Family physicians understand that it takes a lot of hard work to effect change, but hundreds of physicians once again relished that task during the AAFP's 2018 Congress of Delegates held here Oct. 8-10.
Minnesota alternate delegate Renee Crichlow, M.D., of Robbinsdale, speaks in support of a resolution on direct primary care during an Oct. 8 reference committee hearing at the 2018 AAFP Congress of Delegates. "We must try new approaches, and direct primary care is a transparent payment system; it's a relationship between the patient and the physician without a third-party payer," says Crichlow. Delegates adopted a substitute resolution that asks the AAFP to support tax relief for individuals who buy direct primary care services.
On Monday, family physicians took to microphones in five separate reference committees to make their viewpoints known. They spoke as chapter delegates or alternate delegates and sometimes on their own behalf.
The Reference Committee on Advocacy heard testimony on a variety of topics and on Tuesday, the committee's recommendations were presented to the full Congress. Most resolutions or substitute resolutions were adopted or referred to the AAFP Board of Directors for further discussion. The following is a snapshot of that committee's work.
Primary Care Spending Rate
Several chapters joined together to craft a resolution asking for an AAFP toolkit that would help physicians understand and determine the primary care spending rate -- defined as the proportion of all medical spending devoted to primary care -- in their states.
New Hampshire delegate Louis Kazal, M.D., of Lebanon, said, "This toolkit may be one of the most important ones ever assembled by the Academy if these changes sweep across our country. We need to get it right."
Allan Ramsay, M.D., an alternate delegate from Essex Junction, Vt., said physicians had heard many comments from AAFP leaders about the importance of increasing the primary care spending rate. "What we haven't heard from anyone is how difficult that process is," he added.
"The PC spend rate development depends on each state having an all-payer claims database; the spend rate is determined by a claims analysis," said Ramsay. Unfortunately, not all states have such a database.
Delaware delegate James Gill, M.D., M.P.H, of Newark, spoke in support of the resolution. "Our state introduced a bill to do this … but we're floundering. We need a tool from the AAFP to say, 'This is how you measure it.'"
The Congress adopted a substitute resolution that calls on the AAFP to update and expand an existing toolkit to
- include all payers,
- refine its legislative template and
- add guidelines on how to determine primary care spending rates.
A resolution introduced by the New York State AFP urged the AAFP to consider a single-payer national health system as a viable option and to educate family physicians about such a system.
- During the AAFP's 2018 Congress of Delegates, the Reference Committee on Advocacy considered a number of resolutions important to family physicians and their patients.
- Delegates adopted resolutions pertaining to the primary care spending rate, single payer options and funding for the National Guideline Clearinghouse.
- They also considered resolutions on other issues, including providing education about assistant physician licensure and removing the Risk Evaluation and Mitigation Strategies classification for mifepristone.
Wayne Strouse, M.D., of Penn Yan, N.Y., spoke in support of the resolution. "We should be leading this effort. If the AAFP builds it, our patients will come," he said.
Andrea DeSantis, D.O., of Charlotte, N.C., told the reference committee, "Meaning can turn on a word. For instance, the word 'coverage' oftentimes intimates insurance, but insurance doesn't always cover everything that needs to be provided for patients."
Daniel Neghassi, M.D., of New York, N.Y., also expressed concern for his patients. "Seeing people who can't access the care they need is really frustrating as a family doctor, and having insurance is not enough if people can't afford copays and deductibles," he said.
Neghassi argued that the current system is too complicated and wastes too much time. "Imagine if we could spend that time counseling patients and listening."
Warren Jones, M.D., of Ridgeland, Miss., an AAFP past president and a member of the Uniformed Services chapter, told the reference committee that he practiced in a single-payer system for a long long time. "One of the realities in our government and our country is that you'll be asked to do more with less until eventually you're asked to do everything with nothing," said Jones.
The Congress adopted a substitute resolution that asked that AAFP to make available -- for educational purposes and policy programming -- the data and conclusions contained in two reports from the AAFP Board of Directors: Board Report F to the 2017 Congress(37 page PDF) on a single-payer health care system and Board Report G to the 2018 Congress(622 KB PDF) on health care for all.
National Guideline Clearinghouse
The July defunding of the Agency for Healthcare Research and Quality's (AHRQ's) National Guideline Clearinghouse (NGC) website sparked resolutions from both the New York State and Connecticut chapters, which were grouped together for discussion.
