Friday Feb 21, 2014

Building the Family Medicine Pipeline

When I was running for AAFP President-elect, I said during a question-and-answer session at the Congress of Delegates that I would try to say yes to every opportunity that came my way. This can be daunting because there are so many opportunities to represent the Academy each week.

However, being president truly is a once-in-a-lifetime experience, and I have tried hard to follow through on my promise. I do everything I can to jump at invitations from state chapters, to medical student functions and other opportunities to meet with AAFP members all over the map.

Family Medicine Interest Group advisers discuss ways to increase student interest in our specialty during a recent meeting in Nashville, Tenn.

I recently had one such opportunity on my way back from the Nevada AFP meeting. I was invited to stop in Nashville, Tenn., to be a part of a dynamic workshop for Family Medicine Interest Groups (FMIG) faculty advisers. This leadership summit was an opportunity to bring together medical school and residency faculty and staff from all over the country who serve in adviser or support roles to the student-run FMIGs at their own or an affiliated medical school. One of the most important reasons for doing so is to develop relationships and create a sense of family in this group.

There is a significant turnover in this group because the role of student group adviser often falls to the newest faculty member in a department. In fact, many of the folks present had been involved with their FMIG's for less than a year. This makes it important for us to bring people together so we have an exchange of information as well as support systems for this incredibly important work.

FMIG's are remarkable. There is a great deal of direct student leadership involved for each medical school's group, with a select group of medical students elected or appointed to serve in roles to connect and coordinate between FMIGs. The AAFP recently selected its 2014 FMIG Network Regional Coordinators, who hail from Arizona, Illinois, Missouri, Pennsylvania, and Washington, D.C. These dedicated students work tirelessly to share information with FMIG student leaders at each institution and to provide opportunities for those leaders to connect and share best practices, much like what was done at the FMIG Faculty Adviser Summit.

The advisers all play different roles in this process, depending on their institution, environment and engagement of leaders. They have the responsibility for finding ways of sharing the excitement and passion for family medicine with students during their first two years of medical school, through the FMIG and other department efforts.

Most FMIG's are mainly made up of, and led by, first- and second-year students. Third-year students are on their clinical rotations and have less free time, and fourth-year students have often already committed to specialties. The group of advisers focused some of its discussion on how to keep third- and fourth-year students engaged in FMIGs to help support a family medicine specialty choice among the third-years and to use the fourth-years as mentors for the junior students.

This is a huge and critical aspect of addressing our pipeline challenge. The more we can tell medical students about the joys of family medicine, the more we may maintain their interest as they begin choosing specialties. In these challenging times, the message that our country truly needs primary care physicians is one that medical students need to hear, alongside the message of what's in it for them, which is the opportunity to have the greatest impact on population health and a specialty that provides variety, excitement and deep patient relationships.

This meeting allowed us to discuss the frustrations and the opportunities of a rapidly changing health care system and environment. I promised to take what I heard from the advisers back to the AAFP Board of Directors to help inform our deliberations related to developing our workforce pipeline.

I hope all of our active members work with medical students when given the opportunity. When students are early in their training, they are eager to see true patient encounters. At the same time, we have to recognize how impressionable students are. We need to make sure that our love of our patients and our thankfulness for the opportunities to answer our calling is what comes through. The more we do this, the more students will see that no other specialty creates the opportunities to get to know patients, make a difference and to truly impact families the way family medicine can.

Active AAFP members who would like to be connected with an FMIG faculty adviser at a medical school in their area may contact student interest strategist Ashley Bentley. Thanks for being a part of the learning process.

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

Tuesday Feb 18, 2014

Advocacy Improves Community Health Far Beyond Exam Room

I have been involved in advocacy, in one form or another, since middle school: collecting money for the Jerry Lewis telethon, arranging a speaker for my high school class and working on teen pregnancy issues in residency. The issue that helped me fully understand the nuances of advocacy, however, was the death of a patient who was a victim of domestic violence.

Knowing that I wanted to help to change the health conversation, I asked myself, "Who else in the community has a stake in this issue, and what existing programs might need assistance?" Then I met with the local women's shelters to find out what they needed and how family physicians could connect women who need help from these resources. I also worked with law enforcement officials, educated myself and eventually figured out how to get things done.

Family physicians face a lot of challenges, including payment issues, new regulations, public health issues and more, but we don't always know how to fix the problem or create change in our communities.

As President of the Pennsylvania division of the American Cancer Society, I spoke during an event at the State Capitol. Our advocacy efforts helped the Clean Indoor Air Act become law in 2008.

It helps to be able to take our frustration with these various issues and turn them into opportunities for change and leadership. Getting involved in advocating on our issues can provide an opportunity to get off the daily routine hamster wheel and develop and use different skills. We are trained in family and community medicine, so engaging in pressing issues can be a great fit for our skills. Addressing and fixing these nagging problems can help us reenergize, improve our professional satisfaction and build our professional network.

Start by asking, "What am I passionate about?" "What issue is hurting my practice or affecting too many of my patients?" The basic process of identifying a problem, gathering stakeholders, setting goals, developing a communications plan and engaging the community can be applied to an array of public health issues. For example, when I was on the board of the Pennsylvania division of the American Cancer Society, a state senator had been working for years -- without success -- on a bill regarding clean indoor air.

This is where those different skills I mentioned kick in. In this effort, I was able to provide testimony in my state legislature and inform the public about the issue by working with the media. By networking, with persistence and professionalism, we were able to bring critical allies -- including the state restaurant association -- into the discussion. The addition of physician partners adds urgency and credibility to an issue. You can be that valued partner.

By pulling other physicians and medical organizations into the effort, we were able to provide powerful stories from patients whose health had been affected by smoking in public places. We were able to gather data related to the high medical costs associated with working in a smoke-filled environment. These two factors personalized the story and proved to policymakers and the public that this was a public health problem that needed to be rectified.

