Advocacy Agenda Shifts With SGR Behind Us
Last week, I attended the Family Medicine Congressional Conference (FMCC) in Washington, and for the first time in 17 years, we did not have to lobby legislators and congressional staff about the Medicare sustainable growth rate (SGR) formula.
We did thank legislators who voted overwhelmingly to repeal the fatally flawed SGR. Now we're moving into a post-SGR world. This doesn’t mean everything is fixed, but it does allow us to focus our energies and our voices on addressing other much-needed changes in our health care system, including payment reform, graduate medical education reform and truly valuing primary care.
© 2015 Michael Laff/AAFP
Here I am meeting with Sen. Sheldon Whitehouse, D-R.I., (center) along with members of our Rhode Island delegation: Roanne Osborne-Gaskins, M.D., Keith Callahan, M.D., (second from right) and resident Jason Kahn, M.D. (far right). Hundreds of family physicians met with legislators and congressional staff last week during the Family Medicine Congressional Conference.
FMCC is an inspiring event. I looked around the room and saw remarkable people who I have “grown up with” during six years on the AAFP Board of Directors, including three as an officer. It has been rewarding to see family physicians who I installed as state chapter presidents developing as leaders.
These meetings also affirm one of the core attributes of family medicine -- it really is about relationships. Attending an Academy meeting is like coming to a family reunion. The biggest frustration for me is not having enough time to spend with all the people with whom I wish to catch up. (So, if I didn’t get to you this time, I’m sorry and I look forward to our next meeting!)
FMCC has a different focus than other occasions when AAFP officers are on Capitol Hill advocating for our specialty. The Academy staff does an incredible job providing information to chapter leaders and creating opportunities for legislators to address critical topics.
I was honored that my own congressman, Rep. Phil Roe, M.D., R-Tenn., came to speak at one of the plenary sessions. Although he’s an OB-Gyn, he told stories just like we all do to make his points. He’s excited about moving away from the contentious SGR debates and toward new issues. He has appreciated that near the end of the SGR process, physicians learned to speak with one voice and more clearly about health care reform. He understands the value of primary care, and, in the words of one of our attendees, “He gets it.” More and more of our legislators are getting the message about primary care, and its important role in our health care system. They are beginning to understand that the term “primary care physician” is best associated with the specialty of family medicine, and that we need to make many more changes to link value to this recognition.
At FMCC, we addressed the fact that legislation and regulations need to value primary care in practical and immediate ways. For example, we need to push to remove co-pays from chronic care management fees to remove the hurdle that patients and family physicians face in obtaining and providing needed chronic care coordination, and in accessing primary care.
We need to be sure that the definition of primary care is clearly understood, especially when medical schools are still touting, sometimes in a misleading manner, high graduation rates of primary care physicians. We need to make sure that when people are praising primary care, and vowing to value it, that we’re all on the same page in this regard, and the foundational component of family medicine as the primary care specialty is understood.
Although we are pleased that the National Health Service Corps and the Teaching Health Center Graduate Medical Education program have been funded for two more years, we need to continue to push for these vital programs to be recognized as the successes stories they are. Although they were extended by the same legislation that repealed the SGR, they should be permanently removed from the budgetary chopping block.
GME reform was emphasized as a vital issue during last week's event. We’re challenging legislators to look at ways of increasing transparency regarding GME funding and demanding accountability for the $13 billion put into the medical education system each year. The current system is not producing the workforce we need despite the tremendous investment.
It was refreshing to see things come together regarding the way that families and communities care for each other. FMCC featured a plenary about family caregiving. One of our requests of the legislators we met with was that they join the recently formed Assisting Caregivers Today caucus. This effort creates an opportunity for many stakeholders to work together to find ways to care for people outside of hospitals. In so many ways, this echoes our call for people to receive right care in the right place at the right time from the right person. Ultimately, the best answer for providing this care is through team and community-based care.
Finally, I was honored to join our state chapter leaders during visits with their state legislators and congressional staffers. I was incredibly impressed with the Oregon chapter’s discussions with staff members of Sen. Ron Wyden, D-Ore., the ranking democratic member of the Senate Finance Committee. Melissa Hemphill, M.D., who is just two years out of residency, took the lead during this meeting, and she did as good a job as any AAFP officer or other veteran advocates in articulating our perspectives.
I also joined the Rhode Island delegation for a meeting with Sen. Sheldon Whitehouse, D-R.I. He impressed me with his understanding of medical issues, especially as they related to his state. Roannne Osborne-Gaskin, M.D., and Keith Callahan, M.D., clearly expressed the challenges they face in their practice settings in that state. I was impressed with the good work that our state leaders are doing.
It's worth noting that FMCC came right on the heels of the Academy's Annual Chapter Leader Forum, which offers training in areas such as advocacy, communication and more. The process of leadership development and relying on the informed voices of state leaders is such a key aspect of making change. As an Academy, we continue to advocate for our patients and practices.
There is still much work to be done, but I see several doors opening that had been closed for so long. Thanks for all you do, and keep up the great work.
Reid Blackwelder, M.D., is Board chair of the AAFP.
Face-to-Face With Dr. Oz: Benefits of Touting Family Medicine Outweigh Risks
When discussing treatment options with our patients, we consider the risks and the benefits of the various options available. Ideally, we seek choices with benefits that far outweigh the risks.
The same is true for leadership, but sometimes you have to boldly stick your neck out to make your message heard.
| Here I am talking with Mehmet Oz, M.D., on "The Dr. Oz Show." In a show about facing your fears, my segment dealt with the fact that some patients fear going to the doctor. I emphasized that patients need a family physician who can serve as their trusted health adviser.
Earlier this year, I got a phone call from Mehmet Oz, M.D., the cardiothoracic surgeon, author and TV host better known as Dr. Oz. We had met years before when I was working for the local NBC affiliate as a health consultant and reporter. His staff had initiated conversations with the Academy about interviewing me on his show, and now he was reaching out to me directly.
I hadn't jumped at the opportunity, and with good reason. It's been a rough year for Dr. Oz, who was called before Congress last summer because of concerns with some of the products that have been promoted on his show.
"You need to understand that our members aren't happy with some of your advice," I told him. I also let him know that family physicians are spending too much of our valuable time explaining to patients why we don't recommend some of the products and ideas they've seen on his show.
