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Thursday Oct 23, 2014

We Are the Solution: Let's Spotlight Family Medicine's Value

At a state chapter meeting earlier this year I spoke with a family physician who questioned whether the AAFP's elected leaders understand and appreciate the challenges our members -- particularly small practice physicians -- face on a day-to-day basis. It wasn't the first time I had heard this comment, and it might not be the last.

The fact is I am a small-town, small practice physician. I practice full scope family medicine in the same Nebraska town where I grew up in, providing obstetric care, geriatric care and everything in between. I also am medical director for our local nursing home, a team physician for a local school and a volunteer faculty member at the University of Nebraska. I know comprehensive family medicine because it has been my life -- and my passion -- for the past 30 years.

This coming year, however, might be the most exciting yet for me and for family medicine. Today, the Academy, along with seven other national family medicine organizations, will launch a three-year national advertising campaign -- the culmination of the Family Medicine for America's Health  initiative -- using advertising, news media, online and digital communications to educate decision makers about the value of family medicine and primary care. The campaign also is designed to educate patients and get them more involved in their own health care. And work will begin this fall on the implementation of a five-year strategic planning effort.

During the next few years we will work to engage and inspire medical students to work in family medicine by connecting them with our vision for the future of health care. The number of medical students choosing family medicine has increased five years in a row, but we need even more family physicians to meet the needs of our health care system. My own son is a fourth-year medical student who is interested in family medicine, but I understand that the staggering debt many of his peers face coming out of medical school makes it difficult for some to see the rewards of family medicine.

One of the focuses for my presidential term will be to break down barriers that prevent students from choosing a career in family medicine. This needs to be approached on two fronts: debt relief for doctors who make the socially responsible choice to be family physicians and improving payment to appropriately value our services.

The current fragmented system of health care delivery is costly and of low quality. The core value of family medicine -- comprehensive, continuous and coordinated care -- is being recognized as the solution to delivering high quality, cost-effective care. Our new campaign will coincide with a five-year strategic implementation effort that will address not only  payment reform and workforce development but also practice transformation and research that supports our vision for the future of family medicine in an evidence-based way.

Another aspect of our new initiative will be to define family medicine and the scope of our specialty and to help our members practice to the full scope of their training. I tell students, "You choose your future," and I truly believe that statement sums up the advantages of family medicine. We can be as comprehensive as we want to be. If I have a patient who needs heart valve surgery, I can't provide that service. But I can find my patient an excellent surgeon who can perform that surgery, and I will be right there with my patient throughout that experience. The confidence my patients have in me is immense -- they trust me to do the right thing. I tell students they can have that same kind of relationships with their patients no matter where they choose to practice family medicine.

There are a number of new and expanding medical schools, but our country needs more family medicine residency positions to ensure that graduates have a place to continue their training. The Academy recently introduced a proposal that would drastically change graduate medical education.

Another area of emphasis for me will be to reach out to members, listen to their concerns and work to bring the joy back to practicing family medicine. Whether I'm visiting state chapters, lobbying on Capitol Hill or meeting with health plans, you can keep up to date on what I'm doing on your behalf by following me on Twitter @aafpprez and the AAFP President's Facebook page.

In this coming year we are going to shine a bright light on family medicine and define its value. This is an incredible time to be your president, and I thank you for the opportunity.

Robert Wergin, M.D., is president of the AAFP.

Monday Oct 20, 2014

My Year as President: The Honor Has Been Mine

It is hard to believe that a year has passed so quickly. In fact, I was blessed to have a 13-month term as AAFP president, and I did my best to make the most of it. In so many ways, this time on the AAFP Board of Directors has reminded me of my professional path, having worked as a small-town family physician before becoming residency faculty.  

I always tell new faculty at East Tennessee State University that you have to work at least five years to see the patterns in medical training and avoid the panic that often comes when challenges arise. Similarly, I am finishing my fifth year on the Board, and I have learned a lot in that time. It has been an exciting period, and I want to summarize some of my experiences.

 © 2014 Marketing Images/AAFP
Speaking with students, like I am here at the National Conference of Family Medicine Residents and Medical Students, is one important aspect of being the Academy's president.

When I was running for president-elect, I promised I was going to do my best to say yes -- and I have. This has been an amazing year. I topped 1 million miles on Delta and visited 17 AAFP chapters. One of the most profound experiences was the chance to meet not only the state leaders that we install in those chapters, but to meet our members who have chosen to put their energy into patient care and help our communities. Thank you for your dedication, your inspiration and for working through the many challenges. The time I have spent with you has helped me do a better job of understanding those challenges and representing family medicine in Washington, D.C.

I have spent a significant amount of time trying to reframe discussions about health care, including about scope of practice. Although this remains a significant issue from state to state, it's important to remember that we have a number of states that have allowed nurse practitioners to practice independently for years, and the results demonstrate this isn't the right solution to our nation's primary care shortage. Every state in our country is experiencing poor patient outcomes, decreased provider and patient satisfaction, and high costs.

The solution to these problems is to truly focus on increasing the number of primary care physicians in practice, creating more effective patient-centered medical homes, and providing care in a team-based fashion. The Comprehensive Primary Care Initiative for example, is demonstrating that the kinds of changes the AAFP has been advocating for more than 10 years are the changes that lead directly to improved outcomes and decreased costs.

And there are more data to come, so stay tuned.

One facet of the president's job is to represent the Academy at meetings with other health care organizations, which creates opportunities to network and make important connections. After all, it's critical that team-based care also include organizational teams. I was honored to be invited to meet with a number of organizations -- some for the first time -- and help create new relationships for the AAFP or strengthen existing ones. Among the opportunities I have taken advantage of have been invitations to the Academy of Breastfeeding Medicine, the AMA, the American Academy of Physician Assistants, the American Association of Nurse Practitioners, the American Board of Family Medicine, the American College of Osteopathic Family Physicians, the American Osteopathic Association (AOA), the American Pharmacists Association, the Association of Family Practice Physician Assistants, the National Hispanic Medical Association, the National Medical Association,  the Society of General Internal Medicine, the College of Family Physicians of Canada and the Society of Teachers of Family Medicine.  

Another important role of the president is to represent the Academy in Washington, and I was fortunate to be able to make numerous visits to the nation's capital. The sustainable growth rate remains one of our biggest challenges, but I truly have hope that we are moving in the right direction. Proposed bipartisan and bicameral legislation already in play could provide a unique opportunity during Congress' lame duck session. Our comprehensive advocacy approach with organizations such as the AMA, the American College of Surgeons, the American College of Physicians and the AOA have created a unified voice for medicine that is getting the attention of those on the Hill.

We have other serious issues ahead, such as avoiding Medicaid cuts and addressing the regulated sunsetting of the primary care bonus, but we are opening more doors and sitting down at more tables to discuss these matters.  

Years of effort recently culminated in some major steps forward in graduate medical (GME) reform. The Institute of Medicine released its long-awaited report, with which the Academy substantially agreed. We followed that up with our own recommendations and a GME summit on Capitol Hill that was quite positively received. We are challenging long-held processes in significant ways. Much discussion and negotiation awaits, but once again, we are at another table addressing one of our primary goals.  