Finally, the Clean Indoor Air Act was signed into law in 2008, prohibiting smoking in public places and workplaces statewide.

For some, advocacy means stepping out of their comfort zone, or at least expanding it. Speaking in front of large groups can be nerve-racking, especially when cameras are rolling. But the results -- healthier communities and personal growth -- can be fantastic.

Our communities -- and our country -- need us, and not just in our practices. Being involved in these types of issues, whether locally or nationally, showcases who we are, what we do and the fact that primary care physicians are leaders in community health.

On April 7-8 in Washington, family physicians will have an opportunity to learn about advocacy at the Family Medicine Congressional Conference. Attendees will learn how to engage legislators and share stories from their practices in a way that can inspire change. I hope to see you there.

Wanda Filer, M.D., M.B.A., is a member of the AAFP Board of Directors.

Wednesday Feb 12, 2014

Verifying Coverage Key for Patients Insured Via Marketplace

Implementation of the Patient Protection and Affordable Care Act (ACA) has created several challenges in our offices and to patient work flow. For instance, does your practice have a system in place to verify patients' insurance coverage at each appointment? If not, you may need to update your office's check-in procedures.

Under rules issued by CMS, certain consumers now have a 90-day grace period to pay outstanding insurance premiums before insurers can drop their coverage. The CMS rule requires insurers to pay outstanding physician charges during the first 30 days of this grace period. However, if a consumer fails to make a payment to the insurer within the 90-day period and his or her coverage is dropped, insurers will not be required to pay for claims incurred during the last 60 days of the grace period.

That means physicians could be left to work directly with patients to collect payment for services provided during those final 60 days.

The rule, which took effect Jan. 1, applies only to consumers who purchase subsidized coverage through the ACA's health insurance marketplace. The Academy has developed an FAQ to address questions family physicians may have about the new rule.

As of Jan. 24, roughly 3 million people had enrolled in private insurance through federal and state marketplaces since October. People making between 100 and 400 percent of the federal poverty level can qualify for the premium tax credit health insurance subsidy. The Congressional Budget Office has estimated that 7 million people will enroll through the marketplaces before the March 31 deadline, and 86 percent of those, or 6 million, would qualify for assistance.

Although those 6 million patients represent only 2 percent of the U.S. population, the new rule presents a challenge for those of us who care for this group of patients. Again, it will important to verify eligibility for patients who have coverage through an exchange plan at every visit.

It's not yet clear how the new rule affects physicians in states with prompt pay laws. Physicians should consult with their chapters about laws and regulations in their states.

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

Thursday Feb 06, 2014

Dedication to Lifelong Learning Reflects Specialty's Heritage

I recently attended a meeting of the Family Medicine Working Party, which is a convocation of the seven organizations that represent our specialty.

These groups are led by outstanding family physician volunteer leaders, and these biannual meetings allow these leaders to ensure each organization is aware of what the others are doing. Often, a focus area for one group affects the other groups as well. Even if our initiatives don't directly overlap, it is important to hear updates about what is happening.

It also is a great opportunity to talk about some of the remarkable things that we see in family medicine. I was particularly inspired by a story from James Puffer, M.D., the president and CEO of the American Board of Family Medicine (ABFM). One topic that we routinely review with the ABFM is the process of maintenance of certification, and the exam all diplomates are required to take. This conversation allowed us to review the commitment to lifelong learning that has exemplified family medicine.

It is important to recognize that when family medicine began as a specialty, we were the first and only specialty that challenged our members to continue to recertify. Other medical specialty organizations had lifelong certifications in place that allowed a physician to take one exam, one time. Our specialty's founding fathers knew that lifelong learning was a critical aspect, and that certifying only one time would not guarantee that a physician was at the top of his or her game throughout his or her career. We now have data showing that recertification maintains a knowledge base over time, whereas taking a single exam one time allows a person's knowledge base to decline.

However, the inspirational part of this story has to do with a group of family physicians who continue to recertify well into their 80s and even 90s. In fact, the oldest family physician who recently sat for the recertification exam was 93. Puffer personally calls all of these physicians to let them know their scores and to ask an important question. He was especially pleased to call the 93-year-old physician to inform him that he had indeed passed. Puffer asked the man if he was still practicing. The family physician replied that he had not practiced for many years. So, Puffer asked why he was recertifying. This member said that he could not imagine letting his certification lapse. He has always been board-certified, he said, and he always would be.

I think this comment is a testament to something unique about family physicians. This is a dedication to true lifelong learning. This member is going to continue to challenge himself to learn more about his craft even though he is no longer practicing. It also speaks to the pride and work ethic of this member that I think exemplifies family physicians. We recognize that board certification means something. We recognize that in family medicine, we have made a commitment to continue to challenge ourselves to be the best that we can be in order to give the best possible care to our patients.

This kind of story challenges me to continue to do everything I can to help our organization be the best that it can be so it can serve members like this extraordinary family physician in the way they deserve. I hope that I, too, am continuing to recertify until it is time for me to go to my next great adventure.

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

Friday Jan 31, 2014

Support for GME Reform Exists; Agreement on How is Lacking

The Council of Academic Family Medicine (CAFM) recently released a report outlining its four pillars -- pipeline, process of medical education, practice transformation and payment reform -- for advancing primary care physician workforce reform. The article also emphasizes the importance of advocacy moving forward.

In an interview with AAFP News Now, AAFP Vice President for Education Perry Pugno, M.D., M.P.H., the Academy's liaison to CAFM, said the biggest barriers to implementation of these concepts are "the tremendous need for change in how U.S. graduate medical education (GME) is financed" and resistance to reform by people who benefit financially from the flawed system already in place.

Although there is widespread recognition of our nation's need for more primary care physicians, there is not agreement in Washington on how to meet that goal. Two bills have potential to greatly enhance efforts to increase the family physician pipeline, but the lack of progress in moving either bill forward illustrates how difficult -- and frustrating -- the political environment in Washington can be.

