From policy to results: How does it all come together?

The process by which advocacy organizations achieve results for their members can seem opaque to those who are not directly involved. How does advocacy really work?.

The process by which advocacy organizations achieve results for their members can seem opaque to those who are not directly involved. Members may be generally aware that their organization adopts policy on particular issues and that this then somehow translates into lobbying and other advocacy, then sometimes into results that they can see. But how does this really work?

The best way to explain is to use a recent example. ACP sent a 27-page letter of response to the Senate Finance Committee on Jan. 26, commenting on specific bipartisan policy options the committee had offered in December 2015 that would improve payments to physicians, reduce regulatory barriers, and make other needed changes to improve care of patients with chronic illnesses. If ACP's recommendations are accepted, they could lead to many tangible gains for internists, building upon progress that already has been made in implementing new Medicare chronic care management (CCM) codes.

But let's go back a bit. The Senate Finance Committee's options paper, and ACP's response, didn't suddenly come out of thin air. They were the product of years of advocacy by the College and other allied organizations. It all started with the College first identifying that reducing barriers to chronic disease management was an important membership need and priority, considering that the number of patients with multiple chronic diseases is growing rapidly and most of them will end up being cared for by an internist. Yet Medicare's current payment policies, benefits, and regulations make it difficult for internists to provide these patients with the care they need.

This needs assessment resulted in the College publishing a series of position (or policy) papers that summarized the impact of chronic disease on the U.S. health care system, obstacles that stand in the way of improvements, and proposed solutions. The policy papers addressed barriers to team-based care, the role of new delivery models like patient-centered medical homes (PCMHs), the impact of reimbursement restrictions and excessive documentation requirements, strategies to engage patients, the use of telemedicine and other health information technologies, practice transformation and improvement, and measurement of results.

Think of these position papers as ACP's “vision” of how the health care system could be redesigned to support and value physicians' unique contributions in improving care of patients with chronic illnesses.

The next step was for the College to translate this vision into specific recommendations for legislation, regulation, benefits, and coding changes. We helped persuade Medicare to authorize payment for a new code for transitions in care management (TCM), effective Jan. 1, 2014, and for new CCM codes, effective Jan. 1, 2015.

We also worked with Medicare and other payers to support pilot tests of the PCMH and other innovative team-based delivery models. We advocated for changes to make electronic health records more functional, more useful, and less burdensome, including improvements in the government's meaningful use program. And last year's legislation repealing the sustainable growth rate (SGR), the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, included many ACP-advocated provisions to provide incentives to physicians for managing chronic disease more effectively.

Many of these changes were incremental and not enough by themselves. The new TCM and CCM codes have been criticized (with some justification) as being too difficult to use and to document and as providing payments that might be too low for the work involved. The PCMH pilot tests are showing great promise in improving care of patients with chronic diseases while providing more financial support to physicians participating in them, but they have yet to be rolled out on the broad scale needed. And MACRA remains a work in progress.

This is why the Senate Finance Committee's chronic care initiative offers so much potential. Instead of addressing chronic disease on a piecemeal basis—tweaking a new code here, adding a few more dollars there—the committee is looking at the issue holistically, trying to figure out how to connect the dots between payment policies, quality measures, new delivery models, health information technology, engaged patients, and well-functioning clinical care teams. This is just what ACP had urged the committee to do in comments we sent last year that included dozens of specific recommendations for changes in payment policies and regulations. Many of the solutions we gave to the committee ended up in the options paper released in December 2015.

With this background in mind, let's return to ACP's 27-page letter of response to the Senate Finance Committee, which included support for the following policies:

  • Establish reimbursement and coverage of additional codes for CCM services for patients who require more complex medical decision making and additional non-face-to-face time beyond what is currently covered.
  • Create codes to provide reimbursement for diabetic care management and e-consultations.
  • Move CCM services to the preventive services category under Medicare fee-for-service (FFS) to eliminate any beneficiary cost-sharing associated with the services. Better integrate care for behavioral health conditions into the primary care setting.
  • Fill gaps in quality measurement, including electronic specification of the measures; obtain stakeholder input into the measures development process; and focus on needed process and outcome measures, patient and family experience measures, care coordination measures, and measures of population health and prevention.
  • Ease Medicare geographic restrictions and originating site requirements for the use of telehealth services.
  • Give Medicare Advantage plans and accountable care organizations more flexibility to tailor their offerings/benefits to meet the specific health care needs of the beneficiary.
  • Require the Centers for Medicare and Medicaid Services to provide medically related information and educational tools on its website to help beneficiaries learn more about their health conditions and self-management.
  • Expand Medicare's Comprehensive Primary Care Initiative, a PCMH pilot test that currently is limited to 500 practices in 7 geographic regions, to all potentially eligible primary care practices throughout the United States.

We still have a lot of hard work ahead of us, of course, as we continue to advocate with both the legislative and regulatory branches to implement our proposals. Yet our efforts to improve care for patients with chronic diseases is a textbook example of how identifying a membership need, developing policies to address that need, and translating those policies into sustained advocacy for specific regulatory and payment reforms can begin to achieve real results for members.