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.
Primary Care Education at Forefront of Obama Budget Proposal
Washington, D.C., is always an exciting place to be, but it especially was for me this week because the AAFP Board of Directors is meeting here to advocate for our members and improved health care for all Americans. But today was an even better day than I expected. As we gathered this morning before our meeting, we were encouraged by some good news in USA Today.
For months, the AAFP has been working with the White House and the Health Resources and Services Administration (HRSA) to address the need for increased funding in graduate medical education (GME). Today, information provided by the White House Office of Management and Budget reveals that there will be some good news for primary care Tuesday when President Obama releases his 2015 budget.
Specifically, the document released by the Office of Management and Budget to USA Today (and later shared with the Academy) says the Administration plans to budget an additional $5.23 billion during the next 10 years to train 13,000 more residents in primary care "and other physicians in high-need specialties." The document does not specify what those high-need specialties are, but last year the Council on Graduate Medical Education (COGME) called for increases in GME funding in "high priority specialties," including family medicine, geriatrics, general internal medicine, general surgery, high priority pediatric subspecialties and psychiatry.
The AAFP has long advocated that our country put more resources into graduating more medical students into primary care to meet the workforce needs of our country as our population continues to grow, as it continues to age, and as more patients get health insurance because of health care reform. This proposed budget speaks directly to this need.
Additional residency positions in primary care also are needed to keep pace with the opening of new medical schools and expanding medical school class sizes. COGME recommended that Congress continue funding existing GME positions and increase funding to support 3,000 more graduates per year. The President's budget would take a step in the right direction, providing additional funds through HRSA to train an additional 1,300 residents per year in high-need areas, including rural areas. It is critical, however, that any such increase that is implemented must ensure a majority of these positions be in primary care: family medicine, general internal medicine and general pediatrics.
Reinforcing this need, the document says residencies vying for the additional slots would have to demonstrate that they "train and retain physicians in primary care and use team-based models of care that enable all providers to work at the full extent of their abilities, and adopt new models of care, such as the patient-centered medical home or accountable care organizations."
It is important that we identify and finance training sites that may be outside the traditional hospital setting. The budget document says that for the new competitively awarded residency slots, priority would be given to hospitals and other community-based health care entities.
National Health Service Corps
One proven way of getting physicians into primary care is through the National Health Service Corps (NHSC). During the past several years, we have seen important growth in this program. The number of physicians serving in the NHSC has more than doubled during the current administration, from 3,600 in 2008 to 8,900 last year. The President's proposed budget would provide $3.95 billion in mandatory funds, expanding the number of NHSC health care providers in underserved areas to 15,000 each year from 2015 through 2020.
The AAFP has strongly supported growth in the NHSC, which offers scholarships and loan repayment assistance to support qualified family physicians and other health care professionals who are willing to work in communities across the country that are designated as health professional shortage areas. The program makes it easier for students to choose primary care careers without facing insurmountable debt and helps address critical access issues by placing new physicians in areas where they are needed most.
The AAFP has been advocating for the increase of Medicaid payment rates to Medicare levels for more than four years. The proposed budget would extend increased Medicaid parity payments for primary care services through 2015 at an estimated cost of $5.44 billion.
We thank the administration for this proposed increase, and look forward to working with Congress to extend these increased rates for five years to create a period of access stability as our members continue to transform their practices to more effective patient-centered medical homes, and as we transition away from payment models that pay for volume to models that pay for value.
It's important to remember that Tuesday's announcement will be regarding a proposed budget. These specific proposals from the White House directly address the workforce needs of our country, and would help produce the critically needed primary care physicians Americans need and deserve. We are eager to continue our discussions with this administration and Congress to work to achieve these outcomes.
Much work and debate will remain before it is finalized, but this proposed budget is an important step forward as it is a real and meaningful investment in primary care. It represents recognition of the foundational role that primary care must play in our transforming health care system. The AAFP stands ready to help ensure that all Americans get the right care from the right person in the right place at the right time.
Reid Blackwelder, M.D., is President of the AAFP.