But again he asked me to come on the show to tell his audience about family medicine, and that audience is vast. Each weekday, nearly 2 million people tune in to watch on television, and many millions more watch online.
So here was a risk with a potentially huge benefit. This was an opportunity to talk to millions of Americans about the importance of family medicine and the critical role that primary care plays in health care. I could give this audience, which hasn't always received evidence-based information, a better understanding of who we are and what we do as family physicians.
As I considered it, the conclusion that I drew was that the benefits would outweigh any risks if I could reach viewers who don't have a primary care physician and make them realize that they should. Incredibly, that goal was accomplished before the show was ever broadcast.
The topic of the episode, which aired today, was fear. Specifically, my segment dealt with fear of going to the doctor, which can keep people away from our practices even when they are in dire need of care.
So we talked about why everyone needs a family physician, a trusted adviser who knows the patient and his or her family history. We talked about the scope of family medicine and the fact that we care for people from the beginning of life until the end. We also talked about our ability to help patients set and reach their personal health goals.
One woman in the audience had not seen a physician in more than a decade because of her personal fears and concerns about costs. When we had finished taping my segment, I walked over to her and said, "Can I help you find a family physician?"
"I would love that," she said.
I followed up with her, and -- with help from the New York State AFP -- was able to connect her with a family physician in her area. If nothing else, I know my appearance on that show made a difference for one person already.
We mitigated our risks with Dr. Oz as much as possible. We discussed beforehand things I would not do on the show, found out who the other guests would be, and received a guarantee that there wouldn't be any medical products or services or nutritional or diet products promoted during this episode.
This effort already helped at least one person in the studio audience. My hope is that viewers who see the episode on TV or online will find their way into our exam rooms. Americans need to understand the value and importance of what we do. For people to hear our message, we may have to take a few bold risks.
Wanda Filer, M.D., M.B.A., is president-elect of the AAFP.
Your Opinion Matters; Here's How to Share It
With more than 120,000 members working in a wide range of practice models in all 50 states; U.S. territories; Washington, D.C.; and U.S. military bases around the globe, we won't always have a consensus on issues that affect family medicine. In fact, we often don't.
Although family physicians are different in so many ways -- based on gender, generation, political affiliation and race, to name a few -- we all share a common goal: to provide the best care possible to our communities. It's important that we communicate and work together as members and as an organization to achieve that goal.
Tiffany Matson/AAFPHere I am talking with attendees at the AAFP Leadership Conference. Hundreds of members and chapter staff attended the event last week in Kansas City, Mo.
Sometimes, the Academy receives feedback from members who feel they aren't being heard. Small- and solo practice physicians, in particular, have vented frustrations about the growing regulatory burdens their practices face and their need for help in addressing these obstacles. I understand because I am a rural, small-practice physician, and there are others like me serving on our Board of Directors. And I can tell you we do hear members' feedback.
AAFP officers, myself among them, offered updates on a variety of issues facing family medicine and took questions from members during a May 1 Town Hall meeting during the AAFP Leadership Conference in Kansas City, Mo. We discussed payment reform, workforce issues and more. Members will have another opportunity to ask us tough, direct questions Sept. 27 during a Town Hall meeting at the Congress of Delegates in Denver.
But these annual events are only two examples of ways that AAFP leaders and staff listen to members' opinions. There are many other ways to make your voice heard.
The Academy regularly solicits member feedback through randomized surveys. If you want to make your opinion known, this is an excellent -- and easy -- way to provide input that affects AAFP products and policies. In 2013, the Academy polled members more than two dozen times on various issues, so if you receive a survey, please complete it!
The AAFP also gathers feedback about twice a month through the Member Insight Exchange. This is a growing group of family physicians -- currently, about 600 of them -- who have provided input on a wide range of issues, including AAFP products, Medicaid, health care apps, direct primary care and more. The Academy would like to expand the numbers of members who participate (log in required) and earn incentives for providing feedback.
It's also worth noting that we send a member of the Board to nearly every state chapter meeting. These meetings offer a chance for us to provide updates about what the Academy is doing nationally, but more importantly, they provide an opportunity for us to listen to family physicians from across the country.
Last year, the Academy illustrated its commitment to helping all members have their voices heard when it created a pathway for the establishment of member interest groups. To date, 10 groups -- including one for solo/small practices and another for rural health -- have been created. Many of these groups plan to meet at AAFP Family Medicine Experience (FMX) in September in Denver.
AAFP leaders also are participating in quarterly online discussions with family medicine interest group leaders to answer questions and discuss issues that matter to medical students.
In addition, AAFP leaders and staff have responded to members' questions and concerns posted on the Academy's listservs. Although we don't respond to every comment, the Academy monitors and discusses comments we receive via social media. And you can communicate with me directly through the AAFP President Facebook page and on Twitter @aafpprez.
I want to assure you your voice and input matter greatly. As a practicing family physician, I understand firsthand many of the frustrations of our members. As an Academy, we will continue to work hard on reducing those frustrations so that we can bring the joy of practice back to our lives.
Robert Wergin, M.D., is president of the AAFP.
Team-based Training Key to Providing Team-based Care
One of the core components in transforming a practice is team-based care, and this concept is a focus of many conversations when I visit our chapters across the country.
My employer, the Quillen College of Medicine at East Tennessee State University (ETSU), also has embraced this concept. And the outstanding group of interprofessional educators I work with are constantly looking for ways to enhance not only the way we provide team-based care, but also how we address the all-important process of teaching team-based care. Truly, to embrace, understand and implement team-based care, we have to have team-based education.
Photo courtesy American Pharmacists Association
Here I am speaking at the American Pharmacists Association's annual meeting. I gave a presentation about team-based care with Brian Cross, Pharm.D., who is vice chair of the Department of Pharmacy Practice in the Bill Gatton College of Pharmacy at East Tennessee State University.
During my time as an AAFP officer, I have been honored to speak to the boards of several organizations that represent our colleagues who play critical roles in providing team-based care, including the Association of Family Practice Physician Assistants, the American Academy of Physician Assistants, the American Association of Nurse Practitioners and the American Pharmacists Association (APhA). At each of these meetings, I have had a chance to thank each group for helping improve the care of our patients, and to consider ways to work through challenges to find creative ways of providing education.
