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Tuesday Apr 11, 2017

Go Ahead, I'm Listening

"In my mind, I'm going to Carolina"
-- JamesTaylor

One of the most important aspects of this blog, as it is with other AAFP communications, is the feedback provided by each of you. Your feedback plays an important role in shaping the advocacy and policy activities of the AAFP. Your comments serve as the "canary in the coal mine," in some respects, which allows us to gauge the mood, sentiment, and overall feeling of our membership on any given issue, at any given point in time. Sometimes the canary doesn't come out, sometimes it does.

I have a colleague who is a master of the PDSA (Plan-Do-Study-Act) Cycle (tip of the hat to AAFP senior vice president of  education Clif Knight, M.D.) and the value of creating a continuous cycle of evaluation, planning and action. My attention span limits me to one of these activities at a time, so I decided to choose "evaluation." As part of this evaluation, I decided to look at the comments provided in response to my postings since the 2016 presidential election -- about four months. During this time period, I have covered a variety of topics that range from purely political topics, such as the elections; to more wonkish topics, such as the Medicare Access and CHIP Reauthorization Act (MACRA) implementation and the Patient Protection and Affordable Care Act (ACA); to practice management topics such as administrative and regulatory reform.

Your comments regarding these issues fell into three large categories:

  • the AAFP does not represent me or my views;
  • administrative burden; and 
  • the ACA isn't working and should be repealed.

There were secondary issues, such as direct primary care, single-payer, graduate medical education, scope of practice, and a few pithy comments on elected officials. But overall these three themes were dominant. In this posting, I am going to take a deep dive into the first of these three. In my next posting on April 25, I will explore the second and third issue.

"The AAFP doesn't represent me or my views," was the most common theme during the past four months. In most cases it was in reference to a single issue (e.g., the AAFP does not represent my view on single-payer or ACA repeal) and not a definitive statement on the full scope of AAFP's member services. However, there were some pointed comments regarding our advocacy efforts with respect to solo and small practices.

The AAFP represents a diverse membership. The diversity of family medicine is its strength, and diversity is also a key to our future. Diversity should be celebrated, but we also must acknowledge that it requires some patience and it forces us to be honest about the fact that there may be issues where our membership disagrees. Maintaining a focus on a common goal is important to balancing these differences.  

The AAFP mission statement directs us to "improve the health of patients, families, and communities by serving the needs of members with professionalism and creativity." Put more frankly, our goal is to support and advance policies that allow each of you to provide the highest quality of care to your patients in a practice environment that provides you professional satisfaction and financial remuneration that reflects your skills and services. This is our common goal.

The most common comment received was, "the AAFP never asks what I think." I recognize that many of you share this sentiment, but I can assure you that we do want to hear what you think. Each year, since 1992, the AAFP has conducted a member satisfaction survey whereby we ask a sample (5,000) of our membership to share their views and opinions on a variety of policy, education and membership issues. This year, we made the survey available to all members. If you haven't yet taken the survey, there is still time through the end of this month.

The survey's findings are collected, dissected and discussed to determine what we can do to better serve our members. I can assure you these reports do not go on the shelf. They drive work (lots of work) on your behalf. The survey has been issued annually for more than 20 years, so it plays a key role in helping us identify trends in the professional and practice challenges facing family physicians. By following "trend lines" we can develop and advance solutions before "trend" transforms into "crisis."

The second most common comment in this category was, "the AAFP does not represent my views on this policy." AAFP policies are established and reaffirmed by the Congress of Delegates  (COD). The COD is a representative body that meets annually to develop and set policy, and to elect your officers and members of the AAFP Board of Directors. Each year, the COD considers resolutions that aim to establish policy on relevant issues. You can read and comment on the 2017 resolutions in advance of the COD and communicate your support, opposition, or concerns. (None have been submitted yet for the Sept. 11-13 event in San Antonio.)

I would encourage you to first communicate with your state's elected COD delegates on policy issues under the purview of the COD. You also should feel free to reach out to your state chapter  on important issues. The elected delegates from your state are your voice at the COD.

