Federal Update for Nevada AFP: MACRA and ACA Repeal/Replace

Robert HallDirector, Government Relations

Goals of Presentation• Snapshot• MACRA• ACA• CHIP• Help us help you

The US has a Budget Problem

The driver is health cost

Per

cent

of

US

GD

P

$210bnUnnecessary

Services

$190bnAdministrative Costs

$130bnInefficient

Delivery of Care

$55bnPrevention

Failures

$105bnInflated Prices $75bn

Fraud

U.S. HEALTHCARE WASTE = NETHERLANDS GDP

$765bnin wasted spending

Source: Institute of Medicine (2009 data); The World Bank (2009 data)

Healthcare Expenditures vs. Outcomes

Healthcare Expenditures as % of GDP, 2005*

Average life expectancy, 2007

*Bradley EH, et al. Health and Social Services Expenditures: Associations with Health Outcomes. BMJ Qual Saf (2011). *McGinnis JM, Russo PG, Knickman JR. The case for more active policy attention to health promotion. Health Aff (Millwood) 2002;21(2):78–93

Pay Now … Or Pay Later

Hospital inpatient 27%

Hospital outpatient visits/other 28%

Professional procedures (non-

hospital) 30%

Drugs 16%

Primary Care 6%

Source: RWJF/UWPHI.

GENETICS DIET & EXERCISE

TOBACCO USE

ALCOHOL & DRUG USE

SLEEP SEXUALACTIVITY ACCESS

TO CAREQUALITY OF CARE

EDUCATION EMPLOYMENT INCOME SOCIAL SUPPORT

COMMUNITY SAFETY

AIR QUALITY

WATER QUALITY

HOUSING TRANSIT

THE FUTURE HEALTH ECOSYSTEM WILL FOCUS ON THE TRUE DRIVERS OF OUTCOMES

Current State

Over Utilization

Volume over Value

Silos of Care

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Fee for Service

Sustainable Growth Rate2002-2015

“The difference between what’s made available to me as a surgeon and what’s made available to our internists or pediatricians (or family physicians) or HIV specialists is not just shortsighted – it’s immoral”

Atul GawandeThe Heroism of Incremental CareAnnals of Medicine, January 23, 2017

MACRA Legislative Timeline

MACRA enacted

Request for Information

Proposed Rule released

Final Rule w/ comment

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*Medicare physician fee schedule published separately

April 16, 2015 October 1, 2015 April 27, 2016 October 14, 2016

What Does MACRA Do?• Repeals the Sustainable Growth Rate (SGR)

• Extends Children’s Health Insurance Program (CHIP) funding for 2 years

• Provides Annual Baseline Fee Schedule Updates 2016-2018

• Creates 2 payment pathways

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What Does MACRA Do In Medicare?

• Consolidates quality programs

Merit-Based Incentive Payment System (MIPS)

• Potential for bonus payment for participation

Advanced Alternative Payment Models (AAPM)

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QPP Participants

Physicians (MD/DO)

Physician Assistant

Nurse Practitioner

Clinical Nurse

Specialist

Certified Registered

Nurse Anesthetist

MACRA defines eligible clinicians as:Merit-Based Incentive Payment System

(MIPS)

MIPS HighlightsConsolidates existing quality and value programs• Adds a category for Improvement Activities

Establishes a Final Score• Weighted scoring by category

Provides opportunity for payment adjustments• Both positive and negative

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What’s it called?

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ValueModifier

MU

PQRS Resource Use

AdvancingCare

Information

Quality Cost

AdvancingCare

Information

Quality

MACRA – April 2015 Proposed Rule – April 2016 Final Rule– October 2016

AdvancingCare

InformationIA

CPIACPIA

MIPS Final Score

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Quality Cost Improvement Activities

Advancing Care

Information (ACI)

Improvement Activities – New! • Expanded Practice Access

• Population Management

• Care Coordination

• Beneficiary Engagement

• Patient Safety and Practice Assessment

• Achieving Health Equity

• Emergency Response and Preparedness

• Integrated Behavioral and Mental Health

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**2018 Proposed Rule – More Options added included Performance CME and Appropriate Use Criteria

Weighting by Category - 2017

Quality, 60%

Cost, 0%

Improvement Activities1, 15%

Advancing Care Information,

25%

1 - “Certified” PCMH receives the full credit for IA; APM Participants receive half credit

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Proposed Weighting for 2018

[CATEGORY NAME], 50 or

[VALUE][CATEGORY NAME],

[VALUE] or 10%???

