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Tuesday Sep 24, 2019

Steering Family Medicine Through Storm Toward Sunlight

When I took up the mantle of AAFP president last fall, I told you we were going through a storm that was brought about by many factors but that also presented many opportunities. My forecast still calls for stormy weather, but also points to a chance of sunshine. What I have found is that this storm affects not only family medicine but all of medicine and society, and we are in for a wild ride.

[John Cullen, M.D., and wife]

Here I am with my wife, Michelle, on Capitol Hill. On Sept. 11, I testified before the House Committee on Small Business about the toll administrative burdens such as prior authorization take on family physicians.

I still hold that the great promise of family medicine derives from our ability to see our patients across generations, our comprehensive approach and the cost-effectiveness of primary care. We know that an increase in the number of family physicians per capita results in an increase in life expectancy.(www.jwatch.org) We also know that health systems with greater investment in primary care have lower costs and better outcomes.(www.pcpcc.org)

At the same time, I recognize that there is pressure for increased specialization within family medicine. Other specialties are going through the same difficulty. I recall talking with a subspecialist physician about how his specialty was further fracturing into increasing subspecialization, leaving less common ground among his colleagues.

"Well, you know," he said, "you can't know everything."

"Speak for yourself," I replied, "I'm a family physician."

Priority No. 1: Administrative Burden

The AAFP's priorities this year included decreasing administrative burden, increasing payment for family physicians, boosting the number of medical students choosing family medicine and being leaders in addressing health equity.

To this end, I testified in May before the Senate Finance Committee regarding the need to reduce complexity and administrative burden in the Merit-based Incentive Payment System. More recently, I told the House Committee on Small Business that the prior authorization process is out of control. It is negatively impacting our ability to see patients and to get them the care they need. I gave the same message to leaders of the House and Senate when I lobbied with the Group of Six.(www.groupof6.org)

A 2017 study published in Annals of Family Medicine(www.annfammed.org) found that primary care physicians spend two hours completing administrative functions for every hour of direct patient care. During the Senate Finance Committee hearing in May, I testified that family physicians are concerned that MIPS has created a burdensome and extremely complex program that has increased practice costs and is contributing to physician burnout. Understanding the requirements and scoring for each MIPS performance category and reporting data to CMS is a complex task that detracts from our ability to focus on patients.

More than 60% of AAFP members listed administrative burden as their primary issue in our 2019 Member Satisfaction Survey. The Academy has created a task force focused on administrative burden reduction. When I testified in Congress, I tried to convey the deep anger and frustration that we feel and describe how it is harming patient care.


The Academy has notched a big win regarding payment. Specifically, the AAFP succeeded in having the office visit evaluation and management codes reevaluated through the AMA/Specialty Society Relative Value Scale Update Committee process, resulting in a recommended increase in relative value that CMS proposes to accept. If finalized, CMS' proposal will increase Medicare payment for family physicians by about 12% beginning in 2021.

Meanwhile, in a meeting with CMS, I actually asked for a twofold increase in the agency's primary care spend based on the decreased costs and improved outcomes associated with having more family physicians per capita.

Rural Health

I have been personally concerned with deteriorating medical conditions in rural America and with the concomitant increase in maternal and infant mortality. Practicing full-scope medicine in Valdez, Alaska, for more than two decades has given me a perspective on how a high level of care can be provided even in an isolated frontier community. My practice continues to deliver babies and perform cesarean sections. I have been on the road often this year talking about what full-scope family medicine can do to reduce the maternal and infant mortality crisis our country faces.

We've seen a significant loss in delivery of maternity care as well a loss of small critical-access hospitals serving rural communities. The United States has lost more than 100 rural hospitals(www.shepscenter.unc.edu) in the past decade, and more than 400 are now at risk of closing.(www.navigant.com)

One of the effects of this crisis has been a national increase in maternal and infant mortality. It is now more dangerous to deliver a baby in this country than it was 20 years ago. There are U.S. counties where the infant mortality rate is greater than in less developed countries. This is unconscionable.

Scope of Practice

At the same time, the scope of family medicine is being threatened. The AAFP has responded with an initiative to improve care in rural communities. These efforts dovetail well with other initiatives to promote family medicine. There is a commonality, especially between urban and rural underserved.

I have heard concerns about scope of practice from many members during the past year, especially with the ad campaigns being produced for nurse practitioners. On one hand, we have reasons for these concerns, especially with the numbers of nurse practitioner students enrolled. On the other hand, there will always be a place for physicians who practice to the full extent of their experience, training and demonstrated competence.

We cannot allow external forces to restrict our scope, forcing us into an ever-diminishing box until our entire value proposition is diminished. Rather, we need to blow the top and sides right off that box using burgeoning health care technology to do more in our offices while still maintaining a presence in the hospital. I firmly believe that new technologies such as artificial intelligence and applied genomics, not to mention point-of-care ultrasound and telemedicine, will benefit physicians with the deep generalist training of family medicine.

I have been clear with legislators and congressional staff in Washington, D.C., that telemedicine is a tool, not solution. It is no substitute for a well-trained family physician. Our communities need physicians to perform lifesaving procedures, deliver babies and handle the complications of pregnancy, and to be economic drivers not only for hospitals, but for our communities. Family physicians are ideal in this role.

The first time I used telemedicine in Valdez, I didn't realize our new system was hooked up and working. I was called in to the hospital at 2:30 a.m. for a patient who was getting worse. I was working with two nurses getting ready to intubate when a deep, gravelly voice said, "Looks like she's decompensating." I couldn't tell where the voice was coming from. At 2:30 in the morning everything is surreal, but this sounded like the voice of God.

Then the voice said, "Looks like you will need to intubate." I replied, "I know!"

Then I realized that although the screen was off in the patient's room, an intensivist was watching what we were doing remotely. The point is that he could not intubate that patient via telemedicine. He and my patient needed me to do that.


There is a keen need to increase the number of family medicine residency positions, especially in rural areas. Of particular importance is funding for teaching health centers, a program that has been successful as an alternative to traditional residency programs. We know that more than half of graduating family medicine residents stay and practice within 100 miles of where they train. That makes the teaching health center program vital to addressing underserved areas. Funding for the program is set to expire this month, and we are urging Congress to act. You can add your voice(www.votervoice.net) to this important cause, too.

Congress of Delegates

Our nation is facing several contentious and controversial issues. Given that family physicians practice in nearly every community in the country, we would expect the diverse viewpoints within our membership to mirror those of society at large and result in excellent debate this week at the Congress of Delegates in Philadelphia. We cannot shy away from controversy when important issues stand to affect many of our members and patients.

The Academy has taken on controversial issues in the past. What I have seen is that the COD makes policy about these topics years before society at large reaches consensus. One advantage we have as a specialty is that by inclination and training, we listen to each other. We solve problems. One example is same-sex marriage, which our members supported through the COD years before it became legal in all 50 states.

There are many contentious issues that we are dealing with today. My hope is that through the COD, we can deliberate and discuss our way to an understanding that the vast majority of us can tolerate, recognizing the impact that policy has on members and patients.

Unfortunately, we live in a time when outrage is easy, and there are groups that want to capitalize on our divisions. As family physicians, we must recognize our commonality. All of us ultimately feel the same way about our patients. We are family physicians, and that is the glue that binds us together and makes us strong.

It has been an amazing year. It has been an honor to serve you.

John Cullen, M.D., is the president of the AAFP. He will transition to the role of Board chair on Sept. 25.

Posted at 10:44AM Sep 24, 2019 by John Cullen, M.D.

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