If you prefer to communicate with a national representative, then you should feel free to contact any member of the AAFP Board at any time to share your views and opinions.  

The COD represents you and it benefits from engagement and diversity of opinion. If you are interested in participating in the COD, please use these resources.   

These are the mechanisms in place for you to communicate your views and opinions -- through our official representative body, the Congress of Delegates; through our elected leadership, the Board of Directors; and through our annual membership survey. You also should continue to comment on the various AAFP blogs and AAFP News on specific issues. You also can engage with the AAFP via social media at @aafp on Twitter and on Facebook. If these communication channels don't suit you, you can email me. I want to hear from you.

I thought it would be fun to address a few specific comments:

  • "You are not a physician."
    Yes, this continues to be a source of disappointment for my parents.  Despite my lack of medical credentials, I have traveled this road for several years and, in my opinion, have a pretty good understanding of family medicine and the health care system.
  • I have been told, "You are a shill for liberal policies," AND "You are a shill for conservative policies."
    I try to stay fair and balanced.
  • "You just write what CMS tells you to write."
    I do attempt to share information from CMS with our members, but I can assure you CMS doesn't always like what I have to say. They tell me so.
  • "The AAFP forgets who pays its bills."
    I never lose sight of who and what matters.  We might disagree from time to time, but your interests are my interest.
  • "You pick on Texas too much."
    I will never stop (after all I am an Oklahoma fan!)

Thank you for your continued membership and your support of this blog. Most importantly, thank you for what you do for your patients, your community and our country.  

I leave you with Sir Winston Churchill, who said, "A pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty."

I see a lot of opportunity.


You DO NOT REPRESENT ME!!! I want the Unaffordable Care Act Removed. I do not like the red tape I am forced to perform day in and day out. EMR has alot of bonuses but the extra papers we need to print off for our patients (CVS, 10 pages of education) is stupid and OverKILL. YOU do not work in the real world. Small office practicitioners are closing their offices. We are going to only have health clinics run by Universities and Insurance companies. No one cares for the patient. We are forced to care for the insurance company and the" do nothing" USPSTF. If I follow the guidelines from USPSTF I should have just become a therapist since all I do is offer guidance. I am opposed to your constant phone calls demanding me to support your governmental values. When you take away our ability to work independanty you take away our reason for schooling. Get rid of medical school and employ an IBM Watson. Make every visit a SCPE visit. Watch what will happen to society. Patients need doctors who care and listen and physically touch them. Why not appoint doctors who actually have to see patients for a living to bring some insight into your politics? The organization is so far removed from the real world.

Posted by Diane Ojugbeli, M.D. on April 11, 2017 at 11:15 AM CDT #

The AAFP has forgotton it's mandate. It is an organization to represent Family Medicine, and ONLY Family Medicine. It is not there to promote government policy, and it is not there to fight for "patient rights". There are other organizations for that.

We need the AAPF to notice a few things.

1. We are being legislated to death. We now are speding wasted time and effort on mandated policies especially "quality" measures, Meaningful use, MACRA, "Medical Homes", PQRS, etc. Why doesn't the AAFP keep some of this excessive burdensome regulation off of our backs??

2. We are now the LOWEST paid specialty, per recent reports from Medical Economics. Great work.

Please get to work and SAVE us from what we are paying you to to. If I had to go into Family Medicine all over again, I would never have done it. Our organization does not stand up for us, you only try to "suck up" to whichever party happens to be in power. Look where that has left us.

Posted by Kim Merriman MD on April 11, 2017 at 11:36 AM CDT #

I have to agree with those that think you have not been part of the solution but have instead been part of the problem facing physicians in smaller practices. I am still a member but I wonder why at times.

I literally gave away my practice in 2014. I felt like someone tied to the railroad track looking at the locomotive barreling down on me (ACA that cost me many of my patients) at the same time an avalanche of regulation was headed my way.

The deductibles for so many patients now are making insurance more of a catastrophic plan for the unsubsidized. People in the big groups usually have no concept of what it takes to run a successful business in small town America or in smaller practices. When I see what is going on in practices that are trying to do all the measures I don't see better quality overall. I see more attention to some measurable items and far less attention to the overall needs of the patients.

