AAFP 2008 CONGRESS OF DELEGATES
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* Cindy Borgmeyer
* Barbara Bein

In mid-September, the AAFP Congress of Delegates (COD) met for several days to discuss the business of the organization and to propose resolutions regarding the Academy’s ongoing policies and procedures.

Chief among the COD’s concerns were CMS’ valuation of evaluation and management (E/M) services, performance reporting programs, AAFP special constituencies, and funding for tobacco cessation.

## RUC’S FAILINGS SPARK STRONG TESTIMONY, BOARD REFERRAL

During the COD, it became evident that family physicians are getting tired of the status quo when it comes to CMS’ continuing failure to appropriately value the E/M services FPs and other primary care specialists provide.

According to many FPs who testified before the Reference Committee on Practice Enhancement on September 15, the lion’s share of blame for the continuing shortfall lies squarely on the back of the AMA/ Specialty Society Relative Value Scale Update Committee, or RUC, which makes recommendations to CMS for payment of physician services.

The first of the 2 resolutions presented at this year’s Congress called for the Academy to “work to make the voting in the RUC proportional to the number of physicians that make up the constituent voting entities.”

Failing that, the resolution added, the AAFP should “disengage from the RUC and pursue other means to assign appropriate compensation for physician services.”

The second measure was even more to the point, directing the AAFP to petition CMS to “develop an independent Relative Value Scale Advisory Board with membership representative of the current physician workforce providing care to Medicare recipients or mandate representative restructuring of the Relative Value Scale Update Committee.”

After years of pressing for reform of the RUC and trying to attain a level of primary care representation on the committee that is proportionate to the primary care composition of the physician workforce, family medicine keeps coming up short of that goal, said proponents of the 2 resolutions.

Indiana delegate Thomas Felger, MD of Granger, Indiana, a member of the Commission on Practice Enhancement and the Academy’s representative to the RUC, acknowledged his colleagues’ frustration, but he sought to reassure them that the commission, together with the AAFP Board of Directors, is seeking workable solutions.

Earlier this year, the commission proposed an overall strategy for tackling an admittedly complex RUC issue. At its March 2008 meeting, the AAFP Board approved that strategy and, in July, adopted a motion that the Academy would move forward by:

*   Initiating discussions with other primary care groups; the Patient-Centered Primary Care Coalition; CMS; the Medicare Payment Advisory Committee; and other organizations to consider the composition of the RUC;

*   Investigating potential alternative approaches to the RUC;

*   Exploring transparent meetings of the RUC, as well as a method to revalue under- and overvalued services; and

*   Developing metrics for potential resignation from the RUC.

## DELEGATES DEFEAT MEASURE CALLING FOR AAFP TO OPPOSE PERFORMANCE REPORTING

Although they don’t like the practice, most of the delegates who testified on a resolution calling for the Academy to take a stand against physician ranking acknowledged that the practice is almost certainly here to stay. From that perspective, they said, the relevant question becomes: How should this ranking be conducted, and what steps can health plans take to assure physicians that they’re being treated fairly?

Texas alternate delegate Erica Swegler, MD, of Keller, Texas, was one of those who testified that family physicians should support the concept of physician performance measurement, with the goal of collaborating with insurers on how the findings are used.

One problem Swegler said she has run across in her own practice is that despite earning a top-quality rating from one insurer she deals with, the company de-selected her practice from its low-cost network at one point because of a slightly higher than expected risk-adjusted cost of office-based care. That was despite the fact that the insurer reported that the practice had racked up major savings in all other areas of care.

In the end, delegates agreed with the recommendation of the practice enhancement reference committee, defeating the resolution. According to its report, the reference committee acknowledged the collaborative work the AAFP already has done with insurers on this issue and concluded it was neither practical nor in the Academy’s or members’ best interest to flatly oppose physician performance reporting.

## SPECIAL CONSTITUENCIES’ CONGRESS SEATS

Delegates also adopted measures supporting ongoing representation by members of the Academy’s special constituencies.

The Congress was overwhelmingly united on measures safeguarding representation of these member groups, which include women; minorities; new physicians; international medical school graduates; and members interested in gay, lesbian, bisexual, and trans-gender issues.

The delegates adopted resolutions continuing the National Conference of Special Constituencies, or NCSC, and the Annual Leadership Forum and extending until 2015 the 6 delegate and 6 alternate delegate seats reserved for 4 of the 5 special constituencies in the Congress. Those seats had been scheduled to sunset in 2010.

## TOBACCO CESSATION EFFORTS

Members of the Reference Committee on Health of the Public and Science heard impassioned testimony during the 2008 Congress of Delegates about a public health issue near and dear to AAFP members: tobacco cessation. The testimony came in response to a recommendation in a report from the AAFP Board of Directors to the Congress on the Board’s work with the AAFP Foundation Board of Trustees to secure long-term financial support for the Academy’s Tar Wars program, as well as its efforts in the areas of tobacco cessation, education and research.

Two options were laid out in the Board’s report:

*   “That the Congress of Delegates support the AAFP Foundation in contacting private foundations and corporate foundations, consistent with current AAFP policy, in securing a one-time major gift to the AAFP Foundation to create an endowment to be used exclusively to support AAFP programs in tobacco cessation education, research and Tar Wars.”

*   “That the Congress of Delegates allow a one-time exception to the AAFP Tobacco and Smoking policy so that the AAFP Foundation could contact corporations with giving programs funded by tobacco monies to determine if any would be willing to provide a one-time major gift to the AAFP Foundation to create an endowment to be used exclusively to support AAFP programs in tobacco cessation, education, research and Tar Wars.”

Mark Belfer, DO, of Fairlawn, Ohio, president of the AAFP Foundation, strongly supported the option of approaching tobacco-funded giving programs in his testimony. “We want a one-time chance to talk to tobacco companies to say we want $10 to $15 million, so no more children’s lungs are choked with smoke,” he said.

AAFP Past President Michael Fleming, MD, of Shreveport, Lousiana, also spoke in favor of considering even the more extreme option, pointing out that the state tobacco settlement funds slated for tobacco education and prevention programs have all too often gone to fund other endeavors.

Others testified ardently against the notion of dealing directly with the tobacco industry, fearing it could severely compromise the Academy’s credibility.

“We own the trust of our patients; we worked hard to get it,” said Georgia delegate George Shannon, MD, of Columbus, Georgia, adding that the risk of tarnishing family medicine’s public image by seeming to collaborate with tobacco companies was too great.

Erica Swegler suggested a compromise: Try the first, less controversial option for 3 to 5 years before considering moving to the second option.

In the end, the Congress of Delegates adopted a substitute option crafted by the reference committee that directs the AAFP to support the foundation’s efforts “to seek funding for tobacco cessation, education, research, and Tar Wars by contacting private foundations and corporate foundations in a manner consistent with current policy to create a one-time endowment.”

The resolution further asks the AAFP Board to report back to the 2009 and 2010 Congresses on the status of the “tobacco control endowment” funding. It also calls for the Academy to inform members of the “acute, short-term need for bridging funds to continue Tar Wars until the tobacco control endowment is funded.”

*   © 2008 Annals of Family Medicine, Inc.