Medical Student Advocates Make Big Impression on Legislators at FMCC
When I sat down at my state's table at the Family Medicine Congressional Conference (FMCC) earlier this month, I was quite surprised to find two of my Quillen College of Medicine students already sitting there.
Melissa Robertson, left, and Jessica White, right, seniors at East Tennessee State University's James H. Quillen College of Medicine, met with legislators from their state -- including Rep. Marsha Blackburn, center -- during the Family Medicine Congressional Conference in Washington.
The AAFP provides two scholarships for students and two for residents to attend this annual advocacy event in Washington, which trains family physicians (and future FPs) to advocate for their patients and for family medicine. The AAFP Foundation also awards a student scholarship, so I thought perhaps these students -- Jessica White and Melissa Robertson -- had earned scholarships to attend. But as it turns out, they decided to make the trip from Tennessee at their own expense because they thought it was an important learning opportunity.
In fact, 55 students and residents from around the country attended FMCC this year. Their spirit and efforts give me great hope for our future.
FMCC provides a remarkable blend of advocacy education and skills development along with the chance to immediately put those learnings into action. On the first day of the conference, we heard from advocacy experts, representatives of federal health agencies, congressional staff and two legislators.
On the second day of the event, more than 200 students, residents and practicing physicians took what they had learned on day one to Capitol Hill to talk with legislators and staff about issues such as physician payment, education and workforce. One of the best parts of this conference is the opportunity to share personal stories with our legislators. There is no question these conversations have a big impact and are one of the reasons face-to-face meetings have such potential to make a difference in promoting our interests.
Legislators and congressional staff hear from the AAFP Board several times a year, but stories from members can be so important because they speak directly to legislators who are elected to represent their state and district and tell them how constituents are being affected by the various challenges family physicians face.
For example, Jessica and Melissa, two seniors who have matched into family medicine residency programs, were able to talk about important education issues during our visits. As we reviewed the key points from the previous day's advocacy training sessions, we realized their presence was especially serendipitous given their paths to family medicine.
Jessica matched in Asheville, N.C., just across the mountains from Quillen. She will join the family medicine residency at the Mountain Area Health Education Center(MAHEC), which is a teaching health center. These centers provide creative approaches to training family medicine residents based in the communities that most need them.
Under the Teaching Health Center Graduate Medical Education (THCGME) program established as part of the Patient Protection and Affordable Care Act, GME funds go directly to the centers. However, the THCGME program, which started in 2011, is only funded through 2015.
The program is now completing its third academic year, graduating its first cycle of residents and sending almost 300 primary care physicians into the workforce. It should come as no surprise, then, that extending funding for the teaching health centers program is one of the Academy's top legislative priorities during this congressional session.
Without such an extension, Jessica's residency program cannot guarantee her salary for all three years of her training. Accepting this offer represents a remarkable leap of faith on her part. It also provided a great example to the people we talked with about the importance of extending funding for these programs.
Melissa is a nontraditional medical student and former elementary school teacher, so she brings a critical, real-world perspective to both medicine and medical education. She came to the AAFP's National Conference of Family Medicine Residents and Medical Students two years ago and got the advocacy bug there. During that conference, she was elected to the Society of Teachers of Family Medicine's Board of Directors and now is serving her second term.
Melissa, who matched to our East Tennessee State University residency program in Bristol, has a real knack for asking common-sense questions that help cut through administrative layers. Her particular path has made advocacy issues such as student debt and the primary care salary gap extremely important in her world.
Together, the three of us considered the day's congressional visits and how to tell these stories in meaningful ways. First up was Tennessee Tuesday, which is a weekly breakfast during which Sens. Lamar Alexander, R-Tenn., and Bob Corker, R-Tenn., welcome everyone visiting from our home state to Washington. They are always excited to meet their constituents and were especially eager to meet these medical students.
Next, we met with Rep. Marsha Blackburn, R-Tenn. Jessica's family lives in Blackburn's district, so this connection immediately lent relevance to our advocacy stories in a way that had not happened in my previous conversations with the congresswoman. Our legislators certainly pay attention to their constituents, and we were able to get some unscheduled time and a photo opportunity with Blackburn.
Moreover, during a subsequent meeting with Blackburn's health aide, we were able to talk about topics in a totally different light because of the students' circumstances. This latter meeting also showed Jessica and Melissa the critical role legislative aides play in setting agendas for elected members of Congress.
We then met with Rep. Phil Roe, M.D., R-Tenn., who represents Quillen's district. Originally, we had been scheduled to meet his legislative aide, but when he heard there were two medical students from his district present, he immediately made time to meet with them. In fact, their stories were so compelling that he asked if we would walk to the Capitol with him because he had to vote, but he did not want to cut short his discussion with Jessica and Melissa.
Jessica’s story about her uncertain financial situation at the residency program in North Carolina grabbed Roe’s attention in a way my previous discussions with him could not, in part, because Christ Community Health Services in Memphis is one of more than a dozen residencies that are expected to start receiving THCGME funds beginning in the 2014-15 academic year.
As a nontraditional student who made a huge financial sacrifice to become a physician later in life, Melissa's story also sparked his interest immensely. He specifically asked her about her medical school debt and how that influenced her and other classmates in their specialty choice.
Roe also took notice when Melissa addressed another of our advocacy points -- the need to renew and increase commitments to GME, such as through Title VII funding, and to consider how we can increase the number of students choosing primary care specialties.
As he prepared to walk to the Capitol, Roe asked Melissa and Jessica whether they would come back to his office after he returned from the vote because he wanted to talk more with them.
After we finished talking with Roe, I left for a media interview and then headed out of town for the Minnesota AFP meeting. By this point, Melissa and Jessica were seasoned advocates, and I knew our messages were in good hands and would be heard in powerful ways. They went on the next visit on their own and later went back to Roe's office.
The three of us texted about the overall experience later, and we made plans to improve how we present the need for advocacy to students and our residents. In fact, Melissa is meeting with the Quillen Family Medicine Interest Group this week to talk about how to prepare for the Academy's resident/student conference scheduled for Aug. 7-9 in Kansas City, Mo. That is the "pay it forward" concept in action.
So, what can you do to pay it forward? In addition to the scholarship opportunities mentioned above, the Association of Family Medicine Residency Directors sponsors 10 scholarships for residents to attend FMCC. But we could do more. Family medicine residencies, departments of family medicine, state chapters and even individual practices can help send students and residents to FMCC. Exposing students and residents to advocacy, a critical part of how we can improve the care of our patients, can pay huge dividends for those FPs-in-training and for our specialty.
Reid Blackwelder, M.D., is president of the AAFP.
Changing the Conversation: What Would It Take to Make Using Our EHRs Truly Meaningful?
During one of the state chapter meetings I attended as a member of the AAFP Board of Directors, I asked participants if they were using electronic health records (EHRs). About 80 percent said they were. Then I asked the group how many of them were satisfied with their EHRs. Only a few hands went up. In fact, I heard some angry comments.
Administrative hassles are hindering family physicians. “Just one more thing,” is a common refrain, with the implication being that if there is one more thing to report or document -- or anything else that gets in the way of patient care -- it could be the “one more thing” that prompts a physician to quit.