There are many others who play important roles in team-based care, including social workers, behavioral health specialists and our county health departments, but today I want to focus on how we work -- and train -- with pharmacists.
Recently, I had the opportunity to work with my friend and colleague, Brian Cross, Pharm.D., who is vice chair of the Department of Pharmacy Practice in the Bill Gatton College of Pharmacy at ETSU, on a presentation about team-based care (login required) during the APhA's annual meeting.
We also co-teach several sessions with our medical students, pharmacy students and residents at ETSU. We start with a patient case that relates to considering and implementing evidence-based approaches to caring for patients with cardiovascular disease. We break our audience into small groups of junior medical students and second-year pharmacy students who then work through questions about patients to seek the best evidence about possible treatments and put them into practice. Then the groups defend their decisions in our discussions.
This particular educational activity is critical because during the same rotation, students, family medicine residents and the pharmacy team work together to coordinate post-hospitalization care in our transitions clinic. Students and residents take what they have learned from this and other sessions and apply it to patient care, and the results have led to dramatic improvements. For example, this clinic has helped reduce our readmission rate from 25 percent to 13 percent.
Almost every patient seen in this clinic has benefited from the true medication reconciliation that can occur when these students review the clinic medication list, the hospital list, the pharmacy list and what the patient brings into the appointment.
In addition, we have other opportunities in which our pharmacists and their team see our patients in the anticoagulation clinic. They don't work in isolation. Instead, they work directly with our residents and medical students. In addition, our social worker leads a group of medical students, pharmacy students and sometimes a resident to make home visits with our patients.
These examples demonstrate ways that learners from different professions are able to put theoretical educational processes from the classroom into direct actions that impact care.
Even if a school or community isn't blessed with a college of pharmacy, those of us in education still can reach out to our local pharmacies and find ways to involve some of their learners or employees in our educational process, which will help create better relationships. One of the keys to team-based care is having this kind of relationship-building at every level. And it is not just between health care professional and patient. It also is between each member of the team.
If you are not involved in academics, there is value in having discussions with the team members who work not only under your roof, but also with local pharmacists or health departments. Each member of this community-based team can talk about the kinds of patient care issues they see and how each might be able to contribute to improving care. Much of this can be done without specific contracts or organizational memos. The core principle is improving the care of our patients by working together.
It's worth noting that the Patient-Centered Primary Care Collaborative (PCPCC) published a report in December that looks at how seven different programs use interprofessional health training to deliver patient-centered care. The PCPCC also is offering a five-part podcast series on this concept.
Meanwhile, the Robert Wood Johnson Foundation offers a free resource related to improving care through team work. And the National Center for Interprofessional Practice and Education offers articles, presentations and other tools in its resource exchange.
Finally, the Academy will be offering a session Sept. 29 and Sept. 30 at the 2015 AAFP Family Medicine Experience (FMX) in Denver titled "Capitalizing on Team-Based Care to Improve Quality and Office Efficiency." Thomas Bodenheimer, M.D., and Berdi Safford, M.D., will be among the FMX panelists.
I am hopeful that some of these ideas resonate with you. None of us takes care of patients in isolation, so the first question to ask and answer is, "Who are the members of our teams?" The second step is to get everyone together and think about how we can impact education and patient care. Thanks for being a part of this critical process.
Reid Blackwelder, M.D., is Board chair of the AAFP.
Doctors Need the Straight Dope on Medical Marijuana
Nearly half the states, and the District of Columbia have adopted comprehensive medical marijuana programs, and more than a dozen more have approved use for a limited number of medical conditions. Two states -- Colorado and Washington -- have taken things even further, legalizing marijuana for recreational use.
Of course, none of this changes how marijuana is viewed by federal authorities. The Department of Justice has issued guidance to federal prosecutors, reiterating the agency's commitment to the Controlled Substance Act. The FDA has not approved marijuana as a safe and effective drug for any indication.
Legislators are again impacting the care of patients and the health care delivery system. So where does that leave us as physicians? WebMD polled physicians last year and nearly 70 percent of respondents agreed that medical marijuana can help patients with certain conditions. But physicians were less enthusiastic about making the drug available. Half of the doctors polled in states where medical marijuana is legal supported its legality. In those states still debating medical marijuana laws, 52 percent of doctors supported it.
Hence, although an overwhelming majority of U.S. physicians understand the potential benefits of medical marijuana, roughly half oppose it.
In my home state of Illinois, legislators have legalized medical marijuana. Many patients are asking for it; many have valid reasons, such as cancer or chronic pain. For those who do not, the discussion explaining the reason for denial is lengthy. Illinois, like many states, used model legislation to create its medical marijuana program, and physicians are not required to write prescriptions. Rather, we certify which patients meet conditions that allow them to legally buy the drug at a dispensary.
Sadly, conversations with my patients have highlighted some obvious problems with medical marijuana. I have had patients suffering from chronic pain ask for medical marijuana because they fear becoming addicted to prescription narcotics. They, like many others, don't understand that marijuana can also be addictive. According to the 2013 National Survey on Drug Use and Health, marijuana use accounted for more than 4 million of the 7 million Americans who are dependent on or abusing illicit drugs.
In short, many patients don't know the harmful effects of marijuana. So although there are limited health benefits to medical marijuana, we must also ensure that patients understand the risks.
At last year's Congress of Delegates, the AAFP adopted policy stating that decisions about medical marijuana should be based on evidence-based research and called for further studies into the use of medical marijuana and related compounds. But with new studies being published regularly, it can be hard to keep up on what the latest evidence tells us.
The AAFP can help. The March edition of FP Audio has a clinical topic that will help physicians evaluate current evidence on the use of medical marijuana for the treatment of multiple sclerosis and severe childhood epilepsy. Another edition exploring the topic further is scheduled for July.
The Academy will offer two sessions related to medical marijuana Sept. 29-Oct. 3 at FMX in Denver. An interactive lecture will cover what family physicians need to know about medical marijuana. And during an "Out and About" -- an offsite CME session -- a family physician and a patient will discuss legalized marijuana from the physician and patient perspectives. That session will be followed by a tour of CannLabs, an advisor to commercial, governmental and educational entities focused on the cannabis industry.
