• In The Trenches

    What Lies Ahead

    The following is a speech I had planned to give at the Annual Chapter Leader Forum and National Conference of Constituency Leaders in April before those events were canceled. It is a narrative that outlines the defining moments of my life that shaped my views and opinions on our nation's health care system. It also focuses on some themes that should drive our collective action. It was largely written in advance of the COVID-19 pandemic, but I would be remiss if I failed to mention the ongoing impacts of the pandemic on patients, communities and family physicians. The pandemic has forever altered our country and our health care system.

    Target hit in the middle by arrow. Business concept of success. Isolated on white background. 3D Rendering

    This speech is the final chapter of my contributions to this blog.

    I grew up in Enid, Okla., a rural community in the northwest corner of the state, a community largely defined by its once-booming oil industries and its economically stressed family farms. My father had come to Enid to practice medicine and serve a community. This is where my family medicine journey began.

    My father was the typical family physician of his era. He was a broad-scope family physician -- office, hospital, obstetrics, nursing homes, house calls, school physicals. This wasn't called "broad-scope family medicine" in the 1970s and '80s; it was simply family medicine.

    Most people in town knew my father. He was part of their extended family, a trusted advisor, someone who was often with them on the best and worst days of their lives. My father, like so many family physicians, saw everyone, regardless of their ability to pay. People were grateful, and they often paid in their own ways, within their means. The financial transaction was secondary to the human element of the trusting relationship between a patient and a physician.

    The health care system was different then, far less efficient, yet more personal. Medicare was entering its second decade, but payment and delivery systems remained largely undefined by modern standards. Relative values, risk-based models, accountable care organizations and value-based payments were years from even being concepts, much less reality. Still, in many ways, my father's practice set the foundation of my vision for our health care system -- and certainly my vision for primary care.

    Today, I find myself at the epicenter of national debates about health care payment and delivery and the health care system overall. My career has provided me opportunities to represent those on the front lines of care delivery in major health care debates during the past two decades. I have, in my own small way, helped shape the health care system for current and future generations of family physicians. Now I'm setting forth on a new journey, proud of what has been accomplished, yet deeply aware of the work that lies ahead. Eager to do big things but grounded in the realization that progress and reform often come in inches.

    When conversation turns to the future of family medicine, it is easy to slip comfortably into a familiar dialogue about what family medicine isn't, or what it used to be. We all are familiar with the phrase, "When I first entered practice …" The practice environment that existed in the eighth and ninth decades of the previous century is gone. I suggest that we accept this as fact and find the discipline to engage in a process that seeks to identify, define and implement policies that will make family medicine what it should be -- what we want it to be. I accept my share of responsibility for ensuring that the family medicine practice environment in the third, fourth and fifth decades of the 21st century is defined by family medicine -- by us.

    Together, we should seek to create a 21st century health care system that is foundational in primary care, freed from 20th century constructs, yet grounded in the trusting relationship between a patient and a physician that was the foundation of my father's practice. This, my friends, is our burning platform.

    There are hundreds of activities that need to be initiated and executed so we can achieve our goals, but I have narrowed my list to eight points of emphasis that we, the family of family medicine, should consider as we chart our future.

    First, we must accept that like family physicians, the practice of family medicine is not homogenous. However, we also must be mindful that the foundations of high-performing, patient-centered family medicine are replicable and scalable. Family medicine, in all its forms, is comprehensive, continuous, coordinated and connected. We, as a community, must embrace the fact that practice environments and practice structures will vary greatly, but the foundations of family medicine are the same. We should promote what makes our practices similar and look past what makes them different. Strong family medicine practices benefit each other. Furthermore, the AAFP must be a partner that is relevant in your life and your practice, providing you the appropriate resources at the appropriate time and advocating for you regardless of your practice type or location.

    Second, the AAFP must continue to fight for a health care system that is accessible and affordable for all. We must become louder advocates for a system that is inclusive and equitable. The latitude and longitude of where you were born or where you live should not determine your health or the quality of health care you can access. All people deserve health and health care. Family medicine must continue to fight for those individuals and communities that our health care system continues to ignore.

    Third, we must continue our efforts to increase the overall investment in primary care. The United States has a largely a top-down health care system in which the vast majority of spending is allocated for the least-used services. According to published research, primary care accounts for 7% of national health expenditures but more than 50% of all office visits -- approximately 500 million. Compare that to hospitals, which account for 33% of health care spending but only about 7% of patient visits. Each year, more than 190 million people -- roughly 60% of the population -- receive care from a family physician. Today, the most sought-after discipline of medicine is also one of the most underfunded and undercompensated. The value proposition of family medicine and primary care suggests and supports a different level of financial support, yet here we are. If we are truly entering the value era of health care, then it is time for us to forcefully display and articulate the value of family medicine. And it is time to disrupt the legacy programs that have spent the past 30 years suppressing investment in primary care. All of them.