Posted by John M Strong on April 11, 2017 at 01:34 PM CDT #


Help us turn your blog into more than a gripe board. Instead of telling us that you are already following the wishes of academy members, give us some actual examples of what you are doing/changing based on surveys and member input.

Show us a survey that shows that most AAFP members support the ACA. If you don't have data supporting that, explain to us why the academy is still supporting the ACA.

Posted by Solo in Indiana on April 11, 2017 at 01:47 PM CDT #

Even physicians blame the ACA for the problems we face. The ACA if it is allowed to continue, is the best thing that happened to FP's. EHR's, MACRA, Meaningful use, etc are all from Medicare.

Our problem is so many of our specialty want to continue to practice the way we did for decades. We have the potential to do so much more to promote and protect our patients' and our society's health BUT we are not given the reimbursement to be able to implement these changes. If we were given $100/patient/month we could have a full complement in our offices - physicians, NP/PA if desired, RN's, MA's, social service, PharmD, psych support, and lots of support personnel to handle documentation and data collection.

My beef with AAFP is you all know this but the AAFP is not aggressive enough with the Feds. There is general recognition of the need for more FP's doing more comprehensive work for populations in addition to individuals. But until we can afford to do the advanced 21st century care, not only will nothing happen, it will get worse.

Canada found out that when FP's earn 80% of what limited specialists earn, no more FP shortage. Tell Congress to get off their butts and authorize HHS to revamp the payment system and to fund our ability to provide better, more comprehensive care without all the non-physician work. A true medical home can do it but the only ones doing it well are the ones owned by insurance companies: Kaiser, Group Health, Geisinger, etc.

Or, let's get serious and get rid of all the insurance companies and have government funded basic health care. Again, with adequate primary care funding ($100/member/month) so we can actually do something. You need to be MUCH more aggressive about family medicine.

I've been a physician 40 years now. I have not seen enough LOUD support for us yet. We should have people in front of House, Senate and Executive members daily.

Posted by John Messmer, MD on April 11, 2017 at 01:48 PM CDT #

Mr. Martin, as an AAFP member since residency, I appreciate the work you and the AAFP have done and continue to do on behalf of patients and physicians in America, but also beyond. I sympathize with my colleagues and believe that while they certainly each have merit, any sharpness to their critiques comes primarily from the very real pain many are experiencing. It is one of the most trying times mentally and physically to be a doctor. Many are burned out. Many are coping by drugs, alcohol, maladaptive behaviors, even suicide. I feel myself extremely blessed to have gone through my own career burn-out some years ago and come out on the other side; but learned a great deal - mainly humility, and gratefulness. The AAFP appropriately is pressing the envelope with PCMH, ACOs, Direct, and other novel models of care, and wearing many hats. It will never please all of us all of the time. But thank you for all you are doing, including hearing us out in our frustrating time of need. God bless you, and God bless all the doctors on this post, who are doing their best in a very difficult time.

Posted by James Walker, MD on April 11, 2017 at 02:49 PM CDT #

I am about to graduate residency and to start my job as an attending. I thought this article was helpful because it made me realize how diverse the doctors AAFP represents. I am a minority serving underserved minorities in west Chicago. My wife and I plan to teach medicine in other countries in the future-- and while the American system is the most costly and behind in so many measures compared to other medical systems, there is still a lot that we do that other countries want to emulate-- mature and professional organizations like the AAFP being one of them. I cannot say I know how hard it is to be a family doc in a traditional private practice, but I do think there are changes that have happened through the ACA and AAFP's involvement that are for the better and position our country to catching up to what other countries are already doing. Progress is hard because it is slow, but I am still optimistic the AAFP is more helpful than not.

Posted by Henry Del Rosario on April 11, 2017 at 04:37 PM CDT #

The AAFP needs to keep the revision of the ACA be an affordable solution for all Americans. We need to keep it simple and affordable. Need to focus on globalization of the EMR with patient unique number so that there is only one medical record number per patient. This would eliminate medical errors, duplication of services and avoid fraud.
The savings would be in the trillions of dollars.