State chapters also can play a role. The Illinois AFP is offering its second webinar on medical marijuana and its implications for physicians on April 27. Registration is limited to the first 100 participants, but an archived version will be available. (The event is not limited to Illinois AFP members.)
The bottom line is that medical marijuana is becoming available in a growing number of states. There is a tremendous economic advantage to a state’s economy. Consumer advocacy groups have formed to urge the federal government and the FDA to ease federal restrictions and fund marijuana research. When patients come to us for help, we should know the law governing our actions and what liabilities may exist. And, we should have an informed conversation with our patients about the potential risks and benefits of a drug for which long-term safety for adults and children is not yet truly known. The laws are changing rapidly. Family physicians should become knowledgeable of the laws in our own states regarding the use of medical marijuana. Consult your state medical boards and/or departments of professional regulation for guidance where necessary. The train has left the station.
Javette Orgain, M.D., M.P.H., is vice speaker of the AAFP Congress of Delegates.
Don't Be Shy: Health is Primary Trumpets FP Success Stories
Health is Primary made the second stop on its city tour last week in Raleigh, N.C. -- my home state -- and it was a fabulous event that featured speakers representing a broad spectrum of primary care.
Reporter and author T.R. Reid, who moderated a panel discussion, noted that some of the most striking innovations to the U.S. health care system are coming from family physicians and other primary care health professionals, and it didn't take long for the panelists to illustrate his point.
© 2015 David Keith Photography
Here I am speaking with Karen Smith, M.D., during a Health is Primary event. Smith, past president of the North Carolina AFP, was one of the speakers during a panel discussion about primary care during the April 16 event in Raleigh, N.C.
North Carolina AFP President Thomas White, M.D., was among those panelists. White described his realization that the firefighters in his town, Cherryville, had an unusually high fatality rate. The problem was not the inherent danger of putting out fires, but that the lifestyle that came with the job resulted in an elevated risk for cardiovascular disease. White found that firefighters suffered from stress related to their jobs and also from poor diet because of the unpredictable nature of their roles. After examining other risk factors for the firefighters, he ordered lipid screenings and blood sugar tests.
White's story illustrates that we family physicians can improve the health of our communities in many ways. Many of the firefighters were volunteers, and their health and well-being were vital to the health and safety of others in their small town.
When battling a blaze, firefighters work in pairs, following the mantra of "two in, two out." White pointed out that family physicians also work in teams -- we are paired with our patients. We're in it together to improve their health.
It was impressive to hear many stories of how primary care is affecting health care in my state and throughout the country. Family physicians often are humble and don't always share success stories. Health is Primary presents an opportunity to change that. The three-year communications campaign is designed to advocate the values of our specialty, demonstrate the benefits of primary care and engage patients in the health care system.
Last week's event drew a big crowd, including policymakers and members of the press. The message they heard was that family physicians can make a difference; we are innovative and we can solve many of the problems in our nation's health care system. It's a message we shouldn't be shy about repeating in our own communities.
Edward Bujold, M.D., of Granite Falls, was one of the family physicians sharing his story. Bujold transformed his small practice into a patient-centered medical home (PCMH) about five years ago. When he analyzed practice data before and after the transition, he realized his admission rate had dropped 80 percent. Although such dramatic results may be atypical, they show what is possible with practice redesign and team-based care.
Another interesting story came from Cathie Pettit, executive director of DirectNet LLC, a preferred provider organization that worked with a furniture company to match its employees with a PCMH.
Vanguard Furniture was spending about $10 million a year on employee health care when a review showed that two employees accounted for about $800,000 of that care. One of those patients had not received recommended preventive screenings and was undergoing treatment for cancer. The company's leadership decided it needed to do something different to improve the health of its workforce, lower its risks and bolster its bottom line.
Vanguard invested roughly $2 million on a system that linked employees with a PCMH and encouraged them to receive recommended preventive services. Despite the significant investment, the company was able to lower its annual spending on health care overall because its workforce was healthier.
Health is Primary is a product of Family Medicine for America's Health, a partnership of eight family medicine organizations, including the AAFP. The tour's next stop is scheduled for May 19 in Chicago.
Mott Blair, M.D., is a member of the AAFP Board of Directors.
Take a Bow, Physicians -- You Defeated the SGR
No more patches.
No more payment cuts looming on our calendars.
We did it!
When the U.S. Senate passed the bipartisan Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act, or MACRA, tonight, more than a decade of frustration with and instability in the Medicare program ended. The legislation contains many provisions that have long been supported by AAFP members, most notably repeal of the Medicare sustainable growth rate (SGR).
In recent weeks alone, AAFP members weighed in with about 5,000 letters or phone calls to legislators, urging them to support this important legislation.
Thank you for making your voices heard. The long-awaited action by Congress retroactively negates a 21 percent cut in Medicare payments that took place when the most recent patch expired March 31.
How did we get to this point? Congress created the SGR formula as part of the Balanced Budget Act of 1997 as a way to determine annual updates to the Medicare physician fee schedule. By 2002, the SGR was mandating reductions in physician payments, and we began a nearly annual dance of threatened pay cuts and congressional patches.
In all, Congress used 17 temporary patches to avoid payment cuts at a total cost of nearly $170 billion. The longstanding uncertainty regarding Medicare payments has had adverse effects on the long-term health of our practices, as well as on patients' access to care. In a 2013 survey of Academy members, 9 percent of respondents said they had stopped taking new Medicare patients in the past year, and 10 percent said they had stopped taking new Medicare patients more than a year earlier.
Still, nearly 80 percent of AAFP members continue to take new Medicare patients despite years of uncertainty, and the Senate's vote on MACRA is a victory for us and our patients. In addition to repealing the SGR, the legislation will establish an alternative set of annual payment updates. The legislation also extends funding for critical programs that affect primary care:
- community health centers;
- the National Health Service Corps; and
- teaching health centers.
MACRA also addresses another key issue that affects our practices and the health of our patients. The legislation makes interoperability of certified electronic health records a national objective. HHS will be required to establish interoperability metrics next year to measure progress toward achieving that goal by the end of 2018.
The passage of this bill illustrates the value of primary care and the strength of our voice. Thank you for standing with family medicine.
