The AAFP has emerged as a leading voice for primary care and family medicine during the past several years, staking out clear and unmistakable positions on health care reform, Medicare physician payment, the need for more family physicians and other issues that are essential for an effective health care system. New AAFP President Roland Goertz, M.D., M.B.A., of Waco, Texas, CEO and executive director of the Heart of Texas Community Health Center in Waco, addressed these and other issues during a recent interview with AAFP News Now.
AAFP President Roland Goertz, M.D., M.B.A., of Waco, Texas, says that during his year as AAFP president, he wants to concentrate on rebalancing the U.S. health care system more toward primary care and on ensuring members and others truly understand the patient-centered medical home model.
Q. What are the main concerns of AAFP members right now?
A. The main concern of members, particularly from what I have been able to learn going across the country to chapter meetings and meeting members at various other venues and conferences, is a significant frustration with the current health care system -- their position in it, their potential rewards in it and the frustration of what we are about. The family medicine model is not as valued by payers as it ought to be.
Q. And how will the AAFP change that?
A. Ultimately, members have to be involved in the political processes. We have progressively stepped up our political involvement during the past several years to make sure who we are is better understood. And to make sure that what we need and what we want and what we can do to help make a difference with patient care and patient care delivery are continually heard by those who can vote -- by those who can change the system. It can't be just what we do in Washington. The chapters have to be equally committed to what they do in their statehouses, and even members need to include advocacy for family physicians in their interactions with patients.
Q. What will the Academy's priorities be in the coming year?
A. Four primary strategic initiatives drive the priorities of the AAFP. Those are advocacy, practice enhancement, education and health of the public. They include advancing the message about the importance of family medicine in the redesign of our health care system. This reality is going to be a major focus -- trying to improve the rewards system for family physicians. We also are going to look very seriously at how we can help change the pipeline and interest more students in family medicine. That is going to be a very high priority.
Q. Looking back for a moment, how far, in terms of respect and recognition, has family medicine come during the past 10-15 years or even in the past five years?
A. I have had the fortune of being very close to the process. I wish the general AAFP member could feel some of the changes that I have witnessed firsthand. For example, when I first came on the AAFP Board four years ago, I would go to Washington or my own state house, and I would have to explain who I was, what I was and what we represented. I can tell you, it is very, very different today.
Today, when I go into these same places, they all know what family medicine is, and they all know what the patient-centered medical home is. They may not understand it as well as they are going to. But I don't have to say the same things to explain who we are, what we are and what we can do to change the system.
Q. What would you like to accomplish as AAFP president?
A. Two things: first, a more general thing, and then, a more specific thing. The general thing is related to a previous question, and that is furthering our influence and making a change in the health care system based on the primary care model -- rebalancing the system more toward what we are about and a little bit further away from just a predominantly sickness model.
The specific piece is helping our own members and those around us understand what the real patient-centered medical home, or PCMH, model is. The PCMH model is our own attempt to try and re-engineer a really advanced primary care model -- a very advanced family medicine model -- to do some of the things that we have been frustrated with in the past and have not been able to do. It is an attempt to make sure that the definition of the PCMH is understood better by members and others.
Q. How does the PCMH model dovetail with health care reform?
A. I view the patient-centered medical home as a very key piece and one of the only key pieces that was presented during the whole debate on health care reform that represented a significant delivery model change. Now, one could have said, "Why worry about the patient-centered medical home? Just talk about the family medicine model." But we had evidence from the Future of Family Medicine report and the national demonstration project that we needed to tweak our model a bit -- to bring it into this day and age and apply modern tools and techniques to it and to better address patients where they are.
That understanding led us to develop the PCMH and its attributes in collaboration with the American College of Physicians, the American Academy of Pediatrics and the American Osteopathic Association. It was a multiyear effort among organizations representing more than 300,000 physicians. It has had more of an impact along the way in what we are trying to do.
Q. Where do electronic health records, or EHRs, fit into all of this?
A. I view EHRs as one of the major building blocks that will change how we move from our traditional practices to an advanced primary care model or the patient-centered medical home. I have never said that EHRs change the core attributes of what we do -- continuity, comprehensiveness, the coordination of care -- that we do better than anybody. Those things are maintained with EHRs. They do not change our core values.
AAFP President Roland Goertz, M.D., M.B.A., executive director of the Heart of Texas Community Health Center in Waco, Texas, and Chase Thebault, M.D., a full-time family physician at the Elm Avenue Community Clinic in Waco, make good use of the community health center's state-of-the-art electronic health records system.
However, EHRs can add tools that allow us to do those things better. Computers do two things better than humans: They can add and subtract large numbers very quickly, and they don't really forget as long as you put the data in correctly. Those are significant things that can help us if we apply them in the right way to our practices to improve our efficiency and improve care.
Q. How should practices go about implementing EHRs?
A. The one-sentence answer is, "Carefully and deliberately." In my practice, we have used an EHR system for 14 years. We were very fortunate to get in on the very front end of this. We also were very fortunate to align with an EHR vendor who was willing to allow us to help make their system better and address the issues we wanted to accomplish with it.
The evolution of EHR systems has been toward better, more comprehensive products. We all have several good products from which to pick. When we make a decision about which EHR to put in place, it needs to be deliberately thought through, and it needs to be done with deliberate understanding that it is going to be a major change effort the entire practice has to be a part of.
Q. Why did the Academy feel it was imperative to come out strongly in support of health care reform?
A. Support of changes in the health delivery system or, specifically, the health reform effort, is rooted in some of the findings and major recommendations of the Future of Family Medicine report -- No. 1 being that we needed to go out and tell people who we are and how we could help change the system.