Just before coming to this week's Congress of Delegates and AAFP Assembly, I attended a premedical health fair at the University of California in Davis, a gathering of thousands of students who are considering careers in the health professions. In addition, I have been blessed to speak with students everywhere I have gone this year. Students are our life blood and our pipeline. These connections are critical, and I look forward to maintaining them.

One key way to stay connected is social media. Three years ago, the Academy made a commitment to giving members real-time updates about how the president is representing family physicians. The AAFP President's Facebook page now has more than 1,400 "likes," and the AAFP President's Twitter account -- @aafpprez -- has 2,400 followers. The Board also is providing regular and more in-depth updates through this blog. The better we stay informed and connected, the better we can advocate for each other.

It has been an honor to represent you, and I will continue to work for you during my year as Board chair. Thank you for the opportunity to take your stories forward. I am excited this week to be handing off the president's role to Bob Wergin, M.D. A small-town doctor who practices full-scope family medicine, he is the right person at the right place at the right time to lead us forward.

Reid Blackwelder, M.D., is president of the AAFP.

Wednesday Oct 15, 2014

The Flight of My Life: Reflecting on Six Years of Service

In its more than 40 years, my little Hatz biplane has had quite a life. In the two decades we have shared the sky, we have introduced more than 400 kids to the thrill of flying and traveled all the way across the country. It has brought me immeasurable joy.

But like all things physical, wear and age were beginning to show. So six years ago, we started the long process of restoration from the ground up. We replaced fabric covering, installed new instruments and a wood propeller, and finished with an updated paint job.

Today, she looks like a beautiful new airplane that's ready for new adventures. When you fly as a pilot and when you restore a plane, you keep a record -- a logbook -- that lists every flight and every improvement you make.

Coincidentally, it was six years ago that I joined the AAFP's Board of Directors. In many ways, looking back over those six years is like opening my Academy logbook.

Just like for my plane, there was a lot of work to be done in family medicine. The specialty was in crisis. Payment was woefully inadequate. AAFP membership was down. Student interest was low. Forty-seven million Americans were uninsured. As a candidate running for the AAFP Board, I asked the Congress of Delegates, rhetorically, if we were actually witnessing the collapse of primary care.

Fast forward to today, and the outlook for family medicine has changed. Day to day, our work in the trenches continues to be challenging, but the forecast for the future from the 10,000-foot level of the Board chair is now encouraging.

Six years ago, we knew family medicine was valued by our patients -- we could see it every day in our offices. Barbara Starfield, M.D., M.P.H., had showcased the value of primary care in her research. Still, recognition of those truths -- and support for primary care – from payers, employers and government was lacking.

Today, the patient-centered medical home model has shown that improving primary care is the key to meeting the triple aim for health care: higher quality, lower costs and improved care for patients. The Comprehensive Primary Care Initiative launched by CMS' Center for Medicare and Medicaid Innovation is changing the way our government pays for primary care -- paying for value over volume -- and it is expanding. A growing number of employers, health plans and government agencies are beginning to demonstrate that they really value what we do. When it comes to payment reform, we haven't arrived at our destination, but we are on the way.

On Capitol Hill, we no longer have to explain to legislators and congressional staff what we family physicians do and why we matter. Federal agencies seek the Academy's input on important health care issues, and legislators are actively looking for ways to train more family physicians to address our country's primary care shortage.

But what about access to care? Today, there are 10 million newly insured Americans thanks to the Patient Protection and Affordable Care Act (ACA). Our uninsured rate now stands at 13 percent -- 5 percent lower than it was six years ago and the lowest it has been since 2000. Americans may be split on the ACA, but there is overwhelming support for some of the basic tenets of the law: getting more people covered by insurance and reforming unfair insurance rules, including no longer allowing denial of coverage based on pre-existing conditions, caps on coverage, or retroactive canceling of coverage after someone becomes sick.

However, there is still much work to be done. We need restraints on rising health care costs, malpractice reform and a path to creating the primary care workforce our country deserves. And we still have  millions of uninsured. We haven't arrived at our Academy's ultimate goal of health care for all, but we are on the way.

Interest in family medicine is up nationally. AAFP membership reached a record high this year at 115,900. And for the fifth consecutive year, the number of medical students choosing family medicine climbed higher than the previous year. Twenty-five percent of all U.S. medical students are now Academy members.

To meet the needs of our nation's health care system, those numbers must continue to grow; this year, the AAFP took steps to proactively ensure that they can. Last month, the Academy unveiled a proposal that would significantly change the way graduate medical education is financed. Our proposal would bring transparency and accountability to a system that invests $15 billion a year on physician training but is unable to produce a workforce that aligns with the needs of the nation.

I'm also proud of the work the Academy is doing in public health. Last year, we included the social determinants of health in our strategic plan. And this year, we began the process of reimagining Tar Wars -- a program I helped develop more than 25 years ago -- as part of a comprehensive tobacco and nicotine prevention and control program that will include new tools for family physicians, community programs and advocacy.

We've talked about where the Academy has been, but where are we going? During the AAFP Assembly in Washington next week, the AAFP -- along with seven other national family medicine organizations -- will launch a national campaign that is the culmination of the Family Medicine for America's Health initiative and the biggest thing to happen in family medicine since the Future of Family Medicine project in 2004. This campaign will speak not only to family physicians but also to patients, payers and others, defining what we do as family physicians and why primary care is the vital foundation of our health care system.

Now when I climb in my biplane, I can tell she is still the same plane I have known and loved all these years, yet with new energy and new life -- the way she climbs, handles and how her paint flashes in the sun. She has come a long way.

Today, we are all part of a rebirth of family medicine. Our voice is being heard, our contributions are being valued, and we, too, have come a long way. Our country is counting on us to continue to be "bold champions" for America's health, transforming health care for optimal health for everyone.

As for me, my Academy logbook is now full. It's time to open up a new logbook and start my next adventure. Thank you for granting me the privilege of serving you. It has been the flight of a lifetime.

Jeff Cain, M.D., is Board chair of the AAFP.

Patients Need Nutrition Facts From Their FP, Not Dr. Google

I enjoy discussing nutrition with my patients. It is an essential part of the lifestyle and prevention package that family physicians are uniquely positioned to prescribe.

Although I have not eaten meat in 40 years, I live with three people who consume it on a regular basis. I had to self-educate about nutrition when I chose to stop eating meat because this was before I had the benefit of the four nutrition lectures I got in medical school. During those years, I drank a lot of milkshakes and discovered that it picked me up for a short while, but fatigue would roll in within two to three hours.


Diet for a Small Planet by Frances Moore Lappe was my original textbook and guide. It's hard for me to believe that this book is now more than 40 years old. Fast forward to today, and our patients are taking nutrition advice from TV doctors, the Internet and other sources that might not be evidence based. Shouldn't they be hearing the facts from us?

