Challenges, Hope for Small Practices and PCMH
One of the interesting things AAFP Board members get to do is travel to state chapter meetings. This is a great experience because we get to hear the issues that concern our members from across the nation.
One question that has been posed to me multiple times at such meetings regards the challenges small practices face in transforming to the patient-centered medical home (PCMH) model.
There are volumes of data supporting the transformation to a value-based, rather than a volume-based, system. The change results in better patient health outcomes at lower health care costs. Unfortunately, however, most of the available data comes from large practices, and the costs involved in making the transformation often are covered by higher level evaluation and management (E/M) coding, as well as shared savings from reduced emergency room and hospital expenses.
The hope of a blended payment system is on the horizon, but it isn't incorporated yet in most markets. Small practices often don't have the internal support to make the transformation and often don't get the advantage of lower overall health care costs.
The question frequently posed to me is, does transformation make sense for the small practice?
Some small practices have made the transformation and reaped the benefits. But some have suffered financial ruin when trying to make the change. One member told me she had to close her solo practice after moving to the PCMH model. After starting her electronic health record (EHR) and making adjustments to make her practice a PCMH, she went bankrupt. Although she was able to charge more per visit in the new practice model, her visits took longer so she saw fewer patients.
She was not able to collect on the patient portal encounters through insurance. Visits by her nurse and nutritionist were not well compensated. After 20 years in practice, she closed her doors and went to work for a large multidisciplinary group in another town. Now she is away from home 20 days a month and is not happy with the change.
My own residency practice had issues as well. We did not have insurance support paying for some of the PCMH attributes, and the higher E/M charges did not outweigh the longer patient visits. We ended up going back to a volume-based system to survive.
What about the bigger picture? Thirty-eight percent of AAFP members practice in groups of fewer than four providers. There is no data available to tell us how many of these practices have transformed to the PCMH model, but we do know that 57 percent of our small practices have started implementing EHRs, which might be the first step to PCMH recognition. Conversely, 85 percent of our large practices have converted to EHRs, so it seems that those larger practices may have more infrastructure in place to support change.
One of the four strategic priorities of the AAFP is practice enhancement. One of the main goals of this area is the transformation of all family medicine practices to the PCMH model. Another priority in practice enhancement is improved payment for family physicians. It is difficult to separate these two issues because to transform one's practice, it costs both time and money. Our Academy realizes this and is advocating for better payment for primary care and even enhanced payment for those who offer the attributes of a PCMH. The eventual goal would be to have a blended payment system that would incorporate a per-member, per-month base fee plus a fee-for-service payment and a pay-for-performance payment.
The Congress of Delegates asked the AAFP to study the impact of PCMH transformation on small practices last year, and a study on the topic was published earlier this year in Annals of Family Medicine. However, only practices that have achieved National Committee for Quality Assurance recognition were included in the study, which acknowledged small practices that have achieved recognition did so as part of local demonstration projects or with help from financial incentives or other support.
What about practices that are attempting transformation without the benefit of a demonstration project or grants? And what about small practices that have attempted practice transformation but were not, or have not yet been, successful? What has stopped them, and what could make a difference?
Clearly, we need more research on practice transformation and the barriers that small practices face.
The overall cost to transform a practice from a standard, paper-based practice to a PCMH with an EHR is roughly $100,000 per full-time equivalent physician overall. But is this true for small practices? Is the cost more or less? When overall health care costs decline, are the savings shared with the small practice providers?
Do the better health care outcomes seen in large PCMHs translate to small practices? It would seem so, but the evidence is lacking.
So, is there hope for small practices that want to transform to PCMH? The answer is yes.
TransforMED, the AAFP's wholly owned, nonprofit subsidiary, was created in response to the Future of Family Medicine Project to help practices make the transition to the PCMH model, but initial efforts to engage small practices met with little success. The reality is that many small practices lacked the necessary capital to invest in practice transformation, and some did not value consultant services.
The market imperative for TransforMED was to serve health plans, multi-specialty groups and integrated systems because they had the money and the understanding that change facilitation was needed to accomplish this work. As a result of its commercial success, TransforMED has grown and now offers small practices access to information, expert advice and tools on DeltaExchange, which is free to AAFP members.
Many of the changes required for PCMH have to do with organization and workflow and may not be expensive to implement. Small practices can begin the transformation while still in a fee-for-service environment, but the real change will be accelerated when blended payment, global payment and payment for value become the norm.
The Academy soon will offer another resource that will help members transform their practices. The PCMH Planner, which likely will be launched early in 2014, was promoted and available for a "sneak preview" during Scientific Assembly last week in San Diego. The Planner is an online software subscription tool that will help practices assess their needs and provide them with step-by-step guides and links to resources to help them complete PCMH transformation and achieve meaningful use. AAFP members will receive a discounted price when they subscribe to the tool.
As a member benefit, the Academy's Division of Practice Advancement also has subject matter experts available to answer questions about PCMH and provide free resources on the topic. You can connect with them through the AAFP Contact Center at (800) 274-2237.
Finally, last week in San Diego, the Congress of Delegates adopted a resolution that calls for the AAFP to study EHR adoption and PCMH transformation by family physicians who may face additional barriers to change -- including age, practice size and rural location -- and determine the best ways to help them stay in practice.
The Congress of Delegates also referred to the Board of Directors two resolutions that asked the Academy to form a special interest group devoted to physicians in solo or small-group practices. The Academy already has a task force -- chaired by AAFP President Reid Blackwelder, M.D. -- working to determine how best to serve the needs of specific membership groups. That task force met last month and is scheduled to meet again early next year.
I would be interested in your comments about PCMH implementation for small practices and what more the Academy can do to help. Also, it would be interesting to know about small practices that have successfully transformed to a PCMH and how you were able to do it, so we could share best practices with other members.
Daniel Spogen, M.D., is a member of the AAFP Board of Directors.
National Event Can Open Students' Eyes to What Primary Care Is Really About
I came to medical school knowing that I would become a family physician. That goal was driven, in part, by the diversity and complexity of the work family physicians do, caring for patients from birth to end of life. I want to take that comprehensive approach back to rural Alabama, where I'm from, and family medicine is the specialty that allows me to do that.
The choice isn't as clear for many medical students, who often aren't exposed to primary care in their first two years because family medicine and other primary care faculty are underrepresented in most medical schools during the preclinical years.
