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An Inside Look at Three Decades of AAFP Advocacy
Academy VP Reflects on Her 30-Plus Years Advocating Family Medicine's Issues
Now, after 13 years as director of the AAFP's Government Relations Division and nearly 20 years as vice president of practice advancement and advocacy, Sweeney is retiring. During her long career with the AAFP, she was instrumental in turning the AAFP into a major lobbying and legislative force on Capitol Hill and witnessed a lot of changes in how the Academy does advocacy along the way.
AAFP News Now recently sat down with Sweeney to discuss some of the changes that have affected family medicine and primary care during the past three decades, and how the AAFP and its members have driven and shaped many of those changes.
- During her 30-plus-year career with the AAFP, Rosi Sweeney, the AAFP's vice president of practice advancement and advocacy, has seen a lot of changes.
- As she prepares to retire from the Academy, Sweeney looks back on changes in family medicine and the AAFP's advocacy efforts during the past three decades.
- She believes that the future of family medicine is bright as primary care; family medicine; and federal, state and local governments respond to changes in the U.S. health care system.
A. Back then, the Academy was still describing itself as a new specialty because family medicine had become a specialty only 10 years before. Family medicine was very counter-culture compared to other medical specialties. It was very innovative, community-based and people-oriented and really didn't fit into most of the policies in health care -- whether it was for education, payment or research.
Q. How has the AAFP changed during the past 30 years?
A. The AAFP has grown tremendously in terms of the membership. We have grown to more than 100,000 members, which is truly significant. But I would like to talk about what has remained constant about the Academy because there are values that really matter.
The Academy, when I started, really valued what family medicine was doing for people. They valued family physicians in practice. They valued medical students and they valued residents. And those things are constant. I think that is really important. It has made the Academy successful and vibrant because they do value new ideas of medical students and residents. And we listen to our members. Those are constants.
The other constants are: What were the issues the Academy cared about? They really cared about the following issues: How do we have good family medicine education; how do we have a practice and payment environment that allows family physicians to practice and do what they need to do for their patients; how do we encourage a research establishment that is really oriented toward biotechnology to pay attention to primary care research?
Those conversations were going on when I came to the Academy, and those conversations are going on today. What are we lobbying about? Payment issues, the practice environment, making sure there is good evidence-based care and funding for family medicine education. These are sort of the pillars for the family medicine infrastructure, and they have been constant.
Q. What have been some of the changes?
A. There have been significant changes in family medicine and in the health care system. When I came to the Academy, family physicians typically practiced in very small practices. As the health care system has evolved, family physicians are practicing more in groups -- more than half of them are now employed. That has been a huge change.
The AAFP's Future of Family Medicine analysis looked at where family medicine is, what people need and what changes we need to make in the discipline. That really spurred … a dramatic effort to change, update and systematize primary care so that it is team-based and patient-oriented. That is expressed through the patient-centered medical home (PCMH), which is a significant change.
Q. What do you think the future of family medicine is?
A. I think the future of family medicine will place an even greater emphasis on patient-centered care and the patient-centered medical home. Family physicians will practice more as part of health care teams, which is a big change from the way physicians were taught to practice years ago.
Family physicians also will work in a very coordinated way with medical systems, as well as with the health care system and the social system. People need more than medicine to stay healthy and address their problems. Family physicians and the PCMH are central to making sure people get what they need.
Q. What does all of this mean for a solo family physician practice or a small physician practice?
A. I think that it means family physicians have relationships with their peers in medicine. They have relationships with other people in health care, whether they are psychologists or occupational therapists or pharmacists. They also should be aware of the resources in their community, so they can help their patients if they need help with exercise or nutrition, for example.
Family physicians in solo practice typically have good relationships with others in the community. It is all about relationships and working together in a team -- not just the team in the office but the team in the community.
Q. Some pundits say the era of the solo or small physician practice is over, and that particular model of practice cannot sustain itself. How would you respond to that?