Improvement Activities1, 15%

Advancing Care Information,

25%

1 - “Certified” PCMH receives the full credit for IA; APM Participants receive half credit

Jumps to 30% in 2019,as required by statue

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Weighting Progression2019 2020 2021

Quality 60% 50% 30%

Cost 0% 10% 30%

Advancing Care Information 25% 25% 25%

Improvement Activities 15% 15% 15%

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‘Pick Your Pace’

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Test Partial Participation

Full Participation

Advanced APM

‘Pick your Pace’ Options for 2017Test

• Submit some data to QPP

• No negative adjustment

Partial Participation

• Report minimum 90 days

• Smallpositive adjustment

Full Participation

• Report 90 days up to full year

• Modest positive adjustment

Advanced APM

• Qualifying Program & Qualified Participant

• 5% incentive payment

NO NEGATIVE PAYMENT ADJUSTMENTS

“Pick Your Pace” Reporting

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• Report one quality measure, one improvement activity, or all four of the required measures within the advancing care information (ACI) category

• Report one quality measure, one improvement activity, or all four of the required measures within the advancing care information (ACI) category

Test

• Report a minimum of 90 days for more than one quality measure, more than one improvement activity, or more than four of the measures within the ACI category.

• Report a minimum of 90 days for more than one quality measure, more than one improvement activity, or more than four of the measures within the ACI category.

Partial Participation

• Report to MIPS for a full 90-day period or full year• Report to MIPS for a full 90-day period or full year

Full Participation

Annual Performance Threshold• Established by Secretary years 1 and 2

– For transition year 2017, threshold is 3– For 2018, proposed threshold is increased 15

• Below = negative payment adjustments

• Above = positive payment adjustments

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Adjust Payments

-4% -5% -7% -9%

4%5% 7% 9%

2019 2020 2021 2022 onward

*Adjustment to provider’s base rate of Medicare Part B payment

*Potential for

3Xadjustment

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Adjustment Summary

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Performance Score Payment Adjustment

Exceptional Performers (Final Score over 70) =

Eligible for up to 10% positive adjustment in

2019

25th Percentile or below = Maximum negativeadjustment

At threshold = Stable Payment

MIPS Exemptions

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• Year 1 Medicare• Eligible Advanced Alternative Payment Model with Bonus• Below low volume threshold

– Less than or equal to $30,000 Medicare payments; or less than or equal to 100 Medicare beneficiaries

– PROPOSED FOR 2018 – less than or equal to $90K Medicare payments; or less than or equal to 200 Medicare beneficiaries

Advanced Alternative Payment Models

(AAPMs)

DefinitionsQualifying APM• Based on existing payment models

Advanced APM• Based on criteria of the payment model

Qualifying AAPM Participant• Based on individual physician payment

or patient volume

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Qualifying APMs

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• MSSP (Medicare Shares Savings Program)

• Expanded under CMS Innovation Center Model*

• Demonstration under Medicare Healthcare Quality Demonstrations (MHCQ) or Acute Care Episode Demonstration

• “Demonstration required by Federal Law”

Qualifying APMs

Advanced APM Eligibility

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• Quality measures comparable to MIPS

• Use of certified EHR technology

• More than nominal risk OR Medical Home model expanded under CMMI authority

Qualifying APMs

Advanced APMs

Primary Care Advanced APMs

• Shared Savings Program (Tracks 2 & 3)• Next Generation ACO Model• Comprehensive Primary Care Plus (CPC+)

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Qualifying APM Participant

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• Percentage of patients or payments thru eligible APM

• In 2019, the threshold is 25% of Medicare payments or 20% of beneficiaries

• QP status will be determined at the group level

Qualifying APMs

Advanced APMs

Qualifying APM

Participant

Additional Rewards for Qualifying Participants

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• Not subject to MIPS• 5% bonus 2019-2024• Higher fee schedule update to 0.75% 2026

QPAdvanced APM

MACRA Timeline2017 2018 2019 2020 2021 2022-2024 2025 2026

Medicare Part B Baseline Payment Updates

+0.5% +0.5% +0.5% 0% 0% 0% +0.25%*

+0.75%**

*Non-qualifying APM Conversion Factor**Qualifying APM Conversion Factor

Merit-Based Incentive Payment System (MIPS)PQRS, Value-based

Modifier, & Meaningful Use Quality, Cost, Advancing Care Information, & Improvement Activities