ICD-10, the Physician Quality Reporting System, meaningful use -- how much more will it take before family docs just say no?
It's clear the creators of meaningful use had good intentions. The concept was intended to help physicians transition to EHRs. The carrot was financial. The money saved throughout the health care system by using EHRs could be shared with physicians, thus encouraging them to implement EHRs. (With the stick, of course, being a financial penalty for not complying.)
The idea was that going electronic would:
- improve patient care,
- decrease medical errors,
- improve office efficiency and
- avoid redundancy in ordering tests.
Having healthier patients, fewer medical errors, less testing and improved efficiency would net an obvious health care savings. In fact, researchers predicted in 2005 that health information technology would save the country more than $80 billion a year. Yet U.S. health care expenditures have continued to skyrocket due to many factors, including the health IT shortcomings.
So, did we go wrong somewhere?
Interoperability has been, and remains, a major stumbling block despite the Academy's hard work on the issue for more than a decade. Back in 2003, there was a lack of awareness among policymakers and EHR vendors that interoperability was even an issue. So, the AAFP worked with legislators, federal agencies and vendors to get it on their radar.
The AAFP knew standards were needed, so next, the Academy collaborated with other stakeholders to help create the ASTM Continuity of Care Record (CCR), a patient health summary that can be created, read and interpreted by EHRs developed by different software companies. That standard has become part of meaningful use.
As AAFP President-elect Robert Wergin, M.D., of Milford, Neb., recently pointed out in his blog on the topic, when a patient leaves a primary care practice for a subspecialist consultation, the respective EHRs at the primary care practice and the subspecialist’s practice aren’t necessarily able to communicate. This is a barrier to care coordination, and the Academy continues to work with the Office of the National Coordinator (ONC) for Health Information Technology on this issue.
This critical shortcoming is why the Academy was an early contributor and founding member of the direct exchange project, which allows physicians to send secure, confidential emails to other physicians.
Unfortunately, EHR developers have little incentive to change. The ONC recently issued a proposed rule for 2015 that included voluntary updates related to certification criteria, interoperability and regulatory improvements. In a letter to the ONC, the AAFP said that voluntary guidelines would create confusion about what is and isn't required, adding undue complexity to an already complex program. The Academy urged the agency to urge work with stakeholders to create better means than a voluntary certification program.
It seems unlikely that EHR developers are going to fix the issue of interoperability on a volunteer basis. But just think how much more “meaningful” my use of an EHR would be if it could communicate with the EHR of the radiologist or cardiologist across town.
Add to that the fact that many EHRs aren’t user-friendly at all. Documentation and reporting has become cumbersome, and being conscientious about keeping thorough electronic patient records results in less time for patient encounters. In fact, there have been indications that EHRs that satisfy meaningful use and appropriate coding protocols can:
- interfere with patient care,
in mixed patient outcomes,
- increase overall costs, and
- complicate office workflow.
The main thing that electronic records have accomplished is improved billing. But surely this isn't all we want to see come from this investment. We are seeking a system that would improve patient satisfaction and improve patient outcomes. The electronic record is a natural for following patients with chronic disease and surveying your patient population for health concerns.
While tracking specific metrics such as a hemoglobin A1c has improved with use of electronic records, tracking actual improvements in health has not worked so well. What would it take to make this happen?
It is estimated that one-third of health care expenditures overall can be attributed to unnecessary administrative burden. Of that, the time spent doing administrative work and documentation during a patient encounter has been estimated to be as high as 60 percent.
There is a section in the Patient Protection and Affordable Care Act -- Section 1104 -- that seeks to improve these hassles. This "administrative simplification" section was passed by Congress even before meaningful use reporting began. However, the same rules should apply. The section includes operating rules for HIPAA transactions, utilizing a unique identifier and setting up certain rules that would simplify reporting for health plans.
Wouldn't it be great to see a patient and not have to worry about how many bullets are included in the current history of illness? Instead, you could just look at the past medical history as it applies to the patient, review only symptoms that are specific to the patient's problem and pursue only clinical decision-making specific to patient care needs. Charting this way would involve minimal amount of physician time, and patient care documentation would be the purpose. The dual worries of coding and reporting would go away.
My practice is sending one of our physicians to an out-of-town course to become an EHR "superuser" so he can help the rest of us become more efficient in using our system. It seems odd that after years of medical training we need even more training to become IT experts.
Through our state chapter visits and other channels, the members of the AAFP Board of Directors have heard members' concerns -- believe me! We will continue working to ease administrative burdens. We are looking at ways to decrease the number of codes and the complexity of coding. In the meantime, we can all continue to educate ourselves so we can make best use of the current system.
So here's my final question: For better or worse, how has using an EHR changed your practice?
Daniel Spogen, M.D., is a member of the AAFP Board of Directors.
Regional Meetings Offer AAFP Chapters Chance to Share, Learn, Lead
You might already know that each fall, the AAFP's State Legislative Conference offers a national venue for family physicians, constituent chapter leaders and staff to come together to discuss state health policy issues and share best practices for tackling legislative challenges. And during the Annual Leadership Forum each spring -- the 2014 meeting convenes next week, actually -- chapter executives and staff from across the nation gather for leadership training and to trade advocacy tips and other insights with their counterparts in other states.
But what you may not know is that you might be able to find this same sort of interaction -- albeit it on a smaller scale -- within your own region.
I recently had the honor of serving as the AAFP Board of Directors' liaison to the Multi-State Forum in Dallas. There are a number of such events that gather several Academy chapters throughout the year. These events are different from state chapter meetings, but they do have some similarities.
Regional meetings for AAFP chapters offer an opportunity for leaders from several states to come together and share their challenges and solutions. Here I am with California AFP President-elect Delbert Morris, M.D., during the Multi-State Forum in Dallas.
Perhaps the most important thing to recognize is that “All politics is local.” For the AAFP, this means that big impacts start with the state chapters. I encourage each of you to consider how you are getting your messages out, and whether you have considered becoming a more active part of your state chapter to best advocate for your patients, your practice and your community.
Our chapters have many different venues for addressing the kinds of issues that may seem to be unique to individual states. Multi-State is an annual gathering in Dallas of the Arkansas, Arizona, California, Colorado, Iowa, Illinois, Kansas, Missouri, Nebraska, New Mexico, Oklahoma and Texas chapters.
Similar meetings include:
- Ten State Meeting: This event is held in February at rotating sites and involves the Connecticut, Illinois, Indiana, Kentucky, Massachusetts, Michigan, New Jersey, New York, Ohio, Pennsylvania and Wisconsin chapters.
- The Southeast Forum: Held in August at rotating sites, this meeting involves the Alabama, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, South Carolina, Tennessee, Virginia and West Virginia chapters.
- Western States Forum: This forum is meets each year to review resolutions slated to go to the AAFP’s Congress of Delegates and involves the Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, New Mexico, Nevada, Oregon, Utah and Washington chapters.
Typically, chapters select up to five members -- often those involved in leadership positions -- to represent their states at these regional meetings.
Unlike state chapter meetings, CME is not a main focus of these events, although there may be some sessions offered that provide educational credits. The most important aspect of these meetings, however, is for everyone to come together and share. This includes a focus on state legislative challenges and issues. In these sessions, chapter representatives discuss legislation in their states that may impact family medicine or that have been a focus of their chapter's advocacy efforts, including bills the chapters supported and those that generated concern.
