Making the Case for Primary Care-specific Codes
The evaluation and management (E/M) services provided by primary care physicians are more complex, and thus more intense, than those of our subspecialist colleagues. Unfortunately, existing E/M codes do not reflect the scope of our responsibilities, the comorbidities of our patients, the complexity of their care or the coordination that care requires.
They should, and Academy leaders and staff made those points recently during a meeting with CMS officials who are involved in the development of the 2014 Medicare Physician Fee Schedule. We presented them with data that demonstrates how primary care E/M services are different and why they should be valued differently than services provided by other specialties.
Let's backtrack a bit.
A year ago, the AAFP Board of Directors made the difficult decision to stay involved with the AMA/Specialty Society Relative Value Scale Update Committee (RUC), despite the fact that the committee has undervalued primary care services in its recommendations to CMS. The Academy took a stance that it would participate in the RUC process while also advocating directly with CMS.
Around the same time, the AAFP's Primary Care Valuation Task Force made recommendations that included creating primary care-specific E/M codes and valuing primary care E/M services differently than those provided by subspecialists.
I told you in October that the Academy was working with a consulting firm to collect and aggregate data to support our argument about E/M codes. During a March 7 meeting with CMS, we presented the agency with preliminary data from that in-depth research.
Although CMS officials cannot comment on the process during the development of next year's Medicare Physician Fee Schedule, they can ask questions and request more information. When you are asking someone for more money, you can expect questions. We answered a lot of questions.
CMS officials also indicated they were eager to see more data supporting our position.
A draft of the fee schedule is expected in July before a final version is published in November. That gives us some time to continue our efforts and push forward with our request for a coding system that fairly values the important work we perform in the care of our patients.
Glen Stream, M.D., M.B.I., is board chair of the AAFP.
Week in D.C. Creates Opportunities to Advocate for Family Physicians
I recently returned from an extremely busy week in Washington where the Academy's Board of Directors met to review issues that are important to family physicians and our country.
We were able to take advantage of our location to advocate for family medicine on Capitol Hill during the meeting. Despite a government shutdown caused by a snowstorm -- which was predicted to hit D.C., but did not -- many of our elected leaders were able to meet with their representatives. AAFP President Jeff Cain, M.D., director Dan Spogen, M.D., and I met with Senate Majority Leader Harry Reid, D-Nev., (pictured below) to deliver our messages about payment reform -- including the need to repeal the sustainable growth rate (SGR) -- graduate medical education (GME) funding and other critical issues.
Although the Board agenda was filled with a few days' worth of discussions on such topics, this trip also presented an opportunity for me to speak for family physicians in other venues, as well. I actually arrived days before the Board meeting to represent you at some intriguing events.
I attended a press conference organized by the National Commission on Physician Payment Reform. This group was convened by former Senate Majority Leader Bill Frist, M.D., R-Tenn., and Steven Schroeder, M.D., of the University of California-San Francisco, to devise ways to directly address payment reform. The commission made a dozen recommendations, including eliminating the SGR and replacing fee-for-service with a new model based on quality and value.
It's worth noting that the AAFP convened a task force two years ago that made similar suggestions last year.
At the press conference, I applauded the work of the commission and recognized that it supported the AAFP's recommendations to CMS and other bodies on specific ways to steer payment away from a strict fee-for-service model. I also had a chance to talk with a reporter from the British Medical Journal whose subsequent article referenced the AAFP's work, as well as the commission's report. The more we all work and move suggestions together with one voice, the more likely changes are to happen.
Next, I represented the AAFP at a special meeting called by aides to first lady Michelle Obama. We met in her office to discuss the needs of our service men and women and military veterans. I was able to highlight the AAFP's commitment to this special group through the Academy's Joining Forces website.
of the critical needs identified were improving coordination of medical records
between the Department of Defense and the U.S. Department of Veterans Affairs
(VA) system and addressing the needs of our women veterans. In addition,
providing mental health services is a huge need for our veterans. For both of
these groups, family physicians are ideally suited to help. Several physician
organizations -- including the AAFP --
Finally, the AAFP also participated in another effort involving the first lady, the Building a Healthier Future Summit. That dynamic, three-day event brought together more than 1,000 representatives of private and public sector groups to fight childhood obesity. The AAFP was invited based on our Americans In Motion -- Healthy Interventions (AIM-HI) fitness initiative.