So, how do we get students more -- and earlier -- exposure to primary care and family medicine?
Next week offers one opportunity to
do just that. National Primary Care Week will be
celebrated at medical school campuses around the country Oct. 7-11, giving
students an opportunity to learn about, and experience, primary care. It's also an opportunity to highlight primary care physicians in leadership positions. For example, family physician and State Health Commissioner Cynthia Romero, M.D. -- pictured here with family medicine interest group leader Penelope Carter -- was the keynote speaker at the University of Virginia School of Medicine's Primary Care Week last month. (UVA celebrated a bit early).
During my second year at the University of Alabama, Birmingham, I was responsible for planning National Primary Care Week activities on our campus. Each day, we brought in a speaker from a different primary care specialty -- family medicine, internal medicine, OB/Gyn and pediatrics -- who talked about why primary care is the foundation of patient-centered care and how each specialty plays an important role.
There is a myth perpetuated in some academic settings that family physicians treat coughs and colds and refer everything else, but family physicians do so much more than most students realize. It's a powerful experience to have a physician from the community come to campus and describe a typical day in practice, which could include seeing patients in clinic, making hospital rounds, doing procedures, delivering babies and practicing broad-scope primary care.
Although I knew about that extensive scope of practice early on, I had numerous students come to me throughout the week, saying, "I didn't know this about family medicine," or, "I didn't know that about internal medicine."
The upcoming nationwide event has the potential to open students' eyes to what primary care really is about and what it looks like outside of an academic medical center.
So what's on tap for this year's National Primary Care Week? We've heard from family medicine interest groups around the country, and some obvious themes stand out. Students want more information about health care reform, and several schools are featuring speakers or panels that will look at how the Patient Protection and Affordable Care Act will affect primary care. Academy resources available for National Primary Care Week include a PowerPoint presentation with facts and analysis of the Affordable Care Act.
The AAFP also has presentation materials designed to educate students about the patient-centered medical home, which is another common topic for National Primary Care Week activities.
Team-based care and interdisciplinary panels also appear to be popular choices. Other intriguing offerings include residency fairs, flu-shot clinics and clinical skills workshops.
I encourage my fellow medical students to seek out activities on your campus during National Primary Care Week (and bring a friend) and throughout the year. Your colleagues have worked hard to design programming that will give you key insights and understanding you will need to make an informed specialty choice within the next few years. Regardless of whether you choose family medicine like me, we're all going to be working together in an evolving health care system characterized by an increasing demand for family physicians to carry us to better patient health outcomes, better patient experience of care and lower health care costs.
So, what is your medical school doing?
Tate Hinkle is the student member of the AAFP Board of Directors.
The Path That Brought Me Here
We all have had classmates and colleagues who knew from an early age that they were going into medicine, but I was not one of those students. I never wanted to be a physician when I was growing up.
In fact, I was fairly convinced that I wanted nothing to do with physicians during one college break that I spent working as a ward clerk at Grady Hospital in downtown Atlanta. I was incredibly impressed with the dedicated staff I worked with there, however. I saw early on that the true care of patients required a team, including folks who often went unrecognized by physicians and patients alike.
I enjoyed the incredible and diverse educational experiences of Haverford College in Haverford, Pa. I got a wonderful education in science tempered by broad liberal arts training obtained in a collegial setting. But halfway through my junior year, I realized that a degree in molecular biology limited me somewhat. And I did not really want to do research. Reconsidering the time I spent at Grady, I decided that perhaps medical school was a good opportunity after all.
I went home to attend Emory School of Medicine in Atlanta. I was there at a time when the school did not have a family medicine department, so my first exposure to family medicine did not come until my second year when I was fortunate to receive an opportunity to shadow Andy Morley, M.D., a dynamic family physician in Decatur, Ga.
The first day I spent with him, he did a vasectomy in his office, did a well-child visit, and saw people of all ages for acute and chronic problems. I also got to know his staff "family," who became my friends for years. That afternoon we made hospital rounds, which included more procedures and treating a woman who was having a heart attack. We finished the day by swinging by a nursing home to see one special patient and her family.
I was incredibly impressed and excited to experience first-hand the power of my early clinical mentor. I remembered this important time during my third year when I had difficulty choosing among the different specialties. I was one of only two graduates in my class at Emory that went into our amazing specialty.
I was blessed to go on to the Medical College of Georgia (MCG) for residency training and to work with such amazing physicians as Joseph Hobbs, M.D., and Joe Tollison, M.D. But it wasn't until my year as chief resident that I was first exposed to the leadership opportunities of the AAFP. As a chief resident, I was able to go to the National Conference of Family Medicine Residents and Medical Students in Kansas City, Mo. When I asked what it was about, I was told, "Just go and enjoy it."
Of course, I went to Kansas City and got the bug! I came home incredibly excited about the opportunities I had seen. In fact, I stayed at MCG to do a fellowship year and, therefore, was able to run and be elected as one of the resident delegates to the Congress of Delegates along with future leaders such as Anne Montgomery, M.D.
I came back to Georgia and got involved in my state academy. During that time, Andy Morley, my original mentor, was actively serving on the AAFP Board of Directors and ran for president-elect. In retrospect, he actually opened almost every door for me into the broad opportunities of family medicine.
When I moved to Tennessee in 1992, I was fortunate to join a dynamic state chapter that was open for the new kid on the block to become involved. My journey led me here today.
It is hard to believe that my year as president-elect is over, and I am starting a new one as your president. I am extremely excited about this opportunity. Family physicians are poised to be recognized for all of the work we have done and are ready to do for the health care of Americans.
Thank you for giving me this once-in-a-lifetime chance to lead our Academy. I look forward to representing you as your voice during the next year.
During the Congress of Delegates, I am reminded that anyone attending an AAFP meeting for the first time easily could become active on the Board and be elected an officer. Similarly, you could come to just one of these meetings, have an idea, bring it forward for discussion and end up with a resolution that then becomes not only Academy policy but likely a message taken to our representatives in Washington.
We don't know who will be the leaders of medicine in the future. In the photo above, the classmate standing next to me, Christian Larsen, M.D., was named the dean of our alma mater, Emory University School of Medicine, earlier this year. Who could have guessed when that photo was taken in the 1980s that either of us would be where we are today?