Right now, many topics dominate our discussions nationally, such as physician payment, graduate medical education, malpractice and scope-of-practice issues. What is interesting is that at these group meetings, these issues are seen quite differently depending on the state that is presenting about them.
From my perspective, the most important benefit of these gatherings is the opportunity to share best practices. Most of these sessions offer a chance for chapter representatives to talk with one another about what successes they have had in different arenas. One of the biggest challenges for our national organization is how to help connect the chapters. In one important way, we need to make parallel in our organizations what we are asking for in our advocacy efforts. And we need to be sure that we are not duplicating our efforts. The more we can share opportunities, solutions and processes with each other, the better off we all will be.
Some of the other benefits of attending these meetings include the presentations they involve. For example, at Multi-State, we heard from Marci Nielsen, CEO of the Patient Centered Primary Care Collaborative, as well as our own Shawn Martin, AAFP vice president of advocacy and practice advancement. These speakers provided an outstanding framework for some of our discussions. In fact, these discussions preceded a recent JAMA article on the patient-centered medical home (PCMH) that suggested that the PCMH may not produce the outcomes we hoped for. However, we had a chance to consider more recent data than what was included in the article. This demonstrates the ability of these meetings to be on the cutting edge of important discussions.
These meetings also offer an opportunity to meet leaders from around the nation. Many future AAFP Board members and national officers saw some of their early involvement at these meetings and were able to hear the critically important broad view of issues that national leadership requires. But it is also important to note that the representation at these meetings often includes members who may not attend national meetings. These are state leaders who are essential to the function of our chapters. When I go to these sessions, I often meet people who are part of the national delegations, or who come to other national meetings; however, I am also blessed to meet many other family physicians who are working hard in their state chapters to make a difference for their patients, their state and their member colleagues. Ultimately, I leave these meetings feeling energized and optimistic about family medicine.
I am hopeful that you will discover the opportunities that are available to make a difference. Of course, you are involved now as you provide care for your patients and negotiate the challenges that you face every day. But I hope you realize there are also opportunities at the state chapter level to get involved beyond your practice. Step up and contact your chapter executive and move forward in your local leadership. From there, the next step as a chapter leader is to come to some of these larger gatherings where you can work with other family physicians to change things for the better. I look forward to seeing you at one of these meetings.
Reid Blackwelder, M.D., is president of the AAFP.
Tedious Paperwork, Government Regs: Why I Still Love Being a Physician
Today I had a busy day with a full schedule of patients. I struggled to chart my patients' complex histories in an electronic health record that has given me none of the efficiencies it promised.
I lost my lunch break to an administrative meeting, leaving me no time to get caught up from a hectic morning.
I filled out prior authorization forms for medications that a patient has already been on for six months. I completed more forms and insurance paper work than I care to remember and bemoaned the low reimbursement we are being paid for our visits.
I came home hoping to squeeze in time with my family but knowing that I also had hours of catch-up charting to do.
|When I left clinical medicine for a year, I discovered that I wanted, and needed, to come back.|
This is a typical day for me, and I'm sure other physicians can sympathize. There are a lot of reasons to feel frustrated as a doctor right now, and a recent article written by an internist in The Daily Beast outlines how difficult the job can be at times.
But I still love being a doctor, and -- despite the challenges, the paperwork and the burdensome regulations -- I know I'm not alone.
Next month will mark 10 years since I finished medical school and started my journey as a family physician. After residency, I worked at a federally qualified community health center, seeing patients from a wide range of cultural and socioeconomic backgrounds. It often seemed like my patients' problems were bigger than my prescription pad because I couldn't cure the poverty that was at the root of their medical conditions.
I thought I could do more for my patients outside of the examination room than inside, so I left clinical medicine. I spent a year in the federal government as a White House Fellow. In one sense, it was a breath of fresh air: no insurance forms, no call, no charting or EHRs and no worries about whether or not the sustainable growth rate (SGR) was going to be fixed. In addition to gaining a better understanding of how the government works, I also had the opportunity to work on issues such as breastfeeding, hunger and poverty at a national level.
When I started the fellowship, I didn't know if I would return to clinical medicine, but it didn't take me long to realize how much I missed seeing patients. I found myself seeking out clinical experiences, asking anyone with the sniffles if they had other symptoms or if they were taking any medications.
After a year away, I was excited to jump back into patient care. Providing primary care to patients is truly my calling.
I have to admit, I'm a glass half-full kind of person. Although I recognize all of the problems we face in medicine, I also see so much to be excited about.
The Daily Beast columnist pointed out that the majority of medical students typically pick high-paying subspecialties. She also wrote that primary care physicians are the janitors of the medical profession. How nice. The fact is that the number of medical students choosing family medicine has increased for five years in a row, and the number of U.S. medical graduates picking our specialty also is increasing.
It's true, however, that payment -- one of the AAFP’s top legislative priorities in Washington -- remains an immense challenge, both to our practices and to building student interest in family medicine. In a recent MedScape physician survey, family physicians ranked near the bottom of the physician salary scale, yet we had one of the most positive responses when respondents were asked if, given a chance, would they would chose a career in medicine again.
So what do we have to be optimistic about?
I am encouraged that for the first time there is a bi-partisan, bi-cameral proposal for a long-term SGR fix. (Congress hasn’t got the job done yet, but there is still hope.) And CMS, with input from the Relative Value Scale Update Committee (RUC), continues to address overvalued procedures, which shifts money within the Medicare fee schedule to other services, including those commonly done by primary care.
Last year, CMS created two new codes to cover transitional care management, and next year the agency plans to add a code for chronic care management. These new codes should benefit primary care physicians.
I also am hopeful about the prospect of alternative payment models that may actually reimburse physicians based on the value of care that we provide and not the number of people we see (a backwards system that incentivizes physicians to do more and increases medical costs). In addition, more and more practices are operating outside of the insurance framework altogether by providing direct primary care. This option is affordable to patients and puts the patient back in the center of the cost equation.
I am intrigued by the fact that technology and telehealth have the potential to revolutionize how we see patients and provide comprehensive care. Patient portals and virtual medical visits offer opportunities to reduce office visits and increase patient satisfaction.
It has been a joy to see so many patients who are now able to access care with me because they have insurance through the Medicaid expansion created by the Patient Protection and Affordable Care Act.
And for all of the political drama that health care reform has created, it also has opened up a real conversation about the strengths, weaknesses and future directions of health care in the United States for the first time in decades.
But the real reason I still love being a doctor is my patients. So although I could look at today as a tedious mess of charts, forms and administrative haggling, instead I see it as a tapestry of patient experience. I will soon forget the paperwork, but I won't soon forget talking with my patient as we learn her cancer may have returned, or congratulating my patient who lost 20 pounds and dropped his cholesterol by 50 points, or helping a couple start the process of adoption after a long battle with infertility.
In the Medscape survey, the average salary of all physicians was more than $200,000. Eight subspecialties had averages of more than $300,000. Yet when asked what the most rewarding part of their jobs was, only 10 percent of physicians cited money. The top response was "being good at what I do" at 34 percent, followed closely by relationships with patients (33 percent). "Making the world a better place" was third at 12 percent.
