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Internists support broad goals of House 'tri-committee' proposed health-reform legislation

American College of Physicians expresses support for specific coverage and workforce proposals in 'statement for the record' at today's hearing by House Energy & Commerce Subcommittee on health

Washington, June 25, 2009 – Agreeing with the broad goals and most of the underlying policies contained in a comprehensive draft bill on health care reform legislation, the American College of Physicians (ACP) today praised the House "tri-committee." Made up of the House Ways and Means, Energy and Commerce, and Education and Labor Committees, the "tri-committee" unveiled its proposed legislation on June 19.

"We are pleased that the bill takes a comprehensive approach to reforming health care," said Joseph W. Stubbs, MD, FACP, president of ACP. He added that ACP believes it is critical to have legislation "providing all Americans with access to affordable coverage without regard to their health status and pre-existing conditions, giving them access to a wide variety of health plans similar to those available to federal employees, enacting policies to begin to address a critical shortage of internists and other primary care physicians, realigning payment and delivery systems with the value of care rendered and with patient-centered primary care, promoting prevention and wellness, and simplifying—and thereby reducing the enormous cost of—health plan administration."

ACP offered specific comments on reform for coverage, workforce and payment and delivery.

Coverage

ACP supports the overall approach to providing affordable coverage to all Americans including:

• Expanding Medicaid to cover everyone at or modestly above the Federal Poverty Level.
• Providing individuals and small businesses a choice of health plans offered through an exchange.
• Providing sliding scale subsidies for individuals to purchase coverage through such an exchange.
• Requiring that all health plans, both within and outside the exchange, abide by rules relating to acceptance of all individuals without regard to pre-existing conditions or health status, guaranteed renewability, modified community rating, and essential benefits, including preventive and primary care services, as recommended by an expert commission.
• Elimination of cost-sharing requirements for preventive services.
• Shared financing including requirements that employers contribute to coverage or face a penalty and that individuals obtain coverage once it is available and affordable, with appropriate hardship exemptions.

ACP told the Energy and Commerce subcommittee that it also believes that a public plan could appropriately be among the options made available to individuals and employers, but that it is concerned that building such a plan on Medicare rates, even though limited to the first three years from inception, would have a negative impact on physician participation and could particularly have an adverse impact on primary care physicians, since Medicare pays primary care physicians far less than other payers in many markets.

ACP told the subcommittee that it will provide recommendations to help ensure that payment rates under a public plan are sufficient to support primary care and to ensure adequate participation by physicians by specialty and by their locations of practice.

ACP said it supports making physician participation in the public plan voluntary (not linked to an agreement to participate in Medicare). It also supports giving the public plan wide latitude to implement innovative payment models, and it especially appreciates identification of the Patient-Centered Medical Home (PCMH) as being among such innovative models.

ACP supports requiring that the public plan provide essential core benefits including prevention. And it supports funding the public plan out of premiums, instead of taxpayer dollars, and administering it outside of the exchange to reduce potential conflicts of interest.

Workforce

ACP strongly supports and appreciates the recognition of the need for the U.S. to have a national workforce policy to support primary care physicians and other health professions facing critical shortages. Specifically, ACP supports:

• Creating a national advisory council to recommend workforce goals.
• Funding at increased levels for National Health Services Corps and Title VII primary care health professions programs.
• Providing scholarships and loan repayment to primary care physicians in areas of the country with an insufficient supply and high need for primary care.
• Providing grants for primary care training and enhancement.
• Eliminating barriers to training in non-hospital based primary care practices.
• Distributing Graduate Medical Education training positions to primary care programs.
• Providing grants to address health care disparities and to interdisciplinary models of team-based care.

ACP believes that the workforce policies need to be combined with Medicare restructuring of payment policies to recognize and support the value of patient-centered primary care.

Payment and Delivery System Reform

ACP is pleased that the draft bill takes major steps forward to realign payment and delivery systems with the value of care provided, and especially the strong emphasis on the Patient-Centered Medical Home. Specifically, ACP:

• Appreciates the proposal to eliminate the accumulated costs associated with Medicare's flawed Sustainable Growth Rate (SGR) formula and to take physician-administered drugs and clinical diagnostic laboratory tests out of the formula. Elimination of the accumulated SGR "overhang" is imperative if comprehensive payment reform is to be successful.
• Believes that any spending targets to replace the SGR should provide fair, predictable, and stable updates for all physicians and a higher baseline and update for primary care and preventive services. Targets should result in updates that are sustainable moving forward. ACP appreciates the proposal to provide primary care and preventive services with a higher baseline than other services, and recognition of the need to set spending targets for all services at rates greater than the Gross Domestic Product (GDP) growth rate. However, ACP is concerned that the continued reliance on GDP—especially given the current economic downturn—even with an additional growth factor, could result in substantial future payment cuts to physicians, including in services provided by primary care physicians that are not included in the primary care/prevention category. ACP is analyzing the SGR proposals and will provide further input in more detailed comments to committee staff.
• Supports the proposals to fund national pilots of community-based and practice-based PCMHs. Again, ACP will provide committee staff with more specific suggestions on how to ensure that such pilots have the greatest beneficial impact on physicians and patients.
• Supports and appreciates the proposal to provide Medicare bonus payments for designated services by primary care physicians. ACP will explain more fully in its detailed comments to committee staff. It believes that the bonus should be increased from the proposed 5 percent adjustment for designated services to at least 10 percent in total Medicare payments to primary care physicians (with a comparable increase in the bonus for primary care in health professional shortage areas). Because many of the other payment changes to support primary care will take years before they are implemented on a scale that will affect workforce decisions, ACP believes that a higher bonus payment structure would send the most immediate signal to medical students and established physicians in practice of Congress' commitment to reducing inequities in payment for primary care. ACP will explain more fully in its detailed comments to the committee that it also believes—based on a very preliminary analysis—that the proposed criteria for physicians to be eligible for the primary care bonus payments may need to be revised because it could unintentionally exclude many primary care general internists and family physicians.
• Supports raising Medicaid payments to primary care physicians to be equal to Medicare.

"ACP looks forward to continuing to provide suggestions on making sure that these policies are as effective as possible," Dr. Stubbs said. "A better health care system must result in everyone having health insurance coverage, and everyone having access to a primary care doctor. Anything less than that will fail to provide Americans with access to affordable, comprehensive and personal care they need and deserve."

The American College of Physicians is the largest medical specialty organization and the second-largest physician group in the United States. ACP members include 128,000 internal medicine physicians (internists), related subspecialists, and medical students. Internists specialize in the prevention, detection and treatment of illness in adults.

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