The Bargaining Chip We've Been Looking For
There is a David-versus-Goliath perception that makes many primary care physicians dealing with giant hospitals and health care systems feel disadvantaged during payment negotiations, but the truth is that every health system needs a strong primary care base.
Now, more than ever, we can prove it.
Merritt Hawkins, the national physician search firm,
periodically surveys hospital chief financial officers about how much revenue
physicians in 18 different specialties generate for their affiliated hospitals
each year. For the first time since the survey started in 2002, the CFOs
indicated in a report released this month
that primary care physicians generate more revenue, on average, than
Specifically, the report says primary care physicians (family medicine, general internal medicine and pediatrics) generated a combined average of $1.6 million for their affiliated hospitals in 2012, compared to $1.4 million for physicians in 15 other specialties.
In fact, family medicine's average in the overall list ranked third at $2.1 million, trailing only orthopedic surgery ($2.7 million) and invasive cardiology ($2.2 million). It's also worth noting that family medicine's revenue average increased more than 20 percent from the previous report while the overall average for subspecialists declined.
Merritt Hawkins president Mark Smith called it a "seismic shift" away from subspecialists and toward primary care physicians, who are "taking a greater role in driving both the delivery of care and the flow of health care dollars."
What the report also tells hospitals and other employers is that they should be spending more money on our salaries. Family medicine ranks third in generating money for hospitals, but we rank last (tied with pediatrics) in average salaries at $189,000.
To look at it another way, physicians in nine specialties make an average of at least $100,000 more than the average family physician while generating anywhere from $207,000 (general surgeon) to $1.2 million (otolaryngology) less revenue for their hospitals.
Family physicians negotiating contracts should be aware of this report, be empowered by it and make sure that the people on the other side of the table are informed, as well.
The report validates what I've experienced here in Indiana, where I am chief medical officer of Community Health Network, a system with eight hospitals.
In the mid-1990s there was a national trend of hiring primary care physicians, but hospitals tended to know a lot more about inpatient care than outpatient care. And after being disappointed with the financial results, many health systems divested from primary care.
Fortunately, we saw the value of our primary care practices, and today, roughly 200 of Community Health Network's 600 employed physicians are primary care physicians. We have such a strong primary care base that subspecialists have sought employment here based, in part, on the fact that they want to be associated with that primary care base, have the opportunity to prove themselves to our primary care physicians and earn their referrals.
Now the trend toward hiring primary care physicians is back. More than 60 percent of AAFP members are employed, and that figure is expected to top 70 percent within five years.
Merritt Hawkins speculates that the surge in employed physicians is one of the reasons for the increase in revenue generated by primary care physicians. Simply put, employed physicians are more likely to keep tests, referrals and other services in house.
But there could be more to it than that. The report also theorizes that the patient-centered medical home is a factor, and as more primary care physicians become directors of medical teams, they gain "more control of how patients access the system and how revenue streams are directed."
In our current fee-for-service world, where volume trumps value in the eyes of many, this is important information to know. But the system is transitioning, albeit slowly, to one that will be value based. So we should continue to strive to provide the right care at the right time while also knowing and being empowered by the value of the services we provide.
Clif Knight, M.D., is a member of the AAFP Board of Directors.
Relationships Are a Critical Part of Building Medical Homes
The small Nebraska town where I practice family medicine has a population of about 2,000. Although my practice is only 30 minutes west of Lincoln -- the state's capital and second-largest city -- solo and small family practices are common in the rural areas to my north, south and west.
As my colleagues in these small practices ponder the patient-centered medical home (PCMH), I know that it can seem overwhelming to implement. The bodies that recognize or certify PCMH practices have numerous confusing requirements that have more to do with processes than patient care. So when I talk to family physicians who have concerns about the PCMH, I suggest they read the original articles on the subject by Barbara Starfield, M.D., M.P.H.
Instead of a large number of boxes to check, Starfield thought there were three simple things at the core of becoming a medical home.
The first is to be comprehensive in your approach to health care. It is comprehensiveness that separates us from our subspecialty colleagues who focus on a single organ system or a single disease entity. It is comprehensiveness that separates us from midlevel providers who say they can deliver care as well or better than family physicians. Ordering more tests and referring to subspecialists is not comprehensive care. Family medicine is.
The second critical factor is disease management. We all know there are certain diagnoses that predispose patients to increased morbidity and mortality. The Academy has clinical recommendations and resources to help your practice with chronic disease management protocols that fit your practice. You also can develop disease registries to be more proactive with these patients. By doing so, we can reduce morbidity and mortality and ultimately reduce costs to our health care system.
Finally, relationships and continuity of care are important. Knowing our patients and their families facilitates caring for them. This can reduce duplication of tests and improve compliance to treatment plans by understanding each patient's culture and concerns. I recently had this brought home to me by one of my long-time patients.
Oliver was a 92-year-old, retired minister who had contracted pneumonia and required hospitalization. I have cared for his family for years. In fact, I delivered two of his grandsons.
Oliver was not responding to treatment, so as I examined him, I talked to his family -- including those grandsons -- about other interventions we could try to improve his situation. As I talked, his son, David, got out of his chair, came to me and placed his hand on my arm. He said, "Dr. Wergin, you know my dad loves you, and we all love you. You are as much a part of our family as anyone in this room. We wanted to let you know that my father does not fear death and is ready for what's to come. In fact, we are all ready for what's to come, but we're worried about you. You don't seem to be ready."