In 2011, Reps. Cathy McMorris Rodgers, R-Wash., and Mike Thompson, D-Calif., introduced a bill that would establish a pilot project allowing a portion of GME payments to go directly to non-hospital, community-based primary care residency programs. McMorris Rodgers and Thompson reintroduced the bill, which has support from the AAFP and other physician organizations, in the current session of Congress, but no companion bill has been introduced in the Senate. AAFP staff members are working with Senate staff members to try to find a sponsor for the bill in the Senate.

Meanwhile, Sen. Bernie Sanders, I-Vt., has introduced legislation to reauthorize the teaching health center program, which is set to expire in 2015. Republicans historically have been supportive of community health centers (federal funding for the program doubled under President George W. Bush), but thus far, Senate Republicans have been reluctant to put their names on a bill that specifically supports teaching health centers, a concept initiated as part of the Patient Protection and Affordable Care Act. To date, Sanders' bill has nine other co-sponsors -- all Democrats.

Family physicians might not give GME a second thought once they leave residency, but the way GME is funded affects the types of physicians we produce. Funding an outpatient residency through an inpatient facility doesn't work. And the proof that the existing system doesn't work can be seen in decades of failing to adequately increase the primary care workforce.

Providing GME funds directly to residencies would be a more efficient and more logical process. For example, CMS pays resident salaries in my program based on how much time the residents spend at our local hospital. Thus, residents have to work enough hours in the hospital to get paid, regardless of whether the training they need is hospital-based. Does that make sense for a specialty where the majority of physicians are more likely to practice in an outpatient setting?

In the teaching health center model, residencies are funded directly, and an education committee -- not a hospital -- dictates how residents are trained.

Indirect medical education payments also are an issue because CMS leaves distribution of those funds to the discretion of hospitals. Hospitals have legitimate claim to some of that money -- which is roughly $40,000 per resident -- because they provide residents with meals, sleep rooms and more when they are working at the hospital. Although some hospitals are good about sharing those funds, others are not. In my case, our residency receives no money from indirect payments. With 20 family medicine residents (including our first-year residents pictured with me above), imagine what we could do with a fraction of the $800,000 going to the hospital.

The federal government invests $13 billion a year on GME, but those funds need to be used appropriately to produce the workforce the nation needs. The family physician pipeline once again will be one of the key topics during the annual Family Medicine Congressional Conference, scheduled for April 7-8. I hope to see you in Washington.

Daniel Spogen, M.D., is a member of the AAFP Board of Directors.

Monday Jan 27, 2014

Wording of CMS Proposed Rule Causing Undue Angst About Medicare

proposed rule published Jan. 10 by CMS is expected to save the federal government $1.3 billion during a five-year period by curbing fraud, waste and abuse in the Medicare Advantage (Part C) and Medicare Prescription Drug Plan (Part D) programs.

Unfortunately, the wording of the 157-page regulation also created significant angst among some family physicians. Specifically, CMS wrote that it is proposing "to require that physicians or non-physician practitioners who write prescriptions for covered Part D drugs must be enrolled in Medicare for their prescriptions to be covered under Part D."

Some AAFP members who don't participate in Medicare have expressed concern that the proposed rule would affect their ability to prescribe medications for their Medicare patients, but that isn't the case.

"We believe that allowing opt-out physicians and eligible professionals to continue to prescribe covered Part D drugs to a Medicare enrollee would ensure consistency with the Part B program in this regard," the rule says.

In short, the requirement to enroll with Medicare is being confused with a requirement to participate with Medicare. Under this proposed rule, physicians still have the same three options regarding Medicare:

  • Physicians may sign a participating agreement and accept Medicare's allowed charge as payment in full for all of their Medicare patients.
  • They may elect to be non-participating physicians, which permits them to make assignment decisions on a case-by-case basis and to bill patients for more than the Medicare allowance for unassigned claims.
  • They may opt out and become private contracting physicians, agreeing to bill patients directly and forgo any payments from Medicare to their patients or themselves. For example, if you are using the direct pay model of care, you still could do so without changing how you practice or bill. However, you will have to enroll in Medicare for your prescriptions to be covered by these plans.

The rule proposes that physicians and others prescribing drugs for Medicare patients be required to enroll so that CMS can "ensure that Part D drugs are only prescribed by qualified individuals." CMS implemented similar policy regarding durable medical equipment this month. The enrollment requirement actually will have no effect on most AAFP members because both participating and non-participating physicians are already required to enroll to bill for any Part B services that they provide. And, as stated above, CMS plans to continue to allow an option for physicians who opt out.

It is important to remember that this is a proposed rule, and it will not affect family physicians this year. The AAFP has not finalized our response to this proposed rule. Now is the time for you as members to provide the Academy with your thoughts and concerns to help us clarify our response during the comment period. You can do this in the comments area below.

In addition to the enrollment requirement, there are other provisions of this proposed rule the Academy will address. For example, the proposed rule requires formulary inclusion of all drugs within the antineoplastic, anticonvulsant and antiretroviral drug classes, but it no longer requires all drugs from the antidepressant and immunosuppressant drug classes to be included in Part D formularies.

The Academy is in the process of reviewing the proposed rule and will provide comments to CMS before the March 7 deadline. What are your thoughts?

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

Friday Jan 24, 2014

Town Hall Meetings Next Step for Future of Family Medicine Project

If you haven't shared your thoughts on Family Medicine for America's Health: Future of Family Medicine 2.0, it's not too late. In our latest update on this important initiative, you will find research results about family medicine reported this month at a Working Party meeting, a new set of questions being asked related to this project, details about a series of virtual town hall meetings scheduled to begin Jan. 29 and much more.

Family Medicine for America's Health: Future of Family Medicine 2.0

Organizational Update No. 5

Jan. 23, 2014

Work on the Family Medicine for America's Health: Future of Family Medicine 2.0 initiative continues. As a reminder, the purpose of this effort is to develop a multi-year strategic plan and communications program to address the role of family medicine in the changing health care landscape. To read earlier monthly updates from FFM 2.0, please visit the project Web page.

