Family Medicine Advocacy Summit 2017

Welcome & Opening Remarks
John Meigs, Jr. MD
AAFP President

AAFP Officers
• John Meigs, Jr., MD – President
• Michael Munger, MD – President-elect
• Wanda Filer, MD, MBA – Board Chair
• Javette Orgain, MD, MPH – Speaker
• Alan Schwartzstein, MD – Vice Speaker
• Douglas E. Henley, MD – EVP/CEO

Council of Academic Family Medicine
• Mary Hall, MD – CAFM Chair
• Karen Mitchell, MD – AFMRD President
• James Jarvis, MD – AFMRD Past President
• Winston Liaw, MD, MPH – NAPCRG Research
Advocacy Chair
• Beat Steiner, MD – STFM President-elect
• Joseph Gravel, MD – AFMAC Chair

Health Care Coverage
• Maintain & Expand Coverage
• Protect the Safety-Net Programs
• Stabilize the Individual Insurance Market
• Protect Patient-Centered Insurance Reforms
• Reduce Costs
• Increase Investment in Primary & Preventive Care

Teaching Health Center GME
• THCGME funds family medicine residencies
in community-based settings
• Graduates of THCs continue in primary care
and practice in underserved communities
• Unless Congress acts, the THCGME
program expires on September 30, 2017

Congressional Primary Care Caucus
• Ask: If you are not a member of the Primary
Care Caucus, please join it.
• Republicans contact Perry Chappell (Rep.
Rouzer) or Democrats contact Maria
Costigan (Rep. Courtney) to join.
OR –
• If you are a member, thank you.

Introduction of Special Guests
Flora Sadri-Azarbayejani, DO
Chair, AAFP Commission on
Governmental Advocacy

Commission on Governmental Advocacy
• Flora Sadri-Azarbayejani, DO, Chair
• Julie Anderson, MD
• Domenic Casablanca, MD
• Jonathan Cook, DO
• Cheryl Dobson
• Troy Fiesinger, MD
• Andrea Gavin, MD
• Douglas Gruenbacher, MD
• Kyle Jones, MD
• Gordana Krkic, CAE
• Jesus Lizarzaburu, MD
• Tara Mertz-Hack, MD
• Dennis Salisbury, MD
• Karen Smith, MD
• Tina Tanner, MD
• Kevin Wong, MD

2017 AAFP Scholarship Winners
• Anna Balabanova, MD - Illinois
• Alexandra Gits, MD - Ohio
• Elana Curry, BS - Minnesota
• Sean McClellan, BA - Illinois

STFM New Faculty Advocacy Scholarship
• Sarah Coles, MD - Phoenix, AZ
• Kathryn Freeman, MD - St. Paul, MN
• Manasa Irwin, MD - Pittsburgh, PA
• John Nguyen, MD - Renton, WA
• Sarah Stumbar, MD, MPH - Miami, FL

AFMRD Resident Scholarships
• Kristin Bendert, MD, MPH – Portland, OR
• Kathryn Calhoun, MD – Garland, TX
• Joanna Campodonico, MD, MPH – Phoenix, AZ
• Cherry Cockrell, MD – Saint Louis MO
• Mylanie Facelo, DO – Abingdon, VA
• Kirsten Gierach, DO – Appleton, WI
• Kenetra Hix, MD, MPH – Durham, NC
• Benjamin Stacy, DO – Iowa City, IA
• James Suchy, MD – Orange, CA
• Ariela Zamcheck, DO – Sleepy Hollow NY

Health Care Reform 2.0
Grace-Marie Turner
President, Galen Institute
Frederick Isasi, JD, MPH
Executive Director, Families USA

Repeal and Replace:
What’s next?
Grace-Marie Turner, Galen Institute
American Academy of Family Physicians
May 22, 2017

Medicaid: Primary Source of Coverage Gains
Medicaid/CH
IP, 83.1%
Private
Coverage,
16.9%

Effect of Individual Mandate 2015
6.5
12.7
4.3
23.5
2.3
0
5
10
15
20
25
Paid Penalty Hardship
Exemption
Did Not
Report
Total
Subject to
Penalty
Net Increase
Private
Coverage

A rescue effort:
Unhealthy risk pools
Millions could lose
coverage without
congressional action

Higher costs, fewer insurers
• Indiv. premiums increased 99% and
family premiums increased 140%
since 2013, according to eHealth
• Insurers have requested rate hikes
in Connecticut (34%) and Maryland
(59%)
• If Medica leaves, 94 out of Iowa's 99
counties would have no insurer

US Counties with only one insurer

Republican three-pronged plan
• Pass Repeal and Replace legislation
• Regulatory action
First HHS rule to stabilize the market finalized in April
• Shortens the 2018 annual open enrollment period
• Expands verification of eligibility for subsidies
• Allows insurers to collect back premiums before re-enrollment
• Regular order bills that could get 60 Senate votes. First up:
• Competitive Health Insurance Reform Act (H.R. 372) to eliminate anti-trust
protections for insurers
• Small Business Health Fairness Act (H.R. 1101) allowing small businesses to
pool together to try to lower health insurance costs.
(Hope to get some Democrats to vote yes)

Repeal and
Replace
Legislation

Core provisions of the AHCA
• Repeals most ACA taxes (delays the CadillacTax)
• Eliminates tax penalties for the individual and
employer mandates
• Protects people currently on coverage
• Preserves Medicaid expansion, but eventually at
the normal federal match
• Grandfathers current subsidies and provides
new tax credits to help people purchase
coverage

Replace bill also …
• Allows states some regulatory flexibility, including on age rating
and benefits
• Provides $138 billion to states to stabilize their individual and
small group insurance markets, added help to the most needy,
and extra money to protect those with pre-existing conditions
• HSA expansion
• Refundable tax credits to individuals to purchase coverage
• “Continuous coverage” requirement instead of “individual
mandate”

What about pre-existing conditions?
Federal protections stay in place
Under the American Health Care Act, no one will be denied
coverage because of a pre-existing condition
States can waive pre-ex only if they have a safety net in
place, such as a functional high risk pool
At least $138 billion in added subsidies to provide protection
through premium subsidies, risk pools, etc.

Individual responsibility
No one who keeps their insurance continuously will be
charged more because they are sick or get sick.
If people wait to purchase coverage when they need it,
they can be charged more
If people don't buy coverage or drop their plans, they face
a 30% surcharge for one year when they reenroll

And 24 million losing coverage?
CBO ascribes magical powers to the individual mandate…
• 2017: Number of uninsured increases by 4 million
• 2 million Medicaid beneficiaries who pay nothing for their coverage drop it
• 1 million people drop their coverage in the exchanges
• 1 million with job-based coverage drop out
• 2018: 14 million more uninsured.
• 5 million will abandon Medicaid
• 2 million will drop their employer-sponsored coverage
• 6 million will leave the exchanges
• CBO says they don’t lose coverage because of the new bill but because they
are no longer forced to buy insurance since the individual mandate penalty
is repealed

States have new opportunities
HHS is anxious to
approve waivers giving
states more flexibility
with insurance and
Medicaid
HHS is encouraging
states to use a provision
of existing law, “State
Innovation Waivers,” to
reform their health
insurance markets
33

Potential State Opportunity to Reform Care:
ACA Section 1332 Waivers
Gives states flexibility to restructure programs if they achieve
similar coverage, access and costs
• ACA statute requires that waivers provide coverage at least as
comprehensive and affordable without increasing the federal deficit
Expect HHS/CMS to be more generous and flexible with states
Few states have submitted proposals so far
• Alaska reinsurance program
• Hawaii alternative to SHOP exchange

HHS and
White
House
executive
actions

PresidentTrump’s Executive Order
“…exercise all authority and discretion available to them to
waive, defer, grant exemptions from, or delay the
implementation of any provision or requirement of the Act that
would impose a fiscal burden on any State or a cost, fee, tax,
penalty, or regulatory burden on individuals, families, healthcare
providers, health insurers, patients, recipients of healthcare
services, purchasers of health insurance, or makers of medical
devices, products, or medications.”