I looked at David and told him I understood. I went to the nurse's station and wrote a prescription for morphine and other comfort measures. I continued to round on him and talk to him each day. There was no new hospice nurse or shift-working hospitalist. Instead, it was just me and Oliver's family. That's family medicine.
Oliver passed away a few days later. It was a quiet death, and his family members were with him.
Medicine is always changing, and we have to be prepared. It is important to develop a plan to meet PCMH requirements if you want to be recognized or certified as a PCMH practice. We know that our strict fee-for-service model, which has not served us well, is coming to an end. To be reimbursed in a new model of payment, we must show we deliver what we promise. Don't be discouraged, and remember that patient-centered care is based on these three things: comprehensiveness, disease management and relationships.
How do you build relationships with your patients?
Robert Wergin, M.D., is a member of the AAFP Board of Directors.
Nurses Play Vital Role
Trenton is a tiny town in the northwest corner of Georgia. If you could pick it up and move it on the state map, you could just about squeeze it into nearby Cloudland Canyon State Park. Travelers who aren't headed to the park might not notice Trenton unless they need a place to stop on Interstate 59 on a drive from Birmingham, Ala., to Chattanooga, Tenn.
Trenton has fewer than 2,000 residents, but it is the seat of Dade County -- by default. It is the only incorporated town in the county.
It was there, in rural Georgia, that I started my first job out of residency 25 years ago on a National Health Service Corps assignment. I had studied medicine in Atlanta and moved on to residency in Augusta. Now I was a big-city outsider in a small town.
I knew no one.
Verenice Hawkins, R.N., helped changed that.
Verenice was the nurse for the local health department and, as such, was a lynchpin in the community. People knew and trusted her. She helped spread the word about me, and she had good things to say. That was just one of the nice things she did to help me find my way during my four years there.
Long before anyone ever uttered the words "patient-centered medical home," Verenice and I -- along with my two nurses, med tech and front office staff, the local emergency medical services, two chiropractors, one pharmacy, and a physical therapist -- worked together to give our patients a medical home. We communicated, cooperated and coordinated the care we provided to our community.
I left Trenton in 1992 to take a job at East Tennessee State University, and I had not heard from Verenice for years until last week when she reached out to me … on Facebook! She's 80, but she is still working and making a difference. She says she can't fully retire because her community and patients need her, and she's still passionate about what she does.
So this week -- which happens to be National Nurses Week -- I have been thinking a lot about Verenice and the other nurses I have worked with through the years.
Today, the PCMH model is much broader than the small-town medical home Verenice and I provided two decades ago. Now it includes dieticians, physician assistants and so much more. But at its core, team-based care is about doctors and nurses working together for our patients.
Much has been made of the fact that our country is facing a shortage of 45,000 primary care physicians by 2020. But we also should note that an even larger shortage of registered nurses -- 260,000 -- is projected by 2025. We need more primary care physicians, but we also need more nurses. Both pipelines need to be addressed to meet patient needs.
Thank you to all the dedicated nurses who work so hard to care for patients and are critical, valued members of our health care teams.
Reid Blackwelder, M.D., is the president-elect of the AAFP.
Teamwork Key to Improving Quality of Care
I've been interested in the patient-centered medical home (PCMH) since the Future of Family Medicine report recommended that every American should have a medical home back in 2004. I was on the AAFP's Commission on Practice Enhancement (now the Commission on Quality and Practice) from 2006-2010, and the concept was a hot topic for our commission.
When my multi-specialty medical group in New Mexico
decided to implement the PCMH in our own clinics, I served on an advisory
committee that helped make it happen. When it was time to implement electronic
health records (EHRs), my clinic was the guinea pig. We got our EHR up and
running before the system was rolled out to the whole group. Today, all 10 of
our primary care clinics have achieved National Committee for Quality Assurance
Level 3 PCMH recognition.
Although teamwork was critical to the progress we made as a larger organization, looking back I realized we hadn't done enough team building in our own clinic. So beginning in 2011, we worked to improve our practice -- which has 30 employees, including three physicians and three nurse practitioners -- by establishing a high-functioning team dedicated to addressing issues specific to certain diseases, conditions or issues.
We didn't dive right in. It was a deliberate process. We spent six months carefully crafting mission and vision statements and setting goals and objectives.
It might sound like slow going, but it was worth it. Our staff members -- both clinical and office -- now own the concept of working together and are invested in it. We believe in it, and that's huge.
Every Monday morning, we meet to review a list of objectives and select new projects to begin. We have made some significant strides, but quality improvement never ends.
Our diabetes team started with a simple project to become familiar with the process of foot exams. Physicians and nurses, me included, were not consistently performing foot exams for every patient with diabetes. And when they were being performed, the results were not consistently recorded in the right place in our EHR. Our team devised new protocols to ensure that the exams are performed and recorded in a consistent, retrievable manner.
Our pain management team extensively reviewed the new state regulations for opioid prescribing and monitoring to make sure patient agreements are signed and that regular screenings are performed. We added several instruments to our EHR and made it easy for everyone to learn and use them. Now, every patient on long-term opioids has a signed agreement, documentation on a statewide database, periodic urine drug screening and a treatment plan.