So what do I say to physicians who are burned out or dissatisfied? Perhaps it's time to look at other job options? Or maybe it's time to just take a break. When I left clinical medicine for a year, I discovered that I truly love it. It confirmed for me that I wanted, and needed, to go back.
But to do so, I had to do it in a way that was sustainable for me and my family and still allow me to enjoy patient care. That decision sparked my interest in joining the AAFP Board of Directors because I want to help make the world of medicine better for family physicians.
The profession of medicine truly is a calling to help others. I came into it knowing that sacrifices would occasionally have to be made and that patients would often have to come first. If one is in it for money or accolades, he or she likely will be disappointed. I find joy in being able to help my patients navigate their lives in sickness and in health so that they can get back to the joy of living.
Kisha Davis, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.
Chance to Shape FP Training, Education Prompts Career Move
I've lived my whole life in Indiana. My children -- like the three generations before them -- grew up here as well. Those children, now adults, still live near us here in Indianapolis.
My education and training -- from Ball State University to the Indiana University School of Medicine and the family medicine residency at Community Health Network -- all happened in the Hoosier State.
|I'll be leaving my home state of Indiana behind next month to start a new job as the AAFP's vice president of education at the Academy's offices in Leawood, Kan.|
My career started in rural private practice in the
small town of Flora, Ind. -- population 2,000 -- before I came back to
Indianapolis as faculty at the residency where I had trained. I stayed with
Community Health Network for more than 20 years as residency director, vice
president of medical affairs for two of its hospitals, chief medical officer
for the entire eight-hospital network and, most recently, as the network's
chief academic and medical affairs officer.
So what would it take to get me to leave my home state? Nothing less than a chance to make a positive, lasting difference in the education and training of medical students, family medicine residents and our active members on a national scale. That, of course, goes hand-in-hand with enhancing the quality of care delivered by our specialty.
I'll be leaving my position on the AAFP Board of Directors on May 3 (after the Board meets during the Annual Leadership Forum and National Conference of Special Constituencies). Nine days later, I'll start a new journey in Leawood, Kan., as the Academy's vice president for education.
I feel as though I have been training for this role for the past three decades. The majority of my career has been devoted to medical education and improving quality of care, so it's a natural fit. For example, for the past five years, my job responsibilities have included oversight of medical student education at our network's hospitals, our residency programs and the CME offerings we produce.
At the AAFP, I will be responsible for the Academy's efforts related to medical education and CME, including the education and training of medical students and residents; student interest in our specialty, including federal policies that affect it; and CME curriculum development, production, accreditation and regulations.
Many challenges await, but I'm excited to lead the AAFP's excellent staff who work in these areas, including those who support two commissions -- the Commission on Continuing Professional Development and the Commission on Education -- composed of family physicians who volunteer their time to address these vital issues.
We must ensure that medical students have top-notch exposure to family medicine and that they have good experiences when they do. That can be difficult, in part, because practicing physicians who enjoy teaching have competing demands for their time. But there is no doubt that good role models help build student interest in the specialty.
We are facing a shortage of primary care physicians that likely will worsen because of an aging population, a sizable number of physicians nearing retirement and a large number of patients gaining access to insurance as a result of health care reform. More -- and more targeted -- funding for family medicine residencies is needed to meet this demand, and GME funding and reform are high on the list of the Academy's legislative priorities.
Family physicians want to keep up-to-date with evidence-based CME, and the Academy will continue to improve and expand its offerings to ensure timely and convenient access to high-quality CME. We will build on the strong programing currently offered, and we always appreciate input from our members on how to better serve their CME needs.
On a more personal note, the challenges of this role also include succeeding the immensely accomplished and respected Perry Pugno, M.D., M.P.H., who is retiring after 40 years in family medicine, including 15 years of service to the Academy.
The challenges are great, but so are the opportunities. The key to improving health care in this country is to make it more primary care-oriented by placing greater emphasis on prevention and wellness. Family medicine is the specialty that does that better than any other. I am proud to have this opportunity to further strengthen our specialty through continuing efforts to enhance medical education at all levels.
Clif Knight, M.D., is a member of the AAFP Board of Directors.
A Well-Deserved Honor for AAFP President
When I was first elected to the AAFP Board of Directors four years ago, I was fortunate to find a mentor waiting for me.
Reid Blackwelder, M.D., would often give me pointers about how I could be more effective in contributing to the Board's deliberations. Sometimes it was an encouraging email, or he might pull me aside to say, "You made a good point on this issue, but you need to be more succinct."
AAFP President Reid Blackwelder, M.D., second from right, recently was honored by the Tennessee General Assembly for his work as a physician, educator and advocate. State Sen. Joey Hensley, M.D., far left, sponsored the resolution. Tennessee AFP officers Kim Howerton, M.D., and Lee Carter, M.D., also were on hand for the presentation.
Well, I'm working on that, and Reid has been a great role model. His criticism has always been constructive, and he has helped me grow, learn and develop my own leadership style. It's no surprise because he's helped mentor countless others, including the more than 1,400 medical students he's taught over the years at East Tennessee State University's (ETSU's) James H. Quillen College of Medicine.
ETSU medical students have named him Mentor of the Year and Family Medicine Attending Physician of the Year multiple times, and he's also received the Dean's Teaching Award. The AAFP awarded him the Exemplary Teacher of the Year Award in 2008.
He also has been honored by the
Tennessee AFP for his exceptional leadership and outstanding service to that organization.
Whether he is teaching, talking with his patients or lobbying on Capitol Hill, it all comes back to communication. Reid is easy to talk with and is a good listener as well. The same skills have served him -- and the Academy -- well in working with the media. He has been quoted in or contributed to more than 670 articles or broadcast features during his tenure on the AAFP Board.
His cumulative body of work recently led to the Tennessee General Assembly passing Senate Joint Resolution 536, which recognized Reid's "exceptional work as the president of the American Academy of Family Physicians," his dedication to teaching, and his advocacy efforts on behalf of physicians and patients. It also recognized him for dedicating his professional career to improving the lives of others.
I can't think of anyone more deserving of the honor, and I'm proud to call Reid my colleague, mentor and friend.
Currently, we have three candidates for four positions on the AAFP Board of Directors. Our speaker, John Meigs, M.D., recently pointed out on this blog the process of nominating candidates and the need for a deeper pool of candidates I can only say that anyone stepping into these leadership roles will find it a tremendous personal growth experience, and they will gain a new friend and mentor in Reid Blackwelder. Congratulations, my friend, on your well-deserved award.
Robert Wergin, M.D., is President-elect of the AAFP.
Don't Accept Limits on Your Family Medicine Opportunities
With our broad, extensive training, family physicians have opportunities beyond working in family medicine practices. Family docs are working in geriatrics, sports medicine, long-term care facilities, urgent care clinics, hospice care, and as hospitalists, administrators, researchers and more.
It's that diversity that draws some medical students to family medicine in the first place.
When I travel around the country to state chapter meetings, I hear from a lot of family physicians who love what they do. Occasionally, I also hear from members who say they feel trapped.