How HHS Can UseThat Authority
• The phrases “the Secretary shall” and “the Secretary may”
occur 1,400 times in the text of the ACA
• The Obama administration made liberal use of this authority.
• The Galen Institute has identified 43 provisions of law that the Obama
administration either waived, delayed or ignored
• These administrative actions affected everything from individual and
corporate mandates, to cost-sharing provisions, to premium
stabilization and to waivers for non-compliant plans
• TheTrump administration may prove as aggressive in using its
authorities to alter the ACA as its predecessor was in creating it

Grace-MarieTurner
Galen Institute
703-299-8900
gracemarie@galen.org
twitter.com/GalenInstitute
facebook.com/GalenInstitute
@gracemarietweet
Subscribe to our free email alerts at
www.ObamaCareWatch.org

Frederick Isasi, JD MPH
Executive Director
AAFP Family Medicine Advocacy Summit
Health Reform 2.0

FamiliesUSA.org
Families USA, a leading national
voice for health care consumers, is
dedicated to the achievement of high-
quality, affordable health care and
improved health for all. We advance
our mission through public policy
analysis, advocacy, and collaboration
with partners to promote a patient-and
community centered health system.
Working at the national, state and
community level for over 35 years.
Families USA’s Mission and Focus Areas

FamiliesUSA.org
Roadmap of the Discussion
 ACA Fact vs. Fiction
 AHCA Fact vs. Fiction
 What’s Next in Congress

FamiliesUSA.org
The Affordable Care Act (ACA) Led to Historic Gains in Coverage
From 2010 to 2016
20 million people gained coverage

FamiliesUSA.org
Adults Gain Coverage: Historic Drop in Uninsured

FamiliesUSA.org
Kids Gain Coverage: Historic Drop In Uninsured

FamiliesUSA.org
Gains by Demographic Group
v
Sources: Urban Institute Analysis of American Community Survey data (IPUMS-USA,
University of Minnesota, www.ipums.org) for 2010 and 2015.

FamiliesUSA.org
Gaining public and private coverage, 2013-2015
http://www.cbpp.org/research/health/affordable-care-act-has-produced-
historic-gains-in-health-coverage

FamiliesUSA.org
A 50-state look at Medicaid Expansion, 2017

FamiliesUSA.org
The Affordable Care Act: Popularity
Myth:
“…Americans continue to call for Obamacare’s repeal…They spoke loudly
again this November, and about 8 out of 10 favor changing Obamacare
significantly or replacing it altogether." (McConnell, op-ed for Fox News,
January 9, 2017)
Truth:
• Across polls conducted by many different research firms, on average, about 50%
of Americans view the ACA favorably vs. 42% unfavorably.1
• This is particularly true since the push to repeal the ACA began in January.
• Marketplace consumers rate their coverage highly: 68% rated it “excellent” or
“good” in OE3.2
1Real Clear Politics, average of all health law polling data, 2/7-4/25/2017
2Kaiser Family Foundation, Survey of Non-Group Health Insurance Enrollees, May 2016

FamiliesUSA.org
The Affordable Care Act: Plan Choice
Myth:
“[Democrats] gave us a system where choices went away.”
– Speaker Ryan, Feb 28, 2017
Truth:
• 79% of marketplace consumers have a choice of marketplace issuers;
• 34 states had two or more issuers in 2017
• Within issuers, consumers have many choices of plans (PPOs, HMOs,
different levels of coverage, etc.) On average, consumers had a choice
of 30 plans in 2017;
• Marketplace consumers have more choices than most employees
Sources: Kaiser Family Foundation, “2017 Premium Changes and Insurer Participation in the ACA’s Health Insurance Marketplaces,”
October 2016 and ASPE, “Health Plan Choice and Premiums in the 2017 Health Insurance Marketplace,” October 2016.

FamiliesUSA.org
vv79% of exchange enrollees had a choice of three or more
insurers in 2017, down from 96% in 2016.

FamiliesUSA.org
The Affordable Care Act: Marketplace Stability
Myth:
“[Obamacare is on a] respirator and it’s just about ready to
implode” – President Trump, March 17, 2017
Truth:
• CBO: market will remain stable in most areas under current law.1
• Uncertainty caused by the administration and Congress threaten
stability:
• Blue Cross Blue Shield announced it will participate in Knoxville, TN
marketplace, noting its improved 2017 performance. However, they stated
“Given the potential negative effects of federal legislative and/or regulatory
changes, we believe it will be necessary to price-in those downside risks.”2
1CBO, AHCA Cost Estimate, March 13, 2017
2J.D. Hickey, CEO of BlueCross of Tennessee, letter to Tennessee Commissioner Julie Mix McPeak, May 9, 2017

FamiliesUSA.org
Market is on a 5 Year Path to Stability
http://allh.us/PxUf
Truth:
S&P Global Ratings: market is on a 5 year path to stability,
most insurers will break even or profit in 2018 if business
continues as usual

FamiliesUSA.org
 ACA Fact vs. Fiction
 AHCA Fact vs. Fiction

FamiliesUSA.org
American Health Care Act (AHCA) Impact
At least 24 M lose coverage for a tax cut to the rich and
corporations…
Health Tax cuts
Medicaid: - $839 B Mostly to wealthy and corporations: $604 B*
Premium and cost sharing subsidy: - $663 B
Replacement premium credits: $357 B
Patient and stability fund: $138 B
Net cut from health: $650 B Benefit to wealthy/corps: $604 B
*Excludes premium credits and medical deduction threshold
Source: Calculations from March 23 CBO score, table 2 and 3, with addition of patient and stability fund as amended

FamiliesUSA.org
http://www.taxpolicycenter.org/taxvox/dont-forget-those-tax-cuts-house-health-bill
Wealthy Benefit from Tax Cuts

FamiliesUSA.org
Under AHCA: Plans Cost More and Cover Less
AHCA cuts premium assistance, increases prices for those who
are older or have preexisting conditions, eliminates cost sharing
reductions
• A 64 year old earning $27,000 faces a $13,000 premium
increase
• 7 million people lose help that lowers deductibles and
out-of-pocket costs

FamiliesUSA.org
Cost Sharing Help at Risk
Source: http://www.cbpp.org/blog/interactive-map-cost-sharing-subsidies-at-risk-under-
house-gop-health-bill
Most Marketplace Enrollees Receive Significant Help

FamiliesUSA.org
What a single individual with income of $26,500
(175% of poverty) will pay
Age Current law AHCA
Net premium AV Net Premium AV
21 years $1700 87 $1450 65
40 years $1700 87 $2400 65
60 years $1700 87 $14,600 65
What people pay under current law and under AHCA, single
individual with income of $26,500 (175% poverty) (examples
without essential health benefit waivers)
Example: Current Law vs. AHCA
Source: Congressional Budget Office, AHCA cost estimate, March 23, 2017, Table 4

FamiliesUSA.org
vLower-Income Families See Healthcare Costs Soar in House Repeal Bill*
*Families USA analysis based on 2017 national average premium for the second-least expensive silver plan adjusted to
reflect expected premium change using 5:1 age rating bands, and changes in premium tax credits. Deductible estimates
based on average 2016 deductibles for silver plans with and without cost-sharing reductions. Source: Health Insurance
Marketplace Calculator, (Washington, DC: Kaiser Family Foundation, November, 2016); Impact of Changing ACA Age Rating
Structure (Milliman, January 2017); Cost-Sharing Subsidies in Federal Marketplace Plans, 2016, (Washington, DC: Kaiser
Family Foundation, November 2015).

FamiliesUSA.org
v*Families USA analysis based on 2017 national average premium for the second-least expensive silver plan, adjusted to
reflect expected premium change using 5:1 age rating bands, and changes in premium tax credits. Source: Health Insurance
Marketplace Calculator, (Washington, DC: Kaiser Family Foundation, November, 2016); Impact of Changing ACA Age Rating
Structure (Milliman, January 2017)
Seniors’ Premiums Skyrocket under House Repeal Bill*

FamiliesUSA.org
 ACA Fact vs. Fiction
 AHCA Fact vs. Fiction

FamiliesUSA.org
Potential Outline of Congressional Activity for 2017

FamiliesUSA.org
Three “gangs” negotiating
Cassidy (LA)
Collins (ME)
Heller (NV)
Graham (SC)
Sullivan (AK)
Capito (WV)
Manchin (WV)
Donnelly (IN)
Heitkamp (NK)
Others..
McConnell (KY)
Portman (OH)
Cornyn (TX)
Thune (SD)
Enzi (WY)
Hatch (UT)
Alexander (TN)
Cotton (AR)
Gardner (CO)
Cruz (TX)
Lee (UT)
Barrasso (WY)
Toomey (PA)
Collins (ME)
Cassidy (LA)
Capito (WV)
Isakson (GA)
Rounds (SD)
Bipartisan groupModerates, including
Cassidy and Collins
McConnell, et al.

FamiliesUSA.org
• Activate around senators - particularly the moderates and small group of
democrats negotiating - and your governor
• Time is NOW
• Go armed with concrete impact and a focused message: ask Senators
to pledge that they will oppose any bill that
• Cuts and destroys the Medicaid program
• Ends the Medicaid expansion, no matter when
• Increases the number of uninsured
• Undermines the consumer protections under the ACA
We need your help

FamiliesUSA.org
Your voices have
never been
more important!

