AAFP Speaker John Meigs Jr., M.D., of Brent, Ala., seemed to be setting the tone for the entire 2014 Congress of Delegates (COD) here when he opened an Oct. 19 Town Hall meeting by saying, "It's going to be family medicine that turns the American health care non-system upside down as we look to deliver the triple aim of better health, higher quality and lower cost."
During an Oct. 19 Town Hall meeting that kicked off the 2014 Congress of Delegates, Eugene Newmier, D.O., of Cambridge, Md., makes a point about the difficulty of meeting quality measures -- and the financial implications of that -- when patients don't take responsibility for their own health.
Meigs' comment drew enthusiastic applause from members looking forward to a rousing discussion of key issues in family medicine. Speaking to a packed house, AAFP Board Chair Jeff Cain, M.D., of Denver, introduced the evening's first topic: graduate medical education (GME) reform.
Graduate Medical Education Reform
There's currently a major disconnect between what is and what is needed in today's health care workforce, Cain declared. Currently, about 32 percent of that workforce is in primary care, yet only 26 percent of the nation's medical training programs are in primary care.
The good news is that lots of students are currently interested in family medicine. "This year, there are 26,000 medical students who are (AAFP) members," Cain said. "That's one in four medical students in the United States who wants to be a family doctor."
The next step, of course, is converting that interest into a commitment to the specialty.
- During a Town Hall meeting at this year's Congress of Delegates, discussion turned to a recent AAFP policy proposal that offered suggestions to improve graduate medical education.
- Also noted was the Academy's ongoing advocacy for physician payment reform, including repeal and replacement of the sustainable growth rate.
- Finally, attendees got an overview of the Family Medicine for America's Health project to date, including the fact that its final outcomes will be revealed during the Assembly.
Mary Campagnolo, M.D., M.B.A, of Bordentown, N.J., asked how the Academy plans to engage students and show them the passion and empowerment that are the hallmarks of family medicine.
"We need to make certain we're attracting the right people, we're getting them in the right environments and we are getting them excited," Cain responded.
Accomplishing those goals will mean addressing some serious inequities in the nation's GME system, he noted. For example, 78 percent of GME dollars now are going to hospitals east of the Mississippi River -- where only about 56 percent of the U.S. population lives.
Last month, the Academy issued a set of policy proposals aimed at matching the primary care workforce to the country's growing health care needs. Those proposals are
- Limit payments for GME to first-certificate residency programs.
- Establish primary care thresholds and maintenance of effort requirements for all institutions currently receiving public GME financing.
- Require all sponsoring institutions and teaching hospitals seeking new GME-financed positions to meet primary care training thresholds.
- Reduce indirect medical education funding and allocate those resources to support innovative GME training programs.
- Fund a National Health Care Workforce Commission to oversee GME training and funds.
"My hope is that you hear that we are trying to be proactive and not reactive," Cain told attendees. "We want to be able to create the health care system and workforce that we need today."
Physician Payment Reform
AAFP President Reid Blackwelder, M.D., of Kingsport, Tenn., was next up with an overview of the Academy's ongoing advocacy regarding physician payment reform.
The elephant in the room is still, of course, the sustainable growth rate (SGR) formula used to calculate those payments. Yet there is cause for hope, Blackwelder noted, given that bipartisan, bicameral SGR legislation introduced earlier this year remains in play.
Hoping for a timeline, Angela Sparks, M.D., of Olympia, Wash., asks "How long is this change from fee-for-service to value-based payment going to take?"
"We do believe there is a chance for repeal and replacement," he said. "This is critical on a number of levels. ... Nothing else can happen until this is done. We feel confident that there is interest in having the bill move forward and we will do everything we can to get it reintroduced before the next cut in mid-March."
Regarding another important payment topic -- Medicaid parity -- Blackwelder said it is essential to continue advocating with lawmakers against Medicaid cuts set to take effect on Jan. 1. He suggested members use the AAFP's Speak Out grassroots campaign tool to tell their stories about how the enhanced Medicaid payment benefits patients.
