"Do not despair of our present difficulties but believe always in the promise and greatness of America, because nothing is inevitable here. Americans never quit. We never surrender. We never hide from history. We make history." -- Sen. John McCain, R-Ariz.

On Sept. 5, the AAFP gave CMS the Academy's official comments regarding the 2019 Medicare physician fee schedule and Quality Payment Program proposed rule. Our letter(92 page PDF) is comprehensive -- 92 pages -- but it is summarized in this paragraph on the second page:

"Feedback we have received is that most family physicians, especially those in independent practices, believe these proposed changes would have a net-negative impact on their practices. While many have expressed appreciation for the concepts of reforms proposed, they are concerned about the policies as drafted. While comfort with an existing system may play a role, the feedback we have received from family physicians, based on analysis of their practice trends, suggest that the policies would not achieve their stated objectives and would place economic strains on their practices."

I encourage you to read the first five pages, which outline the Academy's thoughts and concerns regarding four themes:

alternative payment models for primary care,



priority proposals in the 2019 Medicare physician fee schedule,



impact on Medicare beneficiaries, and



impact on solo and small practices.

Although much of the letter focuses on responding to the policies proposed by CMS, the AAFP did provide CMS with alternatives and solutions. The Academy made five major recommendations that would strengthen the proposal and advance high-value family medicine.

Those recommendations are:



Proceed with the proposed changes in documentation and implement these immediately, but without the collapse to a single payment for codes 99202-99205 and a single one for 99212-99215. Furthermore, we urged CMS to use its unique position to drive changes in documentation not only in Medicare, but throughout all public and private health plans.



Delay implementation of any changes to evaluation and management (E/M) policies or codes and their descriptors until the AAFP and other medical associations can work with CMS to develop new or revised office visit codes, descriptors and values that incentivize comprehensive, continuous and coordinated primary care -- not fragmentation and churn.



Eliminate the proposed primary care add-on code and replace it with a 15 percent increase in payment for E/M services provided by physicians who list their primary practice designation as family medicine, internal medicine, pediatrics or geriatrics.



Eliminate the proposed 50 percent multiple procedure payment reduction for physicians who list their primary practice designation as family medicine, internal medicine, pediatrics or geriatrics.



Work with Congress to eliminate deductible and co-insurance requirements for the chronic care management (CCM) codes. Eliminating CCM cost-sharing requirements would facilitate greater utilization of these codes and increase coordination of care for those beneficiaries with the greatest health care needs. Furthermore, the AAFP urges CMS to further reduce excessive CCM documentation requirements.

CMS will review and analyze submitted comments, and the AAFP will continue to give input and expertise on the proposed rule to the agency's staff. Thank you to those who provided feedback and perspective on the proposal. Your comments helped make our final letter stronger.

By law, CMS must publish the final rule 60 days prior to the Jan. 1, 2019, implementation date, so mark Nov. 2 on your calendar.

Honoring the Victims of 9/11

Seventeen years ago today, America was forever changed. Like most of you, I will never forget that day, and I will never forget the thousands of people who lost their lives or the families who lost their loved ones. We also should never forget the hundreds of first responders who rushed to the World Trade Center that day. Many of them died from exposure to toxins, and many more are living with lifelong illnesses that resulted from their selfless acts on that day and the days following.

Wonk Hard

On Sept. 2, the nation paid its final respects to Sen. John McCain, whose influence on foreign policy is well-documented and well-understood. What is less known is his quiet and persistent work on health care.

One of the first bills I worked on when I arrived in Washington, D.C., in the late 1990s was the Patients' Bill of Rights, which was authored by McCain and Sen. Edward Kennedy. McCain was also an early and forceful advocate of lowering pharmaceutical prices, and he often forced uncomfortable debates on what is known as "re-importation" of prescription drugs. He also was a forceful champion throughout his career for health care programs that serve military members, veterans and Native Americans.

As I was writing this blog, I couldn't help but draw comparisons between Kennedy and McCain -- two American legends who in their final days as senators played critical roles in the passage (Kennedy) and preservation (McCain) of the Patient Protection and Affordable Care Act.

On Sept. 5, Arizona Gov. Doug Ducey announced that former Sen. Jon Kyl would fill McCain's Senate seat until the 2020 election. Kyl also has played an important role in health care. He was one of the major proponents of repealing the flawed Medicare sustainable growth rate (SGR) and drafted many bills to prevent the implementation of SGR-related cuts.