Advocacy Improves Community Health Far Beyond Exam Room
I have been involved in advocacy, in one form or another, since middle school: collecting money for the Jerry Lewis telethon, arranging a speaker for my high school class and working on teen pregnancy issues in residency. The issue that helped me fully understand the nuances of advocacy, however, was the death of a patient who was a victim of domestic violence.
Knowing that I wanted to help to change the health conversation, I asked myself, "Who else in the community has a stake in this issue, and what existing programs might need assistance?" Then I met with the local women's shelters to find out what they needed and how family physicians could connect women who need help from these resources. I also worked with law enforcement officials, educated myself and eventually figured out how to get things done.
Family physicians face a lot of challenges, including payment issues, new regulations, public health issues and more, but we don't always know how to fix the problem or create change in our communities.
|As President of the Pennsylvania division of the American Cancer Society, I spoke during an event at the State Capitol. Our advocacy efforts helped the Clean Indoor Air Act become law in 2008.|
It helps to be able to take our frustration with these various issues and turn them into opportunities for change and leadership. Getting involved in advocating on our issues can provide an opportunity to get off the daily routine hamster wheel and develop and use different skills. We are trained in family and community medicine, so engaging in pressing issues can be a great fit for our skills. Addressing and fixing these nagging problems can help us reenergize, improve our professional satisfaction and build our professional network.
Start by asking, "What am I passionate about?" "What issue is hurting my practice or affecting too many of my patients?" The basic process of identifying a problem, gathering stakeholders, setting goals, developing a communications plan and engaging the community can be applied to an array of public health issues. For example, when I was on the board of the Pennsylvania division of the American Cancer Society, a state senator had been working for years -- without success -- on a bill regarding clean indoor air.
This is where those different skills I mentioned kick in. In this effort, I was able to provide testimony in my state legislature and inform the public about the issue by working with the media. By networking, with persistence and professionalism, we were able to bring critical allies -- including the state restaurant association -- into the discussion. The addition of physician partners adds urgency and credibility to an issue. You can be that valued partner.
By pulling other physicians and medical organizations into the effort, we were able to provide powerful stories from patients whose health had been affected by smoking in public places. We were able to gather data related to the high medical costs associated with working in a smoke-filled environment. These two factors personalized the story and proved to policymakers and the public that this was a public health problem that needed to be rectified.
Finally, the Clean Indoor Air Act was signed into law in 2008, prohibiting smoking in public places and workplaces statewide.
For some, advocacy means stepping out of their comfort zone, or at least expanding it. Speaking in front of large groups can be nerve-racking, especially when cameras are rolling. But the results -- healthier communities and personal growth -- can be fantastic.
Our communities -- and our country -- need us, and not just in our practices. Being involved in these types of issues, whether locally or nationally, showcases who we are, what we do and the fact that primary care physicians are leaders in community health.
On April 7-8 in Washington, family physicians will have an opportunity to learn about advocacy at the Family Medicine Congressional Conference. Attendees will learn how to engage legislators and share stories from their practices in a way that can inspire change. I hope to see you there.
Wanda Filer, M.D., M.B.A., is a member of the AAFP Board of Directors.
Academy is Working to Define, Value Care Management
Editor's note: During the AAFP's Scientific Assembly in San Diego, a panel discussion on practice transformation generated far more questions than the panelists could answer in the time allotted. This is the second post in an occasional series that will attempt to address the issues members raised -- including the valuation of care management fees -- during the panel.
The AAFP has been advocating for years that a designated care management fee should be paid on a per-member, per-month basis as part of a blended payment model that also includes enhanced fee-for-service and performance-based incentives.
Family physicians always have done what is needed to care for our patients. We answer phone calls and e-mails, review and compile information from subspecialists, coordinate care transfers in referrals and in the hospital, handle prior authorizations, and ensure so many more aspects of making sure our patients get the care they need are covered. Although all these factors are critical for good patient outcomes, none of them generate payment for family physicians doing this important work.
The AAFP is pushing for payers to recognize the value inherent in care management services. Although we are seeing progress in this area, our efforts are complicated because of the amount of confusion -- and disagreement -- regarding what care management services should include and what they are worth. The Academy is working to define patient care management so that these services can be understood and valued appropriately.