Each and every one of us makes a difference every day in the lives of our patients and our communities. We all wear many different hats, and I invite you to try a few new ones on for size. Join me in changing the world for the better. Get active in your state chapter. Come to our Annual Leadership Forum, National Conference of Special Constituencies or the National Conference of Family Medicine Residents and Medical Students.
Together, let's get involved, stay involved and make a difference.
Reid Blackwelder, M.D., is the President of the AAFP.
Family Medicine on the Right Course
Flight has always been a passion of mine, especially antique aircraft. So when I spoke to our Congress of Delegates last year in Philadelphia about preparing for my year as AAFP president, I compared it to planning an airplane flight.
A pilot or a leader takes the same three essential
steps to prepare for a successful flight:
- the preflight check to understand the state of the plane, or in this case, the organization;
- the weather forecast, to understand the challenges ahead; and
- the flight plan, to set a course for the intended destination.
After a year that included state chapter meetings, speaking with our nation’s private payers, lobbying trips to Washington, meeting with other national and international primary care groups, and much more (190 days on the road in all), it's time to close my flight plan.
And just as at the end of any successful flight, it's time to perform a flight review.
How did family medicine and our Academy do this year in planning for our flight? Are we on the right course for family medicine and for our country?
Reviewing some of the highlights of the past year will show that our organization is strong and on the right track.
The AAFP now has 110,600 members, and our ranks are growing in every category: practicing family physicians, students and residents. In the National Resident Matching Program, the number of medical students choosing family medicine increased for the fourth consecutive year. More U.S. seniors matched to family medicine than in any year in more than a decade.
Interest in family medicine is growing among the public as well. We have an outstanding public relations staff. This past year, our Academy placed 8,768 stories about health and family medicine in the media, doubling our media presence in just three years. This year alone, I participated in roughly 200 media interviews -- resulting in nearly 800 print, online and broadcast placements -- on topics including clinical issues, payment for primary care, graduate medical education and workforce. These opportunities help us tell family medicine's story, not only to consumers but also to payers and policy makers.
On a personal note, one of my proudest moments this year was celebrating the 25th anniversary of Tar Wars, the tobacco-free education program for children that I co-founded as a resident in 1988. More than 9 million children have heard the Academy's message worldwide.
And how was our weather forecast -- the challenges that we faced for the year?
During last year’s Congress of Delegates, the forecast -- at least for the short term -- was for stormy weather. The Supreme Court had just upheld the Patient Protection and Affordable Care Act, but a contentious presidential election was yet to come.
With President Obama's reelection, health care reform is moving forward. The ACA may be imperfect, but there are provisions in the law that will benefit our patients and our practices:
- increasing the number of Americans with insurance,
- eliminating restrictions on pre-existing conditions,
- moving our health care system to one that values primary care and
- taking the first steps on creating the right health care workforce.
Our Academy’s role in health care reform is to actively participate in the rule-writing and implementation of the parts of the ACA that work and to actively advocate for improvements where needed, all the while defending the best interests of family physicians and the patients we serve.
And what is our forecast today?
Clearing skies as the patient-centered medical home model (PCMH) moves from pilot programs to implementation.
New forms of payment for family physicians are occurring across the nation with Medicare’s Comprehensive Primary Care Innovation now up and running. Private insurers are starting to pay for the PCMH with care management fees and incentives for improving quality.
Your Academy also is moving forward on three important efforts to improve the health of our country in the long term: a new Future of Family Medicine project, graduate medical education (GME) reform and addressing the social determinants of health.
A year ago, leaders from the Academy and other family medicine groups were beginning to talk about the possibility of revisiting the now decade-old Future of Family Medicine project. This year, a plan is in place, and we are moving forward with a new Future of Family Medicine project that will redefine the role of the 21st century family physician -- including key attributes and scope of practice -- and ensure family medicine can deliver the workforce to perform this role for the U.S. public. You can expect our report this spring.
In addition, the Institute of Medicine is expected to release a review of the governance and financing of graduate medical education in early 2014. That report, which was requested by Congress, should prompt legislative reform, and it will build on momentum from a recently released Council on Graduate Medical Education (COGME) report. The visionary 21st COGME report calls for Congress to increase funding to support 3,000 more graduates per year and to prioritize GME funding based on our country’s workforce needs, specifically calling for more physicians in family medicine and other high priority specialties.
And the movement to integrate primary care and public health is picking up steam, a move that has potential to greatly improve population health for the country overall. For the first time, the Academy has now included the social determinants of health and health equity as part of our new strategic plan
So how did we do with our flight plan?
It has been a great year for family medicine and for your Academy. Though we have not yet reached our destination, we are on the right course and moving forward.
Our heading is true.
Thank you for the privilege of being your president this past year. It has been the flight of a lifetime.
Jeff Cain, M.D., is President of the AAFP.
COGME Report Puts Family Medicine on Priority List
In family medicine, we've known for years that the United States isn't getting the proper return for its $13 billion annual investment in graduate medical education. Federal funds paid to hospitals for training purposes too often result in the expansion of the subspecialty residencies hospitals need to maximize their own bottom lines -- cardiologists, radiologists and a slew of other "ologists" -- instead of producing the balanced workforce our health care system actually needs.
If legislators haven't already heard this message from the AAFP, the Council on Graduate Medical Education (COGME) -- which was created by Congress to provide assessments of physician workforce trends and training issues -- has recently spelled it out for them again.
Three years ago, COGME released a report that highlighted the worsening shortage of primary care physicians and recommended addressing the shortage by narrowing the gap in incomes between primary care physicians and subspecialists and reforming medical education.
In a new report released last month, the physician-led panel continued its call for more primary care physicians. In doing so, COGME was critical of Congress for underinvesting in GME. It also took aim at teaching hospitals for not emphasizing primary care and offering curriculum that was inadequate in related areas, including population health, care coordination and team-based care. COGME also questioned why national accrediting organizations have not taken the lead in bringing about these necessary changes.
There are numerous recommendations in the 28-page report, and we will have a more detailed report this week in AAFP News Now. But here are a few highlights:
- COGME recommends that Congress should continue funding existing GME positions and increase funding to support 3,000 more graduates per year.
- The report recommends that overall GME funding be prioritized based on workforce needs, specifically calling for family medicine and other "high priority specialties" and for programs whose graduates go on to practice in underserved areas.