Some projects are more complex. One team is working toward a goal of having every patient in our practice aged 18 years and older have an advance directive. They are establishing a process to introduce the concept to patients and to follow up and ensure forms are returned. It's not an easy task. But after surveys, training and EHR modification, the process is poised to encourage and track patients' use of the advance directive at whatever level they deem appropriate with our guidance. Our method has been spread to our other primary care clinics, making it easier to approach this sensitive subject.
The work we've done is a step beyond what PCMH recognition calls for, but this is what the PCMH truly is about. It has resulted in better care for patients and more satisfying work for employees. Team building has been a very rewarding process, with no end in sight. It is the future because it is continuous quality improvement that is now part of our clinic culture.
What team work successes have you experienced on your road to PCMH transformation?
Richard Madden, M.D., is a member of the AAFP Board of Directors.
A New Approach to Recruitment and Retention
We invest years of time and energy into our more than 460 family medicine residencies -- selecting, training and preparing our bright new family doctors. But how well do we help our recent graduates find their ideal practice? And once they select a community in which to practice, who does the follow up to ensure that the "marriage" is a success?
What if there was a program for newly minted family doctors looking to find their ideal practice? What if the concept of the National Resident Matching Program (i.e., the Match) was applied to help rural and underserved communities showcase their unique opportunities and compete on equal footing with large health system recruiters?
Let's call it FamilyDocMatch.com.
Perhaps there would be an application that included a personality survey and a desired practice profile, and for recruiting sites a detailed community profile emphasizing their uniquely attractive characteristics specific to workload, patient panel, call demands, scope of practice and community setting.
During a recent visit to the Arizona AFP, I was intrigued by a discussion among new physicians, who voiced difficulty in finding their ideal practice setting. This was a concern especially for those who already were in their first job but looking for a permanent home. They were frustrated by the lack of answers to their questions about jobs, such as, "What is the call load really like?" or "Can I do a reasonable volume of obstetrics?"
In their minds, there is no useful databank from which to compare and contrast jobs.
Family doctors are the backbone of our medically underserved workforce, providing vital clinical leadership in our rural and safety net clinics. Family physicians have been the most sought-after physicians by recruiters for three years running. With worsening primary care shortages predicted due to expanded Medicaid eligibility and anticipated physician retirements, competition for family doc graduates is likely to heat up. Imagine, family doctors as a rare commodity!
Communities that are not part of a larger hospital or health system network struggle to attract young graduates, as do small independent practices. Sometimes, opportunities are missed by virtue of poor visibility. Larger health care systems use central recruiting systems with recruiters who likely are unfamiliar with community specifics and cannot speak to the characteristics of a particular practice. Call responsibilities, patient mix, performance expectations, and practice leadership and philosophy are important aspects to consider in making a successful physician match, but such details are not common on a standard application and often are not available.
Could a website like FamilyDocMatch.com help?
Consider the legal implications that surround negotiating an employment contract. Physician contracts are complex documents written in legalese with noncompete clauses and confusing eligibility for financial incentives programs. With more family physicians becoming employees, how can we educate ourselves on how to best negotiate appropriate pay for the level of work required? Unsuspecting recruits often are ill-prepared to address these issues, especially after they have left the safety net of residency. What if there was a job discussion site (i.e. a secure chat room) that allowed questions and answers to be posted about contracts?
We already have sites such as Monster.com, Physician-Jobs.net, MDJobSite.com and PhysicianDepot.com to aid our searches, but job searchers have to sign up and trust that their personal information does not trigger inquiries from headhunters looking to fill a slot and get their commission.
Residencies often hold "Pick a Practice" opportunities for their graduates, and AAFP chapters, the AAFP and the AMA maintain job boards and career postings for those seeking new opportunities at all ages and stages of their careers. But where can you post a description of your ideal practice and share access to communities that might have the ideal placement for you?
FamilyDocMatch.com could be the answer. Just think, a personalized, confidential and reliable service for finding your ideal job that is not based on commercial exploitation and is not run by high-dollar headhunters. It would be a confidential match service dedicated to finding the best possible placement for the applicant. Maybe, just maybe, we can bridge the gap between rural and urban job placement and provide support and encouragement to retain our well-trained recruits in the job of their dreams.
Would a website like this would be helpful? Please share your comments below.
Barbara Doty, M.D., is a member of the AAFP Board of Directors.
Lessons for Boston: FPs Can Help Amputees Move Forward
In the aftermath of the terrorist attack on the Boston Marathon, the media has put a focus on a topic that has been part of my life for nearly two decades -- amputation.
More than a dozen people have had amputations since two bombs went off near the finish line of the April 15 race.
On a day that started with celebration, lives were changed forever. In that instant, young and healthy athletes on the road to celebration (and spectators who were cheering them on) were shocked to now face the long and challenging road to recovery.
I can relate.
Just one week before the airplane accident that eventually claimed both my legs, I remember joyfully riding my bicycle up a sunshine-splashed hill, reveling in what my body could do.
A week later, I was on a ventilator in my own ICU.
In the hospital, the questions began. "Who am I now, and what can I do in this world with this radically changed body?"
Fortunately for me, I had a team there to to help me find the answers.
There were a large number of subspecialists. Trauma, ENT, orthopedic and plastic surgeons were able to save my face, hands and one foot. But it was my family physician, Tim Dudley, M.D., who had the insight and ability to take care of the whole of me.
