American Academy of Family Physicians (AAFP): Congress of Delegates

ORLANDO – Do you practice family medicine in a region where Medicare is the "better payer," where there is a low number of primary care physicians per capita, and/or where residents get their training but leave to practice elsewhere?

If so, you might be in a "distressed practice environment," and the American Academy of Family Physicians wants to hear from you.

Alerted to these dire circumstances by the New Jersey Academy of Family Physicians, the national academy is in "information gathering mode" to determine a strategy to help family physicians in the affected areas – but concerns reach beyond the Garden State, AAFP President Glen Stream said.

"We are concerned that this is happening in other states in the country," Dr. Stream said at a town hall session held during the annual Congress of Delegates of the American Academy of Family Physicians. "We want detailed information on how to proceed to get objective data to inform our advocacy in this regard."

"This is an issue we feel is very important, not only to New Jersey, but as you said, there are many other areas around the country. We heard that loud and clear from some other chapters," said Dr. Robert Eidus, president of the New Jersey chapter.

New Jersey has the third fewest primary care physicians per capita and ranks fourth highest nationwide in terms of specialists, Dr. Eidus said. "That creates a situation, not surprisingly, where costs are high. What do payers do at this point? They ratchet down fees, not using a scalpel but using a bludgeon."

In some regions of the state, family physicians receive private insurance payments that are 50%-60% of the Medicare rate.

"Having an oligopoly of payers is another issue," said Dr. Eidus, a family physician with a private practice in Cranford, N.J.

Although it varies, a distressed practice environment can arise when two or three major health plans hold the great majority of market share in an area, Dr. Stream said in an interview. "As a result, they offer contracts at a very low payment."

The national academy plans to develop a strategy to encourage private health plans to increase payments for primary care services, including adoption of the Medicare 10% initiative for primary care, according to a report issued by the AAFP board of directors at the congress.

"Pay particular attention to paragraph nine [of the report]," said Dr. Dennis F. Saver, a delegate from Florida. "It is wonderfully understated as a ‘particularly vexing problem’ that insurance companies who are members of the Patient-Centered Primary Care Collaborative [PCPCC] are paying primary care physicians less than the going rate." They need to be held accountable, he added.

That portion of the report states, in part, that some private health plans that are "actively involved in Patient-Centered Medical Home pilots with the intention of shoring up primary care are the very same plans that are offering preferred provider organization (PPO) contracts to family physicians that only pay a fraction of Medicare payment, threatening the financial viability and survival of small practices."

The national academy brought the conflict to the attention of the PCPCC board of directors, Dr. Stream said, and the board plans to meet with key health plans during their annual summit in October. At the same time, the AAFP plans to hold one-on-one meetings with the five top insurers involved in PCPCC, starting with United Healthcare.

Those meetings with top insurer members of the PCPCC are important, Dr. Eidus said, because "they talk the talk but are not walking the walk."

At a recent meeting of the physician advocacy board for Humana Insurance, "I pointed out that in southwestern Ohio, the Cincinnati area, there are now many physicians who are under Medicare for their payment schedules," said Dr. Brian Bachelder, an alternate delegate from Ohio. "Humana, as of Sept. 1, brought their payment levels down to what other competitors in the area were paying," Dr. Bachelder said. "Yet at the meeting, they were talking about going out and trying to engage more primary care physicians – particularly family physicians – in the Humana fold, and even hiring family physicians to work for Humana.

"I pointed out the contradiction ... and they had nothing to say about it," Dr. Bachelder asserted.

A net loss of new physicians is another adverse effect of distressed practice environments, Dr. Eidus said. "We have a fair amount of residency programs in the state, but we’re net exporters. We’re exporting more ... despite the fact that we have a shortage in primary care.

"We also recognize that it’s not in the best interest of the citizens of New Jersey, or any other state, to have family medicine or primary care deserts," Dr. Eidus said. "We have that happening in New Jersey."

The AAFP Commission on Quality and Practice will review all feedback and data collected on distressed practice environments. Dr. Stream said the issue will be a major focus at the next leadership forum in May 2012.

ORLANDO – Do you practice family medicine in a region where Medicare is the "better payer," where there is a low number of primary care physicians per capita, and/or where residents get their training but leave to practice elsewhere?

If so, you might be in a "distressed practice environment," and the American Academy of Family Physicians wants to hear from you.

Alerted to these dire circumstances by the New Jersey Academy of Family Physicians, the national academy is in "information gathering mode" to determine a strategy to help family physicians in the affected areas – but concerns reach beyond the Garden State, AAFP President Glen Stream said.

"We are concerned that this is happening in other states in the country," Dr. Stream said at a town hall session held during the annual Congress of Delegates of the American Academy of Family Physicians. "We want detailed information on how to proceed to get objective data to inform our advocacy in this regard."

"This is an issue we feel is very important, not only to New Jersey, but as you said, there are many other areas around the country. We heard that loud and clear from some other chapters," said Dr. Robert Eidus, president of the New Jersey chapter.

New Jersey has the third fewest primary care physicians per capita and ranks fourth highest nationwide in terms of specialists, Dr. Eidus said. "That creates a situation, not surprisingly, where costs are high. What do payers do at this point? They ratchet down fees, not using a scalpel but using a bludgeon."

In some regions of the state, family physicians receive private insurance payments that are 50%-60% of the Medicare rate.

"Having an oligopoly of payers is another issue," said Dr. Eidus, a family physician with a private practice in Cranford, N.J.

Although it varies, a distressed practice environment can arise when two or three major health plans hold the great majority of market share in an area, Dr. Stream said in an interview. "As a result, they offer contracts at a very low payment."

The national academy plans to develop a strategy to encourage private health plans to increase payments for primary care services, including adoption of the Medicare 10% initiative for primary care, according to a report issued by the AAFP board of directors at the congress.

"Pay particular attention to paragraph nine [of the report]," said Dr. Dennis F. Saver, a delegate from Florida. "It is wonderfully understated as a ‘particularly vexing problem’ that insurance companies who are members of the Patient-Centered Primary Care Collaborative [PCPCC] are paying primary care physicians less than the going rate." They need to be held accountable, he added.