The Working Party, along with the FFM 2.0 Steering Committee and Core Teams, held a meeting in mid-January to inform and guide the project. A retreat will be held in mid-February that will include approximately 60 members of the family medicine community and 40 external stakeholders, including payers, patient advocates, employers and providers outside of family medicine. The goal is to help family medicine narrow in on its strategic commitments for the next five to seven years.

Following is an update on the current progress and status of the FFM 2.0 project.

Strategic Plan

CFAR, the consulting firm leading the strategic planning process, has finalized the "current state" analysis and developed three scenarios that illustrate possible future states for family medicine based on different strategy choices. CFAR co-developed these scenarios with the Core Team, the Steering Committee and the Insight Groups. The Insight Groups include medical students, residents and young leaders in family medicine who are in their early years of practice. Each of the seven family medicine organizations nominated two participants to each of the groups.

Communications Plan

APCO Worldwide, which is leading the communications planning, has completed qualitative and quantitative opinion research that will inform their recommendations. Recently, APCO conducted a quantitative survey of 1,871 individuals across three primary audiences:

  • Patients: 800 interviews with general population adults in the United States;
  • Business and policy community: 271 interviews (96 with health care policymakers, 100 with employers/purchasers, 75 with health care payers); and
  • Medical professionals: 800 interviews (400 interviews with physicians [150 family physicians, 100 other primary care, 150 subspecialists] 300 with medical students and residents, 100 with nurse practitioners and physician assistants).

Following is a summary of the findings presented at the January Working Party meeting:

  • Family physicians are viewed very favorably by all stakeholders, especially patients. At least three of four stakeholders across audiences have a favorable view of family physicians and provide positive comments when asked why they rated family physicians the way they did.
  • Family physicians' broad scope of knowledge, ability to treat entire families and caring nature are key themes that define family physicians positively.
  • When asked about which member of the primary care community will have the biggest impact on the health care system, family physicians are selected most frequently across every stakeholder audience.
  • Audiences believe that coordinating care, treating the whole person and using technology to improve patient care are the most exciting ways family physicians can engage in the new health care system.
  • At least three of four stakeholders across the audiences feel that family physicians should focus more on preventive and chronic care versus acute care.
  • The research shows that family physicians do a good job of connecting emotionally with stakeholders. The emotional connections audiences have to family physicians are important to identifying the right tone for communications positioning and the campaign.

Based on this and earlier research, APCO will develop recommendations on how to communicate the value and role of family medicine to external audiences. Concepts will be tested further in focus groups with various audiences.

Seeking Your Input

Your feedback is critical to this process. We welcome and encourage your comments and questions and have a dedicated email address for input. Since our first report on this initiative, we have received hundreds of comments to this address, and all have been very valuable to the Steering Committee and Core Team.

APCO would welcome your input on the following questions as they build the communications plan:

  • Are there specific issues you believe family medicine should be advocating around? For example, prevention, chronic disease, mental health, etc.
  • Given the diversity of family medicine practices, do you believe there is a way to deliver a consistent "product" or set of services to patients regardless of geography or patient panel demographics?  If so, what would that look like?
  • Are there emerging technologies that family medicine should/can embrace to provide better care for patients or improvements to the health care system overall?

Please share your thoughts at

Family Medicine Virtual Town Hall Meetings

In addition, we are holding a series of virtual town hall meetings to hear from practicing family physicians around the country. After a brief overview of the project so far, we would like to hear from you about the issues that will be most critical to address in family medicine's strategic plan. We are very pleased that Glen Stream, M.D., M.B.I., past president of the AAFP, will be hosting the town hall conversations. 

The first virtual town hall meeting is on Wednesday, Jan. 29 at 8:00 p.m. EST. There will be two additional town hall meetings on Feb. 26 at 8:00 p.m. EST and March 26 at 8:00 p.m. EST.

To register for the first town hall meeting, please click on this link:

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

Tuesday Jan 21, 2014

Chemical Spill Puts Resident, Hospital to Test

Jan. 9 was like any other Thursday. I worked a full, busy and ordinary day as a family medicine resident at my hospital in Huntington, W.Va. Then I drove 30 minutes home to Culloden, W.Va.

It's worth noting that A) Huntington and Culloden are served by two different water treatment plants, and B) I didn't listen to news radio in the car.

On the way home, I stopped to buy groceries for the coming weekend. Although busy grocery stores are nothing unexpected, what I saw on this night was different. It was a new level of frenzy. Still, I didn’t think much of it. Many people in my community had been without power for a few days because of a recent storm. I thought maybe they were restocking their freezers and refrigerators.

I finished my shopping and went to the check-out line. That's when another shopper said to me, "You don't have any water. Why don't you have any water?"

I'm not accustomed to having my shopping cart critiqued, but I was willing to play along.

"Why do I need water?" I asked.

That is how I found out that an estimated 7,500-gallon spill of 4-methylcyclohexane methanol -- a chemical used to treat coal -- had been detected in the Elk River, less than two miles upstream from our area's water treatment plant.

At that point, I was too late. There was no bottled water left on the shelves in that store or any other store in town. I went home to a weekend without water -- me and 300,000 other people.

A state of emergency was declared for a nine-county area that includes Charleston, the state capital and West Virginia's largest city. We were told not to use tap water for any reason, which meant no consumption, no bathing and no cleaning anything.

Schools and businesses closed. The West Virginia National Guard was activated to distribute drinking water and assist residents affected by a chemical spill. Volunteers, like the Poca High School students in the photo above, handed out cases of bottled water to people in need.

Fortunately for me, my hospital and residency program weren't affected. I was able to shower at the hospital and fill water bottles to take home. My fellow residents were wonderful, watching my 6-year-old during his unplanned vacation while I was on call, and they also allowed my husband and son to shower or bathe at their homes.