And of all the members of the health care team that helped put me back together, it was Tim who played the most important role in the weeks, months and years that followed.
In the short term in the hospital, Tim asked important questions about nutrition, rehab and insurance. For a full recovery, it was essential to have a family physician who knew me, would listen to me and would advocate for me. When my insurance company tried to limit the number of physical therapy sessions it would cover for multiple traumas to 10 total home visits, Tim threatened them with a different covered benefit -- six months in a nursing home. The payer listened, and I got my physical therapy, at home.
To this day, Tim writes letters when I need new legs.
Tim, you could say, stands by me. Like all patients, amputees need a physician who will help them see the big picture beyond their immediate loss.
Many well-intentioned coaches and doctors focused on what I would be unable to do with prosthetics. My family, friends and Tim helped me focus on what I could do, even when we had to modify prosthetics or sports equipment.
Yes, amputation is painful, physically and emotionally. Learning to walk again is a hassle.
But re-engaging fully in a life you love makes it worth all the pain and hassle, and that was my message to those injured in the Boston bombing during a recent interview with CNN Radio.
Our job as family physicians is to help patients look forward and find things in their lives that are more important than their pain. By knowing them as people, we can better help them take the steps they need to have a full life after amputation, cancer or any loss.
One year after my accident, I rode up that same hill again on my bike, in the sun. And I marveled at the wonder of what my body, now with prosthetics, could do.
My wish for those wounded in Boston, injured veterans returning from Iraq and Afghanistan, and others facing amputation is for them to be as fortunate as I am to have a family physician like Tim who can help them take the necessary steps and guide them on their path.
And thanks to all of you for what you do for your patients every day.
Jeff Cain, M.D., is President of the AAFP.
They're Your Comments; Make Them Count
Since AAFP News Now opened its stories to member comments in 2010, we've heard from you more than 3,000 times. Through the comments field, Academy leaders and staff have been able to answer numerous member questions, clarify issues and provide additional information from our in-house experts.
We've also been able to correct broken links and other errors that members have brought to our attention.
Since we launched the AAFP Leader Voices Blog in 2011, family physicians have been able to communicate directly with Academy Board members, who have answered questions related to advocacy, education and clinical issues.
Academy staff and leaders also have responded to member questions and comments on Facebook.
Overall, it's a system that has worked pretty well, and the discourse, although sometimes spirited, has been overwhelmingly professional in nature.
But, on occasion, comments can get out of hand. Although we have had many interesting, helpful dialogues between members, members and leaders, and members and staff through comment fields, we also have had a few members resort to personal attacks.
And, there have been a few instances of inappropriate language.
Disagreement is fine. We created the comment fields to encourage and improve communication, but let's remember that we all share a common goal of delivering the best care for patients that we possibly can and steer away from anything that gets in the way of that goal.
It's also worth keeping in mind that our news stories, blogs and social media content are open to the public and anyone -- patients, other health care professionals and members of the media -- can and do read that content.
The issues we discuss in these venues are important to the health of our nation and deserve level-headed discourse. Negative, hostile comments have a polarizing effect. Researchers published findings earlier this year that showed that readers who were exposed to antagonizing comments were more likely to dig in their heels on an issue than commenters who read the same story or blog without the accompanying name-calling.
In other words, readers faced with an online fight aren't open to new ideas or the other side of a discussion. Ugly arguments actually reinforce readers' preconceived ideas -- right or wrong -- on a given topic.
Name-calling can disrupt constructive dialogues, and that's not what we want. We family physicians need to be able to discuss important topics, including payment issues, health care reform and gun laws, with the understanding -- indeed, the expectation -- that our diverse, 100,000-plus members won't all agree. Some topics are divisive, but we can't afford to allow them to divide us.
We're here. We're listening. We want to hear from you. And we hope you'll continue the conversation with your colleagues. How will you make your comments count?
Glen Stream, M.D., M.B.I., is the Board Chair of the AAFP.
Fit Physicians Can Lead by Example
Years ago, I attended an event where tennis legend Arthur Ashe spoke about the need for sustainable exercise -- finding something you enjoy that can be done indoors or outdoors and at any age on a regular basis. His words resonated with me. Teaching people -- including my patients and friends -- the tremendous benefits of regular exercise from an early age has always been important to me.
I have tried many sports in my time, but when my children were old enough, I signed them up for what I hoped would be a sustainable activity. When I told my kids I was enrolling them in taekwondo lessons, their response was, "Only if you do it, too." The usual negotiations ensued.
Fair enough. It's important to be a good role model.
Ten years later, I am a black belt in taekwondo and am working on becoming a second-degree black belt. It is a commitment that takes time each week. I share a weekly lesson with my husband and, typically, on the weekends we practice, train or just "play" together. I also make time to exercise -- even if it's a shorter workout, like a walk with my daughter -- on weekdays.
Our children aren't the only ones who can benefit from a good example. It helps me talk with patients about doing the right thing when I am doing the right thing myself. I tell them that if I can do it, so can they. And sometimes, you have to show them.
About 20 years ago -- before I had children -- I made a standing offer for my patients to walk with me before office hours. I said, "I'm going to be at the office at 6:30 a.m., and whoever wants to join me can. If nobody comes, I'm still doing it."