Physician-Focused & Advanced Payment Models
Jeff Micklos
Executive Director, Health Care Transformation
Task Force, Leavitt Partners
Laura Sessums, JD, MD
Director, Division of Advanced Primary Care,
Center for Medicare & Medicaid Innovation

www.hcttf.org
Health Care Transformation Task Force
Patients, Payers, Providers and Purchasers
Committed to Better Value Now
Jeff Micklos
Executive Director

www.hcttf.org
Who we are: Our mission to achieve results in value-based care
The Health Care Transformation Task Force is an industry consortium that brings
together patients, payers, providers, and purchasers to align private and public sector
efforts to clear the way for a sweeping transformation of the U.S. health care system.
We are committed to rapid, measurable change, both for ourselves and our country.
We aspire to have 75% of our respective businesses operating under value-based
payment arrangements by 2020.

www.hcttf.org
Our Members: Patients, Payers, Providers and Purchasers
committed to better value

www.hcttf.org
Political Landscape for Value-based Payment
• AHCA: all eyes on the Senate
• Value agenda not directly addressed in ACA repeal and replace efforts to date
• Coverage will impact private sector investment in value-based care
• Value-based payment advancement through MACRA retains bipartisan support
• CHRONIC Care Act reintroduced in the Senate

www.hcttf.org
Administrative Actions on Value-based Payment
• Continued MACRA implementation and physician focus: Quality Payment
Program or Advanced APMs?
• Next QPP proposed rule eagerly anticipated
• Focus on reduced provider burden through regulatory reform
• Center for Medicare & Medicaid Innovation “2.0”
• State-based innovation
• Mandatory vs voluntary bundled payment models

www.hcttf.org
Physician-Focused Payment Model Technical Advisory Committee
• Private stakeholders bringing physician-focused APMs forward for
consideration
• PTAC took action on a first set of proposals in April
• Anticipate refinements to the PTAC proposal process
• How CMS will proceed remains an open question

Comprehensive Primary Care Plus Center for Medicare & Medicaid Innovation
Center for Medicare & Medicaid Innovation
Comprehensive Primary Care Plus
(CPC+)
Transforming Primary Care in America
American Academy of Family Physicians
May 22, 2017
75
Laura L. Sessums, JD, MD, FACP

Agenda
CPC+ Model Overview1
• Key statistics
• Geographic regions
• Multi-payer partnership
Impact of the Medicare Quality Payment Program on CPC+
2 Practice Transformation Activities and Supports
3
• Medicare financial supports
• Care delivery and health IT requirements
• Data feedback and learning support
• Alternative Payment Models (APMs)
• Timeline of potential payment adjustments

>1.76 million
Medicare Beneficiaries
ROUND 2
2,891
Practice Sites
13,090
Clinicians
ROUND 1
Comprehensive Primary Care Plus
12
New Payers
Including 5 supporting
Round 1 regions
5
Years
From 2018-2022
4
New Regions
Selected based on payer
commitment to partnership
Up to 1,000
New Practices
Depending on
interest and eligibility
53
Payer Partners
58
HIT Vendor Partners
5
Years
2
Tracks
14
Regions
America’s Largest-Ever Initiative to Transform Primary Care

= Round 1 Region
= Sub-state region comprising contiguous counties
CPC+ Now Offered in 18 Regions
North Hudson/
Capital District (NY)
Northern KY (part of OH region)
New Jersey
Rhode Island
Greater Philadelphia (PA)
Hawaii
OR
MT
CO
OK AR
OH
MI
TN
Greater
Kansas
City
ND
NE
LA
Greater Buffalo
(NY)
= Round 2 Region

Multi-Payer Partnership
Essential for Primary Care Reform
Multi-payer engagement is an essential
component of CPC+.
Support from any one payer covers
only a portion of a practice’s
population.
True comprehensive primary care possible
only with the support of multiple payers.
In CPC+, CMS partners with payers that
share Medicare’s commitment to
strengthening primary care in America.
Medicare
FFS
Public
employee
plans
Medicaid/
CHIP state
agencies
Medicaid/
CHIP
managed
care plans
Self-insured
businesses
Medicare
Advantage
plans
Commer-
cial
insurance
plans
CPC+
Practice

Five Functions Guide CPC+
Care Delivery Transformation
24/7 Patient Access
Patient Assignment to
Care Teams
Patient Risk Stratification
Hospital/ED Discharge
Follow-Up
Coordination with
Other Providers
Patient and Family
Advisory Councils
Practice and
Payer Data Insight
Care Plans for Chronic
Disease Patients
Out-of-Office Care Options
Integrated
Behavioral Health
Psychosocial
Needs Assessment
Self-Management
Support Tools
Full Care Team
Data Review
Access and Continuity Care Management
Comprehensiveness
and Coordination
Patient and Caregiver
Engagement
Planned Care and
Population Health
Track 1
requirements
Additional requirements
for Track 2

Three Payment Innovations Support
CPC+ Practice Transformation
Care Management Fee
(PBPM)
Performance-Based Incentive
Payment (PBPM)
Payment Structure Redesign
Objective
Support augmented staffing and
training for delivering comprehensive
primary care
Reward practice performance on
utilization and quality of care
Reduce dependence on visit-based fee-
for-service to offer flexibility in care
setting
Track 1 $15 average $2.50 opportunity
N/A
(Medicare FFS)
Track 2
$28 average; including
$100 to support patients with complex
needs
$4.00 opportunity
Payment enhanced 10%;
split roughly 50/50 between
upfront “Comprehensive Primary Care
Payment” and reduced FFS claims
CPC+ practices also in the Medicare Shared Savings Program participate in their ACO’s
shared savings/loss arrangement INSTEAD of receiving CPC+ incentive payments.

Track 2 Reimbursement Redesign
Offers Flexibility in Care Delivery
Designed to Promote Population Health Beyond Office Visits
Traditional practice paid only
through FFS; must see patients in
office to receive reimbursement
CPC+ Track 2 practice paid roughly half of FFS payments
upfront in “Comprehensive Primary Care Payment” (CPCP) to
give clinicians more flexibility in how/where they deliver care
CPCP
Reduced
FFS

Health IT VendorsCPC+ Practices
Both CPC+ Tracks require
use of certified health IT.
Health IT vendor partners are
invited to participate in relevant
learning activities with
practices and payers.
Track 2 practices apply with a
letter of support from their
health IT vendor(s) committing
to facilitate the development of
advanced health IT capabilities.
Health IT vendors supporting
Track 2 practices must sign a
Memorandum of Understanding
(MOU) with CMS.
Engaging Health IT Vendors in CPC+

Required Health IT
Functionalities in CPC+ Track 2
Empanel patients to the
practice site care team
Screen for social and community
support needs and link the identified
need(s) to practice identified resources
Produce and display eCQM
results at the practice level to
support continuous feedback
Risk stratify the practice site
patient population
Establish patient focused care
plans to guide care management
Document and track patient
reported outcomes
Health IT vendor partners commit to supporting Track 2 Practices in
developing these advanced functionalities across the five years of CPC+.

Centralized and Aligned
Comprehensive Data Feedback
• Quarterly list of Medicare FFS
beneficiaries attributed, by risk tier
• Quarterly financial support amounts
• Performance on Electronic Clinical
Quality Measures and CAHPS surveys,
compared to other practices
• Quarterly report on care delivery
requirements, compared to other practices
• Practice budget requirement analysis
Quality DataAttribution/Payment Data
Cost and Utilization Data Care Delivery Assessment
Multi-Payer Aligned
Data Feedback
• Expenditures: professional services,
inpatient, outpatient, SNFs, etc.
• Utilization: inpatient, 30-day readmission,
ED utilization
Resource: CPC+ Practice Portal
Online tool for reporting, feedback, and assessment on practice progress

Many Opportunities for Learning,
Collaboration, and Support
Web-based platform for
CPC+ stakeholders to
share ideas, resources,
and strategies for practice
transformation.
National Learning Community
• Cross-region collaboration
• Live and on-demand learning opportunities: action
groups, webinars, affinity groups, office hours
• Durable written products: Implementation Guide,
newsletters, FAQs, case studies/spotlights
• Annual Stakeholder Meeting
Regional Learning Networks
• Virtual and in-person learning sessions
• Outreach to and support for practices
• Clinical and administrative leadership engagement
• Payer and health IT vendor engagement
• Alignment with regional reform
Learning Communities