The No. 2 recommendation was that we needed to change ourselves a little bit by using all the tools available to us to improve patient care. And No. 3 was that we needed to have some system change if we really were going to be a sustaining part of the model. I think those things were a bit of a wake-up call for a number of leaders within the Academy.
If you look at the findings of the Future of Family Medicine report, I think it was imperative that we responded to the challenges it presented our specialty. As I said, one of the three major recommendations was that we needed to work for system change. We needed to work for better and different payment models. We needed to work for better physician positioning of family medicine in the delivery of health care and to include preventive and wellness care along with sickness care. To me, if we just change ourselves without changing the system, we are just going to be frustrated. So, we had to exert our best effort to get some changes made to the health care delivery system.
Q. What impact will the enactment of health care reform have on family physician practices?
A. It will have varying impact. For example, we have the largest group of physicians in nonurban and rural areas. They can choose not to let it change a lot of what they are doing. But they should understand the changes in the payment system that are the result of the reform effort. I think, and certainly hope, that the work we are doing to make sure the payment system supports the pieces of the patient-centered medical home that fee-for-service does not currently cover will help them stay in their locations and do their job.
If you are in a suburban or urban area, I think you are going to be affected because payment systems likely will move rather quickly toward implementing pieces of the reform legislation. What the Academy is trying to do is put together toolkits to allow our members to tap into resources and education that can allow them to make the important decisions they need to make as the pieces of the reform roll out.
Q. What would you say to AAFP members who do not support health care reform?
A. I would remind them of the position we would have been in if nothing happened at all. The AAFP Board and the various advisers to the Board are just like the members. We are members, and we do the same things that members do. The major difference is we are given incredible amounts of information about things that are happening. We are extensively involved in the AAFP's advocacy efforts and that has opened up the floodgates of information about what we can accomplish to help our members live better as family physicians and take care of patients better.
So for members who do not support reform, I would say, "Bear with us." We made a decision based on whether there was enough in the health care reform bill to support the changes we needed in the system to have us be a better and more important part of the system in the future. The decision was that there were enough elements in the bill that will help family physicians to merit our support.
Q. What is the AAFP doing to make sure that the interests of family physicians are represented in the health care reform law as it is implemented?
A. We have largely entered the regulatory phase in terms of health care reform. We are making sure that our voice is heard and making sure our positions are made clear, especially when there are forums for input into federal decisions. We are advocating that there is enough flexibility within the rules to make sure family medicine is part and parcel of the positive changes that need to happen within the health care system.
Q. As you know, physicians are again faced with a steep cut in Medicare payments because of the sustainable growth rate, or SGR, formula. What is the Academy's short-term and long-term strategy for addressing the SGR?
A. We want a fix that goes at least through the end of 2011, if not longer, and we want a positive differential for family medicine and primary care. One of the reasons that the Academy supported the original House health care reform bill was that it had a permanent fix for the SGR, which was the ultimate desire of the Academy and something almost all medicine wants.
We are going to be very, very sensitive to our members who have a large percentage of Medicare patients because if we ask them to take a 25 percent to 30 percent cut and 40 percent of a practice's patients are covered by Medicare, that is going to be very tough. So, we are going to fight very hard to make sure we get a reasonable adjustment that is positive for family medicine.
Q. What would you say to those physicians who are out there and who are faced with this Medicare cut?
A. The Academy has a toolkit that will give members an overview of their choices. That is something they may want to consider when determining whether they want to continue providing services under Medicare. It is ultimately a practice or personal physician decision whether to continue to participate in Medicare. But at least we can help physicians know what their options are. We are committed to providing as much education as we possibly can about these issues.
Q. As health care reform is implemented, it will bring more people into the health care system and that, in turn, will place a greater demand on primary care physicians and family physicians. How do we go about attracting more medical students into family medicine, and how do we go about retaining them?
A. This past year as the debate and rhetoric were positive about primary care and family medicine, we saw a 9 percent increase in U.S. medical graduates selecting family medicine. In real numbers, that is 101 new students selecting the specialty of family medicine. Although this is not an overwhelming number, a 9 percent increase is a 9 percent increase, and we haven't seen anything like that in quite some time.
Now, fortunately, we have a while to work on the changes because a lot of the implementation of the health care reform bill will be done over a fairly long period of time. I have an undying belief that students will see the good of family medicine.
Q. How can we get more members involved in FamMedPAC, the Academy's political action committee?
A. Around 1990, I had a view about political action committees or even political activity as a whole that said, "I don't really like it. It is trying to influence somebody by using money." Many members seem to feel that way, too, but I now think that is absolutely wrong.
We have a political system that has worked pretty well even though we have people who disagree within the system. To get good people elected, they must have money to run their campaigns. And FamMedPAC's purpose is to support the election of the right candidates. It is the Academy's objective to try to get the message of our policies across to whoever gets elected. We are not buying votes by supporting FamMedPAC. We are trying to get the right people elected.
I am very hopeful that when members start seeing the activity, the response to the activity and the results that are happening, they will be more positive about supporting FamMedPAC in a much more dynamic way.
Q. Is there anything else you would like to say to AAFP members as you begin your presidency?
A. We cannot forget the core attributes that made us choose to be family physicians. That is what we are talking about promoting. That is what we are talking about to politicians, to business people, to anyone who will listen. And they are listening to us more than ever before. It will take time and commitment. This is not going to be a one-year turnaround. It is not going to be a single legislative effort. We are doing everything we can to move it in the right direction. But it is going to take all of us working together.