In the bigger picture, it was fortunate for others in the area that the hospital was unaffected because without water, other health care facilities in the nine-county area were unable to care for their patients.

To transfer patients from one facility to another, you have to have an accepting physician on the receiving end. Although other academic and private admitting services at my hospital declined to accept transfers from the affected facilities in Charleston, our family medicine service did. If we hadn't taken these patients, they would have been sent to facilities in Ohio or Kentucky, and we didn't want that to happen to them.

And although I feel good about the care we were able to give, we were quickly overwhelmed. In addition to patients transferred from other hospitals (after being admitted for reasons unrelated to the spill) we also treated numerous patients who were exposed to the tainted water and were suffering with nausea, rash, headache, diarrhea and vomiting.

We also experienced a surge in patients suffering from influenza. Without access to water, people couldn't wash their hands, and the flu spread rapidly within a few days.

Soon, our hospital was full. People were admitted with no bed to go to, so gurneys were set up in the hallways with makeshift bed numbers taped to the walls.

People pitched in and helped out because in a crisis situation you have to adapt and be flexible. Residents who weren't on call offered to help. We stepped up and took care of patients who needed help.

Finally, on Jan. 15, patients from Charleston started going back to the facilities they came from.

This past weekend, people in my community were allowed to flush their pipes -- running faucets and showers, dishwasher and washing machines -- to clear the tainted water from the system. The process made the house smell, and the stuff coming out of the pipes was awful. But it's progress and a step closer to getting back to normal.

Would you be ready if a crisis affected your community? The AAFP has resources available to help families, medical practices and communities prepare for disasters.

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

Editor's Note: Photo is courtesy of Staff Sgt. De-Juan Haley via Wikimedia Commons.

Wednesday Jan 15, 2014

Food Security: Take a Lesson From Your Patients

A recent study in Health Affairs found that low-income Californians with diagnosed diabetes were more likely than the state's higher-income residents to be admitted to the hospital for hypoglycemia. The results were particularly striking when evaluated on a week-by-week basis because low-income residents had a 27 percent increased risk of being admitted for hypoglycemia during the last week of the month compared with the first week.

The study's authors suggest a correlation between economics and health. As patients' funds become limited, so did their access to healthy food. The results indicate that those most vulnerable to food insecurity -- defined as limited or uncertain availability of nutritionally adequate and safe food -- may also suffer adverse health outcomes when resources are scarce.

The results are not surprising, and other studies have suggested a link between food insecurity and adverse health outcomes. These studies should remind us of the importance of asking patients about their access to food. It rang clear for me through my interactions with one of my patients, who we'll call Dennis.

Dennis was in his mid-40s and obese. He also had diabetes and hypertension. When I took over his care, his conditions were well-controlled, and he was compliant with his medications. After seeing him for about a year, his hemoglobin A1c rose significantly and his blood pressure became uncontrolled.

He told me that he wasn't eating as well as he knew he should. We reviewed carbohydrate and sodium goals, and he promised to try to eat more salad. I suggested adding insulin, but he said he wasn't ready to take that step.

At his next visit, when we hadn't seen much change in his numbers, I finally asked why things changed so dramatically. It was at this point that he admitted he now was homeless, surviving on food stamps and the good will of others.

His diet consisted almost entirely of eating at fast food restaurants and soup kitchens, he told me. He was still reluctant to use insulin because he feared he would be robbed for the needles. With that knowledge, we were able to strategize how to use his limited food dollars to get the nutrients he needed and how to titrate his medications more appropriately to match his food intake.

For me, it was a wake-up call to ask not only what people are eating, but also how often they are eating. It opened my eyes to the need to ask my patients about their eating habits. I'm sure I'm not the only family physician who has encountered mothers who water down their baby's formula to make it stretch, elderly patients getting by on tea and toast, or parents who go hungry so their kids don't have to.

Patients often are reluctant to admit that they are having a hard time putting food on the table. And the impact of food insecurity on health is vast, including both malnutrition (from lack of nutrient-rich food) and obesity (due to eating cheap, calorie-dense and nutrient-poor food) , as well as all of the complications associated with those problems.

According to the U.S. Department of Agriculture, 14.5 percent of households were food insecure at some point during 2012. As family physicians, the most important thing we can do to help our patients regarding this issue is to ask about their food practices, especially when there is a change in their health status. There are federal, state, and local programs to help individuals who may be food insecure, including the Supplemental Nutrition Assistance Program for adults; the Special Supplemental Nutrition Program for Women, Infants, and Children, better known as WIC; and national school breakfast and lunch programs for children and families.

For my patient Dennis, asking the right questions about his food practices was the key to getting his health back on track.

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

Thursday Jan 09, 2014

Banding Together Helps Small Practices Achieve PCMH Recognition

Editor's note: During the AAFP's Scientific Assembly in San Diego, a panel discussion on practice transformation generated far more questions than the panelists could answer in the time allotted. This is the third post in an occasional series that will attempt to address the issues members raised -- including the challenges associated with transforming a small practice -- during the panel.

When the topic of practice transformation comes up, one of the most frequent questions we hear is, "What about the little guy?" How are small practices expected to overcome the additional work and expense needed to achieve patient-centered medical home (PCMH) recognition?

This is a valid question, but the answer might be simpler than you think. For my small practice, the solution was to find strength in numbers. And that didn't require anything as complex as joining an accountable care organization or an independent practice association.

There's a common belief in health care that large group practices are more viable during practice transformation. My practice, however, has just two physicians: me and my wife (who is pictured with me here). We think the medical home model is the future of medicine, but we want to remain independent. So, 18 months ago, we sat in a meeting with other small practice owners from in and around San Antonio who also were interested in achieving PCMH recognition.

We realized that if our small practices worked together, we would have the resources of a large group practice. For example, if one practice researched what was needed to meet a specific PCMH requirement and developed a strategy to achieve it, that practice could then share its results with the other nine practices.