Michelle Obama spoke at the summit, and representatives from supporting organizations -- including the AAFP -- were on stage to be recognized. You will be pleased to know that afterwards there was a lot of recognition of the "distinguished-looking" representative from the AAFP. (During my speech in Philadelphia at the Scientific Assembly, I did promise that my beard would not be ignored -- or forgotten.)
These are exciting times. Thank you for the opportunity to represent you and our patients in so many different venues. Wherever I go, people are talking about the importance of primary care. Our task is to make sure they also recognize the vital role that family physicians play in delivering it.
Reid Blackwelder, M.D., is the president-elect of the AAFP.
Delivering an Important Message for Family Medicine
The AAFP Board of Directors met with members of Congress and congressional staff March 6 to discuss issues important to family medicine, including physician payment and graduate medical education. In this video interview with AAFP News Now Washington Correspondent James Arvantes, Carlos Gonzales, M.D., of Patagonia, Ariz., talks about making his first Capitol Hill visit as an Academy Board member.
Carlos Gonzales, M.D., is a member of the AAFP Board of Directors.
Signs of Primary Care Success
When a company or an industry
becomes truly successful, one of the first real signs of that success is a new
level of criticism aimed its way.
Recently, one of our neurosurgeon colleagues wrote a post critical of primary care that appeared on the Neurosurgery Blog. It then was picked up by the Association of American Medical Colleges' blog Wing of Zock.
In the blog, Robert Harbaugh, M.D.,
does a grave disservice to family physicians, medical students, and our country
by misrepresenting and attacking primary care medicine.
Unwilling to let his message stand
unopposed, I worked with the AAFP's public relations staff to craft a response
to Harbaugh's blog as posted on the Wing of Zock blog, and we are very happy that
they posted it.
As our country begins to move toward investing in primary care as an effective way to bend our unsustainable cost curve of health care, we can expect increasing push back from those who either do not understand the real effectiveness of primary care or who stand to lose in this important transformation.
Our Academy will respond forcefully
to these outliers, for the health of our patients, our practices and our
Primary Care Needs Are No Myth
In "The Primary Care Shibboleth: Debunking the Myth," Dr. Robert E. Harbaugh (a neurosurgeon) does a grave disservice to family physicians and medical students who value the professional satisfaction, intellectual challenges and career-long patient relationships of primary care.
Dr. Robert Harbaugh, M.D., is misinformed.
Primary care should be the critical foundation of our health care system. A wealth of published, credible data supports the value of primary care and prevention:
- Health care systems with a strong primary care sector are associated with reduced health care costs and improved quality of care.
- Primary care physicians decrease health care utilization through effective preventive care and enhanced coordination of care.
- Patients who have a family physician as their usual source of care have lower total medical care costs.
Harbaugh wrote, "The United States has a relatively high concentration of primary care physicians and a relatively low concentration of (sub)specialists compared to the OECD (Organisation for Economic Co-operation and Development) average of all countries." Unfortunately, this statistic is skewed by counting all of "internal medicine" as a primary care specialty, erroneously including medical subspecialists as primary care. The truth is the ratio of primary care and subspecialty care proven to produce the best outcomes is now out of balance in the United States and threatens to get worse. Currently, less than 20 percent of medical students who enter internal medicine residencies go on to practice primary care.
Harbaugh asks if anyone believes that by investing more in primary care, we can prevent people from getting sick and save money. It may come as a surprise to Dr. Harbaugh, but not only do our nation's health care policy experts acknowledge the value of investing in primary care, but so do many of the nation's top business executives.
Harbaugh misses the point of primary care by describing it as "a brief meeting with a physician who tells patients what they already know." Primary care's strength is in continuity, the relationships formed with patients over years that allow early detection and intervention in medical illnesses. Family physicians are trained in effective behavioral change methods proven to make a difference in the health of their patients. Investing in primary care and the patient-centered medical home reduces overall system costs by reducing unnecessary hospitalizations and unnecessary emergency department visits.
Overall, Harbaugh fails to acknowledge the very real cost and patient safety differences in primary, secondary and tertiary prevention. His example from his own practice is the carotid endarterectomy, an example of tertiary prevention. Indeed, if a patient had access to a primary care physician to help control blood pressure, smoking cessation, and prescribe statins when necessary, the patient might even avoid the need for this procedure with its associated high costs and surgical risks.
Furthermore, we cannot hide from the truth. Primary care is among the lowest paid physician specialties in the United States, a travesty given the overall value that primary care brings to our patients, communities and the health care system. This huge income disparity has a profoundly negative impact on our country's future workforce. The average medical student today has more than $161,000 in education debt after medical school. Data increasingly show that debt and earning potential are swaying student specialty choice.