That was the case recently when I spoke to a colleague who had done research and developed a business plan that would expand primary care services for her health system. The idea, she thought, would improve outcomes and generate new revenue streams.
Her employer, however, was thoroughly disinterested.
Disappointed and disillusioned, she told me she felt stuck in her job because she had signed a two-year restrictive covenant agreement, or noncompete clause, when she was hired. That agreement excluded her from working in other family medicine clinics within 50 miles of any facility owned by her employer, which has locations in multiple counties in her area.
In my opinion, she was so close to her own situation that she had lost perspective. I told her to think about the diversity of her training and reminded her that family medicine is the No. 1 specialty for which recruiters are hiring. We are only trapped if we accept limitations others try to put on us.
These days there are incredible career opportunities across a wide spectrum because primary care is the backbone of our health care system. Family physicians are in high demand. In fact, there were more than 300 new job postings on the AAFP's CareerLink website during the first seven days of this month.
If you're feeling burned out or resentful, it's time to step back and consider what you might be able to do differently. Personally, I've left a job when I wasn't being compensated fairly and was unable to change unsatisfactory circumstances. When advocating for change within your system doesn't work, it's appropriate to consider other opportunities. Don't sell yourself short.
One of my colleagues recently made the decision to leave New England and move to a new opportunity in South Carolina. After more than 20 years of dealing with the same payers, she was ready to try something new.
That brings us back to the issue of restrictive covenants and whether physicians should be signing them. The AMA adopted principles two years ago that discourage physicians from entering employment agreements that contain noncompete provisions or other restrictions on future employment.
Personally, I've refused to sign restrictive covenants twice. Both times, I was told it was standard operating procedure. Both times, I let them know it was a deal breaker for me, and the employers backed down.
If an employer isn't willing to hire you without placing restrictions on your future, maybe it's not the right place for you. It's important to be able to walk away on your own terms, and there will always be other people who will hire you.
With a shortage of primary care physicians, our health care system can't afford to lose our training and expertise. If you're feeling burned out or trapped, you always can reach out to your colleagues or mentors for perspective and advice. Getting involved with your state chapter and national family medicine activities can expand your professional network.
Remember, there are always other options. With training as a family physician, you are invaluable, and you can find professional satisfaction in other settings where you can provide the expert care our nation needs.
Wanda Filer, M.D., M.B.A., is a member of the AAFP Board of Directors.
Candidates Wanted: Four Spots Available for AAFP Board
If you've ever thought about running for the AAFP Board of Directors, now might be the perfect time to do it. As of today, we have fewer candidates than the number of spots available in an election that is just six months away.
Each year, the AAFP Congress of Delegates elects three family physicians to three-year terms on the Academy's Board of Directors. Between meetings of the Congress, the business and affairs of the Academy are managed by and under the direction of the Board. The Board appoints commissions, committees and other work groups as necessary. Directors also serve as liaisons to the Academy's seven commissions and serve on the Board's various subcommittees.
|The Congress of Delegates will select new directors in October in Washington. To date, there are only three candidates for four positions on the AAFP Board of Directors.
It has been my privilege and pleasure to serve on the Board of Directors for the past six years. This has been a tremendous opportunity for me to learn more about the inner workings of the AAFP and also to benefit from the knowledge, experience, expertise and dedication of the Board members and Academy staff with whom I have had the opportunity to work.
I have come to appreciate the reasoned discussion and debate of the Board as issues are introduced and all points of view considered as the Board tries to reach consensus on the issues we face.
I came to the Board with my rural background and 30 years of private practice experience, and I hope that I have been able to contribute in some small way. I always have felt that I have learned far more than I have contributed. I have gained a broader understanding and deeper knowledge on so many subjects and issues, which has helped me to gain a broader perspective and to make me a better resource for my colleagues back in my practice, community and state chapter.
I would encourage anyone who has the time, dedication, drive and commitment to family medicine to consider running for the Board of Directors. For me, this has been an intensely rewarding and enriching experience that has carried over into the other aspects of my professional and personal life. I am more dedicated than I have ever been to family medicine and more convinced than ever that our health care system needs a strong, vibrant, respected and resourceful primary care workforce to deliver the cost effective quality health care that our patients and our country need and deserve.
So who is ready to step forward?
In nine of the past 10 years, AAFP chapters have nominated at least five candidates for three Director positions. In the 20 years I have been attending the Congress, I have never seen an uncontested election.
However, chapters have nominated only three candidates for the election that will take place in October at the Congress of Delegates in Washington. Complicating the matter is the fact that Director Clifton Knight, M.D., has accepted the role of AAFP vice president for education. He will resign his elected position on the Board, with one year remaining in his term, when he begins his new job in May.
That leaves us with three candidates for four spots. So what happens to the candidate who comes in fourth, assuming more candidates come forward? The candidate receiving the fourth-highest majority vote total would fill Knight's unexpired term and would be eligible to be a candidate seeking election to a full three-year term during the 2015 Congress of Delegates in Denver.
Due to the additional vacancy, the deadline for receipt of candidate information for the candidates' website has been extended to May 30 with the site going live June 13.
That leaves potential new candidates plenty of time to be competitive with the three existing candidates. Campaigning typically begins at the Annual Leadership Forum and National Conference of Special Constituencies, which will be held May 1-3 in Kansas City, Mo.
Chapters are encouraged to nominate qualified and interested individuals to run. Candidates for AAFP offices must be officially nominated by their chapters and must submit an official announcement letter and candidate photograph to EVP and CEO Douglas Henley, M.D.
With a diverse, national organization of more than 110,000 family physicians, medical students and residents, we need diverse representation -- not only of genders and ethnicities but practice types and locations. This is an excellent opportunity for family physicians to represent our organization.
You can read the campaign rules on the AAFP website.
John Meigs, M.D., is Speaker of the AAFP Congress of Delegates.
Visit to Army Medical Center Provides Insight Into Military Care
Recently, I had the good fortune to tour Brooke Army Medical Center (BAMC) Fort Sam Houston in San Antonio, and I came away extremely impressed by the great job that the Army does in caring for our soldiers on multiple levels: keeping healthy soldiers healthy, treating the acutely injured and helping the injured recover.
I also was impressed by the many opportunities available for family physicians to serve in military medicine. And it would be hard not to be awed by the largest inpatient medical facility run by the Department of Defense.
I recently toured Brooke Army Medical Center Fort Sam Houston in San Antonio with Col. Karrie Fristoe, commander of the U.S. Army's Medical Recruiting Brigade, and Rebecca Hooper, Ph.D., retired Col., and former assistant director of BAMC's Center for the Intrepid.
But to me, even more impressive was the commitment to improving the overall health of our soldiers and our country. One of our hosts, Lt. Gen. Patricia Horoho, U.S. Army surgeon general, stressed the importance of both the patient-centered medical home and efforts to emphasize health, not just treating illness and injuries. The Army Medicine Performance Triad -- eating well, being active and sleeping well -- are guides for soldiers to lead a better life with more engagement, energy and fulfillment.
The 2.1 million-square-foot, 425-bed San Antonio Military Medical Center has a certified Level 1 Trauma Center that handles more than 5,700 ER visits per month, yet it also offers primary care, pediatrics, OB/Gyn, bone marrow transplants, a cardiac catheterization lab and psychiatric care to service members, their families, veterans and civilians.