Connecticut alternate delegate Kathleen Mueller, M.D., of Windsor, noted that the loss of the NGC as a point-of-care resource for family physicians was significant. "Now we don't have access to a clear and free resource for guidelines from all of our specialty colleagues; physician educators and authors in this country have also lost a huge resource," said Mueller.
Rupal Bhingradia, M.D., a new physician constituency delegate from Jersey City, N.J., described the clearinghouse as the "go-to resource to find comprehensive clinical guidelines" and said its existence was vital if practices were to continue to provide high-quality evidence-based medicine.
New York alternate delegate Mark Josefski, M.D., of Kingston, pointed out that AHRQ -- the federal agency that had overseen the NGC -- has been subject to a steady stream of budget cuts.
"It cost the federal government $2.1 million dollars to sustain the National Guideline Clearinghouse website," said Josefski. "This is not even a full drop in the bucket of the federal budget," he added.
Missouri AFP President Sarah Cole, D.O., of St. Louis, introduces a resolution that asks for outreach and education on the issue of assistant physicians -- a new licensure category in her state that includes certain medical school graduates. "Other state academies need to be aware of this trend so they can determine their stance or promulgate rule-making" if a similar situation arises in their states, she says.
Ultimately, the Congress adopted a substitute resolution that asked the AAFP to support the AHRQ through advocacy for more resources and to make funding support for the NGC website permanent.
Assistant Physician Licensure
The Missouri AFP introduced a resolution dealing with a novel category of medical licensure denoted as assistant physician. Chapter President Sarah Cole, D.O., of St. Louis, told the reference committee that her chapter was surprised at how quickly the new law was enacted after Missouri legislators pushed it through in 2014.
She described an assistant physician as "a medical school graduate who failed to match into or complete a residency, but who, under this license, may practice medicine under any fully licensed physician who agrees to collaborate with that graduate."
Cole added, "A student may be supervised by a collaborating physician who is up to 50 miles away," and only 10 percent of patient charts must be reviewed by the overseeing physician. State legislators around the country are eyeing the idea as a solution to physician shortage areas.
Michigan delegate Chris Bush, M.D., of Riverview, testified that he had "serious patient safety concerns" and called into question the quality of the assistant practitioners.
Janet Hurley, M.D., of Whitehouse, Texas, said it was her impression that the intent was for individuals to assist in rural underserved areas. "I would argue that is exactly where they should not be, because someone taking care of patients in a rural underserved area needs a breadth of training -- not just four years of medical school."
Mississippi delegate Katherine Patterson, M.D., of Indianola, concurred. "This is not where we need these people; they need to be closely monitored. I can't imagine walking out after I was conferred as doctor and saying, 'Oh, now I'm going to take care of rural Mississippi.'
"I'm 11 years into practice, after three years of residency and a year of OB fellowship, and the things I encounter scare me every day."
The Congress adopted a substitute resolution that directed the AAFP to create and deploy a chapter toolkit on assistant physician licensure within six months.
Mifepristone REMS Requirement
Two separate resolutions dealt with removing the risk evaluation and mitigation strategy (REMS) requirement for mifepristone.
California delegate Jeffrey Luther, M.D., of Long Beach, spoke in support of the resolutions. "Medical termination of pregnancy is a legal and safe procedure available in the United States," he said. "There are numerous less safe medications and procedures that do not have a REMS qualification."
Furthermore, Luther said, "REMS substantially increases administrative burden to physicians and practices who may wish to offer that service to their patients and imposes significant barriers to women who want to avail themselves of this choice."
Cadey Harrel, M.D., of Tucson, Ariz., a member constituency alternate delegate, noted that the United States has one of the highest maternal mortality rates in the world. "We know the mifepristone REMS classification is not founded in evidence. In fact, many OTC medications such as low-dose aspirin carry a greater risk of complication."
The risk of bleeding with aspirin is nearly three times that of mifepristone, said Harrel.
Patrick Connolly, M.D., from Portland, Maine, said he has been put in the position of offering his patients "second-best therapy" because mifepristone is not available.
Ultimately, the Congress adopted a substitute resolution that directs the AAFP to engage in efforts to overturn the REMS requirement for mifepristone.
The Congress adopted two additional resolutions that dealt with reproductive rights. The first directs the AAFP to advocate against any legislative efforts to criminalize self-induced abortion.
A second resolution adopted by the Congress asks the AAFP to oppose the use of nonscientific language -- such as "fetal personhood" -- in the domain of reproductive health in government policies and legislative initiatives.
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