Merit-based Incentive Payment System
(MIPS) Eligible Clinician in a
MIPS APM
Qualifying APM Participant (QP) in an
Advanced APM
CPC+ Payment for 2017 Under the
Medicare Quality Payment Program
In addition to CPC+ Payments and your
physician fee schedule reimbursement, CMS
will make a lump sum payment that is equal
to 5% of the payments for your Part B
professional services one year prior.
CPC+ is Both an Advanced APM and a MIPS APM; Participating
Practitioners Receive MIPS Exemption or Special Scoring.
Of all your Medicare patients eligible for
CPC+, 25% of Medicare Part B professional
services payments or 20% of Medicare Part
B patients seen by your CPC+ Practice are
attributed to CPC+.
You are exempt from MIPS reporting
and scoring.
In addition to CPC+ Payments, CMS will
adjust your physician fee schedule
payments during the payment year based on
your MIPS final score two years prior.
• You are a physician, PA, NP, or CNS
• You have more than one year of Medicare Part
B participation (or opted in)
• You bill over $30,000 to Medicare and care for
over 100 Medicare patients annually
• You are not a QP in an Advanced APM
You need only report the Advancing Care
Information category to MIPS.
Eligibility
Reporting
Payment
OR

Magnitude of MIPS Payment
Adjustments Changes Over Time
2019 2020 202120182017
0% 0%
+/-
4%
+/-
5%
+/-
7%
5%5%5%
MIPS Eligible
Clinicians
Qualifying APM
Participants
Higher maximum
opportunity in MIPS
In 2019, MIPS payment adjustment
based on 2017 performance
In 2019, QP status based on 2017 performance;
5% lump sum bonus based on 2018 services
CPC+ participants in MIPS receive a special
“APM Scoring Standard” for their MIPS adjustments

Interested in CPC+?
Visit
https://innovation.cms.gov/initiatives/
Comprehensive-Primary-Care-Plus
to learn more and apply.
Practice Applications due July 13, 2017
Contact
CPCPlusApply@telligen.com
1-877-309-6114

www.hcttf.org
Physicians and Accountable Care Organizations: the Basics
• Accountable Care Organizations are groups of doctors, hospitals, and
other health care providers, who come together voluntarily to give
coordinated high quality care to the patients they serve.
• Key operational and financial components of an ACO:
• Financial Structures:
• Type of financial risk: one sided (upside only) v. two-sided (upside and
downside)
• Benchmarks: Spending targets against which savings is determined.
• Sharing rates/performance payment limits:
• Minimum savings rates/minimum loss rates/limits: applicability depends on
type of financial risk

www.hcttf.org
Physicians and Accountable Care Organizations: the Basics
• Key operational and financial components of an ACO:
• Beneficiaries and Data Reports
• Patient assignment: prospective or retrospective
• Minimum beneficiary number
• Quality reporting
• Quality measures, EHR usage, and patient satisfaction
• Waivers
• Regulatory waivers to help facilitate effective operations (telehealth,
SNF 3-day, home bound, primary care co-pay)

www.hcttf.org
Physicians and ACOs: Medicare’s Options
• Multiple Medicare ACO options:
• Medicare Shared Savings Program Tracks 1, 2, and 3.
• NEW ACO 1+ model (to be implemented for 2018).
• “Next Gen” (formerly the Pioneer ACO)
• The different ACO options are broadly defined by the level of downside risk
that the ACO must undertake.
• Upside-only vs two-sided risk
• System intended to create Incentives for move toward two-sided risk
models. Higher levels of risk create potential for higher returns.

www.hcttf.org
The Purpose of ACO 1+ Model
• A new two-sided risk model which qualifies participating physicians for
Advanced APM status, resulting in a 5% payment bonus instead of the
QPP’s +4/-4 payment formula.
• The parameters for two-sided risk are less onerous than more mature
models like MSSP Tracks 2 & 3 and Next Gen ACO.
• Recognizes there is a big leap between MSSP Track 1 and existing two-
sided risk models, and provides a more reasonable step to keep
organizations moving toward full population health/capitated type models.

Health Care Transformation Task Force
www.hcttf.org
Jeff Micklos
Executive Director
jeff.micklos@hcttf.org

Teaching Health Centers
Dan Renberg, JD
DC Representative, American Association of
Teaching Health Center
Roxanne Fahrenwald, MD
Faculty, RiverStone Health/Montana Teaching
Health Center

Teaching Health Centers
History and Promise
Roxanne Fahrenwald MD
Montana Family Medicine Residency
RiverStone Health Center
Billings Montana

Pipeline Needs
•How many of you are recruiting family
physicians for your practice?
•How many of you have all the doctors you
need at your site?
•How many of you would like to hire a family
physician trained to be efficient and
resource sensitive?

Community Health Centers and Family Medicine
Partners in Care
• Co-evolved and emerged from the social justice movement in the 1960s
• Began to expand their participation as primary care education sites in
2010 with Teaching Health Center movement and funding

The emergence of our specialty
• 2011 was the 40th Anniversary of Family Medicine
• Our specialty grew out of a movement to reclaim general
practice medicine in an era of increasing specialization and
fragmentation of health care delivery which began
accelerating after WW2
• Medicine was becoming specialized even at the primary
care level
• There was also a growing sense of loss
• of connection with the patient and their family,
• of the gift of a continuous relationship between a physician
and a patient
• of someone able to connect and integrate care delivery

What is Family Medicine all about?
• Wholeness – biopsychosocial model
• Physicians trained in breadth and depth of care
• Care across the life span
• Care in the context of family and community

Birth of Family Medicine 1965-66
• Folsom Report: every American should have a personal
physician to ensure the integration and continuity of all
medical services
• Millis Report: focused on GME – Family Practice should be
a board-certified specialty
• Willard Report: Board oversight of FM residency
• ABFP established 1969
• First residency: 1970
• Now 480+ residencies and over 94,000 family
physicians practicing – AAFP has around 120,000 total
members

Community Health Centers
• 2010 was the 45th Anniversary of the CHC program
• Growing alongside our new specialty was another
health care movement, designed to bring care to the
impoverished and underserved of the nation

International Roots
South Africa in 1940-50s
• A group of physicians, nurses and community organizers
started a “community health center” model to counter the
health consequences of apartheid
• They defined their responsibility as:
• Care of the individual patient
• The health of entire target populations
• Merging the fragmented disciplines of medical care,
epidemiology and public health

Medical Students Can Drive Change
• Jack Geiger was a visiting medical student in 1957 on
an international elective in South Africa and was
exposed to this model
• He considered it only as a unique solution to that
unique third world circumstance … but….

Civil Rights Movement
• During the civil rights protests in the south and the voter
registration drive in Mississippi in 1964, the Medical
Committee For Human Rights brought hundreds of
physicians, nurses, psychologists and social workers to
Mississippi to assist and protect civil rights workers
• They saw devastating poverty, shocking infant mortality rates
and virtually complete lack of access to then-segregated
medical care

Birth of the CHC in the US 1965
• Dr. Geiger was in Mississippi with them - he had seen a model
that worked
• Proposal was brought to Office Of Economic Opportunity
Happening together:
• 1965 -- first two health centers opened -- in a Boston public
housing project and in Bolivar County, Mississippi
• 1965 -- the commissions on generalist health care were
convened to seek solutions to shrinking access to primary
health care in the country

Community Health Center Growth
• Soon there were four more health centers:
Denver, LA, Chicago, South Bronx
• Now over 10,400 CHC sites delivering health
care, serving nearly 24 million people
annually
• The vast majority of CHC physicians are
family physicians
• We provide health care to all, in every sense

CHC and Family Medicine
Children of the 60s
Solutions for Today
• The two systems – one providing the setting and one the
workforce – grew up together with similar missions and goals
• The integration of residency training in Community Health
Centers has been slow but steady and logical, The recent
designation of THCs recognizes that
• As family medicine and CHCs enter their 50’s together, we
still share the larger overarching goal of healthcare for all

Teaching Health Center
• Movement initially called Educational Health Centers
• Grew out of strategic planning session in mid 2000’s at University of
Washington to explore and support this model of training
• There were some successful residencies in health centers – few, but the
model appeared ideal in many ways
• Teaching Health Center funding first was part of ACA for a 5 year pilot
beginning 2010
• Highly successful tho accreditation/ recruiting barriers slowed startup
• Funded at $150K per resident per year, directly to health center
• Reauthorized with MACRA, CHIP, CHCs bundle in 2016 for 2 years
• But fixed total allocation resulted in per-capita lower funding level, initially
$95K but as programs cut back resident number, increased to around $116K
• Ends with this federal fiscal year