That portion of the report states, in part, that some private health plans that are "actively involved in Patient-Centered Medical Home pilots with the intention of shoring up primary care are the very same plans that are offering preferred provider organization (PPO) contracts to family physicians that only pay a fraction of Medicare payment, threatening the financial viability and survival of small practices."

The national academy brought the conflict to the attention of the PCPCC board of directors, Dr. Stream said, and the board plans to meet with key health plans during their annual summit in October. At the same time, the AAFP plans to hold one-on-one meetings with the five top insurers involved in PCPCC, starting with United Healthcare.

Those meetings with top insurer members of the PCPCC are important, Dr. Eidus said, because "they talk the talk but are not walking the walk."

At a recent meeting of the physician advocacy board for Humana Insurance, "I pointed out that in southwestern Ohio, the Cincinnati area, there are now many physicians who are under Medicare for their payment schedules," said Dr. Brian Bachelder, an alternate delegate from Ohio. "Humana, as of Sept. 1, brought their payment levels down to what other competitors in the area were paying," Dr. Bachelder said. "Yet at the meeting, they were talking about going out and trying to engage more primary care physicians – particularly family physicians – in the Humana fold, and even hiring family physicians to work for Humana.

"I pointed out the contradiction ... and they had nothing to say about it," Dr. Bachelder asserted.

A net loss of new physicians is another adverse effect of distressed practice environments, Dr. Eidus said. "We have a fair amount of residency programs in the state, but we’re net exporters. We’re exporting more ... despite the fact that we have a shortage in primary care.

"We also recognize that it’s not in the best interest of the citizens of New Jersey, or any other state, to have family medicine or primary care deserts," Dr. Eidus said. "We have that happening in New Jersey."

The AAFP Commission on Quality and Practice will review all feedback and data collected on distressed practice environments. Dr. Stream said the issue will be a major focus at the next leadership forum in May 2012.

ORLANDO – Do you practice family medicine in a region where Medicare is the "better payer," where there is a low number of primary care physicians per capita, and/or where residents get their training but leave to practice elsewhere?

If so, you might be in a "distressed practice environment," and the American Academy of Family Physicians wants to hear from you.

Alerted to these dire circumstances by the New Jersey Academy of Family Physicians, the national academy is in "information gathering mode" to determine a strategy to help family physicians in the affected areas – but concerns reach beyond the Garden State, AAFP President Glen Stream said.

"We are concerned that this is happening in other states in the country," Dr. Stream said at a town hall session held during the annual Congress of Delegates of the American Academy of Family Physicians. "We want detailed information on how to proceed to get objective data to inform our advocacy in this regard."

"This is an issue we feel is very important, not only to New Jersey, but as you said, there are many other areas around the country. We heard that loud and clear from some other chapters," said Dr. Robert Eidus, president of the New Jersey chapter.

New Jersey has the third fewest primary care physicians per capita and ranks fourth highest nationwide in terms of specialists, Dr. Eidus said. "That creates a situation, not surprisingly, where costs are high. What do payers do at this point? They ratchet down fees, not using a scalpel but using a bludgeon."

In some regions of the state, family physicians receive private insurance payments that are 50%-60% of the Medicare rate.

"Having an oligopoly of payers is another issue," said Dr. Eidus, a family physician with a private practice in Cranford, N.J.

Although it varies, a distressed practice environment can arise when two or three major health plans hold the great majority of market share in an area, Dr. Stream said in an interview. "As a result, they offer contracts at a very low payment."

The national academy plans to develop a strategy to encourage private health plans to increase payments for primary care services, including adoption of the Medicare 10% initiative for primary care, according to a report issued by the AAFP board of directors at the congress.

"Pay particular attention to paragraph nine [of the report]," said Dr. Dennis F. Saver, a delegate from Florida. "It is wonderfully understated as a ‘particularly vexing problem’ that insurance companies who are members of the Patient-Centered Primary Care Collaborative [PCPCC] are paying primary care physicians less than the going rate." They need to be held accountable, he added.

That portion of the report states, in part, that some private health plans that are "actively involved in Patient-Centered Medical Home pilots with the intention of shoring up primary care are the very same plans that are offering preferred provider organization (PPO) contracts to family physicians that only pay a fraction of Medicare payment, threatening the financial viability and survival of small practices."

The national academy brought the conflict to the attention of the PCPCC board of directors, Dr. Stream said, and the board plans to meet with key health plans during their annual summit in October. At the same time, the AAFP plans to hold one-on-one meetings with the five top insurers involved in PCPCC, starting with United Healthcare.

Those meetings with top insurer members of the PCPCC are important, Dr. Eidus said, because "they talk the talk but are not walking the walk."

At a recent meeting of the physician advocacy board for Humana Insurance, "I pointed out that in southwestern Ohio, the Cincinnati area, there are now many physicians who are under Medicare for their payment schedules," said Dr. Brian Bachelder, an alternate delegate from Ohio. "Humana, as of Sept. 1, brought their payment levels down to what other competitors in the area were paying," Dr. Bachelder said. "Yet at the meeting, they were talking about going out and trying to engage more primary care physicians – particularly family physicians – in the Humana fold, and even hiring family physicians to work for Humana.

"I pointed out the contradiction ... and they had nothing to say about it," Dr. Bachelder asserted.

A net loss of new physicians is another adverse effect of distressed practice environments, Dr. Eidus said. "We have a fair amount of residency programs in the state, but we’re net exporters. We’re exporting more ... despite the fact that we have a shortage in primary care.

"We also recognize that it’s not in the best interest of the citizens of New Jersey, or any other state, to have family medicine or primary care deserts," Dr. Eidus said. "We have that happening in New Jersey."

The AAFP Commission on Quality and Practice will review all feedback and data collected on distressed practice environments. Dr. Stream said the issue will be a major focus at the next leadership forum in May 2012.

ORLANDO – Although some proposals at the American Academy of Family Physicians’ Congress of Delegates ignited relatively little debate, one could almost perceive a collective exhale when some of the more contentious resolutions were finally put to a final vote.

With more that 100,000 members among its ranks for the first time, the academy was careful to deliberate and consider where its official stance should be on such issues as access to over-the-counter contraception for low-income women, the health benefits of same-sex marriage, the development of collaborative agreements with nurse practitioners, and the protection of open communication between physicians and patients when it comes to gun safety.