Robert Wergin, M.D., is president of the AAFP.
FPs Have Ability to Inspire, Be Inspired by, One Another
During a recent review course at our local medical school, my practice partner gave a lecture about the patient-centered medical home (PCMH). My partner -- who also happens to be my wife -- was not too keen on making the presentation at first. She doesn't think of herself as a public speaker, but after a bit of encouragement, she agreed to share the story of our journey through practice transformation with an audience of about 250 people. And she was magnificent.
Every practicing physician has interesting and valuable stories that other physicians could learn from, but too often, we don’t seize the opportunities in front of us. Likewise, I think many family physicians fail to realize the value we bring to the health care system. But if our nation is to transition from a specialty-driven health care system to one built on primary care, family physicians must be the change agents in that revolution. We cannot wait for permission or validation from others; if we do not believe in ourselves, who will?
In medical school, we often heard the mantra, “see one, do one, teach one,” which emphasizes student learning through practice. A similar approach of “imagine one, do one, inspire one” could be applied to the changes that are needed in our health care system.
One of the experiences I enjoy most of late is when other physicians come to visit our practice to see what we’re doing. Some come to see what we’ve done with our electronic health record system. Others want to know how a small, rural practice became a recognized PCMH. Still others want to hear about our accountable care organization (ACO).
Being around people who are making changes and succeeding can give us the confidence, courage and inspiration to embark on our own transitions. And that doesn’t have to be a transition to a PCMH or an ACO. A growing number of our members are pursuing other practice alternatives, such as direct primary care.
We can create the change we want to see, but first we have to understand the possibilities. We can’t just sit back and wait to see what happens next. Of course, every family physician doesn’t have to run for a chapter presidency or testify before a congressional committee to consider him- or herself "involved," but we can all share our success stories with our colleagues and work with our staffs to provide the best care possible.
The Academy has pledged to deliver "strong medicine for America." So long as we inspire our family physician colleagues, and allow ourselves to be inspired by others, we will deliver on that promise.
Lloyd Van Winkle, M.D., is a member of the AAFP Board of Directors.
Rx for Success: PBS Film Shines Light on Health Care Triumphs
I recently watched a documentary that put a song in my heart and left me inspired by people who decided to take control and make a difference in the world around them -- for their patients, their teams and their communities. I heard stories of family physicians doing what we do best, despite the many hurdles we all face in a fragmented system. I want you to see what is possible.
David Loxterkamp, M.D., is the son of a physician. For two decades, he was a small-town, small-practice family physician much like his father, a general practitioner, had been. About 10 years ago, however, Loxterkamp decided he needed to make a change.
"I realized medicine is too difficult to do it alone," he said. "This is a really hard, emotionally draining job. You really need someone else to help you out."
Loxterkamp assembled a team to help him care for his small community in Maine, where he still makes house calls. His practice now includes other physicians, nurses, a psychiatrist, a psychologist, a pharmacist, a physician assistant, a medical assistant and a physical therapist.
It's hard to argue with their results. The practice's ER visits have fallen 40 percent in the past four years. One-third of the patients enrolled in a smoking cessation program have actually quit, and the blood sugar level of patients with previously uncontrolled diabetes has dropped dramatically.
David Grubin also is the son of a general practitioner, but he did not follow in his father's footsteps. Grubin is a filmmaker whose documentary, Rx: The Quiet Revolution, makes its debut tonight in many markets on PBS. Grubin said his father had lost faith in the U.S. health care system by the time he retired. Physicians, his father said, didn't have enough time for their patients, and he didn't know how to change a system that valued volume over quality.
Grubin's father, however, had never met anyone like Loxterkamp, one of the four examples the film provides of physicians and systems that have found a way to succeed in a dysfunctional, fragmented health care system.
The film, which will be repeated in most markets and also can be viewed online, delivers a powerful message: It is possible to succeed in our flawed, fee-for-service system. Although Loxterkamp practices in a recognized patient-centered medical home, these success stories didn't depend on the kind of incentives often provided in practice transformation pilots.
For example, Grubin visited On Lok, a San Francisco-based program for the elderly, that has been around since the 1970s. Like Loxterkamp's practice, On Lok takes a team-based and patient-centered approach to care.
The innovative program provides care and social activities for the elderly during the day yet allows patients to remain in their homes at night. In addition to medical care, the program provides services like grocery shopping and cleaning to patients who likely would otherwise be in a nursing home.
According to the film, patients in the program are less likely to visit ERs and hospitals and are less likely to be readmitted than those who live in nursing homes.
With the number of Americas older than 65 expected to double in the next 20 years, such services could be in high demand in the near future. And this film could help more patients be aware of -- and expect -- high quality, patient-centered care.
Grubin's travels also took him to Alaska, where native Alaskans were so dissatisfied with an Indian Health Service program that relied on emergent care that the community took control of the local hospital and built a new system with a strong primary care foundation. Team-based care is again a central theme in this story as is telemedicine, which the system uses to connect remote communities with physicians and pharmacists.
Teams and telemedicine also play prominent roles in the success of a program in Mississippi, which has the nation's lowest median household income and the highest rate of obesity. The state, which has one of the nation's highest rates of diabetes, is trying to address these health problems with a program that provides patients a tablet-based monitoring program that allows them to provide a blood sample each morning.
The program goes beyond monitoring with physicians, nurses, dieticians, physical therapists and more providing care and counseling. As one patient told the filmmaker, "You need somebody that cares."
Clearly, Grubin has succeeded in finding such people. It is critical to point out again that these practices were created in the setting of a flawed, fee-for-service, volume-driven, fragmented and dispassionate system. Individuals, sometimes a family physician and sometimes another team member, took control of their lives and situations. They made changes, big and small, with the most important one being that they would remember to care. They have reclaimed their joy of practice by embracing the essence of team-based, patient-centered care. And now they have shared their stories in this film.
These stories give us hope and show us what is possible.
Reid Blackwelder, M.D., is Board chair of the AAFP.
Dear Payers: Unnecessary Visits Waste Patients' Time
One of the biggest health care challenges we face in this country is the combination of fragmented care and the siloing of different systems. I recently was reminded how important this issue continues to be.