Economy of scale is essential. Having several small practices working together made us much more likely to succeed. Looking for community partners that support the medical home is another move that improved our chances for success. In our situation, those partners include a large health system and a local payer.

With a newfound network of support, we divided the numerous challenges amongst the practices and went to work.

After reviewing the PCMH checklist, my wife and I realized our practice already was meeting three-fourths of the requirements. National Committee for Quality Assurance (NCQA) Level 1 recognition was relatively easy for us to achieve, and all 10 practices achieved it at roughly the same time.

Of course, we had room for improvement. Our practice improved access by implementing open-access scheduling and a patient portal.

Building a staff where everyone buys in to the effort also is critical. Our staff performance has improved through the process. Labs are completed on schedule, we have fewer overlooked test results and we do a better job of ensuring that immunizations are up to date.

NCQA Level 2 recognition was about three times more challenging than Level 1, but within a year of starting this process, we were there. Not all 10 practices reached that milestone at the same time, but all 10 have made it. Five of the practices, including ours, are now working on reaching Level 3, which is a daunting task. Once the first five practices reach Level 3, we'll help the other five do so as well.

So what is the future for small practices? Systems will adapt to allow us to survive. We are too important not to, especially in underserved areas. Still, we have to be willing to listen to options, and sometimes you have to be creative.

Local hospitals have an interest in our survival, and so do payers who want to reduce costs through better care. Our group has asked for help from both. For example, the Christus Santa Rosa Health System has been supportive of our efforts, including by providing space for our meetings. The system has bought into the importance of primary care and the vision of primary care as the foundation and future of health care.

In addition, our project has been partially funded by Blue Cross and Blue Shield, which has provided a case manager to work with our practices. The payer also has pledged to provide a 5 percent payment differential for practices in our group that achieve Level 3 recognition. That 5 percent bump will help us pay the case manager after the project is completed.

Being a small practice doesn't necessarily mean having limited resources. Sometimes you have to look for -- or build -- your own system of support. We're a small, rural practice, but Level 3 is within our grasp.

In the next few weeks, the AAFP will be introducing a new tool that provides step-by-step work plans to guide practices through PCMH transformation. Learn more about this new resource, the PCMH Planner, here.

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

Tuesday Jan 07, 2014

Academy is Working to Define, Value Care Management

Editor's note: During the AAFP's Scientific Assembly in San Diego, a panel discussion on practice transformation generated far more questions than the panelists could answer in the time allotted. This is the second post in an occasional series that will attempt to address the issues members raised -- including the valuation of care management fees -- during the panel.

The AAFP has been advocating for years that a designated care management fee should be paid on a per-member, per-month basis as part of a blended payment model that also includes enhanced fee-for-service and performance-based incentives.

Family physicians always have done what is needed to care for our patients. We answer phone calls and e-mails, review and compile information from subspecialists, coordinate care transfers in referrals and in the hospital, handle prior authorizations, and ensure so many more aspects of making sure our patients get the care they need are covered. Although all these factors are critical for good patient outcomes, none of them generate payment for family physicians doing this important work.

The AAFP is pushing for payers to recognize the value inherent in care management services. Although we are seeing progress in this area, our efforts are complicated because of the amount of confusion -- and disagreement -- regarding what care management services should include and what they are worth. The Academy is working to define patient care management so that these services can be understood and valued appropriately.

For example, the AAFP's Robert Graham Center for Policy Studies in Family Medicine and Primary Care has conducted a literature review that considered more than 600 studies that offered evaluations of care management fees and reimbursement in care management and/or care coordination. Sixty-one articles were deemed relevant for inclusion in the review.

The range of fees found in that review was striking, with a low of 60 cents per beneficiary per month in one demonstration to a high of $444 per beneficiary per month in a congestive heart failure program. Some payers are offering $2 to $4 per beneficiary per month. Obviously, these low numbers are unacceptable.

Some disagreement exists as to what dollar amount per beneficiary per month would be most appropriate to properly value the work required to provide high quality care, but we are working on a process to help make these critical decisions.

The Graham Center's work will be used as the basis for a concise document that defines what the AAFP considers to be the essential elements of care management fees. That document will be vetted in February during a meeting of the Academy's Commission on Quality and Practice.

The next step will be for the health care advisory firm Avalere Health LLC -- which has been working with the Academy on payment issues since 2012 -- to value the AAFP's definition of a care management fee. That valuation, the definition and the underlying literature review then will be used to create a policy document on the valuation of care management fees. That document is expected to be presented to AAFP Board of Directors later this year.

When the work is done, we'll have one seamless document we can take to payers -- both public and private -- and say, "Here is what we do for our patients. This is what care management means. It should be valued and paid for, and this is a reasonable care management fee."

The document also will be used to help AAFP members evaluate contracts that include care management fees.

We'll keep you updated on our progress.

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

Friday Jan 03, 2014

Media Offers Platform to Educate Public About Health, Family Medicine

Cold and flu season is here, and newspaper and TV health reporters from markets around the country likely will be calling their local primary care physicians looking for an interview for what has become an annual story. If the call came to your office, would you respond in a timely fashion? You never know where a simple conversation might lead.

Talking to the media offers us an invaluable platform to share important public health messages, providing a multiplier effect on our ability to care for our communities. It also provides us with an opportunity to show the vast range of family medicine.

Many years ago, I was at grand rounds when it was announced that WGAL, our local NBC affiliate in Lancaster, Pa., was looking for a family physician who could participate in health segments for a new talk show. I was intrigued, and out of a few hundred physicians who applied, they picked me.

It wasn't a paying job, at first, but I saw it as a public service. It wasn't about growing my patient panel. Instead, I saw this as an opportunity to educate the public and decision makers about family medicine and give viewers a better understanding about what we do. I covered topics that involved pediatrics, obstetrics, geriatrics and more and often was asked to comment on breaking news that involved health care. The broad range of topics discussed highlighted the scope of practice that family medicine provides, showcasing our specialty to a 20-county audience.