    Fourth, we must eliminate the legacy practices that have led to the historical compensation bias against female family physicians. Approximately half of the family medicine workforce is female. However, in today's marketplace, female family physicians are compensated, on average, 22% less than their male colleagues in all settings and all geographies. This is unacceptable. The AAFP must stand up and speak out against this discrimination in compensation. As an organization, we should provide family physicians with information and resources to advocate for themselves, but we also must use our brand and our platform to call out this discrimination and demand that it be corrected.

    Fifth, the AAFP must stand up for science and medicine. We must demonstrate steadfast leadership in restoring the public's faith in the art and science of medicine. Our current "post-truth" society is dangerous and is endangering lives. It is important that family physicians remain trusted advisers to their patients and, irrespective of our individually held beliefs or views, that we extend scientific-based information to all patients, at all times.

    Sixth, it is time for family medicine to engage in a new effort to expand our scope of practice. The value of broad-scope, comprehensive primary care is well known, but its practice is fading. We must engage in academic, training and advocacy efforts to restore the broad-scope discipline of family medicine. To do this, we must embrace the digital revolution and rapidly work to incorporate 21st century technology into the practice of family medicine. Information and knowledge are becoming democratized through machine learning and artificial intelligence. Family medicine is without peer when it comes to comprehensiveness. As a matter of workforce policy, family physicians can and must provide a broader scope of services to each individual patient, thus reducing current levels of necessary workforce for some nonsurgical specialties.

    I recognize that this seventh objective remains controversial with some, but I am going to state clearly that fee-for-service, as a foundational financing model, is incapable of supporting the primary care system that patients deserve and our health care system needs. The whole construct of FFS, and especially the resource-based relative value system, has failed primary care. Primary care is comprehensive, continuous, holistic, portable and patient-centered. The RBRVS is, by design, the complete opposite. It is focused on units of care, units of time and sites of service. Our current financing system incentivizes fragmentation and duplication of services, treating patient care as a transaction versus a longitudinal relationship. It is time that we demand a more equitable and appropriate financing structure for primary care. Primary care is best supported by a financing structure that provides prospective, risk-adjusted payments for an attributed population of patients. When units of care and units of time no longer get measured, providing care to patients becomes the focal point. And, when providing care to patients is the focal point, family medicine wins.

    Finally, it is time for family physicians to unite and harness our collective voices through a single membership organization. Family physicians are distinguished by their resolute commitment to patients, health and their communities. All family physicians, regardless of which medical school or country they earned their degree in, are drawn together through a common bond that is the devotion to a professional calling and their love of family medicine. It is time for family physicians, irrespective of the degree they hold, to unite and focus our shared energies on the future of family medicine.

    The AAFP has a talented and dedicated staff. I look forward to working with them to deliver value to each of you, our members. I pledge that we, as a team, will promote family medicine tirelessly and work to create a health care system that allows family physicians to fulfill their calling by letting you focus your energy on patient care -- appropriately financed and free of unnecessary administrative functions. I promise to manage and operate an organization and team that is member-centric, strategically focused, operationally disciplined and a vocal advocate for each of you.

    I am humbled by the opportunity that has been afforded me, excited about the work that lies ahead, and deeply appreciative of those who have encouraged, loved and supported me during the past 50 years. I want to thank so many people because they deserve recognition for ignoring the young man who thought he could change the world alone and shaping him into a more complete person and a better leader, more prepared and more appreciative of the hard work that awaits.

    History is composed of moments in time that define a generation. I firmly believe that family medicine is staring its defining moment squarely in the eyes. Friends, there are two options before us: Define or be defined. As your EVP & CEO, I will never be content with family medicine being the subject of, or a contributor to, someone else's vision for American health care. I suggest to each of you that the opportunity to define the future of family medicine for the next generation of women and men who answer the calling to make family medicine their life's work is before us. We should not accept being the subject of a biography about family medicine. We, family medicine, should be the author -- defining, detailing and demonstrating what family medicine is and how it is the only true foundation of health care. We should not surrender the future of our discipline to policymakers, insurance companies, academics or think tanks. We, collectively, must define the future of family medicine. Our future.

    Shawn Martin is senior vice president of advocacy, practice advancement and policy.


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    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.