During a recent clinic, most of my patients were logged in with notes related to their insurance rather than a medical need for a visit. Some of them were there for health maintenance per insurance, one was for a "diabetic check per insurance," and so on. Oddly, this was a group of patients that I had seen only a few months ago.
I asked these patients why they had come in, noting that I had not expected to see them so soon. (In fact, I had not planned to see them for a year, assuming they weren't ill.) Most of them said they had received phone calls from their insurance companies stating they needed to be seen for a health maintenance visit, but in reality, no such need existed.
Family physicians provide health maintenance during every visit, but we must make sure we code appropriately because, unfortunately, insurance companies often pay more attention to codes than to the actual care being provided.
As I reviewed their records, I realized that in my efforts to care for my patients, I had neglected to care for their charts by indicating an ICD-9 "V" code (e.g., V70.0, "Routine general medical examination at a health care facility") within the timeframe of the insurance calendar. However, each of these patients had indeed had health maintenance evaluations. When I had seen them in November, we had gone through the management of their chronic diseases, any acute issues, their biopsychosocial issues, and we had also addressed their individualized preventive services aspects -- all of the things that we routinely address.
Each patient had Physician Quality Reporting System measures checked and recorded, and I reviewed health maintenance and documented it clearly in the chart; however, as this was just a routine part of what I did, I was billing based on their medical disease management.
Despite their efforts, my patients had been unable to convince the insurance representatives on the phone that they had actually covered all of these issues. In fact, one patient who came to me for a diabetic check per insurance does not even have diabetes, and so this was another issue I documented.
Rather than calling patients -- who reported that they felt "harassed" by the payers -- it would make more sense in a nonfragmented system for insurance companies to call physicians so we can review what care has and has not been offered and provide any necessary information. My hope and ideal would be that all payers look for ways to connect with physician offices or, better yet, implement a system that would note the checkboxes that indicate the appropriate health maintenance measures were indeed done without the V code.
Better and easier communication with payers would benefit patients and physicians and help payers avoid unnecessary costs. Several of the affected patients had Medicare, but when I tried to call that payer I was unable to get a real person on the phone. The patients did not have any related paperwork with them, so I couldn't identify a direct help phone number. So, we covered whatever clinical issues needed some attention. Then, without really requiring anything specifically for the health maintenance, I diligently coded V70.0s and documented the previous discussions in their charts.
The sustainable growth rate formula legislation that passed the House last week includes steps to consolidate performance measures in an effort to decrease administrative burdens. It would be helpful if interoperability existed that would allow immediate tracking when such measures were done anywhere in the health care system. Although we have made some progress, there is still a great deal of work to be done.
One of my favorite quotes lately is, "It is not patient-centered until the patient says that it is patient-centered." Forcing patients to make unnecessary office visits certainly misses the mark.
Reid Blackwelder, M.D., is Board chair of the AAFP.
Mismatch: Why the Disconnect Between Student Interest and Student Choice?
I matched into family medicine. The number of students matching into family medicine increased for the sixth year in a row. Now it's time to celebrate.
Or is it?
|My husband, Rob, helps me find the paper lantern containing my Match information. More than 3,000 students matched into family medicine last week as part of the 2015 National Resident Matching Program.|
Although the number of students matching into family medicine through the National Resident Matching Program increased again this year, the uptick was small, especially among U.S. medical school graduates.
This leaves many -- students and physicians alike -- asking, "What gives?" Everything we have been hearing points to increasing student interest in family medicine, so why aren't more students matching into the specialty?
First, it's true that student interest in family medicine is increasing. The AAFP has reached out to students in many ways, and student membership in the Academy has grown from 14,833 in 2010 to 26,900 today. Student attendance at AAFP's National Conference of Family Medicine Residents and Medical Students has increased substantially each of the past four years. And family medicine interest groups (FMIGs) also are reporting growth, with new groups being formed and interest in existing groups increasing. We even have FMIGs at schools that lack departments of family medicine.
And second, it's not a question of lack of demand. For eight consecutive years, family medicine has been the highest recruited medical specialty for physician employment.
So again we are left wondering, 'Why the disconnect?' The interest and the demand are there, so why doesn't the increase in our match rate reflect this?
Unfortunately, there's no single easy answer. Instead, we see interwoven barriers preventing a smooth translation from student interest into student choice of family medicine. The AAFP has for years investigated these barriers and worked to develop and execute plans to overcome them. That work continues, and there are ways you can help.
The issue of student debt has two components: the debt itself and overall physician payment, which affects students' ability to repay their debt. Many fourth-year medical students recently completed their exit loan counseling, and, after years of trying not to worry about the amount of debt they were accruing, they finally had to face it.
Loan amounts vary from student to student. I consider myself fortunate to be the recipient of a National Health Service Corps (NHSC) scholarship for part of my medical education. Yet even with the scholarship, my student loan debt is $172,000. This is a scary number for me, but not as scary as the mountain of debt some face. One of my colleagues, who also is going into family medicine, owes $410,000.
He applied for an NHSC scholarship during medical school, but there simply was not enough funding for all the students who applied. So yes, we still need to take a look at student debt and how to alleviate more of it, including through more scholarships and loan repayment programs, lower loan interest rates, ensuring public loan forgiveness programs remains intact, and more.
Equally important is physician payment reform. Students are worried their income will not cover their debt and the cost of living, let alone the expense of starting a practice. With a 21 percent Medicare payment cut set to go into effect on April 1 if Congress doesn't act to repeal the sustainable growth rate (SGR) formula, this topic has been center stage for practicing physicians and the AAFP in recent weeks. I urge you to reach out to your legislators and tell them to repeal the SGR.
Despite all the great work going into finding solutions for student debt and payment reform, students still worry these two massive issues are a long way from getting solved. These concerns can make them hesitant to choose family medicine, and this is where practicing family physicians can make an immediate and direct impact through mentoring.
For example, family physician Mark Goedecker, M.D., of York, Pa., has visited many medical schools, including mine, to share his family's story of overcoming substantial student debt. His main message is "You can afford to be a family physician." Of all our FMIG events in the past four years, Dr. Goedecker’s talk was the most well attended and the most inspirational.