- The report also recommends that any increases in GME funding should be directed toward training programs that produce a high proportion of physicians who continue in one of the prioritized specialties, which also include geriatrics, general internal medicine, general surgery, pediatric subspecialists and psychiatry.
COGME's recommendations are well timed. The Institute of Medicine is expected to release a review of the governance and financing of GME early next year. That report, which was requested by Congress, should prompt legislative reform.
The need is clear. Despite the fact that more than half of patient visits are for primary care, only 7 percent of U.S. medical school graduates are choosing careers in primary care. A study published last year in the Annals of Family Medicine stated that the United States will need more than 50,000 additional primary care physicians by 2025 -- 33,000 to account for population growth, 10,000 to accommodate an aging population and more than 8,000 just to care for people who will be newly insured because of health care reform.
Additional residency positions also are needed to keep pace with number of new medical schools and expanding medical school class sizes. In fact, by 2016, the United States likely will have more medical school graduates than residency slots!
Tax payers are investing billions of dollars each year in physician training as a public good. For this level of investment, shouldn't we expect a physician workforce that meets our country's needs?
Jeff Cain, M.D., is President of the AAFP.
Nearing the Finish Line
I always enjoy the AAFP's annual meeting because of the excellent work of our Congress of Delegates, great CME opportunities provided by Scientific Assembly, and the opportunity to network with friends and colleagues, fellow family physicians from around the country. This month's events in San Diego, however, will have added significance for me as I complete my term as AAFP Board Chair and six years of service on the Board of Directors.
The location also is special. San Diego is a wonderful city with
many unique qualities, and it has sentimental significance for my wife and me
because it is where our relationship began. For those attending this year's
meetings -- which are scheduled for Sept. 22-25 and Sept. 24-28, respectively -- I know you also will make your own special connection with the city.
You may not know that one of San Diego’s claims to fame is that it is the original site of the Rock 'n' Roll Marathon Series. The marathon course is lined with live bands roughly every mile, playing music to "rock" you onward.
The marathon is a good metaphor for many individual and organizational efforts. Features of planning, training, endurance, perseverance, support and accomplishment are common to both.
I've always enjoyed challenges. Identifying a worthwhile goal, determining what is necessary to achieve that goal, training and preparing, drawing on others for support, and committing to seeing it through to the finish.
Some years ago, I took on the challenge of completing a marathon. Not having been an endurance runner, this was a stretch for me. I read about marathon training and drew tips from friends who are runners. Training was a big time commitment with occasional minor running injuries to work around. I convinced two younger family members that they should run the same marathon so we could encourage each other.
The day of the Portland Marathon arrived, and my training had gone well. The weather was great, and the first few miles went smoothly. The course in Portland is lined with spectators offering encouragement -- not just to the elite runners in the front, but also to those of us back in the pack.
I learned about "hitting the wall," where your muscle glycogen is exhausted, around mile 20. It was a struggle to continue, but pushing through to the finish line was worth the effort. There was a tremendous mixture of accomplishment and exhaustion when it was over. I collected my medal for finishing, a T-shirt, a space blanket and a banana, and lay down to wait for my younger family members to finish.
For me, the next finish line is in San Diego. I’ve done my best to prepare myself to represent our members, persevere through challenges along the way and draw on the support of many others to succeed.
I'd like to express my thanks to the AAFP Board members and Academy staff I've had the privilege to work with, the many AAFP members who have provided support and encouragement, and to my wife and fellow family physician Anne Montgomery, M.D., without whom I could not have finished.
So what comes after that finish line? Anne and I are relocating from Spokane, Wash., to work at Eisenhower Medical Center in Rancho Mirage, Calif. Anne will be associate director of a new family medicine residency program, and I will be chief medical information officer and also will see patients.
My next marathon? I’ll be continuing with you in our collective family medicine marathon. Together, we've prepared ourselves for the critical role our country needs us to play as the foundation of a high quality and cost-effective health care system. We have a ways to go before we reach our goals. Working together and supporting one another, we can push though that wall to achieve the vision we seek.
Glen Stream, M.D., M.B.I., is the Board Chair of the AAFP.
Physicians Sticking With Medicare … for Now
A brief recently
issued by HHS reveals some intriguing numbers about
Medicare. According to the agency, the percentage of office-based physicians
accepting new Medicare patients increased slightly from 88 percent in 2005 to
nearly 91 percent in 2012. In fact, the percentage of physicians accepting new
Medicare patients was slightly higher than the percentage of physicians taking
new privately insured patients in each of the past two years.
The numbers presented by HHS were not broken down by specialty. According to an AAFP member survey, however, family physicians are accepting new Medicare patients at a lower rate with only 81 percent of respondents doing so last year, down from 83 percent in 2010. Eighty-seven percent of Academy members participated in Medicare last year, down from 90 percent two years earlier. The percentage of patients covered by Medicare in AAFP member patient panels remained virtually unchanged at 24 percent.
The numbers published by HHS are somewhat surprising given the uncertainty presented by the sustainable growth rate (SGR) formula. It's reassuring that Medicare patients still have access to care, despite the fact that physicians are weary of the flawed formula and the annual interventions by Congress that are needed -- in lieu of an actual solution -- to avoid potentially devastating cuts in physician payments.
The SGR will trigger a nearly 25 percent reduction in the Medicare physician payment rate on Jan. 1 unless Congress abolishes the SGR or passes another temporary patch, which it did four times in 2010 and once in both 2012 and this year.
The AAFP and other physician groups continue to advocate for a permanent solution, and the Senate Finance Committee is expected to unveil its own SGR replacement bill this month. In July, the House Energy and Commerce Committee unanimously approved a Medicare physician payment bill that would abolish the SGR formula and provide an annual 0.5 percent physician payment increase for the next five years.
It is encouraging to see that the Energy and Commerce bill emphasizes moving the payment system to one that pays for value rather than the problematic pay-for-volume process that has contributed to our high costs and poorer outcomes. However, it's worth noting that the model envisioned in that bill will require practice investments by physicians, whose pay should be adjusted to reflect those investments.
So, can the two Houses agree to a solution before the scheduled cut in January? Even if they do, the SGR isn't the only issue threatening Medicare physician payments and patient access to physicians who accept that coverage. Sequestration poses small, annual cuts that would be equally devastating in the long term with 2 percent cuts scheduled each year through 2021.
