to the editor: I agree with Dr. McGeeney’s comments that family medicine is indeed in a “dire situation” in the United States. However, surviving as a profession simply by trying to improve our practices via the TransforMED model is not going to work.

Today, the family physician is asked to do more and more while the payments from insurance companies and Medicare stagnate. Dr. McGeeney asserts that after 18 months the new model works “based on anecdotal and emerging qualitative data.”

Before I commit my small practice to the expense and difficulty of adopting this “new model,” I want to see hard numbers showing me that the effort will pay off in terms of a respectable profit-to-expense ratio. I am not convinced that this model will. I have long had the feeling that the TransforMED project is like a lovely dinner table set with fine china, silverware, crystal, fresh linens, and cut f lowers; but, if no one is bringing the groceries through the kitchen door, the main course is going to be sardines and crackers.

I agree with trying to improve service to our patients, but just as much of our efforts must be dedicated to fighting for respectable reimbursements. Medical insurance companies regularly post substantial profits, rewarding their chief executive officers handsomely, while throwing primary care doctors a bone and restricting patients’ access to services.

I heartily applaud the Academy’s stepped-up legislative initiatives over the past couple of years. Tough talk and clear action in our dealing with third-party payors is essential to our survival. Enlightening the public and our elected representatives about the cost effectiveness of primary care should help persuade insurers to loosen their grip on the purse strings.

The advent of retail clinics further complicates our prospects for economic survival. We must all hope that the future of family medicine is on the right side of economic history and that larger marketplace forces will support our continued existence. For our part, we need to do more to tip the balance of reimbursement in our favor, and not put all our eggs into one basket of services.

in reply: Dr. Havron and I agree that family medicine is in a “dire situation.” I also understand his skepticism about the Patient-Centered Medical Home. Dr. Havron’s analogy, that the Patient-Centered Medical Home model is like setting the dinner table, is a good one. Family physicians truly need to set the table in the best way possible if family medicine is going to survive. More importantly, we need to define how the table is set before it is defined for us.

In 2004, the Future of Family Medicine report concluded that if family medicine did not change it would cease to exist in 10 to 20 years. Dr. Havron correctly points out the challenges and decisions family physicians face at this critical time. These are challenging times without easy choices. It is clear that the health care spending pie is not going to get any larger. The only way family medicine will get a larger part of that pie is to redefine itself within the context of a U.S. health care system that places greater value on primary care. Dr. Havron applauded the American Academy of Family Physicians for their work in this advocacy arena and I wholeheartedly agree. The IBM corporation and other major corporations and payers have stated repeatedly that they are not interested in paying more for the same type and level of health care service.

No one is going to solve family medicine’s problem by “buying the groceries” for us or bringing new financial rewards to the table before family medicine practices transform into Patient-Centered Medical Homes to provide what major corporations and payers want to buy. The good news is that we have anecdotal and emerging data that the Patient-Centered Medical Home concept, along with paying attention to the business issues of running a family medicine practice, can improve the practice’s bottom line, allowing it to not only set a fine table but also to buy the groceries.

Time is short, and only family physicians are in a position to solve family medicine’s problems. No one will do it for us. The United States has the highest cost of health care in the developed world but some of the lowest quality of health care. Today, family medicine has the opportunity to be the solution and not a continuing part of the problem, but it will not be without risk and a lot of hard work.