Our personal success story so far……
• Montana Family Medicine Residency and RiverStone Health Center
• Began as 6-6-6 residency in 1995, expanded with THC funding, now 8-8-8
• Patient access grew from pre-residency base of 7000 visits per year to
current over 60,000 visits per year
• 70% of 108 graduates practice in Montana and over 40% have gone to
health centers or other safety net sites to practice
• One resident “line” (1-1-1) currently is temporarily internally funded
(hoped to switch to THC funding if program grew – it did not)
• One resident “line” on THC funding – total 3 residents
• 16 on traditional CMS funding – 2 over cap supported by hospitals
• If THC funding stops, we will reduce one to two residents per year

Problems
• Two year appropriation cycle
• Three year Family Medicine residency timeline
• Plus front end recruiting and match cycle
• ACGME Accreditation requirements state: IV.N.2. the Sponsoring Institution
must allow residents/fellows already in an affected ACGME-accredited
program(s) to complete their education at the Sponsoring Institution, or assist
them in enrolling in (an)other ACGME-accredited program(s) in which they can
continue their education. (Core)
• Hard to make a three year commitment to a resident with two years of funding,
and to program resources when funding occurs at varying levels

Community Health Centers view
• Conjunction of stressors for health centers
• THC funding uncertainty
• Many are AOA programs that need to make accreditation change to ACGME
• Funding cliff for CHCs coincide with THC funding cycle this year
• NHSC funding is in same boat – key recruitment advantage for many CHCs
• Medicaid/ACA uncertainty with potential funding impact on clinical revenues
•CHCs do not have deep pockets – operate generally with tiny margins
•CHC primary funded mission is service not education
•HOWEVER have increasingly embraced education as pipeline started to
produce results and demand increased – THC funding a top NACHC ask too

Attrition already starting
• 741 currently in training at all sites
• Up from 689 last year
• BUT – that obscures the decline
• This total number reflects continued growth from newer programs,
however 33 spots have been cut this year across 8 different
residencies, and 30 more were cut the previous year in 6 residencies
• These programs are NOT taking new resident classes, and are ramping down
• Reasons: decreased funding level below cost to sustain, uncertain
duration of funding vs length of training commitment

The MUST ASK
• Teaching Health Centers funding must continue
• They expand the number of primary care doctors being trained
• They train primary care doctors in resource sensitive care
• They expand access to patients
• Current funding stops this year Sept 30th
• CMS funding is capped– there is no other funding option
• Funding must return to the equivalent of the well-researched 2010 level of
$150K per resident per year – current ask is $157K (only a 5% increase since
2010 level )
• Funding needs to be institutionalized and continuous and not subject to 2
year appropriation cycle to insure stability of programs

Sustained funding will maintain a specific focus on primary care
physician education
Sustained funding will help provide access to patients
Sustained funding will continue to produce family physicians for America
Together we will make the world a better place

Media Perspective
Mary Ellen McIntire
Reporter, Morning Consult

Family Medicine Political Action
Committee Update
Jason Dees, DO, FAAFP Mark Cribben, JD
Chair, FamMedPAC Board of Directors Director, FamMedPAC
St. Louis, MO Washington, DC

The ONLY political organization that promotes family medicine.
Elect candidates to the U.S. Congress who support AAFP’s
legislative goals and objectives.
Since 2005, FamMedPAC raised and contributed over $5
million to more than 400 candidates.

FamMedPAC contributed a record amount in the 2016 election cycle!
2016 Election Cycle Campaign Contributions
$1,020,200 To 154 Candidates
(New Record!)
56 % Democrats, 44 % Republicans
(90% won!)

The 2016 election-cycle saw FamMedPAC receive
record support from AAFP members!
2016 Election Cycle Fundraising
$975,000 received from 3,576 AAFP Members
(New Record!)
If every AAFP member contributed $100, we would have more than $10
million–FamMedPAC would be the largest medical PAC in the country.

2016 PAC Total
American Society of Anesthesiologists $3,991,211
American Assn of Orthopaedic Surgeons $3,537,000
American College of Radiology $2,771,947
American College of Emergency Physicians $2,096,014
American Academy of Dermatology $1,592,839
American Academy of Ophthalmology $1,445,856
American College of Surgeons $1,246,808
The American College of Ob-Gyns $1,200,000
American Academy of Family Physicians $ 975,145
American Osteopathic Association $ 812,375
Trial Lawyers $3.68 million

Who Can Give to FamMedPAC?
AAFP Staff – Including Chapter Staff! Active Members of AAFP
Life Members of AAFP Resident Members of AAFP
Student Members of AAFP
* Not allowed to give: Foreign Nationals and Non-members
AAFP DUES PAYMENTS MAY NOT BE USED FOR POLITICAL CONTRIBUTIONS,
ONLY DONATIONS TO FamMedPAC CAN BE USED FOR THIS PURPOSE

2016 FamMedPAC Chapter Awards
Small Chapter: Montana $10,574.00
Medium Chapter: Oklahoma $10,844.00
Large Chapter: Massachusetts $16,146.00
Extra-Large Chapter: California $35,530.00
Chairman's Award (Club George Percentage):
South Dakota 4.66%
Presented each year at NCCL/ACLF

Visit www.fammedpac.org
to learn more and to
contribute today!

Immunizations
Amy Pisani, MS
Executive Director, Every Child by Two
Sarah Despres
Director, Government Relations, Health Programs,
Pew Charitable Trusts

A M Y PISA NI , M S
E X E C UT I V E DI R EC T O
R 2 02 -2 77 - 75 8 7
A M YP@EC B T . O R G
Our Mission is to…
Protect families and individuals from vaccine-preventablediseases by
raising awareness of the critical need for timely immunizations for
people of all ages; increasing the public’s understanding of the benefits
of vaccines; increasing confidence in the safety of vaccines; ensuring
that all families have access to life-saving vaccines; and advocating for
policies that support timely vaccination.

25 Years of Dedicated Effort
ECBT Cofounders Rosalynn Carter & Betty Bumpers
-ECBT founders helped pass laws in each state mandating
proof of vaccination for school entry
-Traveled the nation building coalitions in every state
to support Iz efforts
-Instrumental in attaining federal and support for vaccines

Every Child By Two’s Expanded Mission Launch

Vaccinate Your Family: Grandparent Toolkit
• Pertussis Video/Motion graphic
• FAQ for Grandparents
• 5 Tips to Soothe a Fussy Baby
• AHealth and Safety Checklist for
Grandparents
• Questions toAsk a Health Care Provider
• Baby Shower Ideas
• APledge to Protect the Baby

ECBT’s Priorities
 Educate the public about the importance of timely immunizations
for people of all ages and the safety of vaccines.
 Collaborate with partners at national, state and local levels (e.g., CDC, AAP, USDA, National
WIC Association,AAFP, State and Local Immunization Programs, and Immunization Coalitions)
 Serve as a source of accurate immunization information to the media
 Keep healthcare providers and public health partners up-to-date on
the latest immunization information, and assist vaccine advocates in
their immunization education, vaccine promotion, and policy efforts.
o Exhibit at conferencesforhealthcareprovidersandbloggers
o DisseminateECBT News and DailyNews Clipsto immunizationadvocatesto helpthemkeepup-to-dateon
immunization-relatednews andto assistthemin beingproactivewhenworkingwiththeirlocalmediaoutlets.
o Providestrategiesandresourcesforvaccineadvocatestousewhentryingto educatethepublicorpatientsabout
vaccines.
 Advocate for pro-immunization policies at the state and federal level

History of Vaccine Hesitancy
• Original study (of 12 children) claiming vaccine-autism link was conducted by
British researcher Andrew Wakefield. Published in The Lancet in 1998.
• Dr. Robert Sears, a pediatrician, promotes his “alternative“ vaccine schedule for
parents.
• Dozens of studies found no link between the MMR vaccine (or any other
vaccine) and autism. http://www.vaccinateyourfamily.org/news/research/
• In 2010, the General Medical Council in U.K. determined Wakefield faked his
data; performed unnecessary medical procedures on the children in his study;
and was paid by lawyers who wanted to file lawsuits against vaccine
manufacturers. Andrew Wakefield stripped of his medical license due to “ethical
lapses” and “unprofessional conduct”. In 2010, The Lancet retracted Wakefield’s
research paper
• In January 2011, the BritishMedical Journal published in-depth investigation of
Wakefield and his research, and called his1998 study an "elaborate fraud.“

Past Events Garnering Anti-vaccine Publicity
• Numerous Larry King Live, Oprah and The Doctors appearances by Jenny McCarthy and others associated with
Generation Rescue (Jenny becomes spokesperson for Gen Rescue)
• Hannah Poling press conference falsely reported that the federal govt. conceded Hannah’s autism was vaccine-
induced – however autism like symptoms are not autism!
• Omnibus Autism Proceeding – In 2009 & 2010 A special vaccine court ruled on a series of cases examining
whether vaccines can contribute to or cause autism. They examined both the MMR vaccine and thimerosal-
containing vaccines and concluded in both cases that there is no link to autism.
http://www.vaccinateyourbaby.org/safe/autism/omnibus_proceedings.cfm

Recent Vaccine Skepticism in News
• Prior to the Inauguration,Robert Kennedy Jr. met with
President-electTrump & Vice President Pence at Trump
Tower – discussed disproven theory that thimerosal in
vaccines causes autism & that govt. involved in conspiracy
• Kennedy claims Trump requested he chair a new commission
on “vaccine safety and scientific integrity.” Trump team
declines to comment,no contact with RFK since
• RFK Jr interviewed by Don Imus 04/18/17
• RFK Jr appears on Fox News 04/20/17

Press Conference – Hill Briefing on Vaccine Safety
Robert F. Kennedy Jr. and actor
Robert DeNiro were featured at a
press conference in DC in February
2017 making allegations about the
dangers of thimerosal in vaccines
and calling for a new “Vaccine Safety
Commission”
Of Note: DeNiro was a no-show at
the Congressional Briefing and few
were in attendance.