The data published by HHS indicates that many physicians are willing to wait for a solution, but for how long? According to The Wall Street Journal, more than 9,500 physicians who had accepted Medicare opted out of the program last year. What will the numbers show if Congress allows the SGR's nearly 25 percent cut to take effect or if sequestration slowly chips away at payments for nearly a decade?
Nearly 47 million Americans -- or more than 15 percent of the U.S. population -- rely on Medicare. What will their access to care be like if threats to payment persist?
We know access to primary care is an issue, and the HHS data backs that up. Although 88 percent of Medicare patients and 83 percent of privately insured patients reported that they had no problem making appointments with new subspecialists, the numbers were much lower, 71 percent and 72 percent respectively, for Medicare and privately insured patients seeking appointments with new primary care physicians.
Access to subspecialty care is important, but these numbers highlight how fragmented our system has become. Primary care physicians, not subspecialists, should be the first point of contact for patients in a high quality, effective health care system. Fixing the SGR, including a positive update for Medicare physician payments, would go a long way to ensuring patients have the access they need to the right treatment at the right time.
Reid Blackwelder, M.D., is president-elect of the AAFP.
Adaptive Sports, Peer Support Give Patients New Perspective
You could feel the discouragement just walking in the exam room door.
Roy sat with his head down and shoulders hunched. His cane was propped against the wall. As the preceptor in clinic, I had been asked by our third-year resident to meet Roy, a 50-year-old patient with diabetes who recently had lost his leg and was having a hard time learning to walk on a new prosthesis.
of this blog may know that I wear two prosthetic legs
since an accident long ago, but when I walked in the room Roy didn’t know that.
With just a glimpse of my carbon fiber ankles, his eyes flew open wide.
“But how can you be an amputee? You’re the doctor!”
It was just a glance, followed by a few words of encouragement and direction to a couple of resources for amputees, but Roy walked out of the room smiling, his back a little straighter, his perception of living well with amputation altered.
Driving home that night, I couldn’t help but ask myself what was it that had brightened Roy’s day, and what had made it possible for me to successfully walk that same path of uncertainty so many years ago?
For me, three reasons came to mind.
The first images to meet my eyes when I woke up in the ICU after my accident were those of amputees engaged in sports. My best friend had gone online, found photos of people wearing prosthetics while doing crazy, fun things, and posted them throughout my room.
Secondly, as a lifelong skier, every ski season has started with a viewing of one of director Warren Miller’s fabulous ski movies. Warren has always included images of adaptive athletes, kicking it on the mountains, in his movies. These images were planted so deeply in my mind that, on my first night out of the ICU, I sat on the edge of my bed visualizing making my first turns on a snowboard while wearing a prosthesis that I had yet to even see.
It was a gift from the filmmaker that I hadn’t even known I had received.
And lastly, but perhaps most importantly, my family physician and friend Tim Dudley, M.D., made me call the National Sports Center for the Disabled (NSCD) from my hospital room before I went home.
The NSCD is one of the nation’s oldest and largest adaptive sports centers and helps people with disabilities discover joy and freedom beyond their perceived limits of disability. It offers skiing in the winter, as well as summer activities such as bike and horseback riding.
With help from the NSCD, I rediscovered the mountains and the thrill of skiing. And together, we introduced a new device, the ski bike, to the North American adaptive ski community.
The great thing about skiing for people with disabilities is that a physical activity that may have been limited by muscle strength or discomfort can be overcome by adaptive equipment and the power of gravity. With adaptive skis or a ski bike, people with disabilities find freedom through speed and movement and the joy of keeping pace all day with their family and friends.
Whether it's skiing, horseback riding, kayaking or any other activity, with the NSCD, people with physical challenges can find ways to enjoy the outdoors and lead an active lifestyle. And it isn't just about sports. Recreation is for everyone, and the benefits -- physical, mental, social and spiritual -- are transformative for body and soul.
Adaptive sports programs also helped connect me with others facing challenges. I met and saw peers who are active and drew inspiration from their experience. It broadened my perception of what is possible, not only in sports but in life.
Perhaps most importantly, organizations like the NSCD are also "stealth" peer support programs. Lessons are personal, visual and more powerful than any printed words, website or stories -- even those from a physician or therapist. For people with physical challenges, peer support can replace self-images of disability with images of ability.
What had brightened Roy's day and what had helped me so much was the power of peer support, which helps us understand we are not alone by allowing us to learn from those with the same challenges.
Groups like the NSCD and the Amputee Coalition certainly helped me with the nuts and bolts of dealing with amputation, like how to ride a bike, travel and even how to answer the questions of inquisitive children at the pool. ("Who would ever guess that sharks could live in chlorinated water?")
More importantly, these groups provided me with life lessons on how to live in a different body.
My hope for you as family physicians is that the next time you sit across from a patient who is discouraged with a new diagnosis of a disease or disability, you will find a way to offer him or her hope through adaptive sports and peer mentoring programs. Remember, peer mentoring programs are not just for people with disabilities; they have been proven to improve lives and outcomes for patients with diabetes, arthritis and even cancer.
Need a few starters? The NSCD is based in my home state of Colorado, but there are adaptive sports programs in almost every city and state in the country. Disabled Sports USA has dozens of chapters nationwide and is a great resource to connect people of all abilities with recreation and the outdoors. Most chronic diseases have online support groups and resources, as well.
Recreation and peer support help people become more active, confident and independent.
Your short conversation, invitation or encouragement can make a huge difference.
Just ask Roy.
Jeff Cain, M.D., is President of the AAFP.
AAFP Members Set Academy's Course at Congress of Delegates
Saturday was the deadline for state chapters to submit resolutions to be considered next month during the Congress of Delegates.
Based on the more than 50 resolutions submitted, it's going to be an interesting meeting. Those resolutions cover topics ranging from clinical issues to education, payment and more. Some, without a doubt, will generate spirited debate.
The Congress of Delegates
the ultimate policy
Although only delegates may vote during the proceedings, did you know that any Academy member present during the September 23-25 event may speak and give testimony during the reference committee hearings? Academy members have the right to be heard and voice their opinions on the issues we address during the reference committees, and our rules actually allow any member to introduce pertinent resolutions (see rule No. 9) to the Congress of Delegates during the opening session.