A. I think it is really going to vary geographically because if you have a sparsely populated rural area, the economics are not going to support a large practice, for example. But you can have individual physicians practicing in different geographic areas, and they can have relationships with one another so they are not isolated. But I don't think there are going to be large physician groups locating in small rural communities. It is not economically feasible.
Q. How was family medicine perceived in the halls of Congress in 1979?
A. Family physicians were perceived as the doctors with the white hats. They were very much supported by people like Sen. Ted Kennedy, D-Mass., and Rep. Henry Waxman, D-Calif., each of whom chaired respective committees in the Senate and the House. Sen. Orrin Hatch, R-Utah, worked very closely with Ted Kennedy on addressing the payment disparities between cognitive and procedural services. They really understood the need for more primary care.
I think family physicians are still considered the physicians with the white hats. I think family physicians are still favorably perceived by congressional members and policymakers.
Q. From your perspective, what were some of the most difficult legislative issues faced by the AAFP during the past 30 years?
A. It was making sure there was funding for family medicine education. It was getting people's attention about the payment system. And the ongoing issue of the primary care physician workforce.
The most challenging issue is one we have not talked about yet. And that is the issue of health care for all that emerged in the 1980s when it became clear that more and more people in this country lacked health insurance. The Academy has had polices since 1980s supporting health care coverage for everyone. We used the term 'universal coverage.'
The Academy always has been in the thick of congressional debates or actions to expand health care coverage for all. This was dramatically demonstrated with the Clinton administration when the AAFP had a close working relationship with the White House in developing the Clinton administration's Health Security Act. Despite the stories that the Clinton administration did not consult with physicians, that is absolutely untrue. We frequently had family physicians at the White House.
Q. What role did the Academy play in the Patient Protection and Affordable Care Act that was enacted in early 2010?
A. The Academy has significant achievements throughout that legislation, not only in expanding health care coverage to people, but also things that are needed to shore up the primary care infrastructure. The primary care incentive payment is one example. The legislation also mentions primary care extensively. That is a direct result of the AAFP and family medicine.
Q. What is your response to our members who oppose the Affordable Care Act?
A. The AAFP since the 1980s has been committed to assuring health care coverage for all, and that can be achieved through different ways. We supported the legislation because it got more people covered, not perfectly, but it resulted in more people having coverage. And it made significant strides in addressing the issue of more primary care.
The Affordable Care Act is not a perfect piece of legislation by any means. But it did accomplish some things that were really important to the Academy and its members for both patients and family physicians.
Q. What would you say has been the AAFP's greatest accomplishment during the past 30 years?
A. I think the fact that primary care and family medicine are now being talked about in Congress, the administration and in the press -- The New York Times and the Wall Street Journal. The AAFP has made a strong case for the importance of primary care to the health of this country. The fact that primary care and family medicine are being written about and talked about and are widely recognized is directly attributable to the work of the Academy and our members.
Q. As you know, a lot of our members are very frustrated with the inability to eliminate the sustainable growth rate (SGR), which continually calls for steep reductions in Medicare physician payments. What would you say to our members about the SGR?
A. I would tell them to look at what Congress has been doing in all areas. It is not just about health care where they cannot agree. In my opinion, until Congress is less partisan and is focused on what is the right policy for the American people and not solely focused on politics, I don't think we are going to solve any problem.
Q. Is there anything you would like to say to AAFP members as you prepare to leave the Academy?
A. I would tell AAFP members to be really optimistic about their future. I am basing that optimism on the fact that there are pilots and things going on with health plans all over the country to value and increase primary care. There are employers who are engaging in this. The CMS Innovation Center established by the Center for Medicare and Medicaid Innovation is all about doing things to have more primary care in the health care system.
I think primary care is in a great spot. But again, it is really going to take stepping up to the plate and doing things differently to stay relevant and important and patient-centered. It really is a matter of "what does that patient need?" and "how can a practice provide it?" If the patient's needs are not being met, that patient will go somewhere else.