Here’s at look at how resolutions on some of the more high-profile issues fared:

• OTC contraception. The "Removing Barriers to Over-the-Counter Contraception for Low-Income Women" resolution yielded considerable debate. In its initial form, the resolution called for the AAFP "to urge the U.S. Congress and federal and state agencies to provide Medicaid coverage for all family planning drugs and supplies approved by the [Food and Drug Administration] for over-the-counter sale and to not require a prescription for such coverage."

The Reference Committee on Advocacy, in its recommendations to the full academy, stated that it acknowledged the need for low-income individuals to have access both to OTC and prescription contraception. The committee discussed whether it was advisable to require prescriptions for OTC contraception, weighing the desire to discuss contraception as part of a comprehensive patient encounter vs. the potential barrier a prescription requirement could pose.

Ultimately, the AAFP passed a substitute resolution that addressed many of the issues raised, including the less-controversial call for expanded insurance coverage. The approved resolution stated that the AAFP "supports policies and legislation that would require public and private insurance plans to provide coverage for family planning drugs and supplies that are FDA approved, including those for sale over the counter."

• Same-sex marriage. The discussion over a proposed resolution entitled "Healthy Benefits of Same Gender Marriage – Not Just a Social Issue" was notable for both the polarity and prolonged duration of the testimony. Proponents of the resolution pointed to an American Medical Association resolution, approved earlier this year, that states that exclusion from civil marriage contributes to health care disparities that affect same-sex households. Supporters also noted that evidence on behalf of improved health associated with civil marriage is strong, according to recommendations from the Reference Committee on Advocacy.

Opponents of the resolution said its approval would make the AAFP the only physician organization to fully support marriage equality for same-sex couples. They also stated that the resolution would essentially legislate morality, and that marriage is a state issue and therefore outside the realm of the academy as a whole.

Ultimately, the reference committee recommended a substitute resolution, one that "would convey the AAFP’s commitment to oppose discrimination and support equality but would not need to use the controversial term of ‘marriage’ to arrive at the desired conclusion." Based on that recommendation, the following resolution was adopted: "That the AAFP support full legal equality for same-gender families to contribute to overall health and longevity, [to improve] family stability and to benefit children of Gay, Lesbian, Bisexual, Transgender (GLBT) families."

• Nurse practitioners. The Reference Committee on Practice Enhancement tackled another controversial resolution: that the AAFP, "through an appropriate avenue, study and develop a functional, mutually beneficial practice collaborative agreement template between nurse practitioners and family physicians."

Supporters of this amended, substitute resolution pointed to a lack of standardization on the content, detail, or scope of such agreements across the country, including in states that require such agreements. Opponents said the resolution could be seen as a tacit approval of independent practice by nurse practitioners. An alternate delegate from Arizona, Dr. Andrew Carroll, pointed out that "when you endorse nurse practitioners but don’t have anything for physician assistants ... you risk offending every PA who works with a physician." The resolution did not pass.

• The RUC, guns, and pseudoephedrine. Of the 46 proposed resolutions at the congress, most were either approved or referred. Put on hold, or officially referred to the AAFP Board of Directors for further evaluation, were four resolutions that called for immediate withdrawal of the AAFP from the RUC (Relative Value Scale Update Committee) or creation of alternatives to the RUC, including an independent relative value scale advisory board to the Centers for Medicare and Medicaid Services.

Also deferred was a resolution to send a letter to the National Rifle Association that outlined a shared recognition of the importance of gun safety while also condemning any impingement on physicians’ ability to counsel patients on that issue, in reference to a Florida law passed earlier this year.

Not adopted was a resolution to support federal legislation that would designate pseudoephedrine a controlled substance available only by prescription. Also voted down was a resolution for the AAFP to officially promote the drinking of tap water vs. bottled water. Proponents cited the municipal monitoring of tap water safety and the environmental impact of discarded plastic water bottles. Opponents pointed to an inability to vouch for the safety of all tap water throughout the country.

A resolution was put forth to not renew a collaboration between AAFP and the Coca-Cola Co. – an alliance that was hotly debated at the 2010 congress and still controversial at this year’s meeting. That resolution was not adopted.

Another industry relationship resolution was adopted, however – one that would "encourage organizations that enter into mutually beneficial arrangements with the AAFP to utilize the services of family physicians for their workforce." Initially crafted to state that employees should be directed to patient-centered medical homes, the resolution was seen by some delegates as premature, given the limited number of such homes available.

In the passed-with-very-little debate category, delegates approved a resolution against the expansion of the scope of practice for naturopaths. Similarly, a resolution to emphasize the dire situation regarding graduate medical education passed as follows: "The AAFP recognizes [that] the funding for and distribution of positions for graduate medical education (GME) is in crisis in the United States, and that meaningful and urgent reform is urgently needed."

ORLANDO – Although some proposals at the American Academy of Family Physicians’ Congress of Delegates ignited relatively little debate, one could almost perceive a collective exhale when some of the more contentious resolutions were finally put to a final vote.

With more that 100,000 members among its ranks for the first time, the academy was careful to deliberate and consider where its official stance should be on such issues as access to over-the-counter contraception for low-income women, the health benefits of same-sex marriage, the development of collaborative agreements with nurse practitioners, and the protection of open communication between physicians and patients when it comes to gun safety.

Here’s at look at how resolutions on some of the more high-profile issues fared:

• OTC contraception. The "Removing Barriers to Over-the-Counter Contraception for Low-Income Women" resolution yielded considerable debate. In its initial form, the resolution called for the AAFP "to urge the U.S. Congress and federal and state agencies to provide Medicaid coverage for all family planning drugs and supplies approved by the [Food and Drug Administration] for over-the-counter sale and to not require a prescription for such coverage."

The Reference Committee on Advocacy, in its recommendations to the full academy, stated that it acknowledged the need for low-income individuals to have access both to OTC and prescription contraception. The committee discussed whether it was advisable to require prescriptions for OTC contraception, weighing the desire to discuss contraception as part of a comprehensive patient encounter vs. the potential barrier a prescription requirement could pose.