-9% -9%? 0 or +/-4%*“Pick Your Pace”

+/-5% +/-7%

Qualifying APM Participant5% Incentive payment

Excluded from MIPS

+0%

+/-9%

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Proposed Changes for 2018• Virtual Groups will begin in 2018 – more details to come• ACI – allowing use 2014 or 2015 Edition CEHRT; new

hardship exemption for small practices • New Small Practice Bonus (15 or less physicians will get 5 bonus

points added to final score if they submit data for at least one performance category)

• New Complex Patient Bonus (3 points added to final score for caring for complex patients)

• Performance Period now 12 months for Quality and Cost/ 90 minimum for ACI and Improvement Activities

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Performance year

2017

Submit

March 31, 2018

Feedback available Adjustment

2018 January 1, 2019

Performance: The first performance period opens January 1, 2017 and closes December 31, 2017. During this period, providers will record quality data and how they used technology to support their practices

Submit data: To qualify for a positive payment adjustment under MIPS, providers must send in data by March 31, 2018. To earn the 5% incentive payment for participating in an Advanced APM, providers must send quality data through their Advanced APM

Feedback: Medicare will give providers performance feedback after the submission of data

Payment: A provider may earn a positive MIPS adjustmentpayment beginning on January 1, 2019 if it submits 2017 data by the deadline. Those participating in an Advanced APM in 2017 may earn a 5% incentive payment in 2019

2017 Performance Period Timeline

Getting Started

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Assistance is Available

• Find a PTN– Go to aafp.org/tcpi

– Click “Find a PTN” to find a practice transformation network in your area

– Email tcpi@aafp.orgwith any questions.

Almost impossible

US House US Senate

Supermajority in Senate needed to override a filibuster for ‘normal’ legislation

The Affordable Care Act: Full Repeal and Replace? Failure of Skinny Repeal Evidence of Deep Political Fragmentation

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Lessons learned from the legislative process of the AHCA

A unified Republican government, including a GOP president and House majority, could not force enough GOP lawmakers to support the AHCA. What caused this lack

of coherence in pursuing a major party initiative?

1 Independence of individual members of CongressIndividual members of Congress have become more willing to act independently of their party’s leadership

2 Heightened influence of well-funded outside groupsThere has been a transfer of influence from political parties to well-funded outside groups that are willing to support Republican representatives who take stances on issues that align with the group

3 Less reliance on party infrastructureMany in Congress now depend less on party financial assistance.

5 Reduced importance of congressional committee assignmentsCommittees did not play a central role in crafting the AHCA. Now, committee assignments are less necessary for PR and fundraising purposes, meaning less leverage for leadership

6 Impact of elimination of earmarksThe elimination of earmarks has stripped a tool that party leaders could have used to entice members to support certain legislation

4 Polarized sources of money in politicsIt is now easier than ever for members of Congress to connect with small donors throughout the country. Small and individual donors tend to be the most ideologically polarized, which further empowers extreme wings of the parties

Why Did it Fail?• Use of reconciliation tactic

• Hard to achieve political balance between states that expanded Medicaid and those that didn’t

• Grassroots engagement!

Key Issues in Health Reform

• Coverage Numbers• Subsidies• Premium Costs• Preexisting Conditions• Essential Health Benefits• Medicaid Expansion States v.

Non-Expansion States

Health care coverage by type, by number of individuals in millions, 2016

ESI still dominates coverage landscape

156

22

62

43

15

29

0 30 60 90 120 150 180

Employment-based

Non-group

Medicaid

Medicare

Military health care

Uninsured

Gaming out scenarios4 scenarios going forward for health care reform

Senate passes BCRA• When the Senate is back in session after the July recess, the most

likely scenario is that the Better Care Reconciliation Act will pass along party lines with the exception of two defectors: Rand Paul (R-KY) and Susan Collins (R-ME) and Vice President Mike Pence to break the tie vote

• Once passed, an amendment will be voted on to replace the House bill with the Senate bill and then the House will have to vote

Bipartisan reform to fix the ACA• In a quote to the Associated Press, Senate Majority Leader Mitch

McConnell expressed interest in the idea of fixing the ACA instead of a full repeal if the Senate health care bill doesn’t pass