Every time I sat down to write this blog post, a new latest-and-greatest declaration in some journal or meeting would derail me. But recently, the Annals of Internal Medicine published an NIH-funded study that confirmed some of the things I have been telling patients. Researchers suggest that a diet that cuts down on carbohydrates may work better than trimming fat to aid in losing weight.

There is no one diet that works for everyone. One size does not fit all. (That is one reason there are so many diets out there.) But it's worth noting that this study included males and females and was racially diverse.

The problem with limiting carbs is that it may lead patients to inadvertently skimp on dietary fiber, which is important for heart and colon health, as well as for making our patients feel "full."

I talk with my patients about moderation in a healthier diet, but the exception is dietary fiber. I talk about going from the national average intake of 14 grams a day up to 30 grams a day, increasing intake slowly. First we assess their consumption, and then we add only 3 more grams per week until we reach our goal. This regimen brought my own LDL cholesterol down by more than 40 points and has been quite effective for a number of my patients, although sometimes our guts tell us that they are not happy with our diet.

The motto of "First, do no harm" is critical, and that applies to supplements. Through my sports medicine affiliations I have been fortunate to glean excellent information on this topic. Just because something is natural does not imply it is safe. I have diagnosed new-onset hypertension in a number of patients who thought they were doing a good thing by taking a multivitamin but did not realize that in those supplements they also were taking herbs that raised their blood pressure. By taking them off the multivitamin, we were able to return patients' blood pressure to normal without medication.

At the end of the day, it is about balance and moderation and trying to get your nutrition from as primary a source as you can.

After I finish my term on the AAFP Board of Directors this month -- and eventually finish the patient-centered medical home recognition process, achieving meaningful use and transitioning to ICD-10 codes -- I think I will sit with a cup of tea and start an outline for a nutrition piece for American Family Physician to update our information because obesity is a prevalent disease, and family physicians are in a position to make a major impact.

Rebecca Jaffe, M.D., M.P.H., is a member of the AAFP Board of Directors.

Wednesday Oct 08, 2014

Asking Right Questions Critical to Making Right Match

It may seem like the academic year just started, but for fourth-year medical students, the decision about where to spend the next three or more years is just around the corner. And the fall and winter, also known as "interview season," is when it gets really interesting.

Fall is the time for fourth-years to prepare for the National Resident Matching Program -- better known as the Match -- by visiting and interviewing with potential residency programs. The AAFP offers a tremendous free resource -- Strolling Through the Match  -- that can be helpful to students regardless of year or specialty interest. The 80-page PDF covers a wide range of topics:

  • residency application timeline and checklist;
  • introduction to the Electronic Residency Application Service and the specialties that participate;
  • a residency program evaluation guide;
  • residency selection steps and interviewing tips;
  • examples of how the Match works for applicants;
  • new tips on post-interview etiquette; and  
  • tips on writing a curriculum vitae and a personal statement.

We used Strolling Through the Match widely at the University of Alabama when I was a student, and the information is practical and thorough. Still, some of the most valuable advice I received when preparing for interview season came from those who had been through the process and got their desired Match results, So, I thought it might be helpful to share the tips and takeaways from my experience just last year.

The most important thing to evaluate at each interview is how well you fit in with the faculty and, most importantly, the residents, because you will be working closely with them for the next three years (or more). If you can't get along with them, your life will be miserable.

After that, you have to prioritize the features you desire in a program, such as teaching exposure and the amount and extent of care you will provide to pediatric, obstetric and adult patients, as well as the amount of time you will spend working in inpatient versus outpatient settings. Your residency experiences form the bulk of your medical training, and if you aren't trained on something during residency, it's far more arduous to make that happen after residency.

If you have a spouse or significant other, involve that person in the decision-making process, especially if you are moving somewhere new. You will be extremely busy during residency, and he or she will have to spend a lot of time without you. Your loved one needs to be happy where you are going.

Realize that you aren't likely to find a perfect program, but you will have a gut feeling about where you belong, and that is more important than anything else.

You may already have interviews scheduled, but do you know what questions to ask? Here are some things to consider asking at each of your visits:

  • What are the program's board passage rates? This will give you an idea of how good the clinical experience is.
  • Where do the program's graduates get jobs? This will tell you whether the graduates are respected and perceived to be well-trained by the local community.
  • What are the strengths and weaknesses of the program? 
  • What kind of interaction do residents and faculty have outside of work?

While you are evaluating the programs you visit, keep in mind that you also are being evaluated at every moment, not just during the formal interviews. Residents will scrutinize you for your "fit" at any moment they interact with you, including meals and tours, so treat every moment seriously and always be on your toes.

Residency representatives will want to know why you are interested in their program and what specific aspects drew you there, so show you have done your research and be prepared to name something about that program other than just its name or reputation.

While fourth-year medical students are planning for the long term, it's not too early for first- through third-year students to start building CVs, learning as much as they can about each specialty, and seeking experiences that can help prepare them to choose their future. Here are some possible scenarios to consider:

  • First-year students, you can use your only summer off during medical school to experience family medicine. Find international service opportunities for students, or find a family physician to shadow. Your faculty or state chapter can help you with this.
  • Second-year students, build your CV by pursuing leadership opportunities on your campus -- for example, with your school's family medicine interest group.
  • Third-year students, get out of the academic health center during your elective rotations and experience primary care where it occurs most often -- in the community. Use the AAFP's clerkship directory to find an elective rotation.

Tate Hinkle, M.D., is the student member of the AAFP Board of Directors.

Friday Oct 03, 2014

The Countdown Begins: One Year to ICD-10

One year. That's how long we have to get ready for the official implementation of ICD-10. Oct. 1, 2015, is the day we have been nervously awaiting since July, when CMS confirmed that as the revised compliance date for the new coding system.

Later this month, the Academy will offer CME courses related to ICD-10 to help us prepare during the AAFP Assembly in Washington. Will your practice be ready?

Every time I read an article about ICD-10, I wonder how small practices like mine will survive this new hurdle. A study conducted by Nachimson Advisors and published by the AMA estimated that small practices could suffer costs between $56,000 and more than $226,000. A large practice's financial impact is estimated to range from $2 million to $8 million. These figures are three times what was estimated by the same research group just five years ago.

ICD-10 has more than 68,000 diagnostic codes compared with ICD-9, which has a little more than 14,000 diagnostic codes. This is a significant shift for family medicine. The differentiation of right, left and bilateral accounts for about 40 percent of the increase in codes for ICD-10. Initial versus subsequent diagnosis codes might create an obstacle for the busy physician but will ultimately be helpful for tracking purposes.

According to the American Health Information Management Association, the new coding system will result in higher-quality data that can improve measures of quality and performance, provide "increased sensitivity" to reimbursement methodologies, and help strengthen public health surveillance.

But how do we get there? Updates to my practice's electronic health record (EHR) system have allowed us to "bridge" to ICD-10 for the past eight months. Testing and payment disruptions are variables that are impossible for me to anticipate, and every consultant we talk to offers a different opinion as we try to assess how to proceed.