Ultimately, the AAFP passed a substitute resolution that addressed many of the issues raised, including the less-controversial call for expanded insurance coverage. The approved resolution stated that the AAFP "supports policies and legislation that would require public and private insurance plans to provide coverage for family planning drugs and supplies that are FDA approved, including those for sale over the counter."

• Same-sex marriage. The discussion over a proposed resolution entitled "Healthy Benefits of Same Gender Marriage – Not Just a Social Issue" was notable for both the polarity and prolonged duration of the testimony. Proponents of the resolution pointed to an American Medical Association resolution, approved earlier this year, that states that exclusion from civil marriage contributes to health care disparities that affect same-sex households. Supporters also noted that evidence on behalf of improved health associated with civil marriage is strong, according to recommendations from the Reference Committee on Advocacy.

Opponents of the resolution said its approval would make the AAFP the only physician organization to fully support marriage equality for same-sex couples. They also stated that the resolution would essentially legislate morality, and that marriage is a state issue and therefore outside the realm of the academy as a whole.

Ultimately, the reference committee recommended a substitute resolution, one that "would convey the AAFP’s commitment to oppose discrimination and support equality but would not need to use the controversial term of ‘marriage’ to arrive at the desired conclusion." Based on that recommendation, the following resolution was adopted: "That the AAFP support full legal equality for same-gender families to contribute to overall health and longevity, [to improve] family stability and to benefit children of Gay, Lesbian, Bisexual, Transgender (GLBT) families."

• Nurse practitioners. The Reference Committee on Practice Enhancement tackled another controversial resolution: that the AAFP, "through an appropriate avenue, study and develop a functional, mutually beneficial practice collaborative agreement template between nurse practitioners and family physicians."

Supporters of this amended, substitute resolution pointed to a lack of standardization on the content, detail, or scope of such agreements across the country, including in states that require such agreements. Opponents said the resolution could be seen as a tacit approval of independent practice by nurse practitioners. An alternate delegate from Arizona, Dr. Andrew Carroll, pointed out that "when you endorse nurse practitioners but don’t have anything for physician assistants ... you risk offending every PA who works with a physician." The resolution did not pass.

• The RUC, guns, and pseudoephedrine. Of the 46 proposed resolutions at the congress, most were either approved or referred. Put on hold, or officially referred to the AAFP Board of Directors for further evaluation, were four resolutions that called for immediate withdrawal of the AAFP from the RUC (Relative Value Scale Update Committee) or creation of alternatives to the RUC, including an independent relative value scale advisory board to the Centers for Medicare and Medicaid Services.

Also deferred was a resolution to send a letter to the National Rifle Association that outlined a shared recognition of the importance of gun safety while also condemning any impingement on physicians’ ability to counsel patients on that issue, in reference to a Florida law passed earlier this year.

Not adopted was a resolution to support federal legislation that would designate pseudoephedrine a controlled substance available only by prescription. Also voted down was a resolution for the AAFP to officially promote the drinking of tap water vs. bottled water. Proponents cited the municipal monitoring of tap water safety and the environmental impact of discarded plastic water bottles. Opponents pointed to an inability to vouch for the safety of all tap water throughout the country.

A resolution was put forth to not renew a collaboration between AAFP and the Coca-Cola Co. – an alliance that was hotly debated at the 2010 congress and still controversial at this year’s meeting. That resolution was not adopted.

Another industry relationship resolution was adopted, however – one that would "encourage organizations that enter into mutually beneficial arrangements with the AAFP to utilize the services of family physicians for their workforce." Initially crafted to state that employees should be directed to patient-centered medical homes, the resolution was seen by some delegates as premature, given the limited number of such homes available.

In the passed-with-very-little debate category, delegates approved a resolution against the expansion of the scope of practice for naturopaths. Similarly, a resolution to emphasize the dire situation regarding graduate medical education passed as follows: "The AAFP recognizes [that] the funding for and distribution of positions for graduate medical education (GME) is in crisis in the United States, and that meaningful and urgent reform is urgently needed."

ORLANDO – Although some proposals at the American Academy of Family Physicians’ Congress of Delegates ignited relatively little debate, one could almost perceive a collective exhale when some of the more contentious resolutions were finally put to a final vote.

With more that 100,000 members among its ranks for the first time, the academy was careful to deliberate and consider where its official stance should be on such issues as access to over-the-counter contraception for low-income women, the health benefits of same-sex marriage, the development of collaborative agreements with nurse practitioners, and the protection of open communication between physicians and patients when it comes to gun safety.

Here’s at look at how resolutions on some of the more high-profile issues fared:

• OTC contraception. The "Removing Barriers to Over-the-Counter Contraception for Low-Income Women" resolution yielded considerable debate. In its initial form, the resolution called for the AAFP "to urge the U.S. Congress and federal and state agencies to provide Medicaid coverage for all family planning drugs and supplies approved by the [Food and Drug Administration] for over-the-counter sale and to not require a prescription for such coverage."

The Reference Committee on Advocacy, in its recommendations to the full academy, stated that it acknowledged the need for low-income individuals to have access both to OTC and prescription contraception. The committee discussed whether it was advisable to require prescriptions for OTC contraception, weighing the desire to discuss contraception as part of a comprehensive patient encounter vs. the potential barrier a prescription requirement could pose.

Ultimately, the AAFP passed a substitute resolution that addressed many of the issues raised, including the less-controversial call for expanded insurance coverage. The approved resolution stated that the AAFP "supports policies and legislation that would require public and private insurance plans to provide coverage for family planning drugs and supplies that are FDA approved, including those for sale over the counter."

• Same-sex marriage. The discussion over a proposed resolution entitled "Healthy Benefits of Same Gender Marriage – Not Just a Social Issue" was notable for both the polarity and prolonged duration of the testimony. Proponents of the resolution pointed to an American Medical Association resolution, approved earlier this year, that states that exclusion from civil marriage contributes to health care disparities that affect same-sex households. Supporters also noted that evidence on behalf of improved health associated with civil marriage is strong, according to recommendations from the Reference Committee on Advocacy.

Opponents of the resolution said its approval would make the AAFP the only physician organization to fully support marriage equality for same-sex couples. They also stated that the resolution would essentially legislate morality, and that marriage is a state issue and therefore outside the realm of the academy as a whole.