The Academy has swelled to more than
members in recent years, and we are a diverse bunch. We are Republicans,
Democrats and independents; liberal and conservative; old, young and in between.
We come from different backgrounds, different religions and different
practice types, and we practice medicine in a wide variety of settings that
come with their own unique needs and provide us with our own unique
That diversity makes for some compelling discussions.
Although we have many common passions and interests, there also are issues that
divide us. We will not agree on everything.
But we will hear all the voices of those who want to be heard, and we will have an informed debate during the Congress. I look forward to it.
Delegates also will choose a president-elect,
a new class of officers and
Board members during the Congress. Y ou can check
out all the candidates online.
For those who can't join us in San Diego, you can follow the business sessions of the Congress via streaming video on aafp.org. More details about that will be published in AAFP News Now prior to the start of the Congress.
John Meigs, M.D., is speaker of the Congress of Delegates, the governing body of the AAFP.
Medical Students Need Washington to Do More
As a recent medical school grad, I spend a great deal of time thinking about my educational debt. I owe $234,000 (and the total is increasing even as I write this). There are many ways I can pay off this debt: National Health Service Corps (NHSC), Public Service Loan Forgiveness, arrangements with future employers, escaping to Mexico, etc.
what about those who are unable to secure a NHSC slot or a job that qualifies for
loan forgiveness? For many students considering careers in medicine, the high
cost will be a burden or even a barrier.
The Student Loan Certainty Act cleared the House and Senate last month, and President Obama signed it into law Aug. 9. The Academy supported the legislation because interest rates on federally subsidized student loans had doubled from 3.4 percent to 6.8 percent on July 1. The new legislation ties undergraduate and graduate loan rates to U.S. Treasury notes and retroactively lowers them -- for now -- to 3.86 percent and 5.4 percent, respectively.
The new law, however, isn't perfect, which is why the AAFP is continuing to advocate for related measures. Specifically, the Academy is asking lawmakers to
- expand funding for federal loan programs targeted to support family medicine and primary care,
- allow deferment of interest and principal payments on medical student loans until after completion of postgraduate training, and
- grant tax-deductibility for interest on principal payment for such loans.
The potential problem with the law is that federally subsidized student loans now will be tied to 10-year U.S. Treasury notes. If bond rates rise, so will the interest rates on this type of loan, which accounts for roughly one-fourth of federal student loans.
The rates are capped at 8.25 percent and 9.5 percent for undergraduates and graduates, respectively, but those potential rates would be significantly higher than current rates and could make education more expensive and more unattainable for some low- and middle-income students.
That scenario could present a problem for our already unbalanced workforce because we know that students with lower income expectations are more likely to choose family medicine as a specialty. Today, our workforce stands at roughly 70 percent subspecialists and 30 percent primary care physicians. What will the workforce ratio be in the future if interest rates approach double figures, making the cost of education an even bigger hurdle?
Three-fourths of medical students come from the top two quintiles of parental income.
Without scholarships, low- and middle-income families disproportionately feel the hit of tuition. A 2002 study from the U.S. Department of Education found that high-achieving, low-income students were five times less likely than high-achieving, wealthy students to enter college in their first two years after high school.
I was fortunate enough to earn a full-tuition scholarship to Saint Louis University as an undergraduate. Without that scholarship, there is no way I could have afforded the $36,000 annual tuition. My parents did not earn the "big bucks." My mom is a speech pathologist and my dad is an economics professor at a community college. The scholarship award was much needed.
So what's the bottom line for family medicine? A 2009 study by the Robert Graham Center evaluated what influences specialty choices and found that as long as debt did not exceed $250,000, students were not deterred from a family medicine career. What we don't know, however, is how many students who are interested in primary care careers are deterred from even entering medical school because of the high cost.
Exposure to the NHSC was one of the strongest predictors of careers in family medicine in the Graham Center study. I know several students who have no medical student debt because of the NHSC's Students to Service Loan Repayment Program, which provides assistance to fourth-year medical students dedicated to working in areas with physician shortages.
It's worth noting that the Academy has a Web page devoted to debt management. As for me, I will enroll in the Public Service Loan Forgiveness program. As long as I work at a nonprofit organization, my loans will be forgiven after I make 10 years of qualifying monthly payments -- if the program is not discontinued, that is. Signed into law in 2007, this program soon will start to see its first wave of enrollees apply for loan forgiveness. My fear is that the program could be discontinued before I have the chance to apply, and then, since I was able to enroll in a discounted payment plan, I will have significantly more interest to pay. I feel very uncertain going forward.
And if I'm feeling uncertain, what are students from low-income families experiencing? When parents discuss undergraduate and medical school debt burden with their children, what are the results of those dinner table conversations?
Lowering the interest rates on student loans, at least temporarily, was a first step, but more work is needed to create a physician workforce that is diversified and represents the population. The time is now to let your voice be heard. Talk to your House and Senate representatives about the importance of a strong primary care workforce. Talk to them about how education should be valued just as much as a home purchase. I encourage you to act.
Aaron Meyer, M.D., is the student member of the AAFP Board of Directors.
From Classroom to Med School and Back: Why I Love Teaching
I recently started a job that combines two things that I love: teaching and medicine. Although I've known for a long time what I wanted to do, it took me a while to get here.
More than 13 years ago, I decided to leave graduate
school at the University of North Carolina to pursue admission to medical
school. At the time, I was three months into a master's degree in linguistics
when I realized pursuing my doctorate in the field just wasn't for me. Although
I needed the opportunity that graduate school had afforded me to be analytical
and thoughtful, I didn’t see myself sitting in an office pouring over
transcriptions of computer-mediated communication (i.e., Internet chat -- the
topic of my master's thesis) for the rest of my life.
I was ready to turn around and head back to Kentucky when my mother, in that way that parents do, mentioned that medical schools might be less likely to admit a student who already bailed out of graduate school.
Best advice ever. Not because I loved linguistics, which I did, but because it made me stay at UNC. During my second year there, I became a teacher, and it changed my perspective completely.
The first time I stood in a class of my own, in front of 22 college freshmen, I sweated bullets. I felt insanely underqualified and unprepared despite hundreds of hours of education pedagogy and at least three weeks of completed lesson plans. Considering that I was teaching English composition, one of the classically hated requirements of college, the great triumph of that first day was capturing the attention of every student by correctly identifying that the Nigerian student in my class spoke Yoruba.