For example, the AAFP's Robert Graham Center for Policy Studies in Family Medicine and Primary Care has conducted a literature review that considered more than 600 studies that offered evaluations of care management fees and reimbursement in care management and/or care coordination. Sixty-one articles were deemed relevant for inclusion in the review.
The range of fees found in that review was striking, with a low of 60 cents per beneficiary per month in one demonstration to a high of $444 per beneficiary per month in a congestive heart failure program. Some payers are offering $2 to $4 per beneficiary per month. Obviously, these low numbers are unacceptable.
Some disagreement exists as to what dollar amount per beneficiary per month would be most appropriate to properly value the work required to provide high quality care, but we are working on a process to help make these critical decisions.
The Graham Center's work will be used as the basis for a concise document that defines what the AAFP considers to be the essential elements of care management fees. That document will be vetted in February during a meeting of the Academy's Commission on Quality and Practice.
The next step will be for the health care advisory firm Avalere Health LLC -- which has been working with the Academy on payment issues since 2012 -- to value the AAFP's definition of a care management fee. That valuation, the definition and the underlying literature review then will be used to create a policy document on the valuation of care management fees. That document is expected to be presented to AAFP Board of Directors later this year.
When the work is done, we'll have one seamless document we can take to payers -- both public and private -- and say, "Here is what we do for our patients. This is what care management means. It should be valued and paid for, and this is a reasonable care management fee."
The document also will be used to help AAFP members evaluate contracts that include care management fees.
We'll keep you updated on our progress.
Reid Blackwelder, M.D., is President of the AAFP.
AAFP Takes SGR Message to Capitol Hill
After spending a week at the AMA Interim Meeting in National Harbor, Md., AAFP leaders met with members of Congress and congressional staff Nov. 19-20 in Washington to discuss the repeal and replacement of the sustainable growth rate (SGR) formula and other issues of importance to family medicine. AAFP President Reid Blackwelder, M.D., offers an update on the Academy's advocacy efforts in the video below.
Reid Blackwelder, M.D., is President of the AAFP.
The Good, the Bad and the Ugly … A Tale of Three Bills
Congratulations to our Louisiana, Ohio and Pennsylvania chapters for winning Leadership in State Government Advocacy Awards at the AAFP's State Legislative Conference, Nov. 1-2 in Broomfield, Colo. Our national and state legislative leaders spent that weekend discussing issues related to scope of practice, the Patient Protection and Affordable Care Act, opioid abuse and rural workforce. This annual event presented a great forum for knowledge sharing and cross pollination of legislative strategies across the states.
If you have spent any time at your state legislature, you know that actions are worth more than words, and that legislators -- despite good intentions -- may craft bills that are good, bad or just plain ugly when it comes to public health and the practice of medicine.
My state legislature is no exception. In California, we just ended the first of a two-year legislative session, which meant that all bills were chartered, killed or pushed onto a second year session for more work. This year, we saw three scope-of-practice expansion bills: one for pharmacists, one for nurse practitioners and one for optometrists.
Here is the low down on each of these bills.
The first in this triad of bills became law, allowing pharmacists to furnish self-administered hormonal contraceptives, nicotine replacement products, and prescription medications not requiring a diagnosis that are recommended for international travelers. In addition, they will be allowed to order and interpret tests for the purpose of monitoring and managing the efficacy and toxicity of drug therapies in coordination with the patient's primary care physician, including by faxing or entering results in patients' medical records. And finally, they are allowed to initiate and administer routine vaccinations recommended by the CDC's Advisory Committee on Immunization Practices.
Why, you ask, is this expansion good for family physicians? The house of medicine initially opposed the bill. However, after several thoughtful discussions with pharmacists, the bill was amended to bring pharmacists into a patient-centered medical home model, which allows them to become a part of the health care delivery team in their area of expertise. This will result in more coordination between a patient's primary care physician and pharmacist, and it will decrease the barriers our patients may face in obtaining certain treatments.
It is always good when each member of the health care team is participating to the maximum that their training allows.
In stark contrast to the pharmacists, the nurse practitioner scope bill exemplified how bills should not be worked through the legislature. After years of working with physician organizations -- including by supporting several prior bills that were passed to allow increased scope of practice for nurse practitioners within a collaborative agreement structure -- nurse practitioners tried to pull a fast one on the legislature this year. Nurse practitioners argued that they can fill in primary care shortage gaps where family physicians cannot or are not willing to do so.