Posted by Juan Rivera, MD on April 11, 2017 at 07:38 PM CDT #

I also agree that the AAFP has become too partisan and too political. I appreciate this blog because it provided an organized map of how my voice can be heard by the AAFP.
I feel that the Academy is more involved in "patient" rights than "physician" rights. As a physician and member I expect the Academy to protect my rights and lobby for ways to make it easier for me to do my job and to be more profitable. Please, stick to being the physicians advocate and we as physicians will be the patients advocates.
I think one issue we can all agree on is the burden placed on us and our staff to complete the numerous and time consuming pre and prior authorizations for imaging studies and medications. What is being done to eliminate this burden?? I find it hard to believe that this one issue that we would all be united on, can not be resolved!

Posted by Mildred Frantz MD on April 11, 2017 at 08:52 PM CDT #

Thanks Shawn for doing your blog and keeping us up to date. I think what you have been seeing is a lot of frustration and anger because we are all stressed to the max mentally and financially and I would say especially us private docs. Health care reform has to be daunting and is very complicated. But I think some common sense should be applied and that would come from us front line docs. I would like to see a panel of non academic front line family docs from diverse practice settings set up to give suggestions to both you guys and lobbyist and congressman. We have a lot to say. ON health care reform, common sense would say first you have to bring down cost before insurance premiums become affordable. That is the starting point. No system is going to work before we do that whether is is all private, a mix or government. Under ACA as I see it insurance companies have no incentive to bring cost down because they are only allowed to make 15% above cost, so how do they make more? They pay out higher cost like 450 dollars for insulin and more for other common medications test etc, and then raise premiums. If they can make their 15% on 2000 dollars instead ot 1000 dollars they make 300 not 150. So prices of drugs and test spiral. However due to pricing mandated by govt and followed by private insurance at slighty a higher rate, doctors visits stay the same price, thus our incomes do not go up. Yet drug companies are raising prices by huge amounts under the guise of free enterprise. Us in the trenches are not really free enterprise as we have no power to negotiate .Yes DPC does alleviate some of that but, some of us in rural areas cannot do DPC. I have a patient that works for lowes company and they have negotiated with hospitals directly and he is going to be flown up North with a private nurse assitant who will be put in a hotel and have his hip replaced at a lower cost than what REGULAR insurance will pay at a very well known reputable hospital. SO yes pricing can be negioated by insurance companies but they have no incentive. Cant negioate drug prices for Medicare? Ridiculous!! THe new cholesteral lowering drug is 1200 a month. Brand name blood pressure medications 250 a month used to be 60 for same medication.. Medicare D program supposed to make medications affordable, I was so hopeful....not! Assistance programs went away and prices soared. Medicare paying 8000 for a scooter?ridiculas. Fraud also plays a role in cost. THen we get into the cost of regulation. MIPS, MACRA, PQRS etc etc drive up cost to use with no reimbursement and a huge cost to the system and for what?? Has it saved money? Has it improved care? Can anyone tell us? I admit I love my EHR because things are so organized. But After the intial incentive no one is helping me pay for it! It bill is large and Macra etc has slowed down my nurses so we cant see as many patinets. Health insurance for my business, no longer affordable so had to drop it for my employees. Now some cannot afford ACA insurance even with a subsidy. So many fingers dipping into the insurance and medicare pool its incredible and mind blowing. So lets work on getting cost and fraud down with some common sense, and then discuss how we will deliver the care whether it be private or government. LEts get rid of some reglulatory burden on everyone and make this easier and use some common sense not what some beurocratic bean counters say is what is best. Lets get a grassroots panel for the AAFP together and make some suggestions outside of the AAFP elected beurocracy. My dad was once President of the NC Academy of FP. ONe of the reasons you may not see too many grassroots docs on State and National committees i that we cant afford to take off time and still have 2 weeks of needed vacation a year. Back then he worked 4 days a week and had some time to devote to FP politics. I do not have that luxury. I have reached out to our congressman Mark Meadows asking To talk about this without response. He is on the front lines. So lets talk about cutting cost and regulations both short and long term and then figure out how to make it affordable for all..ps my premium for bronze is 950 a month with 6100 deductable and almost the same for my 54 yr old employee and her husband (1200 for both)who make a lot less than I do. That is not affordable and In NC only BCBS is the only company doing ACA. 10% of state do have a couple of other plans. Make cost of tests, like MRI's, drug cost, procedure cost transparent..ever tried to find the cost of Medications from your pharmacy? We are left with looking on goodrx. Want to know how much your hip replacemnt is going to cost? Good luck.. I can find out how much a drug from canada is going to cost me. Finally we have one of the worst outcomes of most industrialized countries and it cost us more. What does that tell you. Tells me the pharma, hospital, and insurance lobby is very strong. We are not. Sigh