In my search for assistance on the web, I found "The Road to 10: The Small Physician Practice's Route to ICD-10," an online resource an online resource to help small physician practices transition to ICD-10. This tool was developed by CMS in collaboration with industry partners. It allows a small clinical practice to create a customized action plan for ICD-10 readiness and preparation. It provides a five-step action plan that covers planning, training staff, updating systems and processes, engaging partners, and testing.

Although that resource is geared to small practices, the AAFP and its journal Family Practice Management have resources that can help practices regardless of size.

In addition, CMS recently announced the dates that it will do readiness testing using ICD-10 codes.  What are you doing to prepare?

Rebecca Jaffe, M.D., M.P.H., is a member of the AAFP Board of Directors.

Wednesday Oct 01, 2014

We’re Doing Our Part to Keep SGR Issue on Congress' Radar

I will only be AAFP president for three more weeks, but there's a lot to do in this final month of my term. Throughout the year, I have had opportunities to represent the Academy at meetings with a number of organizations as we discuss important concepts such as team-based care and the patient centered medical home. One such opportunity came just this week when I participated on a panel for a Capitol Hill briefing that addressed payment reform, including the need to repeal the Medicare sustainable growth rate (SGR) formula.

This event was organized by the Society for General Internal Medicine (SGIM), which reissued a 2013 report developed by the National Commission on Physician Payment Reform. Many of the principles and recommendations in the report are in line with what the AAFP has been advocating for several years. Given the urgent need to push for passage of the bipartisan, bicameral legislation on SGR repeal already in play, this was an ideal time for the commission's report to be reissued.

I joined a panel that was moderated by SGIM president William Moran, M.D., and included SGIM health policy chair Mark Schwartz, M.D., and American College of Physicians EVP Steven Weinberger, M.D., also a member of the commission. We used this opportunity to review the principles and recommendations in detail with a room packed with legislative aides from both the House and Senate. Our most important ask was to encourage legislators to pass the SGR repeal proposal before the Congress adjourns in December.  

The commission's report, like the Academy's longstanding advocacy position, stressed the need to repeal the SGR, which again poses a looming threat to cut physician Medicare payments by more than 20 percent if Congress doesn't act by March 31.

As part of this briefing process, we reviewed many of the report's recommendations, which are in line with what the Academy has been saying in our own discussions with CMS, legislators and congressional staff for years.

Some of these important recommendations include the need to transition away from the fee-for-service model. We outlined the perverse incentives that this model has given rise to in our health care system. Although fee-for-service will continue to be important for some aspects of payment, we have to fix the disparities in current fee-for-service payment rates because they will be a foundation for future payment models. There have to be opportunities to rebalance fee-for-service payments, to boost undervalued evaluation and management codes, and to recalibrate overvalued codes -- many of which have not been revisited in more than 20 years despite huge gains in efficiency.

Our patients' health is becoming increasingly complex to manage, especially in a Medicare population in which 60 percent of patients have three or more chronic conditions. This additional complexity further accentuates the dramatic disparity between how our fee-for-service model pays for procedural services compared to primary care services. New technology has reduced the time it takes to perform certain procedures, yet payment for these services has not been reduced.  This contributes to the erosion of primary care incomes which exacerbates our primary care workforce shortage.

We emphasized the real need to recognize that compared with procedural services, primary care services require face-to-face time that cannot be shortened to increase volume without decreasing patient-centeredness and quality.

Another recommendation specifically addresses the significant potential for cost savings and improved care for patients with chronic conditions. The commission report noted that 5 percent of patients in this country account for 50 percent of our health care spending.  This will continue to drive an increasingly disproportionate share of spending as more and more patients develop multiple chronic conditions. This is an area that has significant potential for cost savings as we continue to transform our practices.

As family physicians, we know what to do. Much of the answer lies  in the patient-centered medical home, and implementing better and more efficient team-based care. Our country needs a stronger primary care foundation -- the essential message of the Commission’s report. The more incentives we can find for primary care and improving access for all of our patients, the more we will save in terms of downstream costs. 

We must move away from “wrong care, wrong place, wrong time” to ensuring patients get the right care, in the right place, at the right time and from the right person.  

Overall, attendees of the briefing were interested in the recommendations. We stressed that this push is a unique opportunity that brings together all of organized medicine in support of proposed legislation. In addition, once the 2014 midterm elections are over, the unique political landscape of a lame-duck session could grease the skids for passage of the bill.

Once the 114th Congress convenes in January, the SGR repeal legislation will lapse.  In addition, because of retirements and potential election-driven shifts in power, significant changes will occur within the committee leadership in Congress, posing potential roadblocks to restarting the bipartisan process.  Therefore, this lame-duck session is a unique and rare opportunity for some congressional lawmakers to put a feather in their hat by moving forward on an important and long-sought-after repeal of this fatally flawed formula.

You can help by contacting your legislators to let them know this must be a priority!

Reid Blackwelder, M.D., is president of the AAFP.

Friday Sep 26, 2014

The Doctor is Out: Retention Poses Major Challenge for CHCs

HHS announced Sept. 12 that it is making nearly $300 million available to nearly 1,200 community health centers (CHCs) across the country. The funding is intended to help CHCs hire more than 4,700 new health care professionals and offer longer hours and expanded services, including oral health, behavioral health, pharmacy and vision.

The funding is expected to help CHCs reach about 1.5 million new patients.

Although the funding for additional staff is needed -- and welcome -- the change doesn't address one of the biggest problems CHCs face -- retention. Not only do these clinics need more physicians, they need the physicians already working in these settings to feel motivated to stay in communities where they are desperately needed.

© 2014 Casey Health Institute
My first job after residency was at a community health center, but I now work at an integrative primary care practice. Research has shown that family physicians at community health centers have lower rates of job satisfaction.

Federally qualified health centers (FQHCs) are a source of primary care for millions of uninsured and underinsured patients. They're also the place where many family physicians -- like me -- get their first "real" job outside of residency.

I spent my first four years out of residency at a CHC, and I loved it despite the challenges. I served a culturally and socioeconomically diverse population that was in need of good health care. I truly felt like I was living up to being the doctor I wrote about in my medical school personal statement.

In addition to the reward of serving a community desperate for medical care, many physicians are drawn to CHCs by offers of loan repayment -- either as part of a National Health Service Corps commitment or through state and local programs. Although many physicians enter these doors excited and eager to help the people they went to medical school to serve, too often, physicians are just as eager to leave after their loans are repaid.

Research tell us that family physicians at CHCs are less satisfied with their work situation than other physicians. The reasons are multifactorial, including low compensation and excessive workload. Isolation from cultural activities and limited career opportunities for physicians' spouses in rural areas also contribute to dissatisfaction.

I saw several colleagues come through, do their time, repay their loans, and move on. This is a common theme, because family physicians often feel burned out after just a few years at a CHC. Many went to an FQHC not just to get their loans paid off, but rather to make a difference and fulfill a personal mission to serve the underserved. One friend and colleague told me she planned to come back to an FQHC at some point in her career. But after five years of having worked in that setting, she felt that if she hadn't left when she did, she would never have wanted to go back.