However, physician organizations successfully argued to the legislature that independent nurse practitioners would not improve quality and may adversely affect patient safety. This argument was further augmented by data provided by the California AFP showing that independent nurse practitioners would not improve primary care misdistribution in our state.
To their credit, state legislators heeded our message, and the bill failed to pass out of committee. By focusing on obtaining independence, nurse practitioners sought to further fragment the health care delivery system and to further undermine the cornerstone of health care reform by putting their financial self-interest above coordinated, patient-centered care. The nurse practitioner bill simply highlighted deficiencies in our fragmented health delivery system without providing a workable solution to the primary care workforce shortage.
The last of the three scope bills would have allowed optometrists to diagnose and treat all conditions presenting with ocular manifestations. It would not only allow them to initiate treatment of chronic diseases -- such as diabetes and hypertension -- but also complex conditions such as systemic infections and autoimmune diseases.
Needless to say, the house of medicine was strongly opposed to this bill. Yet, the author, an optometrist himself, would not take on any amendments to his bill. He was able to move this bill out of the committee that he chaired. But facing a high likelihood of defeat on the floor, he pulled the bill for further work next year.
I had an opportunity last week to participate in a community chronic disease forum hosted by the author of this trio of scope bills. After some careful repartee sitting around a small table, I came to realize that he, like many, if not all, legislators, drafts bills with the best of intentions. In this vein, it would be in our best interest as family physicians to keep close tabs on all our legislators and develop relationships with them. Successful advocacy takes good will and influence to bring about change.
So, what can you do? You can join the thousands of family physicians who have signed up to become key contacts for advocacy. Key contacts receive regular updates from the Academy's government relations staff on issues important to family medicine, and they occasionally are asked to reach out to their legislators by phone or e-mail to tell their stories and let lawmakers know how issues are affecting family physicians and our patients.
For those who aren't able to get directly involved with advocating for family medicine, you can still make a difference by supporting FamMedPAC, the Academy's federal political action committee. FamMedPAC enhances AAFP advocacy efforts by making direct, nonpartisan contributions to candidates for the U.S. House of Representatives and the U.S. Senate. FamMedPAC provides AAFP members with an easy way to get involved in the political process and to support candidates who support family medicine.
With mid-term elections approaching, you'll be helping to improve the delivery of health care in this country, and helping put family physicians on equal footing with the powerful insurance companies and trial lawyers. It's one way to ensure our voice is heard on Capitol Hill.
Jack Chou, M.D., is a member of the AAFP Board of Directors.
The Challenge of Working With Health Plans
Every year, AAFP leaders and staff members meet with several of the nation's largest health insurance companies to discuss payment and other issues important to family medicine. Last week at the Academy's headquarters in Leawood, Kan., we met with UnitedHealthcare (UHC), and it provided us with an opportunity to express our concern regarding UHC's recent move to make significant cuts to its Medicare Advantage provider network just a few weeks before Medicare open enrollment.
UHC representatives told us they made the decision because in some markets their networks were significantly larger than their competitors, who already have taken similar steps to reduce the size of their networks. They felt they needed to “optimize” those networks to align with their competitors. A narrower network, UHC's representatives said, will allow the company to invest more in certain practices through incentive payment programs and also will eliminate unwanted variations in care.
Regardless of whether UHC's business decision was good for the insurer, it was poorly timed, catching physicians and patients off guard during a critical time of year. We stated again that decisions that affect such a significant number of patients and physicians -- up to 18 percent of primary care physicians who contract with UHC in some markets -- should be communicated to the Academy in advance so we can alert our chapters and prepare our members.
According to UHC, the company did not remove patients from coverage altogether. Instead, it is working to move them to other practices in their network. As we told them, however, cutting large numbers of physicians could create capacity and access issues in some markets because many of our members do not have the ability to significantly increase their patient panels.
Despite the above matter, we were able to find common ground on some important issues. For example, United agreed that we need a more continuous dialogue at the staff level, and we identified a few issues that we will be actively engaged in with UHC moving forward.