BAMC is home to the Army Burn Center, part of the Army Institute of Surgical Research. We were able to see how the Burn Center has the ability to project ICU level burn care anywhere in the world, to bring injured soldiers home in a mobile ICU, and treat them all the way through rehab and recovery.
It also is the site of the Center for the Intrepid (CFI), a world class facility for service members recovering from amputation. Here you can really see the benefit of combining the complete range of state-of-the-art amputee treatment in one facility: prosthetists, psychologists, challenging sports equipment and even virtual reality systems with one aim: bringing wounded warriors back to the highest level of functioning possible. The CFI and their athletes are inspiring, and the facility is far beyond anything offered in the civilian world.
Most family physicians likely know that the Armed Forces Health Professionals Scholarships Program (HPSP) offers full scholarships for medical school, but during my visit, I was struck by the wide number of opportunities available to family physicians practicing in the military. Indeed, by the age of 42 one of my hosts, Lt. Col. Tom Hustead, M.D., family physician and AAFP member, has already served as a clinic director, a flight surgeon, and a department chair in family medicine. In addition, he has been deployed in a military service area.
Hustead said many of the more than 550 Army family physicians, like him, initially joined out of a desire to serve our country, but they remain for the camaraderie and opportunity found in the in Army Medical Corps.
There are nearly 2,000 active AAFP members in our Uniformed Services chapter.
My message today is for them: Thank you for your service.
Jeff Cain, M.D., is Board Chair of the AAFP.
I Matched! And It's Good News All Around
I knew I wanted to be a family physician before I ever made it to medical school. As a college student with an interest in medicine, I shadowed an anesthesiologist and an orthopedic surgeon before our family physician suggested that I shadow one of his partners. It was that experience that set me on this path.
I was impressed that this family physician had patients who had been in his care for 30 years. He knew entire families and had a deep connection with the community. I spent time at that practice during my Christmas breaks and summer vacations, and it wasn't long before I realized, "This is who I am, and this is what I'm supposed to do."
Friday I got the good news that I had matched at the University of Alabama-Birmingham's Huntsville Family Medicine Residency. My classmates Libby Van Gerwen (who matched in internal medicine-primary care at Tulane University School of Medicine) and Brittany Holley (internal medicine at the University of South Alabama College of Medicine) also had reason to celebrate.
One particular patient encounter stands out in my memory. The physician had to inform a woman that she had cancer, and it was inoperable. Despite the horrible news, he was reassuring and told her that she wouldn't leave that day without a plan. The level of trust she had was clear. She valued his opinion and wanted his advice. It was a defining moment for me.
forward a few years to last Friday when I -- like thousands of other medical
students around the country -- received my National Resident Matching Program letter.
I had hoped to stay at the University of Alabama-Birmingham's Huntsville Family
Medicine Residency. I've been here two years for
clinical training, and I wanted to stay here for residency. I know the faculty, the community and the hospital. It's a good school and a
I felt good about my chances of staying, but you don't know where you're going until you open that envelope. It's a big moment after four years of medical school and four years of college. This is your career, the rest of your life.
Fortunately, I got the news I had hoped for, and I'll be staying in Huntsville. Nearly 10 percent of my class matched to family medicine, and news was good for our specialty nationally, as well. The number of medical students choosing family medicine increased for the fifth year in a row, and the number of U.S. seniors matched to family medicine also increased.
Although the numbers were encouraging, we have a long way to go. Our country is facing a shortage of primary care physicians. And it's projected that within a few years, we will be graduating more medical students than the number of residency spots available. The system clearly needs work.
One thing that would help would be having more family physicians such as the one I shadowed back in my hometown. If you're a family physician with a passion for what you do, reach out to students in your area or from your alma mater and show them what you do. You just might give a future family physician their defining moment.
Tate Hinkle is the student member of the AAFP Board of Directors.
The Truth About E-Cigarettes: Unregulated, Unproven and Unhealthy
Here is a burgeoning twist to the tobacco wars and a new public health risk.
In a new television advertisement, electronic cigarettes are being touted as better than traditional cigarettes because the byproduct is "only vapor," not tobacco smoke. Consumers -- including children -- are being told that e-cigarettes are the “smart alternative” to smoking. The implication is that e-cigarettes are safe for the user and the people around them. The truth is the vapor from e-cigarettes contains carcinogens, including arsenic, benzene and formaldehyde.
|Here I am speaking at a news conference to address Chicago's ban on the use of electronic cigarettes in public places. Family physicians can make a difference in public health issues not only in our exam rooms but also through advocacy.|
A preliminary study recently presented at the Society for Research on Nicotine and Tobacco found that second-hand exposure to e-cigarettes can cause harm after the user has left the room or turned off an e-cigarette because nicotine released by the products leaves residue on indoor surfaces.
Tobacco companies have long tried to glamorize their deadly products, and now e-cigarette marketers are doing the same thing, including using high-profile celebrity endorsements.
But the marketers' unsavory tactics don't stop there. Although proponents will argue that e-cigarettes are tobacco cessation devices, the fact is that manufacturers are targeting the next generation of smokers by marketing their products to kids.
If you have doubts, ask yourself how many middle-aged men are reaching for the e-cigarettes that come in cotton candy and bubble gum flavors. Those clearly are intended for kids, and the percentage of middle school and high school students who have tried e-cigarettes doubled from 2011 to 2012.
That's a huge problem because the products aren't regulated, so the amount of nicotine and other chemicals can vary from cartridge to cartridge.
And those touting e-cigarettes as the "smart alternative" to tobacco are ignoring the fact that many consumers are doubling up, using both conventional cigarettes and their electronic counterparts. In fact, a CDC survey found that more than three-fourths of middle school and high school students who use e-cigarettes also smoke. A recent study in JAMA Pediatrics concluded that the use of e-cigarettes "does not discourage, and may encourage, conventional cigarette use among U.S. adolescents."
A recent survey of e-cigarette users found that only 12 percent were former smokers who use the electronic products exclusively. A study in JAMA Internal Medicine found that e-cigarette users did not quit with greater frequency than nonusers. In fact, among smokers who called a quitline, e-cigarette users were less likely to quit than nonusers.
It's also worth noting that poisoning incidents related to e-liquids increased 300 percent in the past year.
So what are we, as a society, going to do to counter a billion-dollar industry that is spending more than $20 million a year
The FDA was granted the authority to regulate cigarettes and other tobacco products in 2009, and the agency has been trying to gain similar control of e-cigarettes for years. Meanwhile, children are allowed to buy products that could adversely affect their health for the rest of their lives, and targeted advertising is unregulated.
We have a duty to protect those children and our communities, and if a product looks like a cigarette and contains nicotine like a cigarette, it should be regulated like one. So while we wait for the FDA to act nationally, we can advocate locally.
Here in Chicago, the Illinois AFP supported a city ordinance passed earlier this year that will subject e-cigarettes to the same sales restrictions as tobacco, and it also subjects the products to the city's Clean Indoor Air Act.