Former AAFP Speaker Thomas Weida, M.D., of Hersey, Pa., explained that he went a step beyond the Speak Out tool, speaking directly with his legislator Rep. Joe Pitts, R-Pa., who introduced SGR fix legislation earlier this session.
Weida said Pitts told him support for SGR repeal is strong, but noted that the best chance of getting the bill through will be during the upcoming lame duck session. After that, he said, many of the lawmakers who support the legislation will have left the Congress.
"So those of you who have contact with representatives and senators should put tremendous pressure on them to act and not just 'speak out' but 'speak with' them as these congressmen campaign for your vote," Weida said to applause.
Shifting physician payment from strictly fee-for-service to paying for value was another topic Blackwelder addressed. "We are taking care of sicker and more complicated patients. We need to be paid for that," he said.
The AAFP is advocating for blended payment models and other ways to ensure family physicians get paid for the work they do -- all the work they do, said Blackwelder. To that end, chronic care management fees are a step in the right direction, he noted.
Randall Suzuka, M.D., Miliana, Hawaii, tells AAFP leaders that even though evidence-based medicine and quality measures have value, it's hard to gather sufficient statistical evidence in solo and small group practices.
Eugene Newmier, D.O., of Cambridge, Md., said he had concerns about payment being based on quality measures, however.
"We all have a patient with a body mass index of 18,000 (who) just won't do what we recommend," Newmier said. "These patients are going to cost us money. We are trained and our instinct is to take care of the sickest people who need us the most. Because if it isn't for us, nobody is going to take care of them."
Newmier said when there is a move away from a fee-for-service model, which allows physicians to be paid to spend more time with these patients, he is afraid physicians in private practice won't be able to afford to care for them any longer.
But that's not the patient's fault, Academy EVP and CEO Doug Henley, M.D., observed, and it's not the physician's fault. Rather, it's the system's fault. "The system payment model has to change to allow for that more integrated care so that the sickest of us can receive higher intensity care not just from family physicians, but also others in the system," Henley said.
One payment model, in particular, is showing great promise for primary care, Blackwelder noted: direct primary care. "This is another example of your Academy listening to members and taking some bold steps," he said. "Even though only 2 percent of our members are actively engaged in the direct primary care health care delivery and payment model, we still saw a trend."
In response, the AAFP has dedicated resources to swiftly move this concept forward, Blackwelder continued. "Now, 7 percent of our members are actively exploring this kind of a model," he said, "and 50 percent said in a recent survey that they would like more information on the topic.
"So it's an exciting and disruptive shift in how health care is provided and paid for."
Those resources include an education track dedicated to direct primary care at this year's Assembly, upcoming regional workshops on the topic, and an online toolkit designed to assess whether and how the model will work in a given practice. In addition, Blackwelder added, the new direct primary care member interest group, which will be meeting at Assembly, is the largest of these new groups.
Family Medicine for America's Health
President-elect Robert Wergin, M.D., of Milford, Neb., wrapped things up, playing his cards close to the vest when discussing the culmination of the Family Medicine for America's Health project that will be revealed during the first General Session of the Assembly.
The original Future of Family Medicine project, which launched a decade ago, created the momentum for the patient-centered medical home concept of care and the improvements in delivering and tracking care that model represents, Wergin explained. The AAFP and its seven sister organizations revisited the concept to examine the challenges and opportunities facing family medicine today and to define a path forward in the context of a rapidly changing health care landscape.
Wergin said he was excited about what will come of this initiative, into which the Academy and the other organizations have invested considerable time and resources.
"If we were playing Texas Hold'em, we're all in," he said. "In 30 years of practice, I can tell you truthfully, there has never been a better time to be a family physician than right now."
As for what's to come, Wergin put it this way: "(Family physicians) are nice guys. We've always sat quietly in the back of the room.
"But we're not going to sit back there anymore; we're moving to the front row."
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