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AAFP Encourages Use of Medical Home, New Immunization Policy at AMA Congress

From the American Academy of Family Physicians

Of the dozens of attendees who spoke out at a forum that was convened to solicit comments on a draft policy agenda document the AMA plans to finalize by this fall, AAFP Board Chair, Larry Fields, MD, of Flatwoods, Kentucky, was first to the microphone. He credited the work the AMA has accomplished to date in examining the issue of health system reform, but warned against overlooking some key issues.

"There are a lot of excellent ideas" in the current draft of the AMA agenda document, Fields said in a recap of his testimony. "If they will hang those ideas on the frame of a primary care-based medical home, we have a great starting point."

Another essential part of that framework, Fields added, is fair payment for all services rendered. "That’s not only higher payment for primary care services," he stressed, "but also an additional payment for coordination of care and disease-management services."

AAFP President-Elect Jim King, MD, of Selmer, Tennessee, likewise addressed the payment issue during the forum, urging delegates to "think outside the box" when it comes to paying physicians for the care they provide.

"We really need to expand how we think about the way we pay physicians, especially in the primary care world, especially when the patient’s in (his or her) medical home," King said. "One thing we feel needs to be in a payment system is a payment for the management of our patients."

OVERVIEW OF DRAFT POLICY AGENDA

In its current form, the draft agenda is divided into 5 main content areas, each with its own complement of specific issues. The 5 areas are:

• Health care environment, including universal coverage and access to care under a pluralistic and patient-driven system, medical liability reform, patient choice, and transformation of Medicare and Medicaid;
  
• Clinical excellence, including further integration of health information technology into medical practice, voluntary adoption of quality measures, improved patient safety, elimination of health care disparities and better care for the elderly;
  
• Health of the public, including disaster preparedness, boosting immunization rates, improving mental health services, raising awareness of global health issues and advocating healthy lifestyle behaviors;
  
• Physician practice viability and patient access, including antitrust issues, payment for true costs of care and the proliferation of consumer-driven health care;
  
• Physician education and professionalism, including workforce analysis and planning, transformation of the US medical education system, education and training funding, and improving medical self-regulation.
  

IMMUNIZATION ADVOCACY EFFORTS

The AAFP delegation also rallied other primary care delegates and supporters behind a resolution crafted by the Academy and supported by the American Academy of Pediatrics and the American College of Physicians. Parts of that measure, as introduced, direct the AMA to:

• Intensify its efforts to advocate that vaccine manufacturers and distributors make adequate amounts of affordable vaccines available in a timely fashion to medical practices
  
• Advocate that health care purchasers provide plan participants with first-dollar coverage of all CDC-recommended vaccines
  
• Urge public and private payers to cover all vaccine-associated costs, including storage, insurance and spoilage/wastage, for CDC-recommended vaccines and their administration, "with no patient cost-sharing"
  
• Advocate to appropriate organizations the need to ensure that "when immunizations are given in locations other than the patient’s medical home, a process exists to ensure communication to the medical home"
  

One clause of the original resolution created a stir among those testifying in a June 24 reference committee hearing on the topic, however. That resolve asked the AMA to step up its advocacy efforts with vaccine manufacturers and distributors to "assure that physician practices, hospitals, long-term care facilities and other medical facilities receive priority in obtaining immunizations."

Citing preliminary results from the AAFP’s most recent member survey on immunizations, AAFP President Rick Kellerman, MD, of Wichita, Kansas, said that the resolution represented the Academy’s attempt to spotlight problems with the overall vaccine acquisition and distribution system that continue to plague AAFP members. For example, more than 1 in 4 survey respondents reported having trouble ordering annual influenza vaccine for the 2006–2007 season, up more than 8% from the previous season. And nearly 60% of respondents said some or all of their influenza vaccine shipment was delayed.

Carol Berkowitz, MD, a member of the AAP delegation to the AMA house, testified at the hearing that AAP members also had experienced problems akin to what FPs saw during the most recent influenza season. "During the 2006–2007 season, we did receive calls from our members saying that they had been unable to obtain vaccine until November," said Berkowitz.

Still, a number of those testifying at the hearing claimed that when it comes to distributing vaccine, allowing physician practices and other medical facilities to "go to the front of the line" isn’t always in patients’ best interests.

Abigail Shefer, MD, a captain in the US Public Health Service and associate director for science in the Immunization Services Division of the CDC’s National Center for Immunization and Respiratory Diseases, told those at the hearing in no uncertain terms: "CDC opposes the concept of preferentially making vaccine available for any one group."

"Instead of focusing on getting vaccine prioritized directly to physicians, our AMA should focus on removing barriers that keep docs from getting ready access" to vaccine products, suggested a member of the AMA Council on Science and Public Health.

DELEGATES PRESERVE CORE MESSAGE

Apparently swayed by testimony at the hearing, the reference committee recommended that the prioritization clause be deleted from the immunization measure when it came before the full house on June 25; the house adopted that recommendation.

The Academy’s delegates remained committed to preserving the spirit of the original resolution, however, and proposed adding the following clause in place of the omitted language:

"Resolved, that the Board of Trustees study the impact on vaccine supply to medical practices, hospitals and other medical facilities that results from the large contracts, with preferential distribution, between vaccine manufacturers/distributors and large nongovernment purchasers, such as national retail health clinics, with particular attention to patient outcomes for clinical preventive services and chronic disease management."

"This amendment addresses all immunizations, not just influenza," Kellerman assured delegates when he introduced the proposed change. When physician offices are unable to offer routine vaccines to their patients, the overall function of the medical home can be breached, resulting in fragmentation of care and disruption of clinical preventive services and chronic disease management.

"We hope that this study will do 2 things: first of all, study the impact of large contracts with guaranteed delivery, such as to large retail purchasers, and the effect that that has on small practices; and then also study the effect on what happens in our offices when we don’t have vaccines—on things such as evaluating children for developmental delays or elderly patients who have chronic disease."

In the end, the delegates signaled their approval of this middle ground by adopting the amended resolution, which also calls for a report back to the house at the 2008 annual meeting.

Cindy Borgmeyer

AAFP News Now

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