New York, Los Angeles and several counties across the nation also have implemented similar laws that ban the use of e-cigarettes in public places. Some states, including Illinois, prohibit the sale of e-cigarettes to minors. Legislation regarding sales restrictions and use in public places is pending in several states.
But legislators aren't the only ones who need to hear from family physicians about this health issue. Our patients are hearing about e-cigarettes from paid endorsers of the products on a regular basis, but what are we telling them?
Parents need to know that children are using these products, and there are numerous possible harms. Patients who are ready to quit smoking should be encouraged to use evidence-based methods that have been proven safe and effective.
Smoking rates for adults and teens are at historic lows. We must ensure that trend isn't reversed by misinformation and questionable marketing practices.
You can read the AAFP policy on e-cigarettes here. And to learn more about how to talk to your patients about e-cigarettes, the Illinois AFP, the AMA and the Chicago Department of Public Health recently offered a free webinar that is archived online.
Javette Orgain, M.D., M.P.H., is the Vice Speaker of the AAFP.
Academy Tools Could Ease EHR Burdens
Editor's note: During the AAFP's Scientific Assembly in San Diego, a panel discussion on practice transformation generated far more questions than the panelists could answer in the time allotted. This is the fifth post in an occasional series that will attempt to address the issues members raised -- including challenges associated with electronic health records systems -- during the panel.
Two years ago, my practice implemented an electronic health record (EHR) system. The initial results weren't pretty. Transitioning from paper to electronic files takes time, and my productivity plunged.
I worked at it, learned the system and my productivity has improved. Although
my patient volume has not yet returned to pre-EHR volumes, my clinic is running
much smoother than it did initially because my staff and I have adapted. We
have embraced this change, and the benefits have been numerous.
- We qualified for meaningful use stage one incentive payments, and we are working on stage 2, including the launch of a new patient portal. Those incentive payments helped offset the investment in the EHR and that initial dip in clinic volume.
- My practice previously had one full-time equivalent devoted to pulling and filing paper charts. Now, that information is at my fingertips whenever I need it.
- Our clinic system is spread across three communities, so one of the big benefits of the electronic system is being able to access records -- including labs and X-rays -- securely from any location, including our ER.
- A medication reconciliation process has made us more aware of what drugs patients are taking, which helps us avoid medication errors, interactions and duplications.
- We are developing disease registries that will allow us to track our patients, improve follow-up care and provide better care for patients with chronic conditions.
Health care isn't going back to paper records. This is where we are headed, but qualifying for meaningful use incentive payments can be challenging. That's why the Academy has included a step-by-step guide to meaningful use stage one in its new PCMH Planner, an affordable, subscription-based web tool designed to help practices -- particularly small practices -- transform to the patient-centered medical home model. A guide to stage two is expected be available in the PCMH Planner by the end of March.
The Academy created the PCMH Planner at the request of small practices that were asking for help with practice transformation. I recently saw a demonstration of the Planner, and it is an effective, evidence-based way to start the process of transforming a practice. The Planner also includes Practice Foundations for PCMH, a step-by-step guide to quality improvements and other tasks that should be completed before you begin practice transformation. PCMH 101, which covers the basics of becoming a medical home, will be available later this month, and PCMH 201, which offers more advanced topics, is expected to be available later this spring.
What else is the Academy doing to make EHRs easier to use and more effective? The Congress of Delegates has asked the AAFP to create a clinical data repository that would provide data to family physicians in way that is clinically relevant.
In a 10-practice pilot, we've created registries related to diseases, procedures, medications and lab results and provided the participating practices with analytics and comparison data against their peers. The system is capable of identifying potential gaps in care and patients who should be prioritized for outreach. It also provides revenue and cost efficiency metrics.
Although this is only a pilot, evidence to date indicates that it is working. We have found that the clinical data repository is technically feasible and capable of generating value for practices. The repository also could act as a national specialty registry, which would ease the reporting burden on family physicians by allowing us to report data to a single source.
A decision on how this concept might be rolled out to Academy members as a product likely will happen this summer.
And what about interoperability? When our patients leave our practice and go to another -- for a subspecialist consultation, for example -- my EHR won't necessarily be able to communicate with the subspecialist's EHR. This is a major flaw in our health care system, and the Academy continues to push the Office of the National Coordinator (ONC) for Health Information Technology and EHR vendors on this important issue. Unfortunately, vendors have little motivation to fix it because they want customers to buy their proprietary, unique products. It doesn't help that large health care systems aren't in the habit of sharing information with competing health care systems. Thus, interoperability likely remains at least five years away.
Meanwhile, the Academy is one of the sponsors of the nonprofit DirectTrust, which accredits services that allow physicians to exchange encrypted patient information through secure servers. You can read more about the direct exchange process here.
The AAFP is working to develop resources that save us time and money and reduce our reporting burdens. I'll keep you updated on our progress in these efforts.
Robert Wergin, M.D., is President-elect of the AAFP.
For This State Chapter, It Truly Is a 'Family Affair'
One of the characteristics that truly defines family physicians is that we recognize everything is about relationships. We certainly understand this when to come to our patients.
I worked with a medical student recently, and she was impressed by how much I knew about patients I hadn't seen for months. I told her that it's because we family physicians know our patients, and we value their stories. This is how we help take care of folks and how we put everything into context. It's one of the things that make family physicians special.
|Nevada AFP executive director Brooke Wong is her chapter's sole staff member, but her entire family helped the chapter's annual meeting run smoothly. Here, daughters Alexa, 9, and Kendall, 3, along with Bear Farrimond, 5, assist Jeffrey Ng, M.D., with a raffle drawing.|
We walk our talk in so many other ways, too. This relationship aspect is something I see regularly, and thoroughly enjoy, as I travel around the country and talk with Academy members. One of my responsibilities -- it's an opportunity, really -- as AAFP president is to attend state chapter meetings. Often, I am there to install new officers, provide educational opportunities and update members on what the AAFP is doing for them.
But I think what I am really doing is reinforcing the power of relationships. The connections I am making are phenomenal. Many of the physicians I see at chapter meetings are people I have met at other meetings because we often travel the same paths. However, each state chapter also has physicians who are not involved at the national level. These are the dedicated family physicians on the front lines who are often coming together for their own networking and education.
Behind all of this activity are the chapter executives who do outstanding work for their members. These are truly compassionate and remarkable individuals who help each chapter be the best version of what it can be.
I recently traveled to South Lake Tahoe, Nev., for the Nevada AFP's annual meeting. I was invited to the chapter's meeting last year, but I had to cut that trip short to make an unplanned, but very important, other meeting. I was thrilled that the Nevada AFP asked me and my wife, Alex, to come again this year. We were eager to get the full experience this time.
What was remarkable is that you would never know that this actually is a small chapter. A large number of people attended the very well-put-together CME sessions in a beautiful location. However, what was most powerful to me was how much of a family affair this event was. The moment I arrived, executive director Brooke Wong welcomed me into her bustling command center.
Brooke is a staff of one, but her family provided plenty of help to make the meeting run smoothly. Her young daughters helped with a silent auction. Her husband, Conrad, provided IT support and took photographs. He was everywhere, making sure that the CME came off without a hitch and documenting all of the events.
At registration, Brooke's mother and father greeted people with a smile, offered chocolate and signed attendees up for all of the various events.