After four years of occasional appearances, my segments became weekly features. Eventually, the station asked me to contribute daily segments for the evening news.

The high profile position with WGAL -- combined with my involvement in the Pennsylvania AFP and advocacy work related to domestic violence -- led to me becoming the Physician General of Pennsylvania, working as a public health adviser to the governor.

My role with the television station lasted nearly 20 years. Obviously, not every physician who gives an interview will have a career-altering experience. But when your patients read your name in the newspaper or see you on TV, they will feel good, knowing that you are engaged in your community. And by delivering public health messages to a broad audience, you're doing a service for that community and family medicine.

Should the media contact you directly for comment on AAFP policy or positions, or if they want to discuss national health care issues or AAFP clinical guidelines, please refer them to a member of the AAFP's public relations team Jay Senter works with clinical, health of the public and research topics; Leslie Champlin works with health care legislation and policy, workforce and medical education topics. If the reporters want comment on local health issues, please work with them to provide that and let the PR team know if you need any assistance.

Wanda Filer, M.D., M.B.A., is a member of the AAFP Board of Directors.

Wednesday Jan 01, 2014

Challenges, Opportunities Await in 2014

Happy New Year! This really should be a good new year.

Of course, there are always challenges. However, things are moving in some outstanding directions for family medicine. It is exciting that people around the country -- the media, policymakers and others -- are continuing to talk about primary care. What is even more exciting is that it seems the understanding of what primary care is and who provides it continues to become more focused. Moreover, seeing family physicians as the foundation of primary care in our health care system is a discussion that is really ramping up now, and it's long overdue.

It may seem hard to believe, but the sustainable growth rate (SGR) formula may finally be repealed this year! As the calendar year changes, support for the current bicameral and bipartisan effort to repeal the fatally flawed SGR remains strong.

This effort is critically important in and of itself. However, it also has been a huge roadblock for discussions about many other issues that are essential to continuing to transform our health care system. Other needed reforms related to things such as payment, graduate medical education and workforce have in many ways been delayed or derailed because so much time and energy has been needed to deal with the SGR.

I am encouraged, and excited, by the possibility of being able to carry our other important messages forward knowing that we can have some meaningful conversations about them on Capitol Hill.

We continue to see increasing interest from medical students in family medicine. We are seeing an increase in applications from U.S. seniors at my medical school, and many of my peers have reported similar trends. It looks to be a strong class.

Now, we need to have the important discussions about continuing to find ways of changing medical school education to emphasize family medicine and better address the social mission that should be a determining factor in a graduate's specialty choice.

We also need to address the problem posed by the combination of increasing number of U.S. medical school graduates and the cap on the number of residency spots that are supported by Medicare. We will continue to move efforts forward to not only increase the cap, but to push for the majority of the new positions to be in true primary care, especially family medicine.

And, I am pleased that payment reform is moving forward. It is certainly not happening quickly enough, and the issues of the salary gap, overvaluation of some procedures, and the inherent difficulties of the fee-for-service system still exist. However, CMS has signaled its recognition of the valuable services we provide in coordinating our patients’ care by creating new care management codes that allow us to get paid for things that we have always done and will always do.

Moreover, we have data from researchers at the University of Texas Health Science Center at San Antonio that demonstrate the increasing complexity of the kind of care we provide. These data, which we are providing to CMS, will help show this difference objectively and drive home the need for further payment reform that better values the care we family  pysicians provide for our patients. As more and more of our patients have multiple medical conditions, the case we make is increasingly critical.

Our unique and comprehensive education and experience is becoming better recognized and appreciated. A recent patient survey has made it clear that patients value and appreciate us. They want to see their family physician for their health care needs, and they want that family physician to be the leader of their health care team. This validates what we have been saying for more than 10 years. The patient-centered medical home (PCMH) succeeds in meeting the quadruple aim: improving patient outcomes, improving patient satisfaction, improving physician satisfaction, and doing so at lower costs. A core contributor to the success of the PCMH is the role of physician-led teams.

In short, the messages that we have been giving for years finally are being heard and understood. There always will be challenges, but those also can be opportunities.

Thank you for all you do, including your dedication to our patients, our communities, our profession and our country. Your efforts have helped get family medicine to where it is and where it will be. It is an honor to serve with you. I look forward to an exciting new year as we continue to move health care transformation forward in our country.

As the way we deliver care to our patients evolves, I’m eager to further define who we are and where we are going as a specialty. Please follow me on Twitter to see where I think family medicine is going, and use the hashtag #WhereFMisGoing to join the conversation with our colleagues.

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

Friday Dec 20, 2013

Sports Medicine One More Way FPs Support Communities

A regulation hockey puck is six ounces of frozen, vulcanized rubber. Struck by the right athlete, a puck can speed across the ice at more than 100 mph. So when 200-pound athletes are slamming each other into the boards, swinging sticks (and occasionally punches) while skating on solid ice in pursuit of said puck, it's not a bad idea to have a physician around.

That's where I come in.

I recently was attending an Iowa Wild game in my role as team physician for the local minor league team when one of the players was struck by a puck in the lower leg. It hit him hard enough that the crowd let out a collective groan.

I kept an eye on him to make sure he wasn't favoring the leg, but he kept on skating and stayed in the game. When the game was over, a trainer called me over to take a look at the injured leg. The puck had shattered his shin guard, ripped a nickel-sized hole in the tissue and exposed his tibia.

Hockey players, as it turns out, are pretty tough.

I irrigated the wound, removed pieces of the shattered shin guard from the wound and closed it with a vertical mattress.

What I didn't give him was a bill. Sports medicine of this kind -- treating injured players during or after a game -- typically is done on a volunteer basis. Teams show their gratitude with gear, tickets and other perks.