To close the gap in medical student specialty choice, the Council on Graduate Medical Education's 20th report recommended that primary care physicians be paid at 70 percent of subspecialists' pay. When our Canadian colleagues faced a similar decrease in primary care student interest 10 years ago, they increased the mean salary of family physicians and now have more medical students entering family medicine than ever.
Harbaugh interprets the data narrowly and quite selectively. The professional societies representing primary care have never advocated "robbing Peter to pay Paul" by increasing payments to primary care physicians at the expense of surgical specialties and other subspecialties. The AAFP's position has always been that savings from preventing avoidable emergency department use, hospitalizations, readmissions, procedures and tests will more than pay for improved payment for primary care.
Harbaugh says patients are the priority, and we couldn't agree more. If we are to address the toughest challenges in medicine, we must respect the value and expertise of all our medical colleagues -- primary care and subspecialists alike. By bringing physicians together, we can have a profound and far-reaching impact on medicine. But most importantly, we can do what is best for the health and well-being of our patients.
Jeff Cain, M.D., is the president of the AAFP.
Time for a National Conversation About Gun Violence
Growing up in the Pacific Northwest blessed me with a love, and respect, for the outdoors. I am an avid cyclist and experienced skier. I also grew up with guns, and I own sporting guns to this day.
At the same time, my hospital -- Children's Hospital Colorado -- has served as a treatment center for wounded kids after two of the most horrific shootings in our nation's history: the Columbine High School massacre in 1999 and the more recent attack at a movie theater in Aurora, Colo. Twelve students and one teacher were murdered at Columbine, and 12 people were killed in the theater shooting. Seventy-nine others were wounded in the two incidents combined.
Children from my practice, as well as children of my friends and practice partners -- were at the theater on that horrible night in July.
It's time that we, as a country, recognize gun violence as a major public health issue. According to the CDC, more than 31,000 Americans were killed with firearms in 2009, rivaling the number of those who died in traffic accidents. The number of Americans killed by guns in one year on U.S. soil is more than four times the total of U.S. deaths from the wars in Iraq and Afghanistan combined.
Following the recent school shooting in Connecticut, the White House formed a task force to develop policy to prevent these tragedies and reduce gun violence. On Jan. 3, I participated in the first of a series of stakeholder meetings when HHS Secretary Kathleen Sebelius, White House staff members and others met with representatives from groups representing health care professionals and public health organizations.
The causes of this problem are complex, and there is no simple solution. The White House and HHS are expected to meet with a wide variety of those involved in the issue, including mental health experts, law enforcement, gun owner groups and youth advocacy organizations, to listen to their analyses and recommendations.
As family physicians, we focus daily on prevention to improve the health of our patients. Today, we need to help our country focus on prevention that addresses all of the causes of violence in our communities.
Our country needs better mental health care, including improved access to care, substance abuse counseling and coordination with primary care. These points were made loud and clear during the Jan. 3 meeting.
The need to address violence in media -- from
television and movies to video games and music videos -- also was part of our
discussion. Studies have shown that children exposed to media violence are more
likely to cause harm to others. The Academy has a position paper on
We also talked about firearm safety. Guns are not the only source of violence, but gun safety clearly needs to be part of the conversation and part of the solution. Our Academy has long standing policy -- endorsed and upheld by our Congress of Delegates -- supporting legislation requiring trigger locks and safe storage of firearms, as well as policy opposing ownership of assault weapons.
Family physicians need to be able to have appropriate medical conversations with our patients about gun safety, and researchers need the ability to study gun safety. Currently, state and federal laws restrict their ability to do so.
The White House has asked the Academy for input, and we shared with them our policies related to violence, including media violence, gun safety and improving mental health care.
I recognize the diversity of our membership and the fact that there are strong feelings on both sides of the issue when it comes to guns. Yet, all family physicians are advocates for decreasing violence in our communities. This is an opportunity for family physicians to be heard as strong advocates of prevention during the development of national policy that will affect the health and safety of our patients.
Jeff Cain, M.D., is the president of the AAFP.
Working for You: An Update From the AAFP Board Meeting
The AAFP Board of Directors has been meeting at the Academy's offices in Leawood, Kan., this week to discuss a wide range of issues important to family medicine, including physician payment. AAFP Board Chair Glen Stream, M.D., M.B.I., has more details in the video below.
