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Tuesday Jul 15, 2014

Are Family Physicians an Answer to VA's Primary Care Crisis?

In the wake of an escalating scandal involving the Department of Veterans Affairs and the Veterans Health Administration, the AAFP was the first physician organization to make specific recommendations to President Obama and Congressional leaders about how they could facilitate the use of civilian family physicians to enhance access to primary care services for veterans.

Here's a look back at how the situation unfolded and a look ahead at the important work that remains to be done.

In April, news of a “secret” waiting list at an Arizona VA facility emerged in local media reports in that state, where hundreds of sick vets were forced to wait for care. Dozens died while waiting. In May, a Government Accountability Office (GAO) report(www.gao.gov) -- and subsequent media reports -- exposed the profound and systemic deficiencies in care delivery, access and management within the VA, especially regarding primary care and mental health services.

In a matter of days, the Secretary of Veterans Affairs and two senior officials had resigned or retired, and the public, media and Congressional outrage reached a fever pitch.

Staff in the AAFP Division of Government Relations took note of the GAO report and began developing policy options that would allow civilian family physicians to provide care to veterans. During the same time period, several AAFP members raised concerns about the situation during the annual summer meeting of the Academy's commissions

Through a series of conversations and policy discussions, AAFP leadership determined that we should communicate directly to President Obama and Congress on how America’s family physicians could assist in the short-term to alleviate backlogs in the VA system.

On June 3, the AAFP made specific recommendations to President Obama and Congressional leaders regarding the use of civilian family physicians to enhance veterans' access to primary care services. Those recommendations focused on four major areas:

  • permitting veterans to fill prescriptions from civilian physicians at VA pharmacies,
  • allowing civilian physicians to order diagnostic tests and therapy services inside the VA,
  • permitting for the referral of veterans by civilian physicians to specialist inside the VA, and
  • extending federal tort claims act protections to civilian physicians.

Our letter was received positively and led to ongoing communications between the White House and the AAFP.

Simultaneously, Congress moved quickly and developed legislation that would immediately expand access to care for veterans and implement systems changes to prevent similar failures from occurring in the future. The AAFP worked to communicate quickly with legislators of the House and Senate to advance our policy priorities and ensure their inclusion in the legislation.

A few weeks later, the AMA House of Delegates approved a resolution calling on the AMA and the full house of medicine to support policies similar to those advanced previously by the AAFP.

On June 10, the House approved legislation that would invest $50 billion per year during the next decade to improve access and quality within the VA system, including allowing veterans to access the services of civilian physicians. The Senate approved similar legislation a day later.

Given the rapid process, the AAFP determined that it would be advantageous to further define and articulate our policy priorities, which were submitted to the House-Senate Conference Committee June 23, a day before the committee began its work.

In addition to the policy recommendations in the Academy's letters dated June 3 and June 23, we believe that the VA is fertile ground for workforce development, including graduate medical education, and we are advancing these ideas aggressively. Specifically, we are calling on the conference committee to dedicate significant financial resources to the establishment of family medicine, internal medicine and psychiatry training programs inside the VA -- with or without an external academic partner. We believe that the VA has untapped capacity to train family physicians and, at the same time, expand access to primary care services. This is an idea that has support within the conference committee, and we are working hard not only to build support for the concept, but also to make the policy-political arguments for why they should invest money to create this new VA program.

The legislative process slowed significantly during the Fourth of July recess, but the AAFP’s efforts haven’t. The Academy's government relations staff continues to conduct meetings with the legislators and staff of the conference committee to advance the policies outlined in our written communications. We have made this work a priority, and we are pressing to ensure that our policy recommendations are included in the final VA reform legislation.

While nothing is certain in Washington, we are fairly confident that the conference committee will conclude its work, and both the House and Senate will approve a final bill, prior to the congressional recess. Although partisanship is high in this election year, lawmakers from both parties would like to avoid returning home in August and having to explain why this scandal happened in the first place and why they haven’t demonstrated leadership in correcting this national tragedy.

Wonk Hard

Merritt Hawkins has released its 2014 Review of Physicians and Advanced Practitioner Recruiting Incentives(www.merritthawkins.com), and for the eighth consecutive year family physicians were No. 1 on the list. The Merritt Hawkins report is illustrative of the rapid changes in our health care system and the dominant role primary care physicians are playing and will play in new delivery and payment models. Of the 3,158 searches conducted between April 1, 2013 and March 31, 2014, 23 percent were for a family physician. Internal medicine was second at 7 percent. Despite strong promotion from the media and policy-makers, nurse practitioners were the focal point of only 4 percent of searches, and physician assistants came in at 1 percent. A majority of searches, 59 percent, were for positions in communities with populations of less than 100,000 people -- just another demonstration of why graduate medical education needs to be diversified away from urban academic health centers.

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Stephanie Quinn, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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