• In The Trenches

    Reflections on a Decade of Change

    Editor's Note: Due to the holidays, this will be the final In the Trenches blog post for 2019. The next entry will post on Tuesday, Jan. 7.

    White cubes with 2019-2020 change on a white table represents the new 2020 year, three-dimensional rendering, 3D illustration

    "Trying to run from the destruction, you know I didn't even care."
    -- Prince,

    Each year about this time, I like to spend a few weeks evaluating the past 12 months both as a process of reflection and to contemplate priorities and strategies for the upcoming year. This year, however, has been slightly different because not only is the year coming to an end, but so is the decade.

    As I shifted my frame of mind from one year to 10 years, I realized how impactful the past decade has been on health care and our health care system. Regardless of whether these changes will prove to be positive, negative or inconsequential, the decade produced massive shifts in health policy.

    Health care policy in the past decade was largely defined by two issues: the Patient Protection and Affordable Care Act and the opioid crisis. Sure, there were dozens of other health policies enacted during the past 10 years that have had consequential impacts on patients, physicians and the health care system, but the ACA and the opioid crisis are the two defining issues from a national perspective.

    When it comes to family medicine specifically, we saw a handful of substantial new policies that have altered the discipline and the practice of family medicine. The most impactful, without competitor, is the Health Information Technology for Economic and Clinical Health Act -- the HITECH Act -- which brought EHRs into physician offices and fundamentally changed the practice of medicine and the patient-physician relationship. The other policy that I think will prove to be most impactful on family medicine over the next 20 years is the creation of the Teaching Health Center Graduate Medical Education program.

    I would be remiss if I failed to mention the increase in partisanship associated with our health care debates. The past decade ushered in a new era of partisanship in health policy. Although health policy has always been subject to the political winds, the intensity of the political influences on health care policy has increased dramatically during the past 10 years.

    I will be interested in learning what you see as the top health policies of the past decade, but to start the conversation, I offer my top 10 health policy issues that I think defined the past decade for family medicine:

