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Wednesday Jan 09, 2019

Make Sure Policymakers Know We're Knights for Our Patients

It was a spring day in Washington, D.C., when the secretary of HHS walked into the conference room. I was serving on the National Advisory Committee on Rural Health and Human Services for the Health Resources and Services Administration (HRSA), a position the AAFP nominated me for. This was several years ago, it was my first meeting in D.C., and I was a long way from home and my rural practice in Alaska.

[white knight and chess pieces]

The secretary proceeded to tell us about a new program with 64 separate physician quality measures that HHS was considering. She was under the impression that these measures would be easy to use because electronic health records (EHR) vendors had assured her that was the case. This program, she said, would help increase family physician income, especially in rural communities.

I was horrified.

I was the only physician in the room and one of only three clinicians. I knew that although everyone in the room meant well, most had no idea that the robust EHR we had been promised was a myth, and a dangerous one at that.

"This won't work," I blurted out.

I advocated strongly for just one quality measure: Are you a family physician?

If yes, you get paid more.

Maybe, in a few years, after they had buy-in from family physicians who were getting paid more, HHS could add another quality measure.

I paced.

I shouted.

I used hand gestures.

I remember explaining that EHRs are not capable of delivering all the information HHS wanted. Big Data was a dream. Eventually, I realized that what was blindingly obvious to me -- that investing in family medicine without strings attached would pay for itself(www.ncbi.nlm.nih.gov) -- was not a viewpoint shared by anyone else at the table.

To this day, I regard this meeting as my greatest failure. This was a moment where I could have been more eloquent. If only I had had more time to develop partnerships and alliances within the committee. But this was a time when pay-for-performance was a juggernaut, EHR companies were expanding and consolidating, and the Patient Protection and Affordable Care Act had just been passed.

When I returned to Valdez, Alaska, my medical partner of 25 years, Kathy, gave me a British journal article titled "Knights, Knaves or Pawns? Human Behaviour and Social Policy"(eprints.lse.ac.uk) by Julian Le Grand, Ph.D. The gist of the article was that we physicians see ourselves as knights, altruistic in caring for our patients in a compassionate and competent manner. If policymakers also saw physicians as knights, then public policy would develop to promote altruism and minimize time away from patients.

There are other narratives out there, though. We are, at times, considered knaves who are out for our self-interests or pawns driven by reward-and-penalty systems. Most health care policy can be put into one of these latter categories. These narratives are so pervasive that we run the risk of having our opinions discounted.

I am convinced that family physicians are knights, and my duty as AAFP president is to convince policymakers of the same. However, I have had discussions with senators, representatives and other government officials in which that view was not shared.

This creates a quandary. As we push for administrative burden relief and a greater percentage of total health care dollars spent, family physicians run the risk of being branded as knaves. Alternatively, we could be seen as mere pawns.

After one of my practice partners died and another left, there was a time when it was only Kathy and I covering both the clinic and the ER in our isolated community of 4,000 people. Our practice is independent, but we had a contract to cover the ER 24/7. We were working extremely hard and getting little sleep.

When there are two physicians in a small community, it can be difficult to recruit a third. Once you have three, it is easy to get a fourth. Kathy and I were working so hard that we did not have time to recruit. Visiting physicians saw how hard we were working and left immediately. We hired locums, but they were expensive and often needed supervision. The payment we received for emergency services did not help because covering the ER negatively impacted the bottom line of our short-handed clinic.

I include this story in my knight-versus-knave tale because when I went to my hospital's board of directors and then to our city council to ask for help, I was told that we were being greedy and that we must be doing something to keep new physicians away. I realized that few people in our community had any idea of what we were going through -- certainly not the hospital administrator, hospital board or city council. My partner and I were killing ourselves because we cared so deeply for our community, yet asking for help created suspicion.

What worked then, and what works to this day, was to reframe our situation in terms of patient care. We needed more physicians. I was so sleep deprived that I fell asleep during cardiac exams. This resulted in poor patient care. When our narrative was about patients -- instead of about us -- we were able to get help with recruiting as well as better compensation for the ER work.

There are many competing interests in medicine. When I was on the HRSA advisory committee, I experienced first-hand the difficulties inherent in problem-solving with so many varying viewpoints. Family physicians are up against powerful interests that have vastly more resources than we do.

Nonetheless, we are effective in our advocacy. Our opinion is sought by both parties. Independent analysis consistently rates the AAFP as one of the most politically effective organizations, as well as the most bipartisan.

When we speak on behalf of our patients, our voice is amplified. When we speak on our own behalf, it is diminished.

We need to reduce administrative burden because it interferes with caring for our patients. Family physicians need to be paid more so that more students will choose our specialty and more will move to rural and underserved communities. If there are more family physicians, the health care system will be more cost-effective.(www.oregon.gov) There will be fewer hospitalizations and lower all-cause mortality.

The AAFP has been successful in many of its efforts. For those not fully versed in policymaking, it is important to remember that sometimes success can be measured in terms of what was prevented rather than what was created. For example, when the aforementioned quality measures were rolled out, there were only six, not the 64 originally proposed.

We also were successful in advocating for changes in the 2019 Medicare physician fee schedule, keeping provisions of the proposed rule that will reduce administrative burden while delaying or cutting provisions that would result in lower payments to family physicians.

The AAFP has worked closely with CMS to protect and promote small practices participating in the Merit-based Incentive Payment System (MIPS). We advanced a low-volume threshold that exempts small practices from MIPS provisions, but we also secured the implementation of a pathway for practices that could qualify as exempt under that low-volume threshold to voluntarily participate in the program.

CMS also followed the AAFP's recommendation to establish site-neutral payments that don't differentiate between services provided in a community-based doctor's office and those provided in a clinic designated as a hospital outpatient department.

Finally, the AAFP fought hard to ensure that the prescribing authority of physicians would not be subjected to arbitrary review by law enforcement agencies. The AAFP was able to defeat the "criminalization of prescribing" policy, instead focusing public policy on making sure physicians were able to provide care to all patients without fear of punishment.

There will be more changes to the health care system in the next several years. Last fall, the AAFP Congress of Delegates adopted Board Report G: Health Care for All: A Framework for Moving to a Primary Care-Based Health Care System in the United States. This policy document was revised after every state chapter had an opportunity to provide input, and we want to continue to hear your ideas of how we can better care for our patients.

I should say that I still want increased payment for the single quality measure I argued for in that HRSA meeting many years ago: Are you a family physician? What we do is difficult. We are knights. We care for our patients and our communities, sometimes sacrificing ourselves. Together we are more than 131,000 members strong, and when we speak on behalf of our patients, we are heard.

John Cullen, M.D., is president of the AAFP.

Posted at 10:31AM Jan 09, 2019 by John Cullen, M.D.

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