• Bipartisan reform looks like: bills to strengthen and stabilize insurance markets, ensuring cost-sharing payments are permanent, keeping protection of essential health benefits under the current law

Keep ACA and Medicaid expansion as is• Least likely scenario because ACA markets are in trouble• Unstable environment for insurers; many of them are questioning

staying in the individual market for 2018 until bills can be passed to make the market more stable

• GOP has campaigned since 2010 on repealing and replacing the ACA; they’re unlikely to change their message now

Less conservative More conservative

More interventionist

Less interventionist

Least likely Most likely

BCRA doesn’t pass, GOP re-drafts bill • If the Senate GOP feels as though there won’t be enough votes to

pass the BCRA, they will likely go back to adding amendments and fixing the parts of the bill that most defectors are against

• Possible reworking of issues with the bill: large cuts to Medicaid, defunding Planned Parenthood entirely, not being conservative enough in its replacement of the ACA and poor protection of pre-existing conditions

AHCA Impact on Medicaid

AHCA + FY’18 Budget

Impact on Medicaid

Many options for HHS Secretary to unilaterally act on dismantling the Affordable Care Act

Possible ways for Secretary Tom Price to begin dismantling the ACA:

Stop enforcing the individual mandate:In coordination with Treasury, Secy. Price could limit collection of the ACA’s penalty for those without health insurance, or stop collecting the penalty altogether

1

Tweak hardship waivers:The HHS secretary has significant leeway to define what constitutes “hardship” when granting exemption to the ACA’s individual mandate penalty

2

Limit or eliminate women’s preventive services:The HHS secretary can exclude contraception from the list of women’s preventive services, or entirely eliminate coverage of women’s preventive services under the law

3

Expand Hobby Lobby exemption:Currently, the contraceptive mandate accommodation is available to religious nonprofits and closely‐held for profit corporations. Secy. Price can expand this exemption

4

Narrow regulations on essential health benefits:While the 10 EHB categories are codified, CMS can issue regulations permitting insurers to define what it means to cover the categories

5

Restrict special enrollment periods:The Trump administration can require people who are trying to sign up outside of the open enrollment period to provide more documentation

6

Tweak the “like it, keep it” ruleThis administrative fix was put in place by the Obama administration in 2013, and allowed people to keep certain non‐ACA‐compliant insurance plans. Secy. Price can decide whether to end the fix or expand it

7

Approve different 1115 waivers for MedicaidStates can propose Medicaid experiments through 1115 waivers —Trump’s CMS will likely approve different Medicaid experiments than the ones approved by Obama’s CMS

8

Further delay the Cadillac taxThe Trump administration can choose to delay the tax again in 2020, when it is currently set to go into effect

9

Adjust parameters for 1332 waivers1332  waivers permit states to adopt innovative structures, as long as the coverage retains the basic protections of the ACA 

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*This list is not comprehensive and HHS Secretary Tom Price may pursue different courses of action in implementing healthcare reform

What is actually possible?

Stop defending the ACA in court

Dismantle Federal Revenues

Stop Enforcing Regulations

Limit Funding

Congress has begun the process known as budget reconciliation to repeal provisions which affect federal revenues.

Eliminate:• ACA Subsidies• Medicaid Expansion• Medical Device Tax• Cadillac Tax

Block payments meant tooffset the financial risks facedby insurers.

Taking away payments through the risk corridor or risk adjustment programs disincentives insurers from participating in the exchanges.

Limit funding meant to promotesign-ups during openenrollment.

Stop implementing or enforcingsome of the ACA’s regulations.

Such as:• Restrictions on insurers

offering plans with limitedbenefits

• Grant waivers to allowstates to opt out of parts ofthe law

• Broaden hardship exemption to allow people to remain uninsured

The Trump administration could choose to stop fighting the lawsuit the House GOP brought against the Obama administration.

This would shut off subsidies for low-income patients. Without these incentives, insurance companies could drop out of the markets, essentially ensuring their collapse.

Rolling Back the Affordable Care Act

Affordable Care Act’s approval numbers spike amidst GOP’s attempt to repeal the law

What is Worth Protecting?