Glen Stream, M.D., M.B.I., is the board chair of the AAFP.
Tell Congress to Preserve Medicaid Parity Payments
When the Affordable Care Act became law in 2010, more than 48 million Americans -- roughly 16 percent of the nation's population -- were covered by Medicaid. Meanwhile, 36 percent of family physicians surveyed by the AAFP were not accepting new Medicaid patients because the health plan was offering payments far below the cost of providing care. In fact, nearly 20 percent of our members said they were not seeing Medicaid patients at all.
Nationally, Medicaid pays an average of 66 percent of Medicare rates for primary care services. In some states, it pays as little as 36 percent.
Today, more than 50 million Americans are covered by Medicaid, and the ACA calls for expanding Medicaid to as many as 21 million more patients. To increase the number of providers accepting Medicaid and improve access for patients, the ACA also increases Medicaid physician payments for primary care services to Medicare levels in 2013 and 2014. That's significant for family physicians because Medicaid patients already account for 15 percent of our patients.
Unfortunately, House Republicans are eyeing billions of dollars in Medicaid parity funds as part of an ill-advised solution to a different problem that Congress created -- and neglected to fix -- 15 years ago. A House leadership proposal sent to the Senate calls for eliminating the needed increase in Medicaid primary care payments to offset about $15 billion of the cost of extending the sustainable growth rate (SGR) formula for another year.
No doubt, the SGR needs to be extended for one or two years while we look for long-term alternatives for the flawed Medicare payment system. Physicians face a 26.5 percent reduction in Medicare payments on Jan. 1 unless Congress acts to block the cut.
But the House proposal merely temporarily bandages the Medicare SGR issue while eliminating much-needed progress on Medicaid.
The proposal overlooks the fact that expanding Medicaid coverage to millions of uninsured patients would not only improve their health, it also would reduce their reliance on costly emergency room facilities for non-emergent care, increase their use of preventive services and save federal and state governments money in the long run.
A study published earlier this year by the Commonwealth Fund showed that a 10 percent Medicare payment increase for primary care -- a provision of the health care reform law that took effect last year -- will increase primary care visits by roughly 9 percent. Although the costs for overall primary care visits are expected to increase more than 15 percent, the study estimates an actual overall 2 percent net savings for Medicare.
Raising Medicaid physician payments for two years would give us time to demonstrate similar benefits for that program.
The AAFP, the American Academy of Pediatrics, the American College of Physicians, the American Osteopathic Association and the AMA -- along with numerous constituent chapters of each organization -- are sending a joint letter to Congress detailing the importance of preserving the Medicaid parity funding during budget negotiations.
It is imperative, however, that legislators hear directly from you, their constituents. I urge you to send letters to your members of Congress and tell them to oppose the use of Medicaid parity funds as an offset for the SGR. We need to find a way to solve the SGR crisis without disrupting our patients' access to care.
Jeff Cain, M.D., is President of the AAFP.
New Members of Congress Get Orientation From AAFP, Other Physician Groups
For the past two weeks, newly elected legislators who will join Congress in January have been in Washington for orientation. Those new members of the 113th Congress have been briefed on the essentials of working in Washington, including how to hire staff, communicating with constituents and the lawmaking process.
Today, many of them received a medical education of sorts, courtesy of the AAFP, learning how their actions -- or inaction -- will affect our nation's health care system.
Without congressional action on the sustainable
growth rate (SGR) formula, we face a 26.5 percent reduction in Medicare
payments on Jan. 1. Furthermore, the Budget Control Act's sequestration
provision would cut Medicare payments by an additional 2 percent. So for the
first time, the AAFP invited all of the incoming Democratic House members to
its new Washington offices for a meeting with Academy staff and representatives from nearly 20 other
physician organizations. (A similar event for new Republican lawmakers is being
More than a dozen new lawmakers attended and heard why a nearly 30 percent drop in Medicare physician payments poses a crisis for physicians and our practices. Even more importantly for Congress, this is a very real crisis for our patients -- who are legislators' constituents -- because access to care would be jeopardized by the looming cuts.
We also talked to the new legislators about the importance of protecting graduate medical education during the ongoing deficit reduction talks. The United States already faces a growing physician shortage. Cutting these vital funds is simply not an option.
