Omnibus Package Delivered AAFP Advocacy Wins for Primary Care

I want to pick up here where I left off earlier this month in my conversation with AAFP President Tochi Iroku-Malize, M.D., M.P.H., M.B.A., about key Academy and primary care wins in the 2023 omnibus spending package. That $1.7 trillion bill, the Consolidated Appropriations Act of 2023, contains a substantial number of impressive victories for us, and it deserves some detail. So here goes. 

Telehealth

The bill answers the Academy’s telehealth advocacy virtually point for point by extending Medicare flexibilities through the end of 2024, including

• elimination of geographic requirements,
• expansion of originating sites,
• allowing federally qualified health centers and rural health centers to furnish telehealth services and
• delaying in-person requirements for tele-mental health services.

Delivering two more wins resulting from the extensive telehealth guidance we’ve sent regulators and lawmakers since the start of the pandemic, the law also requires CMS to continue covering and paying for audio-only telehealth services through Dec. 31, 2024, and directs HHS to further study telehealth use.

Medicaid and the Children’s Health Insurance Program

As the AAFP recommended, the bill extends CHIP funding and requires states to provide children 19 and younger with 12 months of continuous Medicaid and CHIP coverage. That last point is especially important because it will reduce the disruptions to coverage and care many children face when their parents’ income or employment changes. 

At the urging of many states, the bill decouples Medicaid redeterminations from the end of the COVID-19 public health emergency, allowing states to begin disenrolling patients who are no longer eligible for Medicaid beginning on April 1. However, as the Academy advocated, the bill adds guardrails for this process, including requirements that states protect beneficiaries from unnecessarily losing coverage when they are still eligible.

The omnibus also makes permanent the option, established by the American Rescue Plan, for states to provide 12 months of continuous postpartum Medicaid or CHIP coverage. CMS said this month that Alabama and North Dakota were the latest states to enact this expansion and estimated that it would help 20,000 postpartum women in Alabama and 1,000 in North Dakota. These further wins for our advocacy will improve access to care, help family physicians maintain strong relationships with their patients and help address disparities in child and maternal health.

In line with our advocacy, the omnibus extends Puerto Rico’s 76% Medicaid federal medical assistance percentage through 2027 and permanently extends the 84% FMAP for American Samoa, the Northern Mariana Islands, Guam, and the U.S. Virgin Islands. It also establishes a reimbursement floor for physician services of 75% of Medicare Part B rates for 2023-27 — a small but important step toward addressing the inadequacy of Medicaid’s physician payment rates. 

Workforce

The omnibus adds 200 new Medicare-funded GME positions, half for psychiatry residencies and half for HHS to designate according to criteria used to allocate the 1,000 GME slots added as part of the 2021 Consolidated Appropriations Act — meaning family medicine residency programs are eligible. With an ongoing national behavioral health crisis, the Academy last year devoted considerable effort to achieving this outcome, emphasizing the need to increase residency slots for primary care given its frontline role in connecting patients to mental health services.

The legislation also extends, as we have continually called for, the vital Conrad 30 waiver program. Under Conrad 30, states can request J-1 visa waivers for foreign-born physicians who have completed a U.S. residency training program and agree to work in federally designated shortage and underserved areas for three years. The extension takes us through September of this year. We will continue to work with lawmakers on this important element of the primary care workforce pipeline.

The Public Health Workforce Loan Repayment Program has also been reauthorized. The program, which the Academy supports, is meant to repay student loans for health professionals with expertise in infectious diseases and emergency preparedness and response.

AAPM Bonus

Following our advocacy to improve the Medicare Access and CHIP Reauthorization Act, the omnibus extends through 2025 the incentive payment for qualifying participants in advanced alternative payment models. The amount of the incentive payment is 3.5% of Medicare Part B payments, and the freeze on participation thresholds for qualification for the bonuses is extended for one additional year. 

X-waiver Eliminated

The omnibus at last nixes the X-waiver, improving access to substance use disorder treatment, as we’ve steadily urged. This critical administrative simplification is already making it easier for family physicians to prescribe lifesaving buprenorphine when treating opioid addiction. It also reflects our position that buprenorphine prescribing shouldn’t be stigmatized or subject to unnecessary restrictions. 

What Else?

A necessary piece of legislation passed within the omnibus was the Pregnant Workers Fairness Act, which the Academy had long supported. The law expands protections for pregnant employees and job applicants, including by requiring employers with 15 or more workers to make reasonable accommodations for health limitations related to pregnancy, childbirth or related medical conditions.

Our advocacy also glows recognizably in the bill’s requirement that the CDC expand and improve its public health emergency modeling and analysis. Complementing this is new HHS authority, outlined in the bill, to lead PHE responses across agencies; the legislation also places in the executive branch a new office of pandemic preparedness and response. All of this is well in line with the Academy’s aims.

Finally, this won’t surprise my regular readers: I’m pleased to report that the omnibus includes grant support of the collaborative care model, a welcome move toward expanding behavioral health integration into primary care.

Medicare Payment: Hope on the Horizon

The omnibus contained as much mitigation as could realistically have been expected for a Medicare physician fee schedule 2023 conversion factor that we know could have been worse. After Congress acted, the conversion factor (the amount Medicare pays per relative value unit) went up about 83 cents, to $33.89. That’s an incremental win, but a win all the same.

And on its heels, reflecting guidance we’ve all but screamed for years, MedPAC — the nonpartisan committee that advises Congress on Medicare — this month unanimously recommended that Congress increase physician payment in 2024. Specifically, the group said such improvements should be linked to 50% of the Medicare Economic Index, which measures changes in the market price of the inputs used to furnish physician services. We’ve been pushing for baseline positive annual updates that take into account actual practice-cost inflation. In fact, we’ve just renewed that work, but for now this is a fine conversation (re-)starter.

MedPAC also voted to ask that Congress “enact a non-budget-neutral add-on payment, not subject to beneficiary cost-sharing, under the physician fee schedule for services provided to low-income Medicare beneficiaries.” The recommended add-on payment would, for primary care practices, multiply by 15% a clinician’s allowed charges for low-income beneficiaries.

Your Turn

I’m excited to tell you that registration just opened for the AAFP’s 2023 Family Medicine Advocacy Summit in Washington, D.C., May 22-23. It’s an expressway connecting you to your congressional delegation so you advocate, in person, for your practice, your patients and your specialty. Ahead of appointments, you’ll learn how to communicate your aims powerfully and succinctly while earning CME. I hope to see you there.