AAP RESPONDS
• On January 10, afterKennedy
meetswith President-elect
Trump, AAP issues a
statement declaring vaccines
are safe, vaccines are
effective,vaccines savelives.
• On February 7, AAP sendsa
letter to President Trump signed
by over350 other nationaland
State organizationsthat
expresses unequivocalsupport
for the safety of vaccines.
• Slide credit: Patrick Johnson, AAP

Other Federal Issues
• Oversight & GovernmentReform Committee investigation of the CDC
Whistleblower allegations:
• Background materials available on the www.ECBT.org website
• http://www.ecbt.org/images/articles/Whistleblower_QA012017_updated3-6-17.pdf
• http://www.ecbt.org/images/articles/Vaccine_Safety_and_African_American_Children.pdf
• Anti-vaccine rally/hill visits hosted by Revolution for Truth

Congressional Support for Vaccines Evident in
February Dear Colleague Letter - Drafted by ECBT

Disease Outbreaks Still Occur in the U.S.
• In the past three years 904 Americans were
diagnosed with highly contagious measles, 2017
cases compiling in Minnesota (this month 58
cases, 600 exposures).
• Pertussis (which is particularly deadly to infants) was
diagnosed in more than 67,000 people from 2013-
2016
• Each year, more than 200,000 individuals are
hospitalized and 3,000 - 49,000 deaths occur from
influenza-related complications.
• 20,000 children under 5 y.o. are hospitalized
every year and approx. 100 die as a result of
the flu.

Congressional Update: ECBT Sign on Letter –
4,500 signatures on letter to congress regarding
vaccine funding/ACA Repeal

Legislative & Public Education

State of the ImmUnion Program
Social Media

State of the ImmUnion Program
Infographics

State of the ImmUnion Report to Legislators
• Cost of Preventable Disease Cases
• Additional policy/safety resources
http://www.vaccinateyourfamily.org
/baby- and-child/protect/state-of-the-
immunion

Synopsis of key
challenges to
maintaining
and increasing
vaccination
rates
Solutions for
policymakers
State Iz. Data
http://www.vaccinateyourfamily.org
/baby- and-child/protect/state-of-the-
immunion

http://www.vaccinateyourfamily.org/baband-child/protect/state-of-the-

State of the ImmUnion Report
▪ Sent to members of congress/mediaon the eve of the Trump address to
congress in February
▪ Overview of Success of Vaccines/Cost Savings
▪ Visual of Map highlighting outbreaks
▪ Sections on progressin childhood, adolescent, adult, maternal vax
▪ Challenges, links to CDC andAAP maps with vaccine rates
▪ Vaccine Safety Talking Points, Resources (includingAIM website)
▪ Asks – support vax funding base, support vax services when modifying
Affordable CareAct, general support for vaccines and their safety

State of the ImmUnion Report – Resources Toolkit
Please visit our website to read full report and download
the social media graphics toolkit:
http://www.vaccinateyourfamily.org/baby-and-
child/protect/state-of-the-immunion

Outlook: Federal Appointees
• Assistant Secretary for Health – nominee, Dr. Bret Giroir, infectious disease
expert, history of bioterror and pandemic preparedeness
• Still awaiting nominees for Surgeon General, Asst. Secretary of
Preparednessand Response, and CDC
• Secretary of Health Tom Price, supported meningitis mandatesin GA

ECBT Letter to Congress Requesting Questions on Vaccine
Position during HHS Secretary Price’s Nomination Hearings
Letter signed by 90+
orgs. Three members
of congress asked vax
questions during
hearing; several more
requested written
responses

FDA Commissioner – strong on vaccine science
“It is settled science that vaccines do not cause autism, and policy should move on
accordingly, Scott Gottlieb, MD, said Wednesday at his Senate confirmation
hearing for FDAcommissioner.”
• "This is one of the most exhaustively studied questions in scientific history,"
Gottlieb said at the hearing before the Senate Health, Education, Labor, and
Pensions (HELP) Committee. "I think we need to come to the point where we can
accept 'No' for an answer, and come to the conclusion that there is no causal link
between vaccinations and autism."
• Gottlieb, a hospitalist and former FDAofficial, said he is well
known for speaking truth to power.
• https://www.medpagetoday.com/washington-watch/fdageneral/64383

What do we know about public attitudes toward,
government, science, and vaccines?
According to data from the Pew researchcenter, trust in government is at
historic lows.
However, according to a Pew study from October, 2016, there is still a lot of
trust in medical scientists.
And Pew surveys have also found that while younger parents express more
skepticism about vaccines, most people do believe in immunization.

21st Century Cures Act – Included Provisions on Vaccines
•• ECBT spearheaded the inclusion of a critical provision within the 21st
Century CuresAct that will provide coverage for damages through the
National Vaccine Injury Compensation Program for any live-born child
who mmaayy hhaavvee iinnccuurrrreedd hhaarrmm ffrroomm aa vvaacccciinnee ggiivveenn iinn vviittrroo..
•• ECBT also worked with partners include and refine additional
vaccine provisions within the bill aimed at ensuring vaccine
innovation.

Federal Funding for Vaccines
• Unfortunately,the House version of the American HealthcareAct (AHCA)
eliminates some key provisionsthat will underminevaccination
programs remain in the bill. First dollar coverage of vaccines, which ensures
that families will be vaccinated without deductibles or copays, is at risk of
being eliminated for some populations.Also, there is no planned replacement
for the Prevention and Public Health Fund which under the Affordable Care
Act provided 45% of immunization infrastructureand program funding.

Federal Funding for Vaccines
• In good news, the Fiscal Year (FY) 2017 budget was passed by Congress
• The 317 Program received a small reduction (approx. $4 million) in FY 2017
• The House funded the 317 Program at $560,000,000, which was the
Administration's request, and the Senate funded the 317 Program at $610,000,000.
• The conference level of $606,792,000 for FY 2017 is a good outcome considering
the cuts rendered to other health programs
The bad news is that we expect deep cuts to public health funding in the president's
budget and even though Congressional leadership have said they will do their own
budget, we expect a fairly austere climate for non defense discretionary funding.

Please Help Us Keep You Informed & Share Your Voice:
• ECBTReaches Over 11 Million IndividualsAnnuallyWith Social Media
Messaging/Materials
• ECBTDaily News Clips/MonthlyTop 5/Week in Review– email us at info@ecbt.org
• Guest Post on ECBT’s Shot of Preventionwww.shotofprevention.com
• Like Us on Facebook: Facebook/VaccinateYourFamily
• Followus on Twitter: EveryChildBy2& ShotofPrev
• Contact:Amy Pisani amyp@ecbt.org

Presentation of Congressional Asks
and Role Playing Exercise
Robert T. Hall, JD, MPAff
Director, AAFP Government Relations

Walk-Through:
Packets and Logistics

Hill Visit Basics
• Greeting (2-3 min)
• Introduction (1-2 min)
• Personal Story (2-3 min)
• Supporting Information (1-2 min)
• Asks (2-4 min)
• Closing (1-2 min)
Total meeting time goal: Around 10-15 minutes!

Congressional Primary Care Caucus
House of Representatives Only
• Ask: If you are not a member of the Primary Care
Caucus, please join it.
• Republicans contact Perry Chappell (Rep. Rouzer)
or Democrats contact Maria Costigan (Rep.
Courtney) to join.
OR
• If you are a member, thank you.