As soon as we walked in, we were part of the Nevada AFP family. There is truly no better example of the power of relationships than what occurs at these chapter meetings.
Thanks to all of the chapters I've had a chance to visit, and I look forward to those coming up. It is an incredible opportunity, and I value being a part of each of your families.
Reid Blackwelder, M.D., is president of the AAFP.
Barriers Impede Telemedicine's Potential
Editor's note: During the AAFP's Scientific Assembly in San Diego, a panel discussion on practice transformation generated far more questions than the panelists could answer in the time allotted. This is the fourth post in an occasional series that will attempt to address the issues members raised -- including payment for telemedicine -- during the panel.
We know that telemedicine, the use of technology to deliver care at a distance, has the potential to expand access to care in underserved areas, reduce ER visits and save patients time. Questions remain, however, about how we can best expand telemedicine's use in primary care.
Telemedicine already is used in subspecialty care, including dermatology and radiology. But in our current fee-for-service model, can telemedicine be integrated into primary care without significantly increasing health care costs?
| Kimberly Becher, M.D., left, the resident member of the AAFP Board of Directors, accompanied me on a trip to Capitol Hill while I was a visiting scholar at the AAFP's Robert Graham Center for Policy Studies in Family Medicine and Primary Care. I interviewed more than a dozen representatives of federal government health agencies and congressional staff about telemedicine for my project.
recently spent a month in Washington researching telemedicine and the barriers
to its expansion as a visiting scholar at the Robert Graham Center for Policy
Studies in Family Medicine and Primary Care. Participating in the Larry A.
Green Visiting Scholars Program was an invaluable educational experience, and I
acquired skills that will help me for the rest of my career. The Graham Center
staff provided me with in-depth training on research, including how to plan a
project from beginning to end, proposal writing, information and data
gathering, manuscript writing and more.
The training actually started months in advance as I worked with Graham Center staff to define what my project would be so that I could hit the ground running when I arrived in Washington for one month of intense work.
I picked telemedicine as my topic, in part, because the Graham Center was already in the midst of a research project on the subject. Funded by a $200,000 grant from WellPoint, the project produced a literature review, a report from the meeting of an expert panel, and -- coming later this year -- a survey of AAFP members about our knowledge and use of telemedicine.
It is hoped that the member survey results and my manuscript will be published in peer-reviewed journals. The Academy also intends to share the report from the expert panel.
For my project, I interviewed 14 representatives from government health care agencies and congressional staff to gauge their understanding of telemedicine and to identify barriers to its expansion in primary care and what is required to move beyond those barriers.
Barriers, it turns out, are not in short supply. One of the biggest issues is payment because of the constrained rules that exist in the current payment systems. There are certainly ways that telemedicine can be integrated into care delivery now, but I hope with alternative payment models on the horizon -- where physicians are paid based on quality and value -- we will see more physicians use it to deliver care at a lower cost for their patients.
Reimbursement for telemedicine services vary widely by payer and state. Ten states require Medicaid coverage of telemedicine, and 43 states require Medicaid coverage for some telemedicine services. Eighteen states mandate private payer coverage for telemedicine, and 14 other states have legislation pending.
But telemedicine is complicated in many other ways. According to the American Telemedicine Association, more than half the state legislatures are considering bills related to telemedicine. One of the most prevalent issues is licensure.
In Florida, for example, the state medical association has said that it supports the expansion of telemedicine, but the association is lobbying against a bill that seeks to create statewide standards and establish reimbursement requirements for telemedicine. The association is fighting the bill, which also would create a system for registering out-of-state physicians, because it opposes the idea of physicians licensed in other states treating Florida patients via telemedicine.
That's a significant issue in Florida because of the annual migration of people who spend the winter months in the Sunshine State.
What's at stake? A nonpartisan, nonprofit public policy research institute released a report this month that said reducing costly interventions, such as ER visits, by as little as 1 percent could reduce the state's health care costs by $1 billion a year.
Among my interview subjects, there was broad recognition that telemedicine is an important issued related to access to care. But another barrier we must overcome is that many rural and underserved parts of country still don’t have access to broadband internet. That's important because although the "tele" in telemedicine might prompt people to imagine a physician on a telephone, there's much more to it. Telemedicine can involve video conferencing with a patient from his or her home, electronic monitoring of chronic conditions and so much more. The fact that telemedicine means different things to different people could be a barrier as well. There's no consensus on what the term actually means.
That's unfortunate because more than 50 percent of U.S. hospitals already are using telemedicine in some manner. Incorporating the use of this technology in care delivery is happening, and it will continue to expand, so we have to figure out how it fits in primary care.
A good step forward would be finding a way to expose medical students and family medicine residents to telemedicine. I'm a fourth-year medical student and have yet to experience it. Medical school and residency is where we get our feet wet, and the models we train in influence how we will practice later.
We have the technology and the ability to extend ourselves, improve access to care and save our patients time and money, but there are many questions left to answer. I hope that when the Graham Center's survey lands in your in-box later this year, you will take a few minutes to give us your thoughts on telemedicine. The more people who participate in this important survey, the more valuable our data will be.
How Family Medicine Upstaged Ben Affleck
It's not an everyday occurrence when a family physician proves to be a bigger draw -- at least for a few minutes -- than a two-time Academy Award winner. But that was the case last Wednesday when Sen. John McCain, R-Ariz., stepped out of a Senate Foreign Relations Committee hearing (where Ben Affleck was testifying about issues in the Congo) to talk with me about the sustainable growth rate (SGR) formula and the need to extend funding for teaching health centers.
The AAFP Board of Directors was meeting in Washington, but we made time in the agenda to talk to our own legislators about these critical issues. I had met with McCain's staff several times in previous trips to our nation's capital, but this was my first visit with my state's long-time senator. The meeting was quite encouraging. In fact, McCain was one of nearly two dozen members of Congress who agreed to co-sponsor the SGR Repeal and Medicare Provider Payment Modernization Act last week.
The bipartisan legislation introduced last month in the House and Senate would permanently repeal the SGR and enact reform that would support improvements in health care delivery. If Congress doesn't act before March 31, the SGR would cause Medicare payments to physicians to be cut by 24 percent.
It's easy for individuals to think they can't make a difference against huge challenges like this one, but the reality is that legislators might not even be aware of a problem unless a constituent is willing to bring it their attention. That was the case with the issue of teaching health centers -- or the lack of them -- in Arizona.
Fewer than half of the states have teaching health centers, and Arizona is one of those on the outside looking in. Sen. McCain wasn't aware of that shortcoming. But when I told him about the benefits of teaching health centers and why funding should be extended beyond 2015, he wanted to know more. I will certainly follow up with his staff to make sure he understands the value and importance of teaching health centers.
Arizona, a state with 6.5 million people, has only eight family medicine residencies, including the University of Arizona Family Medicine Residency Program where I am an associate professor. Adding a teaching health center would be a huge step in the right direction, ensuring family medicine becomes a more vigorous force in health care delivery.
Carlos Gonzales, M.D., is a member of the AAFP Board of Directors.
Want to use this article elsewhere? Get Permissions
Search This Blog
Subscribe to receive e-mail notifications when the blog is updated.