Ultimately, the reference committee recommended a substitute resolution, one that "would convey the AAFP’s commitment to oppose discrimination and support equality but would not need to use the controversial term of ‘marriage’ to arrive at the desired conclusion." Based on that recommendation, the following resolution was adopted: "That the AAFP support full legal equality for same-gender families to contribute to overall health and longevity, [to improve] family stability and to benefit children of Gay, Lesbian, Bisexual, Transgender (GLBT) families."

• Nurse practitioners. The Reference Committee on Practice Enhancement tackled another controversial resolution: that the AAFP, "through an appropriate avenue, study and develop a functional, mutually beneficial practice collaborative agreement template between nurse practitioners and family physicians."

Supporters of this amended, substitute resolution pointed to a lack of standardization on the content, detail, or scope of such agreements across the country, including in states that require such agreements. Opponents said the resolution could be seen as a tacit approval of independent practice by nurse practitioners. An alternate delegate from Arizona, Dr. Andrew Carroll, pointed out that "when you endorse nurse practitioners but don’t have anything for physician assistants ... you risk offending every PA who works with a physician." The resolution did not pass.

• The RUC, guns, and pseudoephedrine. Of the 46 proposed resolutions at the congress, most were either approved or referred. Put on hold, or officially referred to the AAFP Board of Directors for further evaluation, were four resolutions that called for immediate withdrawal of the AAFP from the RUC (Relative Value Scale Update Committee) or creation of alternatives to the RUC, including an independent relative value scale advisory board to the Centers for Medicare and Medicaid Services.

Also deferred was a resolution to send a letter to the National Rifle Association that outlined a shared recognition of the importance of gun safety while also condemning any impingement on physicians’ ability to counsel patients on that issue, in reference to a Florida law passed earlier this year.

Not adopted was a resolution to support federal legislation that would designate pseudoephedrine a controlled substance available only by prescription. Also voted down was a resolution for the AAFP to officially promote the drinking of tap water vs. bottled water. Proponents cited the municipal monitoring of tap water safety and the environmental impact of discarded plastic water bottles. Opponents pointed to an inability to vouch for the safety of all tap water throughout the country.

A resolution was put forth to not renew a collaboration between AAFP and the Coca-Cola Co. – an alliance that was hotly debated at the 2010 congress and still controversial at this year’s meeting. That resolution was not adopted.

Another industry relationship resolution was adopted, however – one that would "encourage organizations that enter into mutually beneficial arrangements with the AAFP to utilize the services of family physicians for their workforce." Initially crafted to state that employees should be directed to patient-centered medical homes, the resolution was seen by some delegates as premature, given the limited number of such homes available.

In the passed-with-very-little debate category, delegates approved a resolution against the expansion of the scope of practice for naturopaths. Similarly, a resolution to emphasize the dire situation regarding graduate medical education passed as follows: "The AAFP recognizes [that] the funding for and distribution of positions for graduate medical education (GME) is in crisis in the United States, and that meaningful and urgent reform is urgently needed."

ORLANDO – Part update, part rallying cry, the policy leaders of the American Academy of Family Physicians updated delegates this week on how the academy is getting more aggressive and more specific in its demands to increase the role of, and reimbursement for, primary care physicians through the American Medical Association committee that advises on Medicare payments.

There has been no official word yet from the Relative Value Scale Update Committee (RUC) in response to a public letter sent by the AAFP to RUC chair Dr. Barbara Levy in June, said Dr. Lori Heim, outgoing chair of the AAFP board of directors.

Although the AAFP has sent letters in the past, this time they set a specific deadline for a response – Mar. 1, 2012 – and outlined some very specific requests.

The AAFP wants the RUC to add four additional primary care seats (one each for the AAFP, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association); add a seat for geriatrics; add three new seats for "external representatives" that could include patients, employers, health systems, and health plans; and institute voting transparency.

"Payment is front and center for a lot of what we are doing and for a lot of the problems we’re seeing throughout the country in terms of primary care," Dr. Heim said at the annual AAFP Congress of Delegates.

"We know primary care is particularly disadvantaged because of how the RUC is composed. If Medicare is undervaluing us, then that bottom is even lower than what we can sustain," she added.

Although the AAFP also is advocating for increased payment from private insurers, it all goes back to Medicare, said Dr. Heim, who is also a family physician in Vass, N.C.

"Our objective is to increase payment for primary care physicians," she explained. "We know if we cannot afford to keep our doors open, it affects our community."

While awaiting a response from the RUC, the AAFP also is devising its own recommendations on primary care payment to send to the Centers for Medicare and Medicaid Services. To accomplish that, the academy formed the AAFP Primary Care Valuation Task Force. The group includes 22 members from a variety of disciplines, including policy makers, payment experts, patients, employers, and AAFP board members. "Having that variety of voices is incredibly helpful," Dr. Heim said.

AAFP members will be able to follow task force progress. "We are going to be transparent, because that is what we want the RUC to do," Dr. Heim said.

Should They Stay or Go?

Some AAFP delegates, however, weren’t willing to wait for a response from the RUC. Four resolutions to immediately withdraw from the RUC and/or form an alternative, independent relative value scale advisory board to CMS were introduced at the congress.

After RUC wrangling, or "extensive, impassioned testimony on all sides," the AAFP Reference Committee on Practice Enhancement decided it was premature for the academy to leave the RUC. They also stated that the majority of AFFP members support the current strategy to lobby for greater representation. The reference committee recommended referring the four resolutions to the board of directors, and a vote by delegates approved this move.

So, the wait continues for a response from RUC. No matter what happens, "the board will tackle it and make a very deliberate decision whenever we find out what RUC tell us," said Dr. Roland Goertz, who replaces Dr. Heim this month as chair of the board.

Dr. Goertz added that the RUC committee asked him to attend their meeting Sept. 23, 2011, at which he’ll be allotted 5 minutes to explain the AAFP position in person.

Dr. Paul Fischer and colleagues in Georgia took a more aggressive approach when they filed a lawsuit against CMS earlier this year. "The basis of this suit has to do with the RUC," Dr. Fischer said at the congress. Because of a lack of transparency, "the relationship between the RUC and Medicare is clearly illegal."