No discrimination based on pre‐existing conditions, health care condition, family history, race, 

gender, or income

No annual or life‐time caps

Preventive care services and vaccines should be provided with no out‐of‐pocket costs

Physician workforcestrategy where primary care is fundamental

Contraception and maternity care should be covered 

essential benefits

Viable and equitable safety‐net program for low‐income 

individuals 

Health insurance products should have uniform set of 

minimum benefits

No patient should lose their coverage due to an action or inaction of 

Congress

The Affordable Care Act

$

OHWV

VA

PA

NY

ME

NC

SC

GA

TN

KY

IN

MIWI

MN

IL

LATX

OK

ID

NV

OR

WA

CA

AZNM

CO

WY

MT ND

SD

IA

UT

FL

AR

MO

MS AL

NE

KS

AK

Analysis Finds that in 2017, Seven States Will Have Only One Carrier Per ACA Exchange Market Rating Region

Analysis• Rating regions are the

geographic areas used to set insurance premiums.

• Avalere found that in 2017, seven states –AK, AL, KS, NC, OK, SC and WY – will have only one insurer in each of their ACA markets.

States with ACA exchanges markets facing limited competition■ States with only one insurer in their ACA markets Key

Players: Governors

What’s next for health care?

Will Trump’s administration undermine ACA?• Possibly. However, if Trump’s administration

does cause the law to collapse, there will likely be significant political consequences

Will Planned Parenthood be defunded in the government shutdown fight?• Unknown. House will require, but legislation

defunding PP will not pass the Senate

What about entitlement reform and drug pricing legislation?• Medicare/Social Security reform is unlikely to

occur in the next two years• Drug pricing legislation is possible, but

unlikely in the short term due to a number of other legislative priorities (e.g. tax reform, infrastructure)

Will CHIP be reauthorized in time? Will UFAs be negotiated in time?• CHIP and other Medicare extenders will

probably be passed together with FDA user fee agreements in a must-pass bill

• Reauthorization might be linked to revisitationof ACA – this could prove very difficult and endanger the rest of the package

Will there be any more serious attempts to replace the ACA?• Maybe. Any serious attempt would likely be a

more minor, bipartisan, legislative fix to ACA

Will ACA taxes be repealed through tax reform?• Unlikely – if tax reform is to be passed

through budget reconciliation, the legislation must be budget neutral. As the GOP was unable to cut the programs that these taxes fund, they will also be unable to cut the associated taxes

July

Congress faces many legislative deadlines in the fall, August recess will likely lead to a chaotic session in September

The Children’s Health Insurance Program (CHIP) expands healthcare coverage to uninsured children ineligible for Medicaid. CHIP funding is currently being considered in Republicans’ plan to replace Obamacare

Sept 29 – CHIP funding expiresSept 29 – FAA authorization expires

Since talks to advance long-term authorization for the FAA failed in 2016, the Republican Congress will be forced to take up the issue again next year

Sept 29 – End of FY17

Congress must pass budget and appropriations legislation before the new fiscal year begins on October 1 to avoid a government shutdown

Mid-Oct – US will reach debt ceiling

Since mid-March, the Treasury Department has been using special accounting measures to allow the government to continue borrowing as needed. The Congressional Budget Office has estimated that these special measures can only be used until mid-October

The National Flood Insurance Program (NFIP) provides flood insurance to property owners and insures roughly 5 million homes at present. The current legislation is set to expire at the end of September

Sept 29 – NFIP funding expires

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August (Recess) September October

■ Both chambers in session ■ Senate in session only ■ Major legislative deadline

2017 congressional calendar, July-October

Deadlines Matter:Congressional Cliffs

In CY18 January

December

Debt Ceiling3/15/17

4/15/17

Community Health Center funding, CHIP and THCs; extended under MACRA

9/30/17PDUFA

12/31/17Medicare Therapy Caps Exception Process Expires

Continuing Resolution4/28/17

Budget Resolution

9/30/17

• CHIP funding ends after September, but state/federal interaction on the CHIP block grant likely requires swifter action (March?)

• CHIP extension could be used as an inducement to attract Democratic support to overcome a filibuster• While CHIP is a feel-good program perceived as widely bipartisan, Democrats value Medicaid much more

highly• Unfortunately, kids don’t vote, so CHIP’s continuation is not a given

CHIP as a Vehicle?

End of CHIP Funding Sept.30

Considered “must pass” legislation

• Enrollment in the two programs proves the value is up– Care for ~8 million children financed by CHIP– Medicaid enrollment is currently 74+ million

CHIP as a Vehicle?