UHC representatives also said they want to work with the Academy -- as well as other payers -- to standardize and align quality measures, which would vastly reduce the reporting burden physicians face. They also want to hear more about the new evaluation and management codes for primary care physicians that the Academy has recommended to CMS.
Care management fees are another issue we will be discussing with UHC, which has publicly stated that it plans to have at least 50 percent of its provider network working under value-based contracts, rather than strictly fee-for services arrangements, by 2015.
Fee schedules that pay less than Medicare in some regions also were a topic of discussion. We emphasized that other payers in these areas do pay above Medicare rates, and to be viable, family medicine must be valued appropriately.
Working with health plans can be challenging, but we can build on common issues that keep the patient's best interest as our primary focus. We will stay engaged and continue to promote the value of family medicine.
Robert Wergin, M.D., is President-elect of the AAFP.
When Congress Is Ready to Listen, We're Ready to Talk
What a week this could have been.
making my first visit to Washington as the AAFP's President-elect, but the
agenda is a little thin. My schedule for Tuesday and Wednesday shows a trip to
the White House, meetings with legislators and staff from both houses of
Congress -- and both political parties -- as well as discussions with leaders
from three federal agencies.
like most Americans, I'm waiting for federal employees to go back to work and
for members of Congress to stop pointing fingers and start solving problems. The
perpetual problem we had hoped to discuss with legislators -- one Congress
created -- is the sustainable growth rate (SGR) formula. For the first time,
Congress actually seemed to be taking clear steps toward replacing the flawed
Medicare formula before the government shutdown Oct. 1. In July, the House
Energy and Commerce Committee unanimously approved a Medicare physician payment
bill that would
abolish the SGR. The Senate Finance Committee is expected to release its own
version, or at least it was before things ground to a halt last week.
Without congressional intervention, the SGR will trigger a nearly 25 percent reduction in Medicare physician payments Jan. 1. Rest assured, we will reschedule our meetings with legislators and continue our advocacy efforts as soon as Congress stops is intransigence.
In addition to our meetings with legislators, Academy leaders were scheduled to meet this week with representatives from
- the Agency for Healthcare Research and Quality to discuss primary care research;
- the CMS Innovation Center to discuss studies related to the patient-centered medical home model; and
- the Office of the National Coordinator for Health Information Technology to discuss meaningful use regulations.
With roughly 800,000 federal workers furloughed, those meetings won't happen this week either.
I am disappointed but not discouraged. There will be another day to deliver family medicine's message.
How will the shutdown affect our patients and our practices? Will the prospect of resolving the SGR again be delayed by the process of resolving our budgetary crisis?
For now, there are a more questions than answers. In the past few days, taking care of a critically ill 2-year-old in my ER and seeing patients in my office has made the problems in Washington seem secondary, at least for a few precious moments. We are on the right path, creating access for our patients and providing high quality primary care one patient at a time.
We will get through this, and when Congress is ready to listen, we definitely will be ready to talk.
Robert Wergin, M.D., is President-elect of the AAFP.
Make a Difference Beyond the Exam Room: Join an Academy Commission
During my residency, I treated a woman -- who we'll call Maria -- three times for chlamydia infection. Each time I treated her, I urged her to tell her partner to come see me -- or to see another physician -- and get treated so that Maria wouldn't get infected again.
However, her partner didn't have insurance, had no regular access to care and was reluctant to see a physician while asymptomatic.
I wanted to do more for Maria, but what could I do?
A year later I was in Springfield, Ill., as a member of the Illinois AFP's Governmental Relations Committee, lobbying state legislators about expedited partner therapy, which would allow me to give Maria (and other patients like her) extra medication and instructions for her partner. This legislation passed a few years later and now is a regular part of my practice to prevent reinfection in my patients and the spread of sexually transmitted diseases in the population in general.
It was important for me to be part of my state chapter's advocacy efforts at that time, and later, I was part of the AAFP's Commission on Governmental Advocacy, which allowed me to advocate on the federal level on behalf of members, patients and communities.
Your patients and your practice likely are facing their own issues. What can you do to make a difference?
