to no less than the Medicare rates. Such a provision is urgently needed to ensure that primary care physicians will be available for the more than 10 million persons with incomes up to 133 percent of the Federal Poverty Level who would now be covered by Medicaid.

• Workforce: While expressing broad support for the many policies in the bill to train more primary care physicians, ACP urged the Senate to reinstate the 20/220 loan deferment program in the final Senate health reform bill. This provision, which allows for the deferment of interest and principal payments on educational loans during residency, is the economic hardship deferment criterion that 67 percent of the nation's medical residents have relied upon to defer their student loan debts while completing residency training. ACP also asked the Senate to increase funding for GME positions in primary care training programs. And, it asked the Senate to create a new loan repayment program for physicians who go into general internal medicine, pediatrics, or family medicine and who practice in an area of the country or health care facility with a high need for such specialties.

In the letter, Dr. Stubbs expressed support for the concept of an Independent Medicare Advisory Board but stated that the version in the bill lacks sufficient safeguards and oversight over the Board's actions. ACP made four specific recommendations:

• Representation on the Board: The Senate health reform bill designates the commission to be composed of 15 members, and includes experts in fields related to health care finance, delivery, and management and specifically requires representation of consumers and the elderly. ACP recommended that modifications be made to include specified representation of physicians who deliver care in a community setting, and at least one designated seat for a primary care physician.

• Congressional Authority: ACP expressed concern that the Senate legislation would only allow Congress to block implementation of Medicare Commission recommendations by passing alternative legislation that meets the required savings benchmarks. This legislation could be vetoed by the President and then only overturned by a super-majority vote of both the House and Senate. ACP recommended that Congress be able to block implementation of the Commission's recommendations by a simple majority vote in both Houses through a fast-track joint resolution process. Under this approach, Congress would not have to develop an alternative and current law would remain in effect if the Board's proposals are not approved by Congress.

• Transparency: The Senate legislation states that the Board may hold hearings concerning their proposals if they consider these forums advisable. This places too much authority with the Board deciding when, or even if, to hold hearings on important Medicare payment issues. The Board could simply decide not to hold hearings, regardless of the reason, which would effectively prevent adequate stakeholder input. The College recommended that to ensure transparency in the Commission's proceedings and adequate opportunity for stakeholder input, that the legislation mandates the Commission to hold a minimum number of hearings before proposals are finalized.

• Exemption of Certain Providers: ACP recommended that IMAB be allowed to make recommendations that apply broadly to physicians, hospitals, home health, hospice, nursing home, and other providers.

"ACP is pleased that H.R. 3590 has many of the key policies needed to provide affordable coverage to all Americans, expands the primary care workforce, and improves payment and delivery systems," Dr. Stubbs noted. "We remain firmly committed to the goal of getting legislation passed this year by the Senate that delivers on these essential policies and goals."

"We offer our recommendations for improving on the areas of concern in the spirit of achieving a final bill that would ensure that the policies intended to support primary care are sufficient to the need," Dr. Stubbs emphasized. "We seek to accelerate pilot-testing of innovative delivery models and payment reforms with appropriate congressional oversight, to ensure that the Patient-Centered Medical Home will be among the models to be tested on an accelerated and expanded basis, and to eliminate the cycle of endless Medicare physician payment cuts that threaten access to care."

"We look forward to continuing to work with you to achieve these objectives," the letter concluded.