Role Play #1
“I'm New”
or
“I Don't Know Anything About Health”

Role Play #2
“I Agree”
or
“Preaching To The Choir”

Role Play #3
"I Agree, but…"

Role Play #4
"That Is Not My Position" Or "I Disagree"
(Politely)

Role Play #5
"Don't Call Us, We'll Call You"

Follow-Up
• Fill out your Feedback Form and get it to AAFP
• Send a thank you letter / email to the legislator & staff,
summarizing your conversation & any commitments
• Follow up & provide any additional information that
was requested (as soon as you can)
• Remember the “Five P’s” – Politely Persistent
Physicians Persuade Politicians
• Coordinate with AAFP staff about any next steps

Breakout Sessions
• Primary Care Policy Research – Grand Ballroom
• Direct Primary Care – Springwood
• Telemedicine – Sagamore Hill
• Lobbying 201 – Executive Room

Primary Care Policy Research:
An Update from The Robert Graham Center

Primary Care Function: Measuring what
Matters in an Age of Uncertainty
Andrew Bazemore, MD MPH
22 May 2017—FMAS meeting, Washington DC

Measuring what Matters in Primary
Care and an Age of Uncertainty
Andrew Bazemore, MD, MPH
Director, Robert Graham Center
April 2017

But the reality is, through a health care lens,
our differences couldn’t be any more stark
U.S. spends nearly 2X the OECD avg % GDP
2017: 18.3%; rising to nearly 20% by 2025

Starfield: Expenditures vs Primary Care Score
UNITED STATES
AUSBEL
GER
CAN
DKFIN
NTH
SPA
SWE UK
FRA
JAP
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
$4,000
0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2
worse Primary Care Score better
PerCapitaHealthCare
Expenditures2000
Adapted with permission from Starfield B. Policy relevant determinants of health: an
international perspective. Health Policy 2002;60:201-21.
United
States
AUS
BEL
GER
CAN
FIN
SP
SWE
UK
0
1
2
3
4
5
6
7
8
9
10
0 1 2 3 4 5 6 7 8 9 10 11 12
better------Primary care score ranking-------worse
HealthcareOutcomes
Rank*
NTH/DK

Starfield also defined the nature &
impact of Primary Care’s via 4 Cs
1st Contact, Comprehensive, Coordinated
Continuous
There is now good evidence, from a
variety of studies at national, state,
regional, local, and individual levels that
good primary care is associated with
better health outcomes (on average),
lower costs (robustly and consistently),
and greater equity in health

And as we move into an age of
measurement and quantification, will we
do any better?

These things we know:
Primary Care is Complex
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
One
diagnosis
Two
diagnosis
Three
diagnosis
Four
diagnosis
Primary care
Speciality Care

And remains the main platform of care, even for
Complex Chronic Illness
% of all Visits for
Top 14 Chronic
Diseases by Cost
to Primary Care
% of all Visits
for Top 14
Chronic
Diseases by
Cost to
Specialists
Remember… in
US, 70% of
physicians are
specialists

Breadth & Aspirational definitions of primary care
• 1978, Declaration of Alma-Alta: Primary Health Care
should be ‘the central function and main focus’ of a
nation’s health system, in which it:
– addresses the main health problems in the community,
providing promotive, preventive, curative and rehabilitative
services accordingly
• 1996, Institute of Medicine: “…the provision of
integrated, accessible health care services by clinicians
who are accountable for addressing a large majority of
personal health care needs”
• 2004: Future of Family Medicine: FM is defined by its
comprehensive ‘Basket of Services’

Existential Moment for Family Physicians
• 2004, US: Future of Family Medicine says FM is
defined by its comprehensive ‘Basket of Services’
• Yet, 2004-2014, many elements (e.g.
Maternity/Obstetrical/Pediatric/ Inpatient care) are
waning in practice
• What will define a US Family Physician going
forward, and does scope matter?

Can we measure something like
Comprehensiveness? And does it
matter?

Perhaps the least
studied of PC
characteristics

2-3 (vs. 0-1)
4 (vs. 0-1)
5-6 (vs. 0-1)
7+ (vs. 0-1)
.2 .3 .4 .5 .6 .7 .8 .9 1 1.1 1.2 1.3
Odds Ratio
Hospitalizations (OR)
2-3 (vs. 0-1)
4 (vs. 0-1)
5-6 (vs. 0-1)
7+ (vs. 0-1)
-30 -20 -10 0 10
Percent Change
ln(Part A & B Expenses)
2-3 (vs. 0-1)
4 (vs. 0-1)
5-6 (vs. 0-1)
7+ (vs. 0-1)
-30 -20 -10 0 10
Percent Change
ln(Part B Expenses)
Bottom line:
Comprehensiveness can be measured, &
using any of 3 measures, increasing
comprehensiveness was associated with
fewer Hospitalization and Lower Overall
Costs of Care Among Medicare
Beneficiaries, Adjusted for Patient and
Physician Characteristics

What about Continuity?
• Has a variety of definitions
• Previous measures are of
patient continuity with their
single physician, not
physician-level
• Little thinking about
continuity in a measurement
paradigm
• Or how physician-level
continuity impacts
outcomes.

What about Training?
• $15 billion dollar public investment in GME
(residency) training annually
• Is anyone measuring it? Is it
measureable? Does it matter?
• Imprinting Studies
Bottom line#1:
Training in places emphasizing
primary care not only impacts
likelihood of practice in areas
where we need doctors, it
influences primary care behaviors

Comprehensiveness of Practicing PCPs by their Training
Institution’s % Graduates Practicing Rurally
ICD-9 BETOS
% Graduates Practicing Rurally →
<--Lowest Highest --> <--Lowest Highest -->
Comprehensiveness
→
Bottom line:
Training in places emphasizing
primary care not only impacts
likelihood of practice in areas
where we need doctors, it
influences primary care behaviors

Bottom line:
Training in high cost areas is
associated with downstream high
cost care, and similarly,
Training in low cost areas is
associated with downstream low
cost care

What does all this mean?
• First contact, comprehensive, continuous,
coordinated generalism is under siege
• One of many many countervailing forces was
fee for service payment that favored a
narrowing of scope of practice?
• We are entering an age of Value-based
payment, where measurable outcomes are
increasingly emphasized

• But measurement doesn’t necessarily
equal improvement, particularly if it doesn’t
emphasize or capture key elements of the
Primary Care function which Starfield
demonstrated to be the path to higher
quality, lower costs, and greater equity

• The 4Cs are measurable, and meaningful
• Paths forward: Further work developing
them as measures, or accepting that we’ll
never fully capture their essence absent
alternative payment models?

And finally
• Primary Care is increasingly a Team sport-
and individual 4C performance may be
less relevant than before
• We need to better understand how to
measure and assess outcomes of Practice
and Team-level 4Cs

Thanks!
For Questions & Comments:
Andrew Bazemore
abazemore@aafp.org

Update on Primary Care Costs &
Payments
Winston Liaw, MD MPH

How have ACOs affected the delivery of
primary care?
How can we improve the ACO program to
better support primary care?
What does the future hold for primary
care’s role in ACOs?

146
243
353
404
460
0
50
100
150
200
250
300
350
400
450
500
2012 2013 2014 2015 2016
Next Generation
Pioneer
Medicare Shared Savings
Program
Growth in the Accountable Care Organization Program,
2012-2016

Relative Frequency Histogram of Accountable
Care Organization Savings Rates
0
0.02
0.04
0.06
0.08
0.1
0.12
-13 -10 -7 -4 0 3 6 9 13
Proportion
Of the 333 ACOs, 28% shared in savings

Successful accountable care organizations had
higher benchmarks
$11,178
$10,207
$9,600
$9,800
$10,000
$10,200
$10,400
$10,600
$10,800
$11,000
$11,200
$11,400
Successful Not Successful

“It’s hard to achieve savings, if, like Dartmouth,
you are a low-cost provider to begin with.”
“It is easier for a person who runs a mile in 12
minutes to reduce the time to 10 minutes than for a
five-minute miler to break the four-minute barrier.”
Paying for improvement rather than achievement

Successful Not
Successful
p-value
6.5% -1.7% <.001
2.0 1.8 0.004
770.9 782.0 0.057
177.3 170.4 0.040
46.5% 41.1% 0.036
Shared Saving Tract (%) Savings Only
(Track 1)
97.8% 99.6% 0.130
Savings And Losses
(Track 2)
2.2% 0.40%
85.8 90.4 0.019
Region (%) North East 14.4% 25.3% 0.035
South 65.6% 39.0% <.001
Midwest 21.1% 22.8% 0.741
West 6.7% 21.2% 0.002
Quality Score
Characteristics
Saving Rate (%)
ACO Age (Years)
Follow up within 30 days of discharge (per 1,000)
Physicians in Primary Care (%)
Hospital Readmissions (per 1,000)
ACO Characteristics, by Success