Rep. Allyson Schwartz, D-Pa. (pictured above with Shawn Martin, AAFP vice president of advocacy and practice advancement, and Rep. Denny Heck, D-Wash.) spoke to her new colleagues about the importance of working with physicians on health care issues. Schwartz, who has been a member of the House since 2005, also pointed out what an excellent resource had been presented to them -- a room full of health care policy expertise. The new members of Congress heard a unified message from these groups, who represented everyone from anesthesiologists to family medicine to vascular surgeons.
Now your legislators need to hear from you. Make a difference. Make your voice heard.
Jeff Cain, M.D., is President of the AAFP.
Family of Family Medicine Now Under One Roof in Washington
Family medicine has long had a presence in Washington. The AAFP, the AAFP's Robert Graham Center, the American Board of Family Medicine and the Council of Academic Family Medicine -- which represents the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group and the Society of Teachers of Family Medicine -- all have had offices in our nation's capital.
Now, for the first time, you can find representatives of all those organizations under one roof.
The Academy and its sister organizations recently moved into a new location that not only brings us together but also brings us closer to the White House and Congress. These groups, which are so interconnected, now will be working together in the same place.
In this era of e-mail, texting and smartphones, communication has never been easier. But there still is something to be said for face-to-face meetings. If one of the family medicine organizations has a question about what the other is doing or needs input, staff can simply walk down the hall. Meetings will be easier to schedule. Communication will be enhanced, and our work will be more efficient.
I got a first-hand look at the new offices Oct. 31 and Nov. 1 when AAFP leaders were in Washington to meet with White House and congressional staff as well as other key stakeholders, for conversations about Medicare physician payment, workforce issues, veterans' health care and health research.
The AAFP already had close working relationships with the other family medicine organizations, but that might not have been clear to outsiders. It should be obvious now to anyone who walks through our doors.
And plenty of people did just that last week, including AAFP member Alma Littles, M.D., of Tallahassee, Fla., who is pictured with me here. Academy leaders and staff met with representatives from the AARP, the Agency for Healthcare Research and Quality, and the Bipartisan Policy Center in the new Washington AAFP board room. And representatives from CMS and other health care stakeholders attended our open house.
Advocacy has always been a key part of our mission, but having all our organizations represented in one location makes it clear that we mean business in Washington. It also illustrates the growing visibility and impact of family medicine on Capitol Hill and among federal agencies.
Reid Blackwelder, M.D., is President-elect of the AAFP.
Taking Family Medicine's Message to Washington
Barring congressional action, physicians face a 27 percent reduction in the Medicare payment rate on Jan. 1. Additionally, the Budget Control Act's sequestration provision would cut the Medicare payment rate by 2 percent on Jan. 2.
AAFP President Jeff Cain, M.D., Board Chair Glen Stream, M.D., M.B.I.; President-elect Reid Blackwelder, M.D.; and Academy staff met with White House staff, congressional staff, representatives of federal agencies and other stakeholders Oct. 31 and Nov. 1 in Washington to discuss this looming crisis and other issues vital to family medicine.
Dr. Cain has more details in the video below.
For more information about how you can help, log on to www.aafp.org/grassroots.
New Partnership Aims to Strengthen Academy's Efforts With RUC, CMS
Earlier this year, the AAFP Board of Directors made the difficult decision to stay involved with the AMA/Specialty Society Relative Value Scale Update Committee (RUC), despite the fact that the committee has historically undervalued primary care services in its recommendations to CMS. I explained at the time that though we would continue to participate in the RUC process, the Academy also would advocate directly to CMS.
As part of our commitment to improving payment for primary care services through this two-pronged approach, the AAFP recently reached an agreement with the health care advisory firm Avalere Health LLC. Academy staff met with representatives from Avalere this week in Washington to discuss four specific areas in which the firm might assist the AAFP in our efforts:
- Collect and aggregate data that demonstrate primary care evaluation and management services are different and should be valued differently than services done by other specialties. This aligns with a recommendation of the AAFP's Primary Care Valuation Task Force.
- Identify overvalued and undervalued services in the resource-based relative value scale (RBRVS), which CMS uses to help set Medicare physician payments.
- Help the Academy's participants in the RUC and CPT processes work more effectively in those arenas.
- Define the content and value of care management fees.
Avalere is expected to provide preliminary data for the first three items by March. The proposed timeline will give the Academy time to influence the proposed rule for the 2014 Medicare physician fee schedule.