The RUC also came up in a couple of questions during a candidate forum with the two men vying to become AAFP president-elect. They each replied no when asked if the academy should join in the lawsuit against the RUC. Dr. Jeffrey J. Cain, a family physician from Denver, said the AAFP should not sue the RUC at the same time they are negotiating with them. "Did any of you grow up in a small town? One lesson you learn is you don’t sue the guy fixing your car until you get your keys back."

The other candidate, Dr. George W. Shannon, pointed out that lawsuits can take a long time to resolve and could go past the March 2012 deadline for the RUC response. He prefers the current strategy to approach the RUC and request greater representation.

Each candidate also was asked: If March 2012 arrives and there is still no significant change in the RUC, what will be your recommendation?

"The head of CMS wants a viable alternative on the table. That’s why we have a new task force," Dr. Cain said. "We are using the time right now to develop an alternative method."

"It was a professional, collegial move sending a letter and outlining what our difficulties are, giving RUC two meeting cycles to respond, and saying no matter what they respond, we are going to evaluate," Dr. Shannon said.

Dr. Heim, Dr. Goertz, Dr. Cain, and Dr. Shannon said that they had no relevant financial disclosures.

ORLANDO – Part update, part rallying cry, the policy leaders of the American Academy of Family Physicians updated delegates this week on how the academy is getting more aggressive and more specific in its demands to increase the role of, and reimbursement for, primary care physicians through the American Medical Association committee that advises on Medicare payments.

There has been no official word yet from the Relative Value Scale Update Committee (RUC) in response to a public letter sent by the AAFP to RUC chair Dr. Barbara Levy in June, said Dr. Lori Heim, outgoing chair of the AAFP board of directors.

Although the AAFP has sent letters in the past, this time they set a specific deadline for a response – Mar. 1, 2012 – and outlined some very specific requests.

The AAFP wants the RUC to add four additional primary care seats (one each for the AAFP, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association); add a seat for geriatrics; add three new seats for "external representatives" that could include patients, employers, health systems, and health plans; and institute voting transparency.

"Payment is front and center for a lot of what we are doing and for a lot of the problems we’re seeing throughout the country in terms of primary care," Dr. Heim said at the annual AAFP Congress of Delegates.

"We know primary care is particularly disadvantaged because of how the RUC is composed. If Medicare is undervaluing us, then that bottom is even lower than what we can sustain," she added.

Although the AAFP also is advocating for increased payment from private insurers, it all goes back to Medicare, said Dr. Heim, who is also a family physician in Vass, N.C.

"Our objective is to increase payment for primary care physicians," she explained. "We know if we cannot afford to keep our doors open, it affects our community."

While awaiting a response from the RUC, the AAFP also is devising its own recommendations on primary care payment to send to the Centers for Medicare and Medicaid Services. To accomplish that, the academy formed the AAFP Primary Care Valuation Task Force. The group includes 22 members from a variety of disciplines, including policy makers, payment experts, patients, employers, and AAFP board members. "Having that variety of voices is incredibly helpful," Dr. Heim said.

AAFP members will be able to follow task force progress. "We are going to be transparent, because that is what we want the RUC to do," Dr. Heim said.

Should They Stay or Go?

Some AAFP delegates, however, weren’t willing to wait for a response from the RUC. Four resolutions to immediately withdraw from the RUC and/or form an alternative, independent relative value scale advisory board to CMS were introduced at the congress.

After RUC wrangling, or "extensive, impassioned testimony on all sides," the AAFP Reference Committee on Practice Enhancement decided it was premature for the academy to leave the RUC. They also stated that the majority of AFFP members support the current strategy to lobby for greater representation. The reference committee recommended referring the four resolutions to the board of directors, and a vote by delegates approved this move.

So, the wait continues for a response from RUC. No matter what happens, "the board will tackle it and make a very deliberate decision whenever we find out what RUC tell us," said Dr. Roland Goertz, who replaces Dr. Heim this month as chair of the board.

Dr. Goertz added that the RUC committee asked him to attend their meeting Sept. 23, 2011, at which he’ll be allotted 5 minutes to explain the AAFP position in person.

Dr. Paul Fischer and colleagues in Georgia took a more aggressive approach when they filed a lawsuit against CMS earlier this year. "The basis of this suit has to do with the RUC," Dr. Fischer said at the congress. Because of a lack of transparency, "the relationship between the RUC and Medicare is clearly illegal."

The RUC also came up in a couple of questions during a candidate forum with the two men vying to become AAFP president-elect. They each replied no when asked if the academy should join in the lawsuit against the RUC. Dr. Jeffrey J. Cain, a family physician from Denver, said the AAFP should not sue the RUC at the same time they are negotiating with them. "Did any of you grow up in a small town? One lesson you learn is you don’t sue the guy fixing your car until you get your keys back."

The other candidate, Dr. George W. Shannon, pointed out that lawsuits can take a long time to resolve and could go past the March 2012 deadline for the RUC response. He prefers the current strategy to approach the RUC and request greater representation.

Each candidate also was asked: If March 2012 arrives and there is still no significant change in the RUC, what will be your recommendation?

"The head of CMS wants a viable alternative on the table. That’s why we have a new task force," Dr. Cain said. "We are using the time right now to develop an alternative method."

"It was a professional, collegial move sending a letter and outlining what our difficulties are, giving RUC two meeting cycles to respond, and saying no matter what they respond, we are going to evaluate," Dr. Shannon said.

Dr. Heim, Dr. Goertz, Dr. Cain, and Dr. Shannon said that they had no relevant financial disclosures.

ORLANDO – Part update, part rallying cry, the policy leaders of the American Academy of Family Physicians updated delegates this week on how the academy is getting more aggressive and more specific in its demands to increase the role of, and reimbursement for, primary care physicians through the American Medical Association committee that advises on Medicare payments.

There has been no official word yet from the Relative Value Scale Update Committee (RUC) in response to a public letter sent by the AAFP to RUC chair Dr. Barbara Levy in June, said Dr. Lori Heim, outgoing chair of the AAFP board of directors.