Some days only a few people came. On others, there were more than a dozen of us. That effort lasted for a few years until my office changed locations.
This wasn't targeted only at patients with diabetes or other chronic conditions. It was for anybody, because everybody should exercise.
Sadly, we know that only one-third of adult patients are advised by their physicians to exercise. We also know that physicians who lead a healthy lifestyle are more likely than those who do not to counsel patients about issues such as diet and exercise.
It is important to me to try to be a good role model. We all have too many patients who are not making good choices, but we can make a difference in their behaviors.
I have a patient who, at age 58, had slightly elevated blood sugar and elevated blood pressure. We discussed nutrition -- including high fiber and the DASH (Dietary Approaches to Stop Hypertension) diet -- and exercise, especially cardio. When the patient came back a month later, she said she was having a hard time finding low-salt and high-fiber foods. Together, we found a website that sold foods that could not be found locally. She joined the Y, started going at least three times a week and quickly lost five pounds.
At a recheck two months later, she still was following the diet and exercise plan and had lost eight more pounds.
Fast forward three years, and she is down more than 30 pounds. Her blood pressure and blood sugar are normal, and she's been able to stop taking medications for those issues. Diet and exercise were the prescription she needed.
The take-away message: We should be telling our patients about the tremendous benefits of a healthy diet and regular exercise.
There are five keys to succeed at losing weight and keeping it off:
Eat a high fiber, low-fat diet.
Weigh yourself on a regular basis for feedback.
Eat breakfast daily.
Document everything you put in your mouth so you are mindful of all the calories you are taking in.
Eating mindfully is essential. I advise my patients to use a calorie counter. If they have an appropriate app on their phone, they can put their food options into the calorie counter before they put the food in their mouth. Seeing the caloric imbalance of poor choices allows people to have second thoughts before an unhealthy selection passes between their lips. Is that large plate of nachos really worth it? Probably not. You would have to spend four hours running on the treadmill nonstop to burn most of those calories.
We have had good success with calorie counters because they educate people about what they're putting in their bodies and about energy balance.
Another tool that works (and it's free for Academy members) is the food and activity journal available through the Americans In Motion -- Healthy Interventions program, which positions fitness -- physical activity, nutrition and emotional well-being -- as the treatment of choice for the prevention and management of many chronic conditions.
Of course, some patients need more encouragement, and you have to be creative. I have made bets with patients about how much weight they can lose before a birthday or some other significant date. If they reach their goals, I take them out for a healthy lunch.
Now, I have to admit -- I like to win. I have been fortunate to be a volunteer physician for the U.S. Olympic Committee and Team USA, and I have served as a team physician for a local high school for 30 years. But when it comes to helping a patient push him- or herself to a healthier way of life, that is one instance where I don't mind losing.
Rebecca Jaffe, M.D., M.P.H., is a member of the AAFP Board of Directors.
Duke Students Show Keen Interest in Family Medicine
I am always impressed with the passion of medical students and family medicine residents, and my recent trip to Duke University was no exception.
Duke's Family Medicine Interest Group (FMIG) invited me to be a speaker at their annual awards meeting in Durham, N.C. This created an opportunity for me to meet with the school's chair of community and family medicine, Lloyd Michener, M.D., (who recently made news for his work on integrating primary care and public health) and to spend some time with family medicine residents.
This trip, however, was primarily about students. There was a great deal of excitement and enthusiasm about this year’s Match and what it may mean for Duke's future. The school had four students match into family medicine residencies, including one who will be staying on at Duke.
Although four may not sound like a big number, it doubled last year's total and matched the school's highest number of students matching into family medicine residencies during the past six years. (For some perspective, Duke produced zero family medicine residents out of a class of 112 students in 2009.)
The students asked good questions about ways to stimulate interest in family medicine and invigorate their FMIG. We talked extensively about leadership opportunities at the AAFP's National Conference of Family Medicine Residents and Medical Students, which is scheduled for Aug. 1-3 in Kansas City, Mo., and how this can extend to students regardless of career choice. However, once students come and participate in this event, it is hard not to get excited about family medicine.
We also talked about ways of handling the usual challenges students face in family medicine. Even early in their careers, students are hearing the usual refrain of "You are too smart to go into family medicine" from their faculty and peers. This is a very real issue for our students, and it is difficult to withstand over time.
We talked about one way of reframing the situation, which is to recognize that family medicine is the largest specialty. Second, most folks who go into internal medicine, for example, subspecialize. Another way of looking at that choice would be to talk about becoming a limited practice specialist. This allows an opportunity for students interested in family medicine to say how they truly don't want to limit themselves. They want the excitement and the challenge of doing more than "just" being an orthopedist. And they could praise their peers who recognize that they need to limit their options by subspecializing. It is good to know one’s boundaries.
Most important, however, is a message that we all need to hear -- not just the students. What we have been doing for many years is critical to the creation of a true health care system in this country. It has been, and continues to, be difficult at times. People don't always understand what we do. However, for the first time, people in power are talking about primary care and the patient-centered medical home. Even if they don't fully understand what those terms mean, it is a start.
Winston Churchill once said, "You can always count on Americans to do the right thing -- after they've tried everything else." We are getting to the point where our country has tried everything else to create a health care system instead of a disease-management process.