So why do it? Sports medicine is one more way that family physicians can support our communities, whether through a local high-school team, a pro franchise or something in between.

I was a track athlete in high school, and I stay active with cycling, running and skiing. As a medical resident, I knew my days of being an athlete were behind me, but I still wanted to be involved in sports. So I took extra training in sports medicine, and when I started my practice I volunteered as a team physician for the local high school.

A few years later, our town landed an arena football team, and it needed a primary care physician to work with orthopedists. It also needed someone to manage care of its players, coaches and their families. I not only see them at the games, but they come to my office for preventive medicine as well as when they are ill.

It's been fun to get to know the team and their families on a personal level and build those relationships. These are people who are extremely talented at what they do, and it's gratifying when they look to me for expertise at what I do.

Sports medicine can build your practice without an official connection to a team. Athletes -- pro and amateur -- talk amongst themselves about their injuries and how and where those injuries are being treated. And when an injured weekend warrior comes to me for rehab, often his or her whole family follows.

Over time, people in the community have come to associate me with sports medicine. When my sons were playing high-school sports, other parents often told me that having me on the sidelines was reassuring. That's a good feeling, much better than, say, a puck to the leg.

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

Wednesday Dec 18, 2013

Future of Family Medicine 2.0: What's Your Opinion?

It's time for another update on Family Medicine for America's Health: Future of Family Medicine 2.0. In addition to providing you with details of the latest actions related to this important project, the update below offers family physicians an opportunity to provide input on four specific questions related to payment models, family physician training, research and the triple aim (improving patient care and outcomes and lowering costs).

You can address the questions below -- and offer other thoughts on the project -- at

Family Medicine for America’s Health: Future of Family Medicine 2.0

Organizational Update No. 4

Dec. 17, 2013

This is the fourth update of the Family Medicine for America’s Health: Future of Family Medicine 2.0 initiative. The goal of this effort, which was launched in late August, is to develop a multiyear strategic plan and communications program to address the role of family medicine in the changing health care landscape.

      As a reminder, the Family Medicine Working Party identified a set of key principles that will underpin this effort:

  • Deliver on the triple aim: improving the health of the population; enhancing the patient experience of care (including quality, access, and reliability); and reducing, or at least controlling, the per-capita cost of care.
  • Focus on the needs of residents and medical students, as well as practicing family physicians. 
  • Manage the tension between addressing the needs of family medicine as a specialty and needed changes to the health care system of which it is a part.

Strategic Plan

CFAR, the strategic consulting firm hired for this project, is now working on its "current state" analysis. This document is designed to create a shared understanding about where the profession is today. This shared understanding serves as a foundation on which to build an implementable strategic plan that identifies risks to take, investments required to do so, and a realistic understanding of how to bridge the gap between the current state and the desired future we want to create. Following are the key issues that are being examined as part of this process:

  • Core attributes: What are the core attributes of family medicine today, and what do they need to be in the future, for our profession to achieve the triple aim in the service of our patients and the larger health care landscape?
  • Evolving ecosystem: How should family medicine change in response to the challenges of an evolving health care system to best meet the needs of the nation?
  • Education: What changes are needed in the continuum of education (from medical school through residency and into CME) to train the family physicians needed in the new health care system? 
  • Communicating value: How do we best communicate to relevant stakeholders the value and benefits of family medicine and the important role family physicians play in meeting the health care needs of the U.S. population?     

CFAR has sought broad input from family physicians -- and those who work alongside them -- in the development of the current state analysis. This has included

  •  conducting in-depth interviews with thought leaders and stakeholders in the field of family medicine; and
  • conducting a strategic options survey designed to test the assumptions the community holds about the present, as well as perspectives on strategic choices in the future. The survey was sent to more than 6,000 front-line family physicians, as well as a variety of other primary care health professionals, such as OB/Gyns, general internists, nurse practitioners and physician assistants and physicians early in their careers.

     We encourage feedback and would welcome input from family physicians through our dedicated email address on the following questions:

  • Can you share any examples of family physicians -- yourself included -- who are working in payment environments other than fee-for-service? How has that experience affected their practice (or your own)?
  • What are some concrete steps family medicine can take to increase the number of family physicians trained to meet the needs of the American public in the future? 
  • How can the leadership of family medicine help family physicians meet the demands of the triple aim (improved patient care, improved health of populations, lower cost)?
  • What kinds of research would help improve your practice?

Communications Platform

      APCO Worldwide, the communications consulting firm, is conducting research to develop the communications platform to reflect the strategic plan. APCO has conducted in-depth interviews to elicit attitudes and opinions about family medicine from external audiences including policymakers, major insurers, employees and purchasers and other primary care health professionals. These interviews focused on perceptions of family physicians, the role of family physicians in the new health care era and the future of family medicine. Following is a brief summary of the findings:

  • There is marked appreciation for the skills and patient rapport that family physicians bring to health care.
  • Family physicians are viewed as having a solid diagnostic ability based on their scope of medical and clinical knowledge.
  • Treating the entire family gives family physicians an advantage compared with other primary care physicians in being able to consider social and behavioral dynamics in their diagnosis and treatment.
  • Expertise in prevention and education helps position family physicians for the new health care landscape.
  • Family physicians are seen as the natural choice to lead the patient-centered medical home and accountable care organizations, coordinating care and stressing wellness.
  • There is a strong belief that new comprehensive care models provide family physicians the greatest opportunity to succeed in the new system.
  • Retail clinics are seen as the greatest threat to the family physician.
  • Most cannot imagine a health care system without family physicians.

APCO currently is conducting the quantitative research element of the communications planning process. The results of its broad public opinion survey will be presented in January.

We strongly encourage you to share your input. Again, you can provide feedback at We welcome comments on the items outlined above or other suggestions/insights that would be useful to this process.

Upcoming Meetings

The fifth meeting of the Core Team will be Jan. 9. The next combined meeting of the Working Party, Steering Committee and Core Team will be Jan. 16-18.

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

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