But financial topics are not the only issues medical students want to hear about from residents and physicians. We want and need more family physician role models! We need to see your enthusiasm and passion for family medicine; we need to see family medicine's broad scope and its diversity of patients; we need to see you combating burnout; we need you to show us the way.
We can get some of this insight from conferences and meetings, especially National Conference, but you can help build and maintain student enthusiasm and passion for family medicine all year round. We want to see family doctors caring for kids; performing vasectomies; and doing prenatal care, palliative care, sports medicine and more. Show us, talk to us and teach us.
Showing us your passion for family medicine through mentorship also helps us understand the strength, value and importance of family medicine. Show us how primary care is delivered in teams, and that all members of the health care team, including our nurse practitioner and physician assistant colleagues, have a unique and valuable role in patient care. Help dispel the many myths and misperceptions about family medicine that students hear.
Imagine what would happen if some of these barriers to student choice were removed, and more students who would make phenomenal family doctors followed their passion to family medicine. It's what needs to happen to eliminate the primary care shortage and achieve our quadruple aim of better care, better health, lower costs and happier physicians.
Kristina Zimmerman is the student member of the AAFP Board of Directors.
FP Recommendation Key to Boosting Colorectal Cancer Screening Rates
Each year, more than 130,000 U.S. adults are diagnosed with colorectal cancer, the nation's second-leading cause of cancer deaths. Despite those stark statistics, nearly one-third of adults ages 50 to 75 aren't getting screened as recommended.
In an American Cancer Society survey of unscreened patients, one of the leading reasons respondents gave for not being screened was that they had not received a screening recommendation from a physician. Family physicians are positioned to make a huge difference in closing this gap because we provide roughly 200 million office visits each year to a vast spectrum of patients.
A physician discusses care options with a patient. An American Cancer Society patient survey indicates that a physician recommendation can make a big difference in whether or not patients are screened for colorectal cancer.
So it was no surprise last year when the National Colorectal Cancer Roundtable (NCCRT) -- chaired by family physician Richard Wender, M.D. -- sought the AAFP's support for its 80% by 2018 initiative, which seeks to increase the percentage of adults ages 50 and older who get screened for colorectal cancer to 80 percent by 2018.
It's been estimated that achieving that goal would prevent more than 200,000 deaths because colorectal cancer can be detected early -- when treatment is more likely to be successful -- and even prevented through the removal of precancerous polyps.
So where do we stand? The percentage of U.S. adults who have been screened increased from 56 percent in 2002 to 65 percent in 2010. And as the screening rate has risen in recent years, cancer incidence has dropped in this age group.
Still, much work remains to reach the initiative's goal. College graduates are screened at a rate of more than 80 percent, but disparities exist for many other populations. Patients with less education and income, the uninsured, underinsured and certain minority groups have dramatically lower screen rates and higher cancer rates.
So how do we reach these populations? I recently participated in an event hosted by the American Cancer Society and the NCCRT that looked at the progress made during the first year of the 80% by 2018 initiative. We heard from some of the more than 200 groups that have pledged to help boost the screening rate. Those groups range from individual physician practices to national physician organizations and also include payers, public health groups, national retailers and others. In some communities, family physicians, gastroenterologists, public health officials and others are working to identify unscreened patients and direct them to affordable care.
For example, John Allen, M.D., M.B.A., president of the American Gastroenterological Association, said during the event that a grant from Walgreens had helped physicians in Connecticut identify and screen more than 300 patients. Of those, 46 percent had precancerous polyps.
In Arizona, the state department of health is working with one payer to provide screening information to 200,000 patients, as well as providing related CME to physicians.
Earlier this month -- which happens to be Colorectal Cancer Awareness Month -- Mississippi announced a statewide program that aims to increase screening rates in that state to 70 percent by 2020. Although that goal is lower than the NCCRT's objective, it would be a giant leap for Mississippi, which has the nation's highest mortality rate -- and one of the lowest screening rates -- related to colorectal cancer.
What can we do in our own practices? We can make that all-important recommendation during visits with patients ages 50 to 75, and we can follow up with reminders through mail or email.
We also can be sensitive to what type of test patients are willing to do because although some may be hesitant to have a colonoscopy, they may agree to do a take-home test. Remember that a typical series of take-home stool tests does qualify as screening and should be done annually. However, a single, one-time, in-office stool test does NOT adequately screen for colorectal cancer.
In my federally qualified health center, we are helping eligible patients get coverage through the health insurance marketplace. Although screening is a covered preventive service, follow-up care could require a copay in some health plans.
Family physicians build relationships and trust over time. By making a recommendation and providing reminders, we can help achieve this important, life-saving goal.
Wanda Filer, M.D., M.B.A., is president-elect of the AAFP.
The Envelope, Please: Waiting for Match Results
We are almost there, mere months from realizing a dream we have poured our hearts and souls into for years. Although thoughts of graduation are in the backs of our minds, something else remains at the forefront: the National Resident Matching Program (NRMP).
Match week activities start March 16 when we fourth-year allopathic medical students find out whether we have matched to a residency, and programs find out whether they have filled their positions. We won't know our specific results until March 20.
It's been a long and sometimes grueling process since Match registration opened six months ago. We have fretted over letters of recommendation, decisions about which residencies to apply to, travel and other expenses, interviews, and ranking our residency choices.
All this led up to officially submitting our rank order lists on Feb. 25.
Whew. Take a breath. That was a lot. So now what?
Now, we wait.
My husband also is waiting -- somewhat patiently -- to see where I land so he can figure out where we will be living and, thus, where he will be working. He's a Pennsylvania state employee, so the majority of my 14 interviews were with in-state programs.
I have faith that wherever we end up will be the right spot for us. I feel confident that I'll be able to fit in anywhere because of the passion family physicians share for primary care, our patients and our communities.
I also think residents get out of a program what they put into it. We not only have a lot to learn but a lot to give, so my plan is to give my new program everything I can and become the best doctor I can be. If that happens, I'll be happy with the final result.
Since I submitted my program rankings, I've completed an obstetrics rotation and started another in emergency medicine. The good news is that I'm too busy during work hours to think about the magnitude of the letter I'll be opening soon.
There are 23 days from the time we submitted our rank order lists until Match day. As I post this, I am keenly aware that there are only 10 days left -- but who’s counting? (Well, actually, many fourth-year medical students likely have it calculated down to the second.)
