AAFP Board Chair Wanda Filer, M.D., M.B.A., of York, Pa., has visited dozens of state chapters during her six years on the Academy's Board of Directors, talking with family physicians all over the country about a wide range of issues. But one of the most frequent concerns voiced by members is the cost and time required for them to maintain their board certification status.
Alan David, M.D., of Brookfield, Wis., says during a Sept. 10 Town Hall meeting that although the maintenance of board certification process "needs to be cleaned up," family physicians shouldn't view the American Board of Family Medicine as the enemy. "They are our peers," he noted.
"It's the cause of a great deal of angst, anger and frustration," she said Sept. 10 at a packed Town Hall meeting held here before the opening of the Congress of Delegates (COD).
In fact, the American Board of Family Medicine's (ABFM's) Family Medicine Certification process, better known as maintenance of certification (MOC), was one of the top three issues raised by family physicians in the AAFP's annual member satisfaction survey. Academy leaders meet with their counterparts from the ABFM twice a year, and Filer said the AAFP Board shared members' concerns about MOC -- again -- during a July meeting.
Filer said MOC has become burdensome because it's no longer perceived as voluntary. When family medicine was recognized as a specialty in 1969, it was the first to require physicians to pass a certification test every seven years to maintain their status as diplomates of their specialty's examining board. But being a diplomate was not expected to be mandatory. Filer said for many employed physicians and those who participate in certain payer programs, it now is.
"It's something you must have," she said. "That was never the intent of board certification. It's being misused in a number of ways."
- AAFP officers fielded questions on multiple topics during a Town Hall meeting held before the opening of the Congress of Delegates in San Antonio.
- Maintenance of board certification and the Academy's advocacy efforts in Washington were among the topics discussed.
- Prior authorizations and other problematic administrative and regulatory issues also sparked discussion by participants.
Filer said ABFM representatives share some of the Academy's concerns and may eventually do away with the "high-stakes exam" that is currently part of the certification process.
"We encouraged them to do so more expediently," she said of the July meeting discussions.
In a Board report to the COD(4 page PDF), AAFP leaders outlined the steps being taken to address the issue, including forming a task force that will consider "additional AAFP policy, as recommended by the (Commission on Continuing Professional Development), regarding … considerations of alternative options to certification." The task force is expected to make recommendations to the Board by April.
Alan David, M.D., of Brookfield, Wis., acknowledged that "MOC needs to be cleaned up," but he also urged family physicians to remember that, "ABFM is not the enemy. They are our peers."
James Taylor, M.D., of Zachary, La., said it was important to fix MOC rather than simply ending it.
"It is what sets us apart from nonphysicians who want to practice in our place," he said.
Filer said the goals are to improve the system, ease the burden on physicians and make MOC what it was supposed to be: a self-regulating process.
"It's part of our identity," she said. "It's about our commitment to quality."
Advocacy With New Administration and Congress
AAFP officers covered a wide range of other issues and answered members' questions during the 90-minute Town Hall meeting.
Vivian Jiang, M.D., of Rochester, N.Y., asked whether the Academy had tweaked its advocacy efforts with the change of administrations in Washington.
"Our advocacy efforts are based on policy, not politics," AAFP President John Meigs, M.D., of Centreville, Ala., responded. "The players change, but our policies remain the same. We continue to advocate for health care for all."
Health care for all has been AAFP policy since 1989, and Meigs said that policy -- set by members through the COD -- was the basis for the Academy's support of efforts to improve the Patient Protection and Affordable Care Act (ACA) rather than repeal it.
"An ACA repeal would have resulted in tens of millions of Americans losing health care coverage," he said. "The replacement bills would have increased costs and decreased access. … The ACA isn't perfect. We never said it was. It needs to be fixed."
The fixes the AAFP supports include covering primary care visits without deductibles or copays, stabilizing the individual insurance market, curbing drug costs and reducing administrative burden.
The Academy has standing to speak credibly on these issues. A recent survey conducted by Ballast Research asked more than 14,000 elected officials, administration and congressional staff, and national thought leaders to evaluate organizations based on respect, consideration, influence and sharing.
AAFP President-elect Michael Munger, M.D., of Overland Park, Kan., said the researchers found that the Academy is one of the most bipartisan health care organizations.
"In D.C., we are seen as an organization that can work with anyone," he said. "We're keeping patients in focus."
Meigs, who made several trips to Washington during his year as president, said the AAFP's reputation on Capitol Hill hadn't "taken any hits for standing up to the powers that be and telling them what they need to do."
Munger said administrative burden also ranked as one of the top concerns voiced by members in the annual satisfaction survey. He said AAFP leaders meet with the nation's six largest payers regularly to discuss not only payment but issues such as performance metrics and administrative burden.
Daron Gersch, M.D., of Albany, Minn., said physicians should be judged on metrics that are based on outcomes rather than processes.
Academy CEO and EVP Douglas Henley, M.D., pointed out that the AAFP is a member of the Core Quality Measures Collaborative. That group, which includes CMS and America's Health Insurance Plans, created a set of core measures for primary care and the medical home that could be used by all payers.
Henley said it is still early in what will no doubt be a challenging process to make that argument.
Julie Anderson, M.D., of Saint Cloud, Minn., asks a question about scope of practice after relating that her private practice in Saint Cloud, Minn., had been sold to a larger health care system. Some of the practice's physicians departed, she said, and have since been replaced by nurse practitioners and physician assistants.
Wisconsin's David asked why the Academy can't simply organize its roughly 129,000 members and say no to problematic issues such as prior authorizations.
Meigs explained that such efforts would run afoul of antitrust laws.
"I love going to Kansas City to visit our Academy headquarters, but I have no desire to go to Leavenworth," he said, referring to the United States Penitentiary in Leavenworth, Kan.
James Gill, M.D., M.P.H., of Newark, Del., asked what the Academy is doing to address social determinants of health. Meigs said the Academy launched its Center for Diversity and Health Equity this spring, and that initiative is beginning to ramp up its efforts.
"We will be a dominant player in this area," Meigs pledged, "and you will be proud of your Academy."
Health System Reform
AAFP officers fielded multiple questions about health care reform and single-payer health care systems. Based on actions of the 2016 COD, the Board has prepared a report(37 page PDF) on that issue, as well.
Henley said the report contains background information that is intended to inform future boards and CODs about the "pros and cons of various options of single-payer systems."
Filer noted that through her chapter visits, she has ascertained that members are "all over the board" on the single-payer issue, and this week's COD will provide an opportunity for discussion.
Henley also sought to clear up apparent confusion about the Shared Principles of Primary Care recently developed by the Patient-Centered Primary Care Collaborative and Family Medicine for America's Health. Henley said the document is complementary, but not directly related, to the Joint Principles of the Patient-Centered Medical Home(3 page PDF) and is "not about who, but what."
With health care putting increased emphasis on primary care, Henley said there are those now claiming to offer primary care who do not.
"They aren't primary care," he said. "We are. This defines primary care, and we can use that to make that point to those who need to hear it."
Scope of Practice
Julie Anderson, M.D., said her private practice in Saint Cloud, Minn., had been sold to a larger health care system. In the aftermath, some of her partners retired and were replaced by nurse practitioners and physician assistants. In addition, remaining physicians had seen their scope of practice limited by the new employer.
Filer said physicians in such circumstances need to ask themselves, "'Is this the right place for me or not?' Family medicine is the No. 1 recruited job in medicine 11 years running. There are always places you can find a role."
She also said those willing to speak up about the issue could also seek help from their state chapters and make their voices heard through local media outlets.