Ultimately, what family physicians have been doing all along is what our country needs most. Now, people are finally turning to true primary care.
Reid Blackwelder, M.D., is president-elect, of the AAFP.
Primary Care Physician Shortage Requires Bold Action
If we build it, they will come.
For the first time in more than 100 years, a new medical school will open this summer in Indiana. Marian University's College of Osteopathic Medicine has a decided focus on primary care. The dean, the associate dean and two of the trustees -- including me -- are family physicians. We have taken a deliberate approach to screening, looking for students who not only have an interest in primary care but who also are interested in staying in the Hoosier State to practice medicine. We hope the new school will produce more than 90 primary care physicians per year, starting in 2017.
Student interest in the school has been encouraging. For the 150 spots available in Marian's first class, we received more than 3,200 applications.
This effort is an important step in addressing a glaring need. Indiana University's School of Medicine, the state's only med school (until now), boasts the nation's second-largest student body, but the school has not produced enough primary care doctors to meet demand.
That demand is going to increase dramatically in the near future as veteran physicians retire, the Patient Protection and Affordable Care Act expands access to health care and an aging baby boomer population becomes eligible for Medicare. By 2020, the state is expected to face a shortage of 2,000 primary care physicians.
Health care leaders in my state are well aware of the need, and opening a new med school is one strategy to address it.
Indiana isn't alone. The United States is facing a shortage of 45,000 primary care physicians by the year 2020. Marian is one of three osteopathic med schools opening this year, and more than a dozen new allopathic medical schools are in various stages of development.
Of course, it won't do much good to churn out more medical school graduates if we don't also increase the number of residency slots available. Although there are bills under consideration in Congress that would increase the number of Medicare-funded residency positions, there is no guarantee that such legislation will produce more family physicians.
Here in Indiana, we're taking steps to do just that.
Marian -- a small Catholic school in Indianapolis -- won't offer a residency program, but the new medical school has partnered with two hospital systems that do. St. Vincent Health is a network of 20 hospitals, and Community Health Network has eight. (I am the chief medical officer of the latter.)
Community Health Network has two family medicine residencies -- one allopathic and one osteopathic. We recently expanded our allopathic residency from seven slots per class to eight per class.
We also successfully applied and received CMS funding for 22 additional residency positions. We now must decide whether to expand our existing programs or develop a new residency program. Whichever way we decide to go, we need to act quickly before Marian's first class graduates in 2017.
It's becoming increasingly clear that it will take bold action and creative thinking to address the looming physician shortage. What is happening in your state?
Clif Knight, M.D., is a member of the AAFP Board of Directors.
Overtime: Finishing the Story on Scope of Practice
Once again, the media is reaching out to get family medicine’s perspective on an important health care issue.
I recently was interviewed about scope of practice issues by The Washington Post.
As a result of that opportunity, I was invited to be on "The Diane Rehm Show," a Washington-based radio program that is distributed by National Public Radio and SIRIUS satellite radio. It reaches more than 2 million listeners nationwide.
Happily, AAFP staff members were able to arrange for me to drive to a Knoxville, Tenn., radio station rather than flying to Washington, and I was able to link in and be a part of the discussion.
The show's other guests were Mary Agnes Carey of Kaiser Health News; Ken Miller, Ph.D., R.N., C.F.N.P., associate dean at Catholic University School of Nursing; and Sandra Nattina, M.S.N., A.P.R.N., N.P., past president of the Nurse Practitioner Association of Maryland.
I was the sole physician, and we had a lively discussion about scope of practice, including whether or not nurse practitioners should be allowed to practice independently.
Unfortunately, there is never enough time to provide all the needed information. I applaud all our members who participated through e-mail, tweets and other social media. It is important, however, to address a couple of issues that needed more time than provided in this hour-long program. Many aspects of this discussion can be misunderstood or misrepresented, so I want to be sure that all of our members -- as well as other health professionals -- hear these points.
Primary care is being defined by some in creative ways, and even in this broadcast, the suggestion was made that nurse practitioners can do everything we do as family physicians. I made it very clear that although many different professionals can provide some primary care tasks and services, nurse practitioners are not family physicians. Both members of the team play critical roles, but we are not interchangeable.
Family physicians are intensely prepared for practice through a nationally standardized process of education, training and certification. Family physicians have a clear and consistent path from undergraduate through residency. By the time they graduate, each and every family physician has an undergraduate degree and a total of 21,000 hours of didactic and clinical training. They also have passed national exams at several stages in their training.
Depending upon the state and system, an NP may or may not have an advanced degree, may or may not have extensive clinical experience, and may or may not be receiving ongoing recertification. Examples of individual NPs with many years of clinical experience being able to provide independent practice cannot be used to overcome an inconsistent and non-standardized educational and training system for NPs as a whole. Moreover, a Health Affairs blog this week pointed out that 63 percent of all NPs are older than 45 years and 15 percent are older than 60 years. In hard numbers that means of the 155,000 NPs in the United States, 98,000 are older than 45 and 23,000 are older than 60. This means the most experienced NPs likely will soon leave the primary care workforce, emphasizing the need to standardize education and training for their replacements.
Regulatory frameworks are not designed to limit access. Instead, they are in place to ensure patient safety. That is one mechanism by which patients receive the right care from the right provider at the right time. No health care professional can function within their scope of training without a regulatory framework. In scope-of-practice bills all over the country, states are pursuing different kinds of legislation regarding different processes from different providers, which further fragments our already broken health care system and creates more silos of providers.