Although the AAFP has sent letters in the past, this time they set a specific deadline for a response – Mar. 1, 2012 – and outlined some very specific requests.

The AAFP wants the RUC to add four additional primary care seats (one each for the AAFP, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association); add a seat for geriatrics; add three new seats for "external representatives" that could include patients, employers, health systems, and health plans; and institute voting transparency.

"Payment is front and center for a lot of what we are doing and for a lot of the problems we’re seeing throughout the country in terms of primary care," Dr. Heim said at the annual AAFP Congress of Delegates.

"We know primary care is particularly disadvantaged because of how the RUC is composed. If Medicare is undervaluing us, then that bottom is even lower than what we can sustain," she added.

Although the AAFP also is advocating for increased payment from private insurers, it all goes back to Medicare, said Dr. Heim, who is also a family physician in Vass, N.C.

"Our objective is to increase payment for primary care physicians," she explained. "We know if we cannot afford to keep our doors open, it affects our community."

While awaiting a response from the RUC, the AAFP also is devising its own recommendations on primary care payment to send to the Centers for Medicare and Medicaid Services. To accomplish that, the academy formed the AAFP Primary Care Valuation Task Force. The group includes 22 members from a variety of disciplines, including policy makers, payment experts, patients, employers, and AAFP board members. "Having that variety of voices is incredibly helpful," Dr. Heim said.

AAFP members will be able to follow task force progress. "We are going to be transparent, because that is what we want the RUC to do," Dr. Heim said.

Should They Stay or Go?

Some AAFP delegates, however, weren’t willing to wait for a response from the RUC. Four resolutions to immediately withdraw from the RUC and/or form an alternative, independent relative value scale advisory board to CMS were introduced at the congress.

After RUC wrangling, or "extensive, impassioned testimony on all sides," the AAFP Reference Committee on Practice Enhancement decided it was premature for the academy to leave the RUC. They also stated that the majority of AFFP members support the current strategy to lobby for greater representation. The reference committee recommended referring the four resolutions to the board of directors, and a vote by delegates approved this move.

So, the wait continues for a response from RUC. No matter what happens, "the board will tackle it and make a very deliberate decision whenever we find out what RUC tell us," said Dr. Roland Goertz, who replaces Dr. Heim this month as chair of the board.

Dr. Goertz added that the RUC committee asked him to attend their meeting Sept. 23, 2011, at which he’ll be allotted 5 minutes to explain the AAFP position in person.

Dr. Paul Fischer and colleagues in Georgia took a more aggressive approach when they filed a lawsuit against CMS earlier this year. "The basis of this suit has to do with the RUC," Dr. Fischer said at the congress. Because of a lack of transparency, "the relationship between the RUC and Medicare is clearly illegal."

The RUC also came up in a couple of questions during a candidate forum with the two men vying to become AAFP president-elect. They each replied no when asked if the academy should join in the lawsuit against the RUC. Dr. Jeffrey J. Cain, a family physician from Denver, said the AAFP should not sue the RUC at the same time they are negotiating with them. "Did any of you grow up in a small town? One lesson you learn is you don’t sue the guy fixing your car until you get your keys back."

The other candidate, Dr. George W. Shannon, pointed out that lawsuits can take a long time to resolve and could go past the March 2012 deadline for the RUC response. He prefers the current strategy to approach the RUC and request greater representation.

Each candidate also was asked: If March 2012 arrives and there is still no significant change in the RUC, what will be your recommendation?

"The head of CMS wants a viable alternative on the table. That’s why we have a new task force," Dr. Cain said. "We are using the time right now to develop an alternative method."

"It was a professional, collegial move sending a letter and outlining what our difficulties are, giving RUC two meeting cycles to respond, and saying no matter what they respond, we are going to evaluate," Dr. Shannon said.

Dr. Heim, Dr. Goertz, Dr. Cain, and Dr. Shannon said that they had no relevant financial disclosures.

ORLANDO – If nothing changes between now and Jan. 1, Medicare payments will be cut by nearly 30%, causing a "catastrophic effect" on family physicians’ ability to run their practices, said Dr. Glen Stream, incoming president of the American Academy of Family Physicians.

While it’s nowhere near certain, the 12 members of the Joint Select Committee on Deficit Reduction – better known as the super committee – could be family medicine’s best shot at getting a quick and permanent fix to Medicare’s sustainable growth rate (SGR) formula.

"What has really turned things a bit different this time is the ‘Super 12’ deficit reduction process that’s in place," said Dr. Roland Goertz, outgoing AAFP president.

This is a unique opportunity because the super committee will have "huge protections" from the usual political wrangling in Washington, Dr. Goertz said during a Town Hall session at the AAFP Congress of Delegates.

For example, any proposed legislation has to remain amendment-free and cannot be filibustered in the Senate. In addition, their proposals are only subject to a simple up or down majority vote.

The challenge, though, is for the AAFP and its membership to get the super committee’s attention, said Dr. Stream.

The AAFP is calling on Congress to repeal the SGR and to provide at least a 3% increase in payments for primary care, said Dr. Stream, a family physician in Spokane, Wash. "Even repealing the SGR is a ‘Band-Aid’ fix on a flawed pay-for-service system. AAFP is looking at models that more properly pay for our services."

The six Democrat and six Republican lawmakers appointed to the super committee are charged with finding $1.5 trillion to cut from the U.S. federal budget by Thanksgiving. Their focus – the entire federal budget, not just health care – is part of the challenge for the AAFP.

"If you think about how many people are trying to contact those 12, it’s got to be immense," said Dr. Goertz, who is also a family physician in Waco, Texas.

"The [AAFP] Board approved what I think is an innovative way to try to reach some of the super 12 and others." The academy will produce videos featuring real family physicians who describe the real impact of these cuts for their practices, Dr. Goertz said. With a nod to the sometimes viral nature of electronic communication, he told town hall participants, "We’re going to ask that all of you send them to everybody you could potentially send them to."

In addition to these videos, the AAFP sent letters to each member of the super committee. Also, in each state these 12 lawmakers call home, the AAFP local chapter requested a meeting. "We have got to mobilize. Our advisors say the most effective thing is getting our member voices heard by the super committee as much as possible," Dr. Goertz said.