More than half the states and the District of Columbia are expanding their Medicaid programs under provisions of the Patient Protection and Affordable Care Act. Many of these new Medicaid enrollees will be seen at CHCs because many private practices don't accept Medicaid. This could lead to an increase in patient visits -- and potential headaches -- at the centers, which often struggle to fill vacant positions for physicians and other clinicians. To make matters worse, the low retention often creates a burden for those who do stay.

My interest in CHCs started in high school because I had a mentor who worked in that setting. Later, I volunteered at CHCs during medical school, and I had no doubt where I wanted to go after residency.

When I left my first job at a CHC, it wasn't because I was burned out. I had an amazing opportunity to work as a White House Fellow and spent a year advising the U.S. Department of Agriculture on a range of issues related to nutrition. When my time there was up, I didn't go back to an FQHC. Although I don't miss the headaches, I do miss serving that population.

Today, I'm the medical director of an integrative primary care practice where we incorporate some of the features of an FQHC to ensure access to care, including a sliding payment scale for uninsured patients and a sliding scale for insured patients who seek services that may not be covered, such as chiropractic, acupuncture and massage therapies. At the same time we're trying to ensure access in the way FQHCs do, we're trying to avoid some of the pitfalls these centers face. We try to give our clinicians the time, space and support they need in order to be there for patients and to make them feel valued and respected.

So how do we get more CHCs to operate the same way and improve their recruitment and retention rates?

  • The Bureau of Primary Health Care (BPHC), a segment of HHS that funds health centers, should track physician retention at FQHCs and publish these data along with other quality measures. Ultimately, the goal would be to create a recommended standard for clinician retention that centers can be compared against.
  • Once a physician commits to a community for the long term, that community has a powerful advocate. The BPHC should encourage FQHCs to create strategies for physician recruitment and retention. The National Association of Community Health Centers has already done a lot of work in this area.
  • The AAFP recently established member interest groups to provide a forum for AAFP members with shared professional interests. A CHC member interest group would provide physicians who work in these settings to communicate with each other and develop relevant AAFP policy. If you are interested in starting a member interest group for family physicians in CHCs, you can find more details -- including information regarding the criteria and application process -- online.

Kisha Davis, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.

Wednesday Sep 24, 2014

Lively Debate, Election of New Leaders Await at Congress of Delegates

The deadline for AAFP chapters to submit resolutions to the Congress of Delegates passed this weekend, and more than four dozen items will be up for debate when the Congress meets Oct. 20-22 in Washington.

© 2014 Marketing Images/AAFP
The AAFP's Congress of Delegates will meet Oct. 20-22 in Washington. Here I am addressing the 2013 Congress in San Diego.

The resolutions reflect the breadth of family medicine and the passion of our members, covering a variety of issues -- from clinical topics (contraception, end-of-life care, sterilization, tobacco and vaccinations, to name a few) to physician payment, scope of practice and more.

With more than 115,900 members, the AAFP represents a diverse group of physicians from many different backgrounds, practice types and political affiliations. Our members are passionate about numerous issues, and sometimes those passions collide.

For example, the Minnesota AFP has submitted a resolution urging the Academy to "participate in national deliberations and discussions pertaining to single-payer financing systems for health care reform."

The prospect of supporting a single-payer system likely would thrill some delegates and leave others itching for a fight. But spirited debate is what makes the Congress interesting, and we will no doubt hear from members with widely divergent views

Each chapter can send two delegates and two alternate delegates to the Congress. Delegates typically are individuals who have played leadership roles in their chapters. It's worth noting, however, that although only delegates may vote during the Congress business sessions, any Academy member present may speak and give testimony during the reference committee hearings.

A resolution from the Texas chapter seeks to examine the Congress' senatorial makeup and consider making the Academy's ultimate policymaking body one "based on limited proportional representation." Such a move would allow more opportunities for member participation in big states such as Texas, where physicians now often have to wait years for leadership opportunities. However, one might expect that delegates from smaller states will offer some impassioned testimony on this resolution.

Delegates also will choose a president-elect, other officers and a new class of Board directors. Unlike most years, when three new directors are chosen to serve three-year terms, delegates to the 2014 Congress will select four directors from a field of six candidates. The candidate receiving the fourth-most votes will serve a one-year term to fill the spot vacated by Clif Knight M.D., who resigned his position on the board earlier this year to become the AAFP's vice president for education.

For those who can't join us in Washington, you can follow the business sessions of the Congress via streaming video on aafp.org. More details about that will be published in AAFP News before the Congress convenes.

John Meigs, M.D., is speaker of the Congress of Delegates, the policymaking body of the AAFP.

Friday Sep 19, 2014

'What? Me Worry?' Family Medicine Residency Trained Me Well

From the first day of medical school we start a countdown to graduation and cannot wait until we are finished. Then we do the same thing in residency with even more vigor. The most frequently asked question we hear is, "When will you be finished?" We all answer -- with longing in our eyes -- that we are eager to be free, out on our own and liberated from residency requirements. No more checking out to attendings, holding interns' hands, or eating five consecutive meals in the hospital cafeteria.

It wasn't that long ago that I was worried about seeing patients outside the comfort zone of my residency program. Now I am  mentoring David Paxton, left, a fourth-year medical student at West Virginia University.

But there is a point -- near the end of June -- when the end is in sight, and it is terrifying. The elation I thought I would experience (in my head, it always involved singing and skipping through the office past the exam rooms) was replaced by a GERD-inducing, mind-numbing fear that bordered on panic. I kept thinking, "Next week, I will see a patient and have NO ONE to ask to look at that rash or listen to this murmur. I will be alone."

Then, after a couple of weeks of being consumed by the fear of leaving my residency faculty, it was suddenly time to go to work. I had never even met my nurse. I was going to see patients -- MY patients -- who I will follow for the rest of their lives. And although I had my own panel of continuity patients during residency, there seemed to be so much more at stake with these new patients. What if they don't like me? What if I can't figure out what to do with the very first one? It felt like a major case of stage fright.

Much like during my medical school rotations, when the day arrived, I got up, made coffee, and left early ... but not too early because I've sat many a time in a parking lot of an office that wasn’t even unlocked yet. My drive to work is 25 miles on a two-lane state road along a river where there is zero cell phone service and little traffic. About halfway to the office I saw something huge and black leap out of the river and attempt to sprint across the road. I slammed on the brakes and then watched a black bear climb up the side of the mountain that borders the road. All the while I was thinking that no one would believe this. But when I got to work and told my new co-workers about my bear sighting, they were unimpressed. They have all hit bears with their cars or seen them in their yards.

A couple of hours later, it was time to see a patient. My first patient. The front desk gave me an easy case, a walk-in who already had been diagnosed. I finished that patient, struggled through using a new electronic health records system and even submitted billing. I survived (so did the patient) and the world had not ended.  I knew what to do and how to do it.

I looked a few days ahead in my schedule and found some seriously complicated stuff: refractory cases, uncommon or rare diseases, undiagnosed problems and genetic disorders -- lots of all of them. After about a week of seeing patients, I emailed my residency program director at Marshall University to say thanks. I had the training and background to take care of every patient who had walked through the door.