Nominations now are open to state chapters for the AAFP's national commissions, and there is a commission to match any family physician's passion. Whether advocating for federal policy on payment reform, influencing the future of education or updating the AAFP's official clinical recommendations, we all can do more for our profession, patients and communities by being bold champions and active voices as members of one of seven AAFP commissions.
To be considered, your chapter must
provide the following:
- letter of nomination,
- typed commission nomination form,
- passport photo and
- completed online conflict-of-interest form.
If you are interested in participating in the Academy's decision-making process, contact your constituent chapter before the Oct. 15 nomination deadline. You can find more information about the process online.
In addition to 21 physician positions available on the commissions, the Academy also must fill four slots on its AMA delegation and select a nominee for the American Board of Family Medicine Board of Directors.
These are great opportunities to contribute to our specialty, share your perspective and make your voice heard.
Ravi Grivois-Shah, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.
Physician, NP Roles Still Not Interchangeable
The Wall Street Journal devoted an entire section of its print edition to six big issues related to health care.
The Journal posed questions, and then asked advocates on either side of the issues to weigh in. Thus, readers benefit from point-counter-point discussions on subjects such as circumcision, expanding residency programs, organic diets and pay-for-performance programs.
The Academy was invited to "square off" (that's The Journal's phrasing) with the American Association of Nurse Practitioners (AANP) on the subject of scope of practice. First, I would encourage all of us to be cautious with using such confrontational words when framing this important discussion.
This is not about turf, or better/worse, or good/bad. It is about teams, which also include physician assistants, who have not been a routine part of the scope of practice conversation. We must create and implement efficient physician-led teams to meet the triple aim of better patient outcomes, improving the health of our patients and lower costs.
This isn't the first time the AAFP and individuals representing nurse practitioner (NP) organizations were invited to the same debate.
Back in March, I discussed scope of practice on the "The Diane Rehm Show," the Washington-based radio program that is distributed by National Public Radio and SIRIUS satellite radio. I was joined by Ken Miller, Ph.D., R.N., C.F.N.P., associate dean at Catholic University School of Nursing; and Sandra Nattina, M.S.N., A.P.R.N., N.P., past president of the Nurse Practitioner Association of Maryland. I was disappointed that the tenor of that program was heavily weighted toward the NP perspective, and did not allow me to present the other side of this important issue.
That same month, AAFP Director Wanda Filer, M.D., participated in a Politico Pro policy forum that also featured Angela Golden, D.N.P., president of the AANP.
This week's Wall Street Journal health care report paired me with Golden, which means the Academy and NP organizations have now debated the topic in person, in print, online and on the air. Although the venues have changed, the debate has not. You can read Golden and my essays here.
But the short version is this:
- The AANP argues that about one-third of states already allow nurse practitioners to treat patients without physician oversight, so the other states should, too. This argument overlooks the fact that not all NPs are created equally. Unlike standardized physician training and licensing, requirements for NPs vary from state to state. Nurse practitioners' coursework and training ranges from 3,500 to 6,600 hours, and the actual clinical aspects of that education and training vary tremendously. Accreditation can come from one of three groups, each with different criteria.
- Primary care physicians complete 21,000 hours of standardized education and training, including passing exams that are overseen by one certification body. NP organizations often dismiss the disparity in the amount of training their members receive compared to physicians and suggest that the extensive rotations required by medical schools are "peripheral" to the care we deliver. The truth is that those rotations broaden our clinical experience and strengthen our diagnostic skills in ways no other group can claim.
- Nurse practitioners like to point to the primary care physician shortage and say they can fill that void. This overlooks a couple of key points. One is that our country also faces a shortage of nurses. Most important, though, is that access to care issues still exist in the states that already allow independent practice for NPs. This is a critical point as the push for independent practice is specifically being made an answer to the need for more primary care. The evidence shows it is not the answer.
There is no question that nurse practitioners, physician assistants and others are each vital parts of our health care team. But they are not physicians. Each member of the team provides needed skills, and brings their education, training and experience to bear. Although some tasks and services can be shared, the roles each of us play are not interchangeable. The medical expertise of primary care physicians must be a part of the team-based care patients need and deserve.
I welcome your thoughts below on this ongoing debate.
Reid Blackwelder, M.D., is President-elect of the AAFP.
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.
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