I loved spending that first semester learning to disseminate information, but also being a part of the development of my students' lives.
After realizing that my teaching style really could include me sitting on a desk in the front of the room, answering students' cell phones that rang during my lecture and confiscating anything that didn't explicitly pertain to that day's subject matter, I never questioned that teaching is where I belong.
But I did question what I should be teaching.
I started medical school, four years after finishing that master's degree, knowing that I would graduate looking to return to education. So, this past year, when the job search was finally upon me, I looked exclusively for academic jobs.
I had been bombarded by countless job solicitations beginning in my first year of residency promising no call, no weekends, no OB, no inpatient, exotic parts of the country, the possibility of loan repayment. And, believe me, a future of no late-night awakenings and uninterrupted Saturdays had a certain appeal, but by the end of residency, I loved the hospital, labor and delivery, late nights, early mornings and the satisfaction of the breadth of what I can do.
The search began late for me; it was November before I started looking and March before I interviewed anywhere in person. I know many residents who did substantially more interviews than I did, who cultivated contacts for years, keeping up with hometown doctors who might be their ticket to a perfect job. I went to three in-person interviews, having done a few more phone interviews, but I knew I was not the right match for those places. I found two really wonderful job possibilities in interesting places, both very different from Milwaukee where I had been living.
I'm excited to start anew, finished with medical school and residency (and any other degree programs for a while!) as an assistant professor in the Department of Family Medicine at the University of Kansas School of Medicine. I’m excited to be able to continue in as full a spectrum of practice as I can and to teach and learn from medical students and residents.
Sometime close to the end of my intern year, I was contacted through Facebook by a young man who had been in one of the last English classes I taught. He wanted to tell me that he had decided to become an English teacher based, at least in some part, on his experience in my course. He added that he was still in contact with many of those classmates and that during a number of years of discussion, they all felt that my classroom had become a community. That conversation, and the hope that someday I might be honored with another like it, is why I continue to teach, to help students find that community, whether in medicine, linguistics, or life.
Tully Marks, M.D., is the resident member of the AAFP
Board of Directors.
Make a Difference Beyond the Exam Room: Join an Academy Commission
During my residency, I treated a woman -- who we'll call Maria -- three times for chlamydia infection. Each time I treated her, I urged her to tell her partner to come see me -- or to see another physician -- and get treated so that Maria wouldn't get infected again.
However, her partner didn't have insurance, had no regular access to care and was reluctant to see a physician while asymptomatic.
I wanted to do more for Maria, but what could I do?
A year later I was in Springfield, Ill., as a member of the Illinois AFP's Governmental Relations Committee, lobbying state legislators about expedited partner therapy, which would allow me to give Maria (and other patients like her) extra medication and instructions for her partner. This legislation passed a few years later and now is a regular part of my practice to prevent reinfection in my patients and the spread of sexually transmitted diseases in the population in general.
It was important for me to be part of my state chapter's advocacy efforts at that time, and later, I was part of the AAFP's Commission on Governmental Advocacy, which allowed me to advocate on the federal level on behalf of members, patients and communities.
Your patients and your practice likely are facing their own issues. What can you do to make a difference?
Nominations now are open to state chapters for the AAFP's national commissions, and there is a commission to match any family physician's passion. Whether advocating for federal policy on payment reform, influencing the future of education or updating the AAFP's official clinical recommendations, we all can do more for our profession, patients and communities by being bold champions and active voices as members of one of seven AAFP commissions.
To be considered, your chapter must
provide the following:
- letter of nomination,
- typed commission nomination form,
- passport photo and
- completed online conflict-of-interest form.
If you are interested in participating in the Academy's decision-making process, contact your constituent chapter before the Oct. 15 nomination deadline. You can find more information about the process online.
In addition to 21 physician positions available on the commissions, the Academy also must fill four slots on its AMA delegation and select a nominee for the American Board of Family Medicine Board of Directors.
These are great opportunities to contribute to our specialty, share your perspective and make your voice heard.
Ravi Grivois-Shah, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.
Do Your Patients Know How Health Care Reform Will Affect Them?
Health care marketplaces created by the Patient Protection and Affordable Care Act are scheduled to open for enrollment Oct. 1. Unfortunately, fewer than one-fourth of Americans are aware that the marketplaces -- formerly known as exchanges -- exist, according to a Kaiser Health poll released in June.
In fact, fewer than half of U.S. consumers are aware that the ACA is being implemented, according to a poll released by Kaiser Health in April.
Kaiser Health's April poll said that 12 percent of consumers thought the health care reform law had been repealed by Congress, and 7 percent thought it had been overturned by the Supreme Court. Consumers who are unaware that the ACA is being implemented aren't going to be ready for enrollment deadlines and likely aren't aware of new services and benefits available to them.
Where are consumers hearing about the ACA? Forty percent of respondents said they were getting information (possibly misinformation) from friends and family. Roughly one-third named news outlets as their source of information.
Only 11 percent said they had received any information about health care reform from their physicians. In a more recent poll by HealthPocket, a website that compares health plans, half of respondents who had a primary care physician said they had not talked with their doctor about how the law will affect them.
But, providing good information to help our patients make informed decisions about their health care is something we do every day, and that's what we need to do now to help make sure our patients are aware of the options open to them.
In the short term, physicians can direct patients to a FamilyDoctor.org web page that addresses common consumer questions. Consumers also can get information about health insurance marketplaces -- and find out if they qualify for lower premiums and lower out-of-pocket costs -- at www.healthcare.gov.
A question-and-answer article in Family Practice Management also addresses numerous ways the ACA will affect family physician practices.
In addition, the Academy is working on developing resources to help physicians answer patient questions and to address how the law will affect our practices. Those resources are expected to be available September 3.
The bottom line is that family physicians need to be informed. We need to look at the parts of the Affordable Care Act that are good for our patients and make sure they are prepared to benefit from those provisions. We also need to be aware of how our practices may benefit from health care reform. We also need to continue to identify areas of the law that are not good for our patients or us and work to change them. We should find those aspects of the law that have potential and work to improve them. And we need to be able to answer our patients’ questions about how the law and its implementation will affect them.