    1. Patient Protection and Affordable Care Act -- The ACA was enacted on March 23, 2010, and the decade will conclude with the fate of the ACA once again hanging in the balance because a lawsuit to repeal the law sits before the U.S. Court of Appeals for the Fifth Circuit in New Orleans. Without question, the ACA had a positive impact on expanding coverage to previously uninsured individuals. However, it also is true that the law did little to control health care costs. In fact, health insurance premiums and deductibles have increased at a steady pace since the enactment of the law. The cost conundrum, in my opinion, will define the next decade of health care policy.
    2. Opioid Crisis -- It is hard to truly quantify the impact of the opioid crisis, but the numbers are startling. According to the CDC, more than 500,000 people died from opioid overdoses in the past decade. The impact has been devastating. West Virginia, at the height of the crisis, experienced 57.8 overdose deaths per 100,000 people, and the national average rose to an astonishing 21.7 deaths per 100,000 people.
    3. HITECH Act -- The Health Information Technology for Economic and Clinical Health Act, enacted on Feb. 17, 2009, (just outside our 10-year window) has had a profound impact on the practice of medicine and the health care system. It is hard to imagine a 21st century health care system functioning on a paper-based system, but the transition to EHRs that was put in motion by the HITECH Act has not gone well. The EHR has become a staple of physicians' offices, but it also has become a primary source of frustration for family physicians. The EHR has changed the patient-physician relationship, and only time will tell whether these changes are positive or negative. I will say this: The performance of EHRs so far has been disastrous, and I am not sure they can ever overcome such a bad launch.
    4. Teaching Health Center Graduate Medical Education Program -- Originally enacted as part of the ACA, the THCGME program has grown into one of the most successful programs ever enacted. To date, the program has trained more than 880 primary care physicians and dentists. More importantly, it has created a proven pathway to train family physicians in community-based settings. It also doesn't hurt that the large number of community health centers around the country provide opportunities for rapid growth and expansion of the program in the future. As I noted in my opening, I think time will demonstrate that the THCGME program is one of the most impactful policies ever enacted.
    5. Medicaid Expansion -- Today, an estimated 75 million adults and children rely on the Medicaid program for their health care coverage, making it the largest health care program in the country. The Medicaid program has been a focal point of state-based health policy debates since the U.S. Supreme Court determined in June 2012 that the Medicaid expansion provisions of the ACA were optional. To date, according to the Kaiser Family Foundation, 36 states and the District of Columbia have expanded Medicaid. The decision whether or not to expand Medicaid has demonstrable consequences. The average uninsured rate in the 14 nonexpansion states is 11.14%, compared to 6.95% in expansion states. As of 2018, Texas has the highest uninsured rate, with 17.7% of the state's population younger than 65 currently uninsured. Massachusetts has the lowest uninsured rate at 2.8%.
    6. Sustainable Growth Rate -- The sustainable growth rate, established as part of the Balanced Budget Act of 1997, wreaked havoc on physician payments and health care policy for years. The SGR produced annual consternation in Washington, D.C., as Congress scrambled to prevent cuts in physician payments that would have, without question, resulted in reduced access to care for Medicare beneficiaries. The SGR also served as an albatross on delivery system and payment innovation. It is no coincidence that we saw an explosion of new delivery and payment models after the repeal of the SGR in 2015.
    7. MACRA -- The enactment of the Medicare Access and CHIP Reauthorization Act not only resulted in repeal of the SGR, it also brought to the forefront new delivery and payment concepts that are altering the physician practice landscape. MACRA created two payment pathways for physicians participating in the Medicare program: the Merit-Based Incentive Payment System and the advanced alternative payment model pathway. The MIPS program has, to date, failed to create the consolidated performance and quality improvement process promised, but the AAPM program has started to create new opportunities for family physicians.
    8. Alternative Payment Models -- The transition from volume-based to value-based payment models initially started with the ACA, but MACRA threw kerosene on the fledgling movement. The AAFP has been active in the development and advancement of APMs, working closely with the Center for Medicare and Medicaid Innovation on the Comprehensive Primary Care Initiative, Comprehensive Primary Care Plus and accountable care organization programs. In addition to our collaboration with CMMI, the AAFP developed the Advanced Primary Care Alternative Payment Model, which was recommended for testing by the Physician-Focused Payment Model Technical Advisory Committee in 2017. The APC-APM is the foundation for the new Primary Care First model that will launch in January.
    9. Direct Primary Care  -- The direct primary care model burst onto the scene early in the decade and has been growing at a respectable rate during the past few years. This remains an unsettled practice model, but the core elements of DPC are driving a meaningful conversation about what primary care is and what it should be in the future.
    10. Social Determinants of Health -- I have been pleased to see a national conversation around the simple fact that there are factors impacting the health and well-being of individuals that have nothing to do with clinical care. Housing security, food security, changes in the environment and countless other issues impact the health of the population. Now, I am not sure that the volume of activity around the social determinants of health will suddenly result in unicorns riding rainbows to a better health care system, but it is past time that we start to incorporate the social determinants of health into our health care delivery and payment systems.

    Looking Forward to 2020-2029

    As the old saying goes, "It is difficult to make predictions, particularly about the future." But I think there are some themes that will dominate health policy during the next 10 years.

    Health care policy in the coming decade likely will be defined by how we allocate/distribute health care services, as well as by accelerated efforts to control health care costs. As recently reported by the Kaiser Family Foundation, the cost of health insurance now exceeds $20,000 for a family of four. This is a problem, obviously. I am not sure how this plays out, but there is a health care bubble, and we all should be more than a little worried that this bubble will burst à la the housing bubble of the mid-2000s.

    The second item that I think will become prominent in the next decade is the transformation of our health care system from one in which the patient is expected to go to the source of care to a system where the source of care is more likely to go to the patient. Technology will facilitate this transformation, but I think the days of physician offices and health care sites establishing the hours of operation will change to reflect the mobile society we live in.

    I hope each of you has a great holiday season and a happy new year filled with personal and professional success. I remain humbled by the opportunity to represent family medicine and promote the great work you do for millions of people each day.


    The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.