I love my job, and now I feel silly that I was ever nervous. Family medicine residencies are rigorous, and for good reason. We are the primary care workforce, and we have to be well trained and confident to manage complex patients and serve our communities well.

I had multiple patients who reported their reason for visiting was that they had been "waiting for the new doctor to come." These patients had high hopes, and I had to meet those expectations. Although I am not doing obstetrics (there isn't one hospital in the entire county) I have had multiple pregnant patients, so I have to know how to safely treat -- and just as importantly, counsel -- them, so my obstetrics training is well utilized. There are days when I see more pediatric patients than adults, and there are other days that the average age is 70. 

Throughout medical school and residency, I heard every argument that exists against choosing family medicine. The one I can 100 percent discount after just two short months of practice is the concept of getting bored doing primary care. Really? Bored? I could be a lot of things in my office (annoying, loud, messy) but bored is not one of them. Every day is full of amazing variations that I think highlight family medicine as a specialty.  I learn new things, read new articles and teach every day. 

My patients are my favorite part of my job, but my second-favorite part is that I have medical students. I'll never forget my first patient as a student, my first continuity patient as a resident, or my first patient in my new office. And I'll definitely always remember the first medical student who trusted me to teach him family medicine. Of all the awards and achievements I have hanging on the walls, nothing beats having a medical school place a student in my office. 

I remember asking my rural preceptor when I was a third-year medical student why she took students into her office. Did she get paid or have access to university resources? Now I know why she just smiled at me and explained that she thought they gave her an email address.

Obviously, no one asks me when I'm going to be finished with school/residency anymore. But now I have new daily questions that follow a similar theme: Where are you from (and they want a town name because they can already tell that, like them, I'm from West Virginia)? Are you going to stay here? How long do you think you'll stay?

It feels good to be wanted, and it feels good to be a family physician. And yes, it feels amazing to be done with residency!

Kimberly Becher, M.D., is the resident member of the AAFP Board of Directors.

Wednesday Sep 17, 2014

GME Reform: An AAFP Call to Action

Primary care is the foundation of high-performing health care systems throughout the world, but in the United States, we primary care physicians make up less than one-third of the physician workforce, and our numbers are dropping.

 I talked about the need to reform the graduate medical education system during a presentation Sept. 15 in Washington. Other speakers, from left, were pediatrician Fitzhugh Mullan, M.D.; Kisha Davis, M.D., M.P.H., the new physician member of the AAFP Board of Directors; AAFP President Reid Blackwelder, M.D.; and AAFP EVP and CEO Douglas Henley, M.D.

A growing number of organizations -- including the Association of American Medical Colleges, the Council on Graduate Medical Education (COGME), the Pew Health Professions Commission and the Robert Wood Johnson Foundation -- have stated that at least 40 percent of U.S. medical graduates need to enter primary care fields if we are to meet the needs of our nation's health care system. But our current GME system is failing to hit that mark because nearly 80 percent of new physicians are choosing subspecialty careers. We are rapidly falling behind.

A primary care physician shortage already exists, and it will only be exacerbated by our changing health care needs: a growing population, the increase in chronic disease seen in our aging population and expansion of health insurance coverage.

The calls for change are mounting. Last year, COGME -- which was created by Congress to provide assessments of physician workforce issues -- released a report that called for drastic changes in the GME system, including increased funding to support 3,000 more graduates per year and prioritized funding for high-priority specialties, including family medicine.

Just this July, the Institute of Medicine released its analysis of GME in the United States and found that the current system lacks transparency and accountability and is producing a physician workforce that doesn't meet the country's needs -- despite an annual $15 billion investment from U.S. taxpayers.

On analysis, it's not surprising that our current GME system produces the outcomes that it does, because funneling funds through hospitals leads to residency workforce decisions based on the financial needs of those local institutions and not on the overall needs of our health care system.

This week, I was pleased to join other AAFP leaders on Capitol Hill as we took things a step further, unveiling a new budget-neutral proposal that would address those issues of transparency and accountability while aligning funding resources with actual workforce needs. The Academy's proposal recommends that policymakers and legislators take the following steps:

  • Establish primary care thresholds and maintenance-of-effort requirements for all sponsoring institutions and teaching hospitals that currently receive Medicare and Medicaid GME financing.
  • Require all sponsoring institutions and teaching hospitals seeking new Medicare- and Medicaid-financed GME positions to allocate one-half of their new positions to primary care.
  • Limit direct GME and indirect medical education (IME) payments to training for "first-certificate" residency programs. Repurposing funding currently spent on fellowship training would be used to create more than 7,500 new first-certificate residency training positions.
  • Align financial resources with population health care needs through a 0.25 percent reduction in IME payments and reallocation of those resources to support community-based primary care training.
  • Fund the National Health Care Workforce Commission. The Patient Protection and Affordable Care Act created this panel to review health care workforce supply and demand, but Congress has failed to allocate funding for it.

Yet it is important to note that the current and future physician workforce cannot be corrected through GME reform alone.

Earlier this year, a task force created by the Council of Academic Family Medicine -- which comprises the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the Society of Teachers of Family Medicine and the North American Primary Care Research Group -- with support from the AAFP, the AAFP Foundation and the American Board of Family Medicine, created the "Four Pillars for Primary Care Workforce Reform" concept, a comprehensive approach that includes:

  • the medical school pipeline,
  • the process of medical education, 
  • improving the practice environment for a more rewarding professional setting and 
  • primary care payment reform.  

Even as we work on all of these comprehensive reforms, changing the GME system is one of the most important policy levers we can pull now because of the vast government investment in the program and the multiple recent national reports calling for reform. Our GME system is stale. It was created in 1965 -- a different time -- and for a different purpose. Now, it is one of the few areas of the health care system that has not experienced major disruption in composition, function or financing.

Please join me in engaging our nation's leaders in a conversation about why our GME system should be reformed. It is time for the investment our nation makes in GME to be transparent and accountable and to produce the physician workforce our country needs and deserves.

Jeff Cain, M.D., is board chair of the AAFP.

Thursday Sep 11, 2014

FSMB Offers Licensing Solution for Docs Looking to Practice in Multiple States

My home state -- Iowa -- shares its borders with six other states. With my state-issued driver's license, I can drive not only in all six of those states but in any other state in the nation. As part of this system, a longstanding interstate compact allows the vast majority of states to share information regarding license suspensions and traffic violations of nonresidents. The states where infractions occur may forward information to a driver's home state, which then applies its own laws to the out-of-state offense.

That system makes sense. Unfortunately, the same can't be said of the way states view medical licenses. I've been in practice for more than 20 years, but the second I drive across one of those state lines, my Iowa medical license is invalid.

On Sept. 5, the Federation of State Medical Boards (FSMB) took a major step toward solving this problem when it finalized model legislation to create an Interstate Medical Licensure Compact that would expedite the process of issuing licenses for physicians who wish to practice in multiple states.

The key word here is "expedite." Under the current system, physicians who wish to practice in more than one state have to navigate a fairly burdensome process that involves paperwork, fees and three to six months of waiting.