Blackwelder, M.D., is President-elect of the AAFP.
A New Assembly Experience: Discussing Real Issues; Providing Real Answers
Are you joining us
for Scientific Assembly this year? If you make it to the Sept. 24-28
event in San Diego, you're going to notice some exciting changes.
Assembly already is
the premier learning event for family physicians, but the Academy is transforming
its signature meeting to make it a more engaging experience that offers members
more than just CME. It will be more interactive with more opportunities to
network with our colleagues and simply more interesting and fun.
Assembly, as always, will continue to offer more than 300 evidence-based CME sessions and workshops. But we also can experience other learning opportunities outside the meeting room. Downstairs at the "Hub" in Hall A, CME credit will be available through more than 60 poster presentations and the AAFP Learning Centers, which will offer interactive, self-paced activities about opioid abuse and men's health.
The Hub also will be
the place to go if we want to learn more after CME sessions. Select CME faculty
will be available for (non-CME) Ask the Expert question-and-answer sessions.
A variety of informational presentations on topics, such as direct primary care and my own presentation on improving payment for family physicians, also will take place in the Hub. Attendees can ask questions after these presentations, as well.
During the lunch hour, tables in the Hub will be designated by scope of practice, type of practice, demographics and more to help us connect with colleagues who have interests and issues similar to our own.
By now, you may have seen -- either on the Academy website or on materials received in the mail -- information regarding Assembly that promises "real issues, real answers, real voices." But what does that mean?
Throughout the Assembly's three general sessions, we'll all be looking at the real issues we face every day. We'll be listening to each other's voices and trying to find solutions. For example, during the first general session, we'll talk about "real issues" based on the top 10 concerns members identified in the Academy's 2013 Member Satisfaction Survey.
Those "real issues" then will be addressed with "real answers" during a panel discussion featuring Samuel Nussbaum, M.D., EVP and chief medical officer for WellPoint; Marci Nielsen, CEO of the Patient-Centered Primary Care Collaborative; and John Bender, M.D., senior partner and CEO at Miramont Family Medicine in Fort Collins, Colo. Once again, there will be opportunities for audience participation.
The "real voices" will be ours. Video booths near the CME meeting rooms and outside the Hub will allow all of us to talk about the issues facing our practices, as well as what gives us the most joy about being a family physician. A sample of those videos will be played during the general sessions.
Your opinion matters, so make sure your voice is heard.
Scientific Assembly already is a highly successful meeting, but the AAFP is not going to be complacent. Academy staff and members are working hard to give us the best experience possible. Even more changes and new features are planned for the 2014 Assembly in Washington. More on that later, but for now, I hope to see you in San Diego.
Glen Stream, M.D., M.B.I., is the board chair of the AAFP.
Understanding Patients' Literacy Level is Crucial Step in Care
Fewer than half of U.S. patients have the necessary skills to read and follow drug label instructions, respond to insurance forms, provide a patient history or communicate effectively with a physician, according to the National Institutes of Health.
If patients don't understand us, how can we possibly expect them to follow our instructions? This massive shortcoming puts patient safety at risk, jeopardizes our patients' quality of life and adds costs to the health care system. According to the NIH, health literacy -- or lack of it -- costs our nation up to $236 billion a year.
The problem isn't new. More than 20 years ago, researchers at the University of Arizona found that the health care costs of Medicare patients with low levels of health literacy were more than four times higher than those who were health literate. In 1993, a national survey found that up to 22 percent of Americans were unable to read a medicine bottle.
The numbers aren't surprising when you consider that more than 40 percent of the U.S. population speaks something other than English as a first language. But this issue is not limited to immigrants or those with low levels of education. It is pervasive, affecting all ethnic, economic and age groups.
The 2003 National Assessment of Adult Literacy ranked subjects into four categories based on their skill levels: proficient, intermediate, basic and below basic. That study found that only 12 percent of Americans (14 percent of whites, 4 percent of Hispanics and 2 percent of blacks) were considered proficient. Meanwhile, 41 percent of Hispanics, 24 percent of blacks and 9 percent of whites were considered below basic.
Although patients with higher levels of education
scored better, only 30 percent of subjects with a bachelor's degree or higher
were considered proficient.
So where does that leave us? Do we understand the extent to which people are health literate? Do we speak and write instructions at a level our patients understand?
One easy, critical step to gauge the level of health literacy in our practices is to include the following question on patient history forms: "How far did you go in school?" Then include check boxes so patients can indicate the appropriate grade level. It should be a standard question, and we need to teach our medical students and residents to ask it.
Sadly, students and residents receive little formal training on this important issue. If you work with residents and students, listen to how they speak to patients, and challenge them to speak at a level patients understand. And ask patients, "Do you understand what is being said?"
Teaching back is vitally important, not only for students and residents, but for all health care professionals. At least 40 percent of information patients receive is forgotten soon after an appointment, and roughly half of what they do remember is inaccurate. The brief time it takes to ask a patient to repeat the instructions you have given them can make a huge difference in compliance and outcomes.
We also should educate our staff members who have contact with patients to be aware of patients' education levels. Not only that, we need to ask in what language patients prefer information -- both written and spoken -- be delivered.
Health education material should be written at a fourth- or fifth-grade level, but it often is prepared at an eighth-grade level. The problem can be even worse when materials are translated into other languages. For example, college-level Spanish isn't helpful to Spanish-speaking patients with a lower education level.
I specifically look for educational materials that address health literacy, and I have even taken the step of making my own handouts when necessary. Keep in mind that pictures and symbols say a lot to patients who aren't literate. Reading isn't the only skill in question. Numbers and measurements are barriers for some patients, who may need extra help from you or your staff.
If you know what issue a patient is being seen for and what their literacy level is, you can give them appropriate materials to read while they wait during their appointment. (FamilyDoctor.org has a number of patient education resources available.) Hopefully, this will help them understand their condition and help them ask questions during their visit.
Patients often don't know what they should ask. The NIH initiative has resources for patients to help them prepare for an office visit and suggests questions they should ask related to a wide variety of conditions, including heart disease, diabetes, weight loss and more.
We might have the best training, the right diagnosis and great bed side manner, but if we don't take the time to understand where our patients are coming from, they might not understand us.
Javette Orgain, M.D., M.P.H., is Vice Speaker of the AAFP.