Despite these changing, yearly legislative discussions, the AAFP consistently has championed the physician-led, patient-centered medical home. We need to be creative in developing these teams in each state given different situations. But the end result must be the right care from the right professional at the right time. Health care team members do not have to be in the same building or practice, but they do need to be involved with connecting the health care pieces throughout each community and system. Only family physicians are uniquely and consistently trained to provide leadership for this type of team-based care.
One of the other guests said during the broadcast that NPs can diagnose and make the right referrals. This concept of treating diseases based on specialty has contributed to the high cost and poor outcomes of our system. Family physicians have the education, training and experience to be able to manage many problems that often are sent by nurse practitioners to high-cost specialty care.
Not everyone with a broken ankle needs to see an orthopedist.
Not everyone with congestive heart failure needs to see a cardiologist.
And not everyone with COPD needs to see a pulmonologist.
I could go on.
We must be the next layer of care and referral when an advanced practice registered nurse reaches the limit of his or her scope, not a limited-practice specialist.
Finally, much is made of the "wealth of research" that supports similar outcomes between care provided by nurse practitioners and family physicians. Although often quoted, this data has been carefully evaluated, and it has several flaws in its methodology. Perhaps most important is that majority of the studies included in this review were from collaborative and not independent NP practices. Generalizing outcomes from nurse practitioner care alone is impossible with this kind of data. Moreover, much of the data comes from studies done after a diagnosis has been made. You cannot compare outcomes produced from following a treatment protocol for a diagnosed problem with those from the process of taking an undifferentiated problem, making the diagnosis and implementing a treatment plan.
There obviously are many other points that are important in these discussions. However, our impact improves when we speak with the same facts and emphasis. Decisions our citizens and politicians make should be with facts in hand, not based on the strong emotion of personal belief or anecdote. This is the essence of informed consent and good communication.
Thank you for your support, keep listening and keep tweeting.
Reid Blackwelder, M.D., is president-elect, of the AAFP.
Physicians, NPs Should Work Together to Improve Primary Care
If one were to skim the latest headlines about scope of practice, you might think you were reading coverage from the sports pages. The media continues to inject words like "fight" and "battle" into the important discussion about independent practice for nurse practitioners.
This isn't a turf war. It is an issue of patient safety. Nurse practitioners can provide numerous primary care services that are within their scope of practice -- immunizations, screenings, management of acute and many chronic conditions, etc. -- but physicians provide the needed expertise when a patient's condition requires care beyond that level, when it is complex or ill defined. With the ever increasing complexity of care and the rising health care needs of society, collaboration is critical.
This should not be an us-versus-them debate. We should be working together.
I recently participated in a Politico panel discussion on the topic with American Association of Nurse Practitioners President Angela Golden, D.N.P., and others. Leading up to the webcast, some people seemed to be expecting an ugly scene.
Admittedly, many family physicians and nurse practitioners disagree on this topic. However, our stage was set for an intelligent conversation, not an episode of "Jerry Springer." Family physicians work side by side with nurse practitioners every day. Hostility isn't good for any of us or our patients.
I had never met the AANP's president before, and what I found during our time backstage was that we agreed on more topics than we disagreed. We had common clinical interests and had a very collegial conversation.
We're not going to agree with our colleagues -- nurses or physicians -- 100 percent of the time, and that's OK. The key is to make sure those disagreements don't interfere with patient care.
For me, that's what this issue is about -- patients.
Although nursing advocates have been quick to point out a worsening physician shortage, they have ignored the fact that our country also is facing a shortage of nurses. You can't replace one thing you lack with something else you don't have. Primary care should be the foundation of our health care system, and our country needs more primary care physicians, primary care nurse practitioners and physician assistants working together to address both access to care and quality of care issues.
Together with our nursing colleagues, we can improve primary care and our nation's health.
Wanda Filer, M.D., is a member of the AAFP Board of Directors.
Mainstream Media Can Help Us Share Our Stories
The life of an AAFP officer is never dull. We have an amazing staff that ensures our leaders are able to make it to all kinds of media and advocacy opportunities.
For example, I recently represented the Academy at the Association of Health Care Journalists annual convention in Boston. This was a dynamic conference that brought together more than 700 journalists from all over the country to explore pertinent topics, as well as to network and develop their skills.
I participated in a panel about improving patient outcomes and decreasing costs with Nancy Shendell-Falik, R.N., M.A., chief nursing officer and senior vice president of patient care services at Tufts Medical Center, and Donald Berwick, M.D., former head of CMS. (I also talked to several reporters one-on-one after the panel.)
The audience was composed of people who were experts in communication and in tune with social media. In fact, before our panel was completed, one person tweeted about wanting a photo with Dr. Berwick, while someone else tweeted that they wanted a photo with the "guy with the awesome beard!"
This kind of forum is important in many ways. It allows a formal presentation of our emphasis on developing physician-led, team-based care, as well as clarification that a patient-centered medical home (PCMH) is best defined by its community.
Here's the example I shared. Long before the PCMH was even an acronym, I had a small practice in Trenton, Ga. It had two nurses, a lab person, a front office person and me. However, that community also had two chiropractors, a physical therapy office, a home health agency, one pharmacy, the health department and emergency medical services. Together, we were our patients' medical home. We all took care of our patients and ensured that we coordinated care in our town. If a patient needed hospitalization, then we worked together to create that transition.