Expediting the process would benefit physicians who live near a state line, are licensed to practice on one side of that state line and seek privileges at a hospital or other facility on the other side of that line. The change also could help alleviate physician shortages in rural and underserved areas and pave the way for greater use of telemedicine. (It's worth noting that earlier this year, FSMB adopted new guidelines for telemedicine.)

Under the terms of the model legislation, a physician would apply for a multi-state license through his or her home state. That state would determine whether the physician meets the following eligibility requirements for the compact:

  • Possession of a full and unrestricted license in a compact state;
  • Successful completion of a graduate medical education program approved by the Accreditation Council for Graduate Medical Education or the American Osteopathic Association;
  • Specialty certification or possession of a time-unlimited certification recognized by the American Board of Medical Specialties or the American Osteopathic Association Bureau of Osteopathic Specialists;
  • A clean disciplinary record;
  • No discipline from any agency related to controlled substances;
  • No pending investigations by any agency or law enforcement entity.

The proposed legislation would make it easier for states to share information and improve tracking and investigation of physicians who have been disciplined or are under investigation. Physicians who do not meet these criteria may still be able to receive a license in multiple states but not through the expedited process.

The model legislation has the potential to help put more physicians in the areas where we are needed most, but, ironically creating an expedited process could take time. Now that the model legislation has been finalized, state legislatures and medical boards can begin to consider its adoption. Each state must pass the compact to participate. That means family physicians who want this proposal to succeed should talk to your state chapters, who could help move this issue forward, or your state medical boards. Better yet, share your opinion directly with your state legislators.

Robert Lee, M.D., is a member of the AAFP Board of Directors.

Friday Sep 05, 2014

Called to Serve: Being Patient-Centered Puts Joy Back Into Practice

One of the exciting things about being president of the AAFP is the many opportunities to interact with medical students from all over the country. I have frequently said that students are not so much our future as they are our present. They have the ability to affect us in a positive way with their curiosity, fresh perspective and drive. And we, in turn, have the ability to make an impact on them and to influence their education and training.

Along those lines, I wanted to share two recent experiences and challenge each one of us to step up and build these critical relationships.

Our recent National Conference of Family Medicine Residents and Medical Students drew more than 1,200 students and nearly 1,100 residents to Kansas City, Mo.

I was honored to be asked to welcome all attendees to the National Conference of Family Medicine Residents and Medical Students a few weeks ago in Kansas City, Mo. This is the largest meeting of medical students and residents in the country, and this year we had record attendance, with 1,211 medical students and 1,092 residents.

For students in particular, National Conference is a critical leadership development opportunity. Obviously, we want to expose them to family medicine, and the experience of attending the conference often solidifies students' decision to pursue family medicine as their specialty of choice. But the conference has another important function: educating and challenging students to advocate and be part of our policymaking process.

One of my main messages at National Conference also was the focus of my closing main stage presentation. During that session, I challenged students to be patient-centered in all they do. I let them know that they have this opportunity, from the ground up, to be patient-centered even before they enter the workforce.  

National Conference is a great experience for attendees, but our engagement needs to extend beyond those three days each year. We can all look for other ways to reach out to medical students where they are. For example, we recently had our second Family Medicine on Air session using Google Hangout. This is an innovative approach to connecting people, and it is a technique the Academy likely will be using in other ways to connect with members.

The structure of the Google Hangout -- which you can view on Google Plus or YouTube -- allowed people to actually see me, moderator Alice Esame (a fourth-year student from Howard University School of Medicine who also is the AAFP's student liaison to the Student National Medical Association), and AAFP student interest staff as we talked about the patient-centered medical home (PCMH). I gave a brief introduction in which I emphasized that the PCMH is truly about a philosophy and an attitude as well as about being patient-centered. Students need to understand the PCMH, yes, but most importantly, they need to be empowered to become patient-centered even if they don't yet understand all the aspects of practice transformation.

The opportunity to be patient-centered truly is a way to put joy back into a practice. It is a way for all of us to remember that we are called to serve, and that we can truly help our patients often just through the compassion we display in recognizing that they are dealing with difficult issues. This is especially important for students to understand as they consider choosing a career in family medicine that will be satisfying to them, as well as to their patients.

I was impressed with the quality of the questions that came from the students. For example, they were concerned about the administrative hurdles that come with practice transformation. This allowed me to emphasize our advocacy efforts to help streamline the process involved with PCMH recognition.

Another question acknowledged the important role of other members of the health care team, such as care managers, nurses and others. Specifically, the student's question addressed how to assemble a team in rural settings where there are fewer resources. This gave me a chance to talk about how at my first practice in Trenton, Ga., the small town's health care professionals (chiropractors, pharmacists, public health officials, etc.) worked together even though we weren't in the same building -- or the same business -- to make sure that we provided the care our community needed. The key was good communication as well as the recognition that we all were working together for our patients' well-being.  

The students were on top of recent evidence, too, quoting an article in JAMA that found PCMH pilots from 2008-11 were not associated with health outcome improvements. I pointed out that this article described older PCMH models, and so was essentially similar to being concerned about a review of the iPhone 2 when we're actually using the iPhone 5. PCMH models now are significantly different. Those pilots did not have many of the patient-centered changes in place such as extended hours, and did not really study decreased ED visits, and hospitalizations which are clear improvements in current PCMH pilots.

Students keep us on our toes. They challenge us, in a good way, with their fresh viewpoints, inquisitive minds, and drive to do things the best way possible. And the questions these students asked amply illustrated that reality.

The challenge for us as educators is to recognize that our students need a different approach for many of these issues. If you are an educator, or involved with a family medicine interest group, consider watching the Hangout and sharing the link. You can also refer to or use supporting materials that are available to help our family medicine interest groups, faculty and others who influence medical students frame these critical issues for them.

For members who work with students -- even if you're not faculty, I challenge you to engage them in discussion about patient-centeredness. Talk about how you have been changing your practice to become more patient-centered. Take advantage of this chance for us to walk our talk and demonstrate to our students how much we love what we do.  

Although I still say students are our present, they are definitely also our future. We have a chance to give them a solid grounding in patient-centered education, and they can help to move us forward in our own processes.

Our next edition of Family Medicine on Air will address what medical students need to know about direct primary care. Stay tuned for more details about that event, which is planned for November.

Reid Blackwelder, M.D., is president of the AAFP.

Tuesday Sep 02, 2014

Family Medicine for America's Health to Launch at Assembly

I am extremely excited that the launch of Family Medicine for America's Health is less than two months away; the official rollout will occur in October in Washington, D.C., at the 2014 AAFP Assembly. As president-elect of the AAFP, I want to personally invite you to be there for this big event. This is truly history in the making, placing family medicine at the center of health care delivery in our nation.

For those of you who are unable to attend the Assembly in person, stay tuned, because we are working on a plan to deliver this event to you through digital channels.

Here is our latest update on this important project.