The fourth item likely will take longer. The AAFP promotes a blended payment model that includes a fee-for-service component, quality incentives and a per-member per-month care management fee (PMPM) to support the patient-centered medical home. However, no one has consistently defined what a PMPM care management payment should cover or its true value. Medicare is paying an average of $20 -- with a range from $8 to $40 -- in CMS' Comprehensive Primary Care initiative. But private payers' PMPM fees vary widely, and some are as low as $2.
Avalere will help us demonstrate the value of our ability to coordinate and manage care and the return on investment for payers.
We're optimistic this partnership will strengthen our position in our dealings with the RUC as well as in advocating directly to CMS. Primary care physicians must be paid differently than subspecialists and more fairly than we have been. The outcomes from this project should make that clear once and for all.
Glen Stream, M.D., M.B.I., is Board Chair of the AAFP.
Grateful for Opportunity, Eager to Serve
If I had to pick one word to describe my life's work in the world, it would have to be advocate.
As a family physician, my goal in clinic is to improve the health of my patients, one person at a time.
As a family medicine resident in Denver, I learned I could affect the health of my community one classroom at a time when we created Tar Wars.
In Colorado, we were able to create change statewide by enacting laws that defined the medical home, raised taxes on tobacco, and required insurance companies to pay for prosthetic arms and legs.
My entire adult life has been about being a physician and an advocate, stepping up to do what needs to be done. Each time we have seen success -- that our efforts really do make a difference -- it makes me eager to do more.
I can't think of a better position to affect the health of our patients and our practices than by serving as the national voice for family physicians. This is an exciting time for family medicine, and I'm grateful for the opportunity and eager to serve as your president this year.
Our Academy's top-level ultimate goal is to improve the health care of America while improving our practice environment.
It won't be easy.
But it is so very important.
For our patients, and for our practices.
We face many challenges in the coming months, including Medicare payment cuts scheduled to take effect as a result of the sustainable growth rate (SGR) formula and the Budget Control Act's sequestration provision.
During this election year, we cannot allow the noise of politics to drown out the voice of our patients. If we allow legislators to take a meat-cleaver approach to cutting Medicare costs, it will have disastrous results -- for the elderly, the disabled and our military veterans -- as well as our practices.
In the face of these challenges, we also have some really good news. We have always believed that family medicine is the way to improve health care and bend the cost curve. Now we have proof that primary care, specifically the patient-centered medical home model, reduces unnecessary emergency room visits and hospitalizations and delivers higher quality care. A strong primary care system is the path to achieving the triple aim of better health, high quality outcomes and lower health care costs.
AAFP leaders, including our Board Chair Glen Stream, M.D., M.B.I., will join me this month making visits to Washington to share this truth -- that family medicine is the future -- with lawmakers. But it can't just be the Jeff and Glen show. Our specialty needs all of us -- our more than 105,000 members -- to make our voices heard.
When Paul Grundy, M.D., M.P.H., IBM's global director of health care transformation and co-chair of the Patient-Centered Primary Care Collaborative, recently addressed the AAFP Board of Directors, he had this to say about family medicine: "Your voice is so very powerful… and you don't even know it."
We need to harness that strength so we can address not only payment reform but other vital issues for our country's health: workforce issues, tort reform and health care for all.
What could be more powerful than our own stories about our patients -- many of them registered voters -- and how cuts to Medicare will threaten their access to care? And remember, many private payers base their fee structures on Medicare; this threat isn't limited to patients covered by Medicare.
The looming payment cuts present a potential crisis. But they also present an opportunity for us to tell our stories, to shine a spotlight on the fact that family physicians have been underappreciated, undervalued and underpaid.
When we combine the moral authority of our patients' stories with the now proven economic efficacy of family medicine, we really will be able to transform health care for everyone.
My job this next year will be to be the voice of family medicine. To tell our story. But to be truly successful, we all must make our voices heard for the good of our patients, our practices and our specialty.
Jeff Cain, M.D., is President of the AAFP.
Two Sentences That Changed My Life
My time on the AAFP Board of Directors is drawing to a close. Truly, it's been a great ride.
I've visited roughly three dozen states -- including two dozen constituent chapter meetings -- on Academy business during the past six years. I never tired of visiting our chapters and talking with you. Hearing your difficulties and frustrations was incredibly important to me. Instead of making me feel discouraged, those conversations gave me more energy and motivation to make our voice heard with legislators and payers. That extra energy often was needed. During my year as AAFP President in 2010-11, I spent 200 days on the road. That's a lot of flights, hotels and cab rides.