Posted by Michael Brown on April 11, 2017 at 09:04 PM CDT #

Thank you for your hard work. I appreciate the AAFP very very much. As for politics, it is important for the AAFP to take a stand. The ACA is not perfect, but it has done the more than any previous healthcare legislation to promote healthcare for as many Americans as possible. That's important, and It is right to advocate for the ACA. I thank the AAFP for trying hard to understand it's members. We are a very large and diverse group of people and that is to be celebrated. From my perspective, the people at the AAFP don't get enough positive strokes. Thank you, thank you! I am proud to be a Family Physician and I am proud of the AAFP!

Posted by John Merrill-Steskal on April 11, 2017 at 10:56 PM CDT #

I appreciate anyone who will stand up to public scrutiny as a representative for the entire population. It is hard to negotiate issues for every special interest and I say this as I am a rural private physician in single specialist practice.

I have personal knowledge that ACA is not affordable and does not cover the population it intended. My brother and sister have had pre-existing conditions since they were under my parent's insurance and have never been offered insurance. That issue was corrected with Obamacare, but then it was too expensive and obtrusive. They were offered $1500.00/month to cover them individually, not their family and had $5000 deductible. None of the physicians or hospitals in her county took the insurance. They opted to pay the $900.00 fine for no insurance. My sister delivered twins vaginally and still could afford that more than Obamacare.

Insurance should be competitive, cross state lines, allow adjustments in coverage and deductibles to fit the patient's needs, cover hospital and physicians in their county, transparent drug costs and not be tied to employment!! They need the opportunity to buy insurance......what we have does not make that possible!!!

Posted by Belinda Maples on April 13, 2017 at 05:32 PM CDT #

I have been thinking a lot on the state of our union so to speak. There are so many things wrong with the direction that health care is going. A few small wins but they have been dismal in effecting true change. So I wrote a long letter but cannot attach it here because of space limitations. So I sending it to you direct. It is very hard for me to put things into one or two points. Part of our issue is that health care is complex and cannot be reduced to talking points or one liners. Not sure if it will help or if there is a better way to send it but let me know.

Posted by Scott Macleod on April 15, 2017 at 10:35 AM CDT #

Shawn, your comments reflect what many of us know to be so true "It is not easy to represent the views of a group as diverse as the AAFP". One recent survey showed that Family Physicians were more split 50/50 politically than any other medical specialty. Sometimes I wonder how the AAFP is able to rise to the occasion and accomplish as much as it does. But one thing is clear-- all of us want to see the American health care system fixed--not a Republican fix or a Democratic fix. There has been far too much politics already. We should not focus on Trump Care or Obama Care we need Ameri Care a program that addresses our basic AAFP goals of affordable accessible high quality care with a foundation of comprehensive primary care that addresses, acute, chronic and preventive care. And the needs of physicians, especially in primary care need addressed as well. The AAFP should advocate to overcome this intense partisanship that strangles progress and push for a stronger middle ground consensus, We should all be able to support that.

Posted by Michael Baxter, MD on April 17, 2017 at 05:12 PM CDT #

Excellent blog post. Thanks for all you are doing. We'll keep challenging our Academy from all perspectives.

Posted by Stephen S Stabile on April 23, 2017 at 02:24 PM CDT #

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About the Author

Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.