Family Medicine for America's Health
Organizational Update No. 8
September 2014

The goal of the Family Medicine for America's Health initiative is to meet the needs of the American public by achieving the triple aim of better care, better outcomes and lower costs. This initiative includes two integrated elements: a communications program aimed at consumers, policymakers, payers and the medical community and a strategic plan that will focus on addressing key issues facing the specialty of family medicine. I will unveil the communications program at the first Assembly general session on Oct. 22.

 Family medicine's strategic direction is composed of seven statements. Working together with its health care colleagues and other engaged stakeholders, family medicine aims to achieve the following:

  • Show the value and benefits of primary care.
  • Ensure every person has a personal relationship with a trusted family physician or other primary care health professional in the context of a medical home.
  • Increase the value of primary care.
  • Reduce health care disparities.Lead the continued evolution of the patient-centered medical home.
  • Lead the continued evolution of the patient-centered medical home.
  • Ensure a well-trained primary care workforce.
  • Improve payment for primary care by moving away from fee-for-service and toward comprehensive primary care payment.

The strategic plan is focused on six key implementation areas: practice, payment, workforce education and development, technology, research, and engagement. We are in the process of developing teams that will focus on tactics in each of these six areas. These teams will rely on support and input from a broad network of expertise in family medicine and beyond. Please be on the lookout for ways you can get involved.   

We strongly welcome and encourage your input on this process. We are developing a calendar of events where you can hear directly from, and share your views with, Family Medicine for America's Health leadership about this initiative. We will work to ensure you have a wide variety of in-person and virtual opportunities for engagement. Look for a calendar of events in the next update. We are also in the process of building a website -- FMAHealth.org -- to keep you fully informed on the progress of this effort.

As a reminder, the list below shows the members of the Family Medicine for America’s Health Board of Directors and the organization or other affiliation each represents. We are still working to identify a patient advocate to join the team and expect to have that vacancy filled in time for the launch.

Representative and Organization/Affiliation

  • Glen Stream, M.D., M.B.I., Chair, AAFP
  • Michael Tuggy, M.D., Vice Chair, Association of Family Medicine Residency Directors
  • Paul Martin, D.O., Secretary and Treasurer, American College of Osteopathic Family Physicians
  • Jen Brull, M.D., represents full-scope, full-time practicing family physicians
  • Thomas Campbell, M.D., Association of Departments of Family Medicine
  • Jennifer DeVoe, M.D., D.Phil., North American Primary Care Research Group
  • Lauren Hughes, M.D., M.P.H., represents family physicians early in their careers
  • Vincent Keenan, C.A.E., represents AAFP chapter executives
  • Jerry Kruse, M.D., M.S.P.H., Society of Teachers of Family Medicine
  • Robert Phillips Jr., M.D., M.S.P.H., American Board of Family Medicine
  • Jane Weida, M.D., AAFP Foundation
  • TBD - patient advocate

Additional background and earlier updates on this project are available online

Robert Wergin, M.D., is president-elect of the AAFP.

Wednesday Aug 27, 2014

More Than Meets the Eye: Value of Small Practices Shouldn't Be Ignored

For years, we've been hearing about the decline -- even death -- of the small primary care practice, but I'm here to say that obituary is premature, if not flat-out wrong. When a recent study published in Health Affairs touted the value of small practices, I didn't need convincing. I'm a small practice owner and have been for nearly 30 years.

The study found that primary care practices with one or two physicians had one-third as many preventable hospital admissions compared with practices with 10 to 19 physicians. The study also reported that smaller practices achieved their impressive results despite caring for a higher percentage of patients with chronic conditions than larger practices.

© 2014 Texas AFP

My rural, two-physician practice recently achieved Level 3 patient-centered medical home recognition from the National Committee for Quality Assurance.

So how did the small practices in the study manage to have better results regarding preventable admissions (and likely lower costs) than their larger counterparts? The authors point out patients in smaller practices may have closer relationships with their physicians, which might offer greater insight into patients' comprehensive health needs while facilitating ready access to care.

Patient-centered care, which includes enhanced access to care along with other elements, has become a focal point of the movement to improve our health care system in the past decade and, increasingly, is being embraced by small and large practices alike. Large practices, in particular, are likely to benefit from economies of scale that enable them to readily invest in health information technology and other organized care processes recognized as components of the patient-centered medical home (PCMH) model. And indeed, in this study, some of the larger practices appeared to use more such processes than the smaller practices, yet didn't fare as well in keeping patients out of the hospital.

Clearly, there's more to the story.

An abundance of evidence tells us that the PCMH can lower costs and improve outcomes. Just think: How much more could we bolster those outcomes if we combined the efficiencies of a Level 3 PCMH with the strengths and accessibility of a small practice?

Welcome to my small rural practice, which recently achieved Level 3 recognition from the National Committee for Quality Assurance (NCQA).

Regardless of a practice's size, there are hurdles to jump through on the way to PCMH recognition. The process can be overwhelming at the outset, and the AAFP has discussed the need to simplify the process with the NCQA and other such groups.

Although the process can be especially difficult for small practices, which lack the time, capital and resources of larger practices, it can be done. My two-physician practice achieved Level 3 recognition, from start to finish, in two years. We did it by working together with other small practices in our area, combining our efforts and resources.

The key, for me, was taking the process one step at a time, which made it seem more attainable. To that end, the AAFP has created a PCMH Planner to help practices of all sizes transform to the new model; that resource offers a step-by-step guide to follow.

I'm sure many small-practice physicians look at the PCMH checklist and think, "I'm already doing this. I'm already patient-centered."

I was one of those docs. And I was wrong. That's a difficult thing to realize, but my practice is better now than it was two years ago. We've improved vaccination rates, lowered the number of missed screenings and made care more accessible.

I realize now that it's important to be open to change and to always be looking for opportunities to improve. For example, I initially thought a patient portal -- a requirement to achieve the recognition level we did -- would be money wasted, but it's actually changed the way I practice. Giving patients access to their individual records improved the overall quality of our data. I've had patients point out mistakes in their records that were quickly corrected, and I even had one patient point out something we hadn't billed for that we should have. One benefit I had not expected is that my patients who are hearing-impaired now communicate with my office more often and with greater ease through the portal.

For our patients, the quality of care we provide has improved; so what's the payoff for the practice? BlueCross and BlueShield has agreed to a 5 percent payment differential for small practices in the group we are working with if they achieve Level 3 recognition. Four of the practices already are there, and six have Level 2 or Level 3 paperwork pending.

Moreover, my accountable care organization, which also is made up largely of small primary care practices, is in negotiations with two other payers to increase payment for those who have achieved PCMH recognition.

For years, payers marginalized small practices, which lacked the bargaining power of our larger counterparts, leading to more and more employed physicians and fewer and fewer small practices. But if those of us in small practices continue to prove our value, our future may be a lot brighter than anyone anticipated.

As the authors of that recent Health Affairs article noted, "Small practices have many obvious disadvantages. It would be a mistake to romanticize them. But it might be an even greater mistake to ignore them, and the lessons that might be learned from them."

Lloyd Van Winkle, M.D., is a member of the AAFP Board of Directors.

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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.