As the anticipation grows, and the Match draws closer, find solace, my fellow fourth-year students. We are ready. We have done everything we can. I'm happy and excited to take the next step in my training, and the wait is almost over.
Come back to the AAFP website on Match Day for NRMP results and AAFP News coverage of those results.
Kristina Zimmerman is the student member of the AAFP Board of Directors.
On the Hill: Academy Promoting Family Medicine's Perspective
The AAFP Board of Directors spent a day lobbying last week on Capitol Hill. We each met with legislators and congressional staff from our own states, meaning that the offices of representatives and senators from more than a dozen states heard about issues critical to primary care.
Although the conversations undoubtedly varied, many of the topics covered in our meetings were the same. We asked Congress to do the following:
- Avoid the 21 percent Medicare payment cut scheduled to take place April 1 and work to repeal and replace the flawed sustainable growth rate formula;
- Reauthorize and adequately fund the Teaching Health Center Graduate Medical Education program, which is responsible for training more than 500 residents at 60 residency programs in two dozen states;
- Reform graduate medical education funding; and
- Increase Medicaid payments for primary care.
| Photo courtesy Architect of the Capitol
Rep. Robin Kelly, D-Ill., whose husband is a physician, was receptive to my message about the need for action on these pressing issues. And, although members of the Board covered a lot of common ground about payment and education in our separate meetings, my meeting with Kelly also offered a chance to discuss important clinical issues.
Kelly serves as chair of the Congressional Black Caucus (CBC) Health Brain Trust, which collaborates with stakeholders in the health care system to address issues of health equity. Some of the Health Braintrust's priorities overlap with those of the AAFP, including addressing social determinants of health, expanding access to primary care and tackling health disparities.
In addition to the CBC's legislative efforts to address health equity, the group's Health Braintrust supports research related to how education, economic stability and neighborhood affect a person's health. The group also hosts health fairs across the country and annually hosts a fall health policy event organized as part of the CBC's Annual Legislative Conference, as well as a spring forum on health disparities. It also holds monthly meetings with health advocates and policy experts.
When opportunities present themselves to promote primary care and advocate for our practices and our patients, we have to seize those opportunities. The CBC was seeking feedback on a number of health issues, and the Academy provided this group -- which includes nearly 50 members of the House and Senate -- with as much information as possible.
In addition to my meeting with Kelly on Feb. 25, Academy staff participated in a Feb. 27 Health Braintrust roundtable meeting that included Kelly, congressional staff, advocates and representatives from the American Hospital Association, Morehouse School of Medicine, the National Medical Association, the National Urban League and others.
With such a diverse group, the latter meeting covered a wide range of topics, including access issues associated with health care reform and technology. In addition, the forum addressed public health issues such as federal nutrition standards, healthy communities, health disparities and violence prevention. The Health Braintrust sought feedback on its agenda and how to address these issues. The group plans to continue to engage stakeholders and generate short-term and long-term goals for health priorities, and we were eager to provide family medicine's perspective.
For our issues to be addressed, it's important for legislators to hear from their constituents. It's worth noting that hundreds of family physicians from across the country will be in Washington May 12-13 for the Family Medicine Congressional Conference. That event offers a full day of advocacy training followed by a day on Capitol Hill. It's not too late to lend your voice.
Javette Orgain, M.D., M.P.H., is vice speaker of the AAFP Congress of Delegates.
The Folly of Judging Physicians Based on Patients' Foibles
Physicians write nearly 4 billion prescriptions each year in the United States, yet roughly half the patients who come to us for help fail to take their medications as directed. Among older patients, the proportion could be as high as 75 percent.
Patients often suffer the consequences when they don't take their medications as directed, but so, too, do physicians when reimbursement is tied to outcomes and community metrics. This can create an adversarial relationship between a prescriber and a "noncompliant" patient, which is antithetical to the kind of relationship family physicians want to have with their patients.
I recently attended a presentation about minimally disruptive medicine, which means simply health care that is designed to meet the goals of the patient while also considering the capacity of the patient to meet those goals.
This overall concept gets at the issue of noncompliance and whether we should even use that term. Noncompliant conjures up an image of a patient who disregards our advice because he or she doesn't value it, but the truth is that any number of factors can prevent a person from adhering to a prescribed regimen, including insurance coverage, out-of-pocket costs, health literacy, cognitive issues, social problems, transportation and more.
The speaker gave the example of a 55-year-old man who had several chronic conditions, including diabetes, high cholesterol, hypertension and obesity. Due to his multiple conditions, his physician advised him to exercise, but the man had a blue-collar job that caused him back pain. That pain rendered him largely sedentary at home, which exacerbated his chronic conditions.
In addition to his physical health concerns, the man's chemically dependent daughter had moved into his home along with her children to escape an abusive relationship. And on top of everything else, the man was suffering from depression.
The patient said he was simply overwhelmed, was unable to exercise and had little time to make the office visits his physician recommended to keep his conditions in check.
We've all had patients like this. They are aware of their health problems and would like to address them but feel unable to do so. Some are merely treading water. That leaves the physician with the unenviable choice of "firing" patients or continuing to try to help them under the very real threat of financial penalties.
Payers would like patients to fit neatly into a single mold but the reality is that patients need an individualized plan that fits their needs. Progress in addressing chronic conditions -- even if it's just baby steps -- should be valued rather than discounted, and physicians should not be penalized for being unable to force a patient with multiple chronic conditions to make miraculous improvements in the face of a litany of obstacles.
I had a patient whose hemoglobin A1c was 14. We were able to bring that number down to 10, which is a significant improvement. But from a payer's perspective, it wasn't good enough because my community metric is 8.
Using these types of quality measures across the board has unintended consequences, and physicians are being punished unfairly for failing to live up to these expectations. Drawing a line in the sand and saying, "Meet this number," fails to recognize the value of the work primary care physicians are doing to reduce the burden of illness and costs to the health care system if a patient happens to land slightly outside an ideal target area.
Being sick is emotionally, physically and financially hard on patients. We need to look at how we can partner with patients and individualize their therapies so they can make progress toward health goals that make sense for them -- not just for us and certainly not for payers.
Lynne Lillie, M.D., is a member of the AAFP Board of Directors.
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