My current path would have seemed unlikely when I was completing residency in 1984. AFP leadership wasn't a goal of mine -- or even a thought -- at the time. I was excited about going home to practice, and I had 1-year-old twins to focus on. That seemed like more than enough. However, things happen that change even the best of plans. The initial change was the closing of the small hospital where I practiced and a change of career path to residency teaching.
And then it was two simple sentences that really changed my life.
I was the program director of the family medicine residency program in Corpus Christi, Texas. In 1988, our specialty had disastrous results in The Match. Two months later, family medicine program directors met during a state medical association meeting in San Antonio and agreed that The Match results were bad for health care in our state, and something had to be done.
Coincidentally, an interim study on postgraduate health institutions was being conducted for the state legislature, and the program directors agreed to try to influence the process leading up to 1989 legislative session. We managed to get a request to be heard by the committee involved in the interim study, and I sat down one night and wrote what I thought would be good testimony for someone to deliver on our behalf.
That someone turned out to be me.
In my testimony, I said family medicine absolutely had to have a third-year core rotation that was the same duration as every other core rotation in medical school. It wasn't received well by many of our state's academic institutions, but it garnered support from key legislators -- including then Rep. Mike McKinney, M.D., a family physician who later became chancellor of the Texas A&M University System.
When McKinney was working on an omnibus health care bill a year later, his staff asked what family medicine wanted from the legislature to get the curriculum changes we needed.
And therein lies the two sentences, which were inserted in the health bill that set me on this path.
With some help from then Texas AFP Executive Director Jim White, we wrote that all medical schools that receive state money would have a core rotation in family medicine during the third year. And that core rotation would be of equal length to other core rotations in that year.
The law resulted in Texas medical school students gaining more exposure to family medicine, and more students matching into family medicine residency programs.
My involvement in its passing made me unpopular with some people in academic circles, but it set me on a leadership path in the Texas AFP. By 1991, I was chair of the Department of Family and Community Medicine at The University of Texas-Houston Health Science Center, and people in my state chapter were encouraging me to get involved at the national level with the AAFP.
By then I had three young children, and it didn't seem like the right time to take a big leap into national advocacy. Instead, I stayed closer to home and served as president of the Texas AFP in 1994-95. Later, I served the AAFP as a member of its Commission on Education, which I eventually chaired. After that, I was a member of the Academy's Commission on Legislation and Governmental Affairs and went on to chair that commission as well.
The point is that you can choose when in your career and where in our country to invest time in advocating for our specialty and at what level to do it. Advocacy, in its most robust form, can be grueling. (Did I mention 200 days on the road in one year?)
But it doesn't require a big time commitment to simply do what you can. Any one of us can go talk to our local Rotary Club, Optimist Club or patient group about family medicine. Any one of us can give the primary care perspective at a community forum on health care.
Do what you can. Be part of your community. It makes a difference. I have found talking to community groups fun and rewarding. As a young physician, those conversations helped build my practice.
For those who catch the policy bug and want to do more, I urge you to try. Despite the challenges and frustrations, it is a rewarding experience. I'll never forget meeting with the four leaders of Congress in a two-hour span one day in Washington. I also was privileged to speak before Congressional Committees on multiple occasions.
And I don't care if you're a Republican or a Democrat, if you have a chance to meet the President of the United States, talk to him about health care and represent our members in the White House, that is a career highlight.
There is still much work to be done for family medicine. I wish we could have fixed the sustainable growth rate formula during my time on the Board of Directors. I would have liked to have accomplished more to increase payment for primary care. But as an old politician once told me, sometimes the system won't let you accomplish everything you want, so you have to understand how to take what you can get and come back and fight again. And hopefully, you pass that passion on to those who follow you.
Soon our Congress of Delegates will elect four new board members and select a new president-elect. I wish them well.
What can you do to help? You can find information on our website about getting involved with the Academy's grassroots advocacy efforts, serving on AAFP Commissions, and student and resident leadership opportunities.
It's never too early, or too late, to get involved.
Roland Goertz, M.D., M.B.A., is the Board Chair of the AAFP.
Nurse Practitioners No Substitute for Physician-led Team
By the year 2020, our nation is expected to face a shortage of 45,000 primary care physicians. To address this shortfall, as well as rising health care costs, the nation is seeing a movement to grant independent practice to nurse practitioners.
But, this flawed, stop-gap approach overlooks some obvious obstacles to replacing physicians with non-physicians. For example:
- The nursing field faces its own deficit with a shortage of 260,000 nurses projected for 2025. You can't fill a gap with something else you lack.