End of CHIP Funding Sept.30

Considered “must pass” legislation as SGR has ended

• This would be a real loss, because gains in Medicaid and CHIP enrollment have led to the highest rate of child insurance ever: greater than 95% of US children now have health insurance

Other Entitlements IssuesCMS implementation of QPP –• virtual groups for 2018• “Pick Your Pace”

Regulatory Burden - 54 House members (almost all GOP) letter to Sec. Price 5/23 requesting HHS reduce the regulatory burden

Direct Primary Care: • Primary Care Enhancement Act (sponsored by Rep.

Erik Paulsen) would allow patients with HSAs to avail themselves of DPC.

• President’s FY2018 Budget request (released yesterday) indicates intent to work with states to promote DPC in Medicaid.

Other Entitlements Issues (cont’d)CHRONIC Care Act (sponsored by Sen. Hatch) – result of a heavily stakeholdered 2-year process. • extension of Independence at Home • expansion of telehealth in Medicare Advantage and

ACO models, and • prospective attribution of beneficiaries to ACOs. Independence at Home - Bipartisan support exists in House and Senate for big expansionTelehealth -- Momentum in Senate for the CONNECT Act(sponsored by Sen. Schatz), gives CMS waiver authority

Other Entitlements Issues (cont’d)GME - first part GAO study expected within weeks or daysVeterans Affairs committees in House and Senate are looking at ways to use resources from VACAA (the 2014 Veterans bill in response to crisis in Arizona) to pay for FM training outside of VA facilities. THC GME - Coalition is working to get stand-alone bills introduced to extend program past Sept. 30.

Teaching Health Centers

• Started with 63 residents; now have 742 residents and 59 THCs in 27 states

• 55% of residents stay in underserved area (vs. 26% nationally); 82% practice primary care (23% nationally)

• Expires 09/30/17; MACRA extended for 2 years• 91 Members of the House request at least three year

reauthorization in 04/12/17 letter

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Budget and Approps Highlights• “America First - A Budget Blueprint to Make America Great Again”• “Consolidate” AHRQ activities into a “National Institute for Research on

Safety and Quality or NIRSQ” at NIH – Cuts AHRQ’s appropriation from $324 million to $272 million in FY 2018 – Highlights “critical survey activities, support for USPSTF, evidence-based practice

centers, patient safety, investigator-initiated grants, and researcher training grants” as well as “evidence-based practice centers, addressing the opioid epidemic, and the Healthcare Cost and Utilization Project”

• Eliminates Title VII, Section 747 primary care training grants and nearly all health professions and nursing training programs citing a lack of evidence of “significantly improving the Nation's health workforce”

• HRSA Rural Health programs would be cut from $156 million to $74 million• Level-funds family planning• Propose to eliminate the Public Service Loan Forgiveness (PSLF) program

Public Health• Goals: prevent legislative interference

regarding women’s health and increase access to vaccines, chronic disease and injury prevention

• Two public health legislative vehicles– $1 trillion transportation infrastructure bill

may include funding for walking paths and built environment initiatives

– Farm Bill renews Fresh Fruit Veg program, Supplemental Nutrition Assistance Program, and SNAP’s Nutrition Education program

Tobacco and Public Health• In 2009, Congress enacted the Tobacco Control Act giving

the FDA broad authority for tobacco and products derived from tobacco that were not previously regulated. – In Feb, the AAFP opposed legislation (HR 564) to exempt cigar

products from FDA’s Tobacco Control Act’s authority. – May 11 - the AAFP signed a letter supporting legislation requiring

Veteran Health Administration facilities become smoke free (HR 1662).

– On May 9, Congress confirmed the new FDA commission, Scott Gottlieb, who is an internal medicine physician who has strong drug industry ties. AAFP will certainly monitor his willingness to maintain strong FDA TCA enforcement.

Impact Policy

As public health experts and constituents, your legislators genuinely want to hear from you. Join the Network, organize, and with one voice, shape family

medicine!

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Join the Family Physician Action Network

Get Informed Speak TogetherCoordinate

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97% of Legislators now participate on social media *

77% of Legislators were

directly influenced by constituency comments on social media *

www.aafp.com/grassroots

Join the Family Physician Action NetworkAccess Network-only contentEngage in grassroots campaigns Move in coordination with fellow physiciansParticipate at the level you see fit

*According to a 2015 study done by the Congressional Management Foundation

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