This concrete example of what creates a medical home is an important message to get out because it is easy for people to misunderstand or misrepresent some of these important buzz words and terms.
It also is important to realize what a critical role journalists play in sharing our message. At this meeting, I recognized that reporters and journalists are often community members who are looking at ways to help the citizens of their cities or towns get better health care. These are not folks quick to emphasize partisan talking points. They truly are interested in hearing perspectives and finding the middle ground.
There were many experienced journalists present at the meeting, but there also were a remarkable number of reporters who were new to covering health care. The connections that I made will allow me to continue to talk with people who are going to take our message back to the grassroots level, which is where change truly happens.
I challenged all of the people I talked with to truly look for the positives. These may not be the most exciting stories, but they are stories that need to be told for us to have positive change. Find the bright spots. Identify and write about those family physicians and practices that are truly working to make things better on the front lines. The more we share our stories, the better we all work together in the larger sense to create a seamless patient-centered medical home.
I challenge each of you to tell your story. Find a reporter in your area who is looking for a connection and wants to make a difference. Together, we can bring about transformation.
Reid Blackwelder, M.D., is president-elect of the AAFP.
Making the Case for Primary Care-specific Codes
The evaluation and management (E/M) services provided by primary care physicians are more complex, and thus more intense, than those of our subspecialist colleagues. Unfortunately, existing E/M codes do not reflect the scope of our responsibilities, the comorbidities of our patients, the complexity of their care or the coordination that care requires.
They should, and Academy leaders and staff made those points recently during a meeting with CMS officials who are involved in the development of the 2014 Medicare Physician Fee Schedule. We presented them with data that demonstrates how primary care E/M services are different and why they should be valued differently than services provided by other specialties.
Let's backtrack a bit.
A year ago, the AAFP Board of Directors made the difficult decision to stay involved with the AMA/Specialty Society Relative Value Scale Update Committee (RUC), despite the fact that the committee has undervalued primary care services in its recommendations to CMS. The Academy took a stance that it would participate in the RUC process while also advocating directly with CMS.
Around the same time, the AAFP's Primary Care Valuation Task Force made recommendations that included creating primary care-specific E/M codes and valuing primary care E/M services differently than those provided by subspecialists.
I told you in October that the Academy was working with a consulting firm to collect and aggregate data to support our argument about E/M codes. During a March 7 meeting with CMS, we presented the agency with preliminary data from that in-depth research.
Although CMS officials cannot comment on the process during the development of next year's Medicare Physician Fee Schedule, they can ask questions and request more information. When you are asking someone for more money, you can expect questions. We answered a lot of questions.
CMS officials also indicated they were eager to see more data supporting our position.
A draft of the fee schedule is expected in July before a final version is published in November. That gives us some time to continue our efforts and push forward with our request for a coding system that fairly values the important work we perform in the care of our patients.
Glen Stream, M.D., M.B.I., is board chair of the AAFP.
Match Opens Door to New Challenges
It should have been easy, but it wasn't.
On Friday afternoon, I was sitting with my parents, who had driven 100 miles to watch me perform the simple, mundane task of opening an envelope. This, of course, was no ordinary piece of mail. The letter inside was the culmination of eight years of hard work and a lifetime of dreams.
This was The Match.
It took me less than 10 seconds to open that envelope, but it seemed much longer. I knew what I wanted, and I felt confident that I would get the result I had hoped for. But until you pull out that letter, there is uncertainty.
Where was I going? There were plenty of choices.
Last fall, I completed four-week rotations at clinics in Pennsylvania and California and interviewed at a dozen other residency programs in between (as well as another in Alaska).
The letter in the envelope held the answer and would influence my life and career for years to come. The entire day had been one big swell of emotion. I was exhausted, and it was only 2 p.m. when it was over.
I have wanted to be a doctor for as long as I can remember. It's not surprising considering the amount of time I spent around physicians during my childhood. I was born with a heart defect and had open heart surgery when I was 2. That led to annual visits with a cardiologist. I also was fortunate to have a great pediatrician.
So when I headed to Saint Louis University as a college freshman, I already knew I would become a doctor. The question was what kind.
The answer -- family medicine -- came during the year I spent working at the Nativity House, a homeless shelter in Tacoma, Wash. I also developed an interest in psychiatry while working at the U.S. Department of Veterans Affairs during my third year in medical school.
When it was time to look for a residency, my goal was to match into a program that combined family medicine and psychiatry. I found it in November during my rotation at St. Vincent de Paul's Family Health Center, a medical clinic in a homeless shelter that is affiliated with the University of California, San Diego.
It is a challenging, five-year program. And there were only two spots available. By the time Match Day rolled around, San Diego was my first choice.
When I opened my envelope and saw San Diego on the letter inside, it was a huge relief. This is the program that gives me the best opportunity to be the person and physician I hope to become.
I have less than two months of medical school left. I have a three-week rotation in rural family medicine in Illinois and then a two-week primary care course before my residency program starts in San Diego.
I'm excited for the transition. It is thrilling and terrifying at the same time.
Here I come.
Aaron Meyer is the student member of the AAFP Board of Directors.