Thanks!
Winston Liaw
wliaw@aafp.org

What Proportion of US General
Internists are Hospitalists?
Douglas Kamerow, MD

Background/Context
• Use of inpatient-only MDs, “hospitalists,” has
been increasing in the US, based on survey data
(Soc.Hosp.Med.)
• Now ~44,000 US hospitalists (SHM, 2014)
• Most (80-85%) hospitalists are general internists
• About 15 million stays, half of inpatient costs are
paid by Medicare (2011)

Kuo, et al, NEJM 2009: Bi-modal

Primary Care Visits, 2008
• Almost 1/3 of 2008
primary care visits were
to general internists
(GIM)
• What will happen to
those patients if there
are fewer primary care
internists?
• And what about new
patients, since ACA?
FP/GP
45%
PD
24%
GIM
31%
Source:

Design
• Using 2012-2014 Medicare billing data
• Around 70,000 general internists billed at least 100
E&M codes annually in 2012-2014
• MDs placed in deciles by inpatient E&M billing
proportion
• Separately, using AMA Masterfile, internists and
family physicians were stratified by med school class
and % hospitalist (≥90% inpatient billing) to look at
trends

Results: 20121-2014 Data
2012 2013 2014
Hospitalist
(≥90%
inpatient
billing)
28% 30% 32%
Mix
(11-89%
inpatient
billing)
30% 27% 24%
Only
outpatient
(≤10%
inpatient
billing)
42% 43% 44%

Results: 2001, 2006 vs. 2012-14

2013 Results: Stratified by Med School Class

Conclusions
• An increasing proportion of general internists are
becoming hospitalists (this trend may be leveling off)
• This will likely diminish the supply of general
internists serving as primary care physicians,
exacerbating the shortage of primary care clinicians
• To come: analyses of churn and replacement

Thanks!
Doug Kamerow
dkamerow@aafp.org

Bright Spot in Care Management
Megan Coffman
Policy Research Administrator

Definition of Care Management
• “A team-based, patient-centered approach designed to assist patients and their
support systems in managing medical conditions more effectively.”
– Care coordination: Organizing patient care—both information and
activities—with the patient, family, and all care providers in a coordinated
fashion with the patient, placing the patient’s care wishes at the center of the
activities.1
– Self-management support: Helping patients cope with all aspects of their
illness when they are outside of the health care system.
– Patient outreach: Reaching out to patients, and caregivers, before, after, and in
between health care visits by phone, mail, electronically, or in person.

John Hopkins Medicare Advantage Plan

Policy Opportunities to Expand
Effective Care Management
• Incentives for the use of risk stratification to identify high need, high risk patients.
• Coordination by primary care for each managed patient.
• Incentives for the use of care management teams that include appropriate personnel,
including a Registered Nurse, Social Worker and/ or a CHW working closely with
clinical staff.
• Align different payment system and benefits dually eligible individuals and patients
with multiple chronic conditions through the use of value based capitated payment.
• Flexibility in payment and coverage to enable providers to treat patients at the most
appropriate site of care and to offer additional benefits as needed to meet care goals.

Thanks
Megan Coffman
mcoffman@aafp.org

• 140 Larry A. Green
Visiting Scholars
• 16 Robert L. Phillips
Policy Fellows
-Fellowship now funded by
HRSA, fellows serve as
SME’s for Bureau of
Primary Care
-Alums are leaders and
innovators in PC (e.g.
AHRQ Medical Director,
Your comments and questions welcomed!

Thoughts from a Physician,
Member of Congress
Rep. Ami Bera, MD (D-CA)

Breakout Sessions
1) Lobbying 201
2) Telemedicine

E: david@keyadvocacy.com
P: 571.308.9539
www.keyadvocacy.com
Family Medicine Advocacy Summit 2017
Thank You for Participating in the
BUT
Am Org of Nurse Executives (100 in May)
Am Diabetes Assn (150 in March)
Air Line Pilots Assn (150 in June)
SHRM in March (500 in March)
Alzheimer’s Assn (1,300 in March)

P: 571.308.9539
www.keyadvocacy.com
Keep Up the Momentum Back Home
• Engaging in DC is important – build a
relationship by being active back home
• Start planning NOW for the next meeting
with your MoC back home
• There are no limits on how often you may
engage with your MoC’s office

P: 571.308.9539
www.keyadvocacy.com
The Most Successful Advocacy Efforts
Use Diverse Advocacy Strategies
E-mail campaigns
Phone calls from VIPs
Constituent visits
Town hall meetings
Congressional Management Foundation
PAC Activities
Letters to the Editor

P: 571.308.9539
www.keyadvocacy.com
• Lobbying and Policy Change: Who Wins, Who Loses and Why
• Authors followed 98 issues from 1998 to 2002. Of the 98
issues reviewed, “the side with more lobbyists, more PAC
donations, bigger organizational budgets and more
members won only half the time”
• “A better predictor of success …was the support of …high-
level congressional and government officials and …party
leaders and the president”
• Leadership changes (1998, 2014 & 2015)
• “Change Elections” can swing majorities in Congress & party
control of White House
Why Be an Advocate Back Home?

P: 571.308.9539
www.keyadvocacy.com
Town Halls, Community Events or
Create Your Own

P: 571.308.9539
www.keyadvocacy.com
Create Your Own
…San Antonio Hispanic Chamber of Commerce met with Congressman Lamar Smith, 21st
Congressional District. He provided a few sentences on his legislative initiatives before
taking questions from the audience. I provided a few talking points on Employment
Verification, specifically I-9's...
…stated that he is introducing a Bill next Tuesday that would address SHRM's
concerns. Thinks we should be pleased. After the meeting, I gave him a copy of the
Employment Verification Paper you prepared. He briefly reviewed it, and placed it in his
coat pocket. He stated he knew I-9's were not working...
…Congressman Smith was surprised to see a SHRM Affiliate Chapter in San Antonio...

P: 571.308.9539
www.keyadvocacy.com
Create Your Own
• Town Hall meetings & Tele-town Halls
• Letters to the Editor & Op-Eds
• Scheduled office hours
• Community Events elected officials attend
(county & state fairs, parades, picnics, etc.)
• PAC Events
• Create your own: “Congressional Coffees”, “Lunch
with a Legislator”, “Learn from a Legislator”

P: 571.308.9539
www.keyadvocacy.com
Building Relationships:
Giving Instead of Asking

P: 571.308.9539
www.keyadvocacy.com
Don’t Discount or Forget About
District Staff

P: 571.308.9539
www.keyadvocacy.com
David Lusk, Founder
Key Advocacy
david@keyadvocacy.com
571-308-9539
www.keyadvocacy.com

Telehealth / Telemedicine
the not too distant
Steven E. Waldren, MD, MS
May 22, 2017

Definitions
Telemedicine - the practice of medicine using technology to
deliver care at a distance, over a telecommunications infrastructure,
between a patient at an originating (spoke) site and a physician, or other
practitioner licensed to practice medicine, at a distant (hub) site.
Telehealth - a broad collection of electronic and telecommunications
technologies and services that support at-a-distance healthcare delivery
and services. Telehealth technologies and tactics support virtual
medical, health and education services.
3
Source: http://www.aafp.org/about/policies/all/telemedicine.html

Adoption
• Telemedicine and telehealth have been growing
at a greater than linear rate for the last few years.
• Emergence of direct to consumer, telemedicine
only offerings have seen exponential growth
• Private practice adoption in family medicine is
growing but was only 15% in 2015 Robert
Graham Center study
4

Key Challenges & Issues
• Practice adoption
• Training / Education
• Reimbursement
• Capital & operational costs
• Potential liability issues
• Complexity of regulations and payment rules
• Disruption of continuity of care
5

Potential Role in Care
• Improved access
• Improved continuity of care
• Improved care coordination
• Reduced cost of care delivery
• Patient convenience
6

Payment Policy
7
Fee for Service
Value Based
Payment

Regulations
• State based laws
• Licensure
• Payment policy
• Medicare payment
policy
8
Source: https://imlcc.org/
Interstate Medical Licensure Compact

AAFP Telehealth Activities
• Recently revised telehealth policy
http://www.aafp.org/about/policies/all/telemedicine.html
• Advocacy issues
• Support of continuity of care and care coordination
• Appropriateness of telemedicine delivery
• Adequate payment
• Telehealth Member Interest Group (MIG)
• Collaboration with National Telemedicine Resource Centers
http://www.telehealthresourcecenter.org/
• Development of educational resources in telehealth
• Exploring potential new products and services in telehealth
• FMX - CME Presentation and Office of the Future
9

Family Medicine Advocacy Summit 2017

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