This doesn’t mean the AAFP does not have a back-up plan.

"At the same time we are working as hard as we can with the super 12, we are also anticipating that if they do not tackle this ... and the issue of SGR reverts to the routine committees of record in the House and Senate, that we are ready to influence them as best we can," Dr. Goertz said.

The AAFP wants and prefers a permanent fix to SGR, Dr. Goertz said. "If a permanent fix is not possible, we want long-term fix of 5 years and a 3% positive update for primary care services and primary care each year of that 5-year fix."

ORLANDO – If nothing changes between now and Jan. 1, Medicare payments will be cut by nearly 30%, causing a "catastrophic effect" on family physicians’ ability to run their practices, said Dr. Glen Stream, incoming president of the American Academy of Family Physicians.

While it’s nowhere near certain, the 12 members of the Joint Select Committee on Deficit Reduction – better known as the super committee – could be family medicine’s best shot at getting a quick and permanent fix to Medicare’s sustainable growth rate (SGR) formula.

"What has really turned things a bit different this time is the ‘Super 12’ deficit reduction process that’s in place," said Dr. Roland Goertz, outgoing AAFP president.

This is a unique opportunity because the super committee will have "huge protections" from the usual political wrangling in Washington, Dr. Goertz said during a Town Hall session at the AAFP Congress of Delegates.

For example, any proposed legislation has to remain amendment-free and cannot be filibustered in the Senate. In addition, their proposals are only subject to a simple up or down majority vote.

The challenge, though, is for the AAFP and its membership to get the super committee’s attention, said Dr. Stream.

The AAFP is calling on Congress to repeal the SGR and to provide at least a 3% increase in payments for primary care, said Dr. Stream, a family physician in Spokane, Wash. "Even repealing the SGR is a ‘Band-Aid’ fix on a flawed pay-for-service system. AAFP is looking at models that more properly pay for our services."

The six Democrat and six Republican lawmakers appointed to the super committee are charged with finding $1.5 trillion to cut from the U.S. federal budget by Thanksgiving. Their focus – the entire federal budget, not just health care – is part of the challenge for the AAFP.

"If you think about how many people are trying to contact those 12, it’s got to be immense," said Dr. Goertz, who is also a family physician in Waco, Texas.

"The [AAFP] Board approved what I think is an innovative way to try to reach some of the super 12 and others." The academy will produce videos featuring real family physicians who describe the real impact of these cuts for their practices, Dr. Goertz said. With a nod to the sometimes viral nature of electronic communication, he told town hall participants, "We’re going to ask that all of you send them to everybody you could potentially send them to."

In addition to these videos, the AAFP sent letters to each member of the super committee. Also, in each state these 12 lawmakers call home, the AAFP local chapter requested a meeting. "We have got to mobilize. Our advisors say the most effective thing is getting our member voices heard by the super committee as much as possible," Dr. Goertz said.

This doesn’t mean the AAFP does not have a back-up plan.

"At the same time we are working as hard as we can with the super 12, we are also anticipating that if they do not tackle this ... and the issue of SGR reverts to the routine committees of record in the House and Senate, that we are ready to influence them as best we can," Dr. Goertz said.

The AAFP wants and prefers a permanent fix to SGR, Dr. Goertz said. "If a permanent fix is not possible, we want long-term fix of 5 years and a 3% positive update for primary care services and primary care each year of that 5-year fix."

ORLANDO – If nothing changes between now and Jan. 1, Medicare payments will be cut by nearly 30%, causing a "catastrophic effect" on family physicians’ ability to run their practices, said Dr. Glen Stream, incoming president of the American Academy of Family Physicians.

While it’s nowhere near certain, the 12 members of the Joint Select Committee on Deficit Reduction – better known as the super committee – could be family medicine’s best shot at getting a quick and permanent fix to Medicare’s sustainable growth rate (SGR) formula.

"What has really turned things a bit different this time is the ‘Super 12’ deficit reduction process that’s in place," said Dr. Roland Goertz, outgoing AAFP president.

This is a unique opportunity because the super committee will have "huge protections" from the usual political wrangling in Washington, Dr. Goertz said during a Town Hall session at the AAFP Congress of Delegates.

For example, any proposed legislation has to remain amendment-free and cannot be filibustered in the Senate. In addition, their proposals are only subject to a simple up or down majority vote.

The challenge, though, is for the AAFP and its membership to get the super committee’s attention, said Dr. Stream.

The AAFP is calling on Congress to repeal the SGR and to provide at least a 3% increase in payments for primary care, said Dr. Stream, a family physician in Spokane, Wash. "Even repealing the SGR is a ‘Band-Aid’ fix on a flawed pay-for-service system. AAFP is looking at models that more properly pay for our services."

The six Democrat and six Republican lawmakers appointed to the super committee are charged with finding $1.5 trillion to cut from the U.S. federal budget by Thanksgiving. Their focus – the entire federal budget, not just health care – is part of the challenge for the AAFP.

"If you think about how many people are trying to contact those 12, it’s got to be immense," said Dr. Goertz, who is also a family physician in Waco, Texas.

"The [AAFP] Board approved what I think is an innovative way to try to reach some of the super 12 and others." The academy will produce videos featuring real family physicians who describe the real impact of these cuts for their practices, Dr. Goertz said. With a nod to the sometimes viral nature of electronic communication, he told town hall participants, "We’re going to ask that all of you send them to everybody you could potentially send them to."

In addition to these videos, the AAFP sent letters to each member of the super committee. Also, in each state these 12 lawmakers call home, the AAFP local chapter requested a meeting. "We have got to mobilize. Our advisors say the most effective thing is getting our member voices heard by the super committee as much as possible," Dr. Goertz said.

This doesn’t mean the AAFP does not have a back-up plan.

"At the same time we are working as hard as we can with the super 12, we are also anticipating that if they do not tackle this ... and the issue of SGR reverts to the routine committees of record in the House and Senate, that we are ready to influence them as best we can," Dr. Goertz said.

The AAFP wants and prefers a permanent fix to SGR, Dr. Goertz said. "If a permanent fix is not possible, we want long-term fix of 5 years and a 3% positive update for primary care services and primary care each year of that 5-year fix."