- Though some have supported the idea of independent nurse practitioners because of the lower costs involved with training and employing nurses, the approach fails to consider that those savings may be offset by decreased productivity and less efficient use of staff resources.
- Granting independent practice to nurse practitioners would create two classes of care: one run by a physician-led team and one run by less-qualified health care professionals. Physicians are required to complete roughly 16,000 more hours of training than nurse practitioners.
The Academy addressed all these issues yesterday when it released a report -- with support from the American Academy of Pediatrics, the AMA and the American Osteopathic Association -- that explains in detail the differences in training and clinical expertise between physicians and nurses, why a team-based approach is preferable, and why substituting non-physicians for physicians just won't work.
Our report is intended, in part, to educate the public about those differences in training. Consumers are not discerning purchasers of health care when they don't know the facts. Many patients, however, already express a preference for physicians. According to a recent AMA patient survey, 86 percent of respondents said that they benefit when a physician leads a primary care team, and 75 percent said they prefer to be treated by a physician -- even if it takes longer to get an appointment.
At a time when the AAFP is advocating a team-based approach to health care to improve outcomes and lower costs, some nurse practitioners are eager to go it alone. Our report makes a strong statement that the patient-centered medical home model is designed to be run with a physician leading a team of health care professionals. A recent report by the Patient-Centered Primary Care Collaborative offers more than 30 examples of public and private payers finding that better care, better outcomes and lower costs are possible in the PCMH model. Specifically, team-based care has been proven to reduce emergency room visits, hospital admissions and total inpatient stays.
The PCMH gives patients access to physicians, nurse practitioners, physician assistants and other health care professionals. Together, these health care professionals can complement each other with their experience and expertise.
Finally, the report stresses that national workforce policies are needed to ensure adequate supplies of family physicians and other health care professionals to improve access to quality care and avert the anticipated shortages of primary care physicians and nurses. Wholesale substitution of non-physicians for physicians is not, and should not be, an option.
Please share your thoughts below.
Roland Goertz, M.D., M.B.A., is the board chair of the AAFP.
Democrats Hear AAFP's Message About Health Care
During my six years on the AAFP Board of Directors, I've testified before Congressional committees, lobbied in Capitol Hill offices and been to the White House. But I'd never been to a national political convention until this week, and I wasn't sure what to expect.
What I've found during the Democratic National Convention is that AAFP representatives -- Mark Cribben, director of FamMedPAC, the Academy’s political action committee; David Carlyle, M.D., a member of the FamMedPAC board of directors; and myself -- have enjoyed excellent access to legislators here in Charlotte, N.C.
Tuesday alone, we meet with more than half a dozen members of Congress,
including Senate Majority Whip Dick Durbin of Illinois. Durbin (pictured with me below) was one of the speakers at a morning function along with Sen. Patty
Murray of Washington and former Virginia governor and current Senate candidate
We made our way through a series of afternoon receptions, meeting with Rep. James Clyburn of South Carolina, Rep. Eliot Engle of New York, Rep. Frank Pallone of New Jersey, Rep. Nancy Pelosi of California, Sen. Sherrod Brown of Ohio and Sen. Dan Inouye of Hawaii along the way.
On Wednesday night, the Academy co-sponsored a lounge for members of Congress and staff before the convention. We had a good turn out with several legislators stopping to spend time with us, including Rep. Allyson Schwartz of Pennsylvania, Rep. Jan Schakowsky of Illinois and Rep. Gene Green of Texas.
Wherever I've been this week, and regardless of whom we are talking to, people have recognized the AAFP. Legislators know that we are a player in our nation's ongoing dialogue about health care, and the reception has been incredible.
These aren't just handshakes in a receiving line. Brown spoke to me for at least 20 minutes about our issues -- physician payment, work force and medical liability reform. When I ran into him again later Tuesday evening, he thanked me for my time.
This isn't a partisan effort, either. Last week, the AAFP sent representatives to the Republican National Convention in Tampa, Fla. Many of the legislators we've met during these two weeks are people we have spoken with in the past. In fact, most of the lawmakers I have talked to here I have previously visited with in their Washington offices. Being here, however, reinforces those contacts and shows them our commitment to our specialty and our patients.
We will follow up with members of Congress after they return to work later this month, reiterating our message that the key to fixing the health care system is investing in and strengthening primary care.
Roland Goertz, M.D., M.B.A., is the board chair of the AAFP.