Advocating for payment reform which fairly compensates family physicians and assures the viability of our practices

Family physicians have recognized that we are underpaid for the services we provide for some time. The situation has only gotten worse over time. The disparity between payment for primary care services versus specialty and procedural services has widened. The resulting income gap between family physicians and sub-specialists has contributed to the declining medical student interest in family medicine over the past 10 years. The situation has reached a crisis with prompt and decisive action necessary to avert a disaster in the supply of family physicians in the future. We must demonstrate to future family physicians that our specialty is not just personally and professionally rewarding, but is also a financi ally viable career choice.

Government and private health payers have begun to recognize the inequitable payment gap but thus far have done little to address this problem. The first priority of the AAFP regarding this issue is to clearly articulate the magnitude of this crisis to those who pay for health care. We must continue the strategy of appealing not just to the health plans, but directly to employers and to patients. In coalition with patients and employers we will be more effective in efforts at payment reform.

Seeking increased payment for our services, with health care costs already extremely high and rising at an unsustainable pace, represents a serious political challenge. We must continue to educate the payers and the public regarding the cost effectiveness and improved quality of care provided by family physicians. This will enable us to make our case for increased payment as we provide cost savings in return.

Continued across the board small payment increases for all specialties will never address the payment disparity and will not provide sufficient payment increases to family physicians to assure our future. Seeking payment decreases from procedural specialists in order to increase payment to family physicians is unwise and politically perilous. Many of our own members have made their practices more financially viable by providing procedural services that are better compensated. This allows them to accept the poor margin on other services they provide. If we seek decreased payment for these procedures, we are harming our own members.

However, I do believe we should seek to have future payment increases for a significant period of time allocated only to primary care providers. We need to partner with ACP/ACIM and AAP to lobby for support for this strategy. It is in the best interests not just of the primary care specialties, but of our health care system and even the sub-specialties. Our health care system will fall into chaos without a strong primary care foundation. This primary care coalition should first seek support for this strategy within the house of medicine at the AMA. If we are unable to convince the AMA of the necessity of this strategy, we should not be deterred. With or without the support of the other primary care specialties, or the house of medicine as a whole, we must stress to both government and private payers the necessity to allocate any increase in payments for physician services exclusively to primary care. This strategy is fair, equitable, and in the best interests of us all.

Supporting health system reform which assures access for all to preventive services as well as basic care for acute and chronic illness

Few would question that our health care system is fundamentally broken. However, there is considerable debate as to what should be done to address the deficiencies of this system. Clearly, no one would purposely design a system as we have currently, but it is the unavoidable position from which any reform must begin. Despite the fact many of us would prefer to see rapid fundamental change, we must also accept the political reality that the reform process will be incremental.

As we address the issue of health care system reform, I believe we must first establish the fundamental principles on which the reforms will be based. These are principles on which I believe reform should be based:

• In a first world country such as the United States, basic health care services are a basic human right.
• The provision of this basic health care is a responsibility of government not different than public funding of basic education for all.
• The concept of insurance for basic health care is fundamentally flawed. The purpose of insurance is to spread the risk of a low probability/high expense event, where basic health care is needed by all.
• Employer based funding of health care is inequitable, ineffective, and a serious disadvantage to American companies competing globally.

In considering a single payer government health care system, many point to the deficiencies of such programs in other countries. Certainly none of those systems is perfect, but it is equally certain that they produce better measures of health status compared to the US. We spend more than twice as much per capita on health care as any other country, but lag far behind in measures of health status. I refuse to believe we cannot learn from the experiences of other countries to create a uniquely American system that is superior to any. Such a system must guarantee adequate payment for physician services.

Beginning with care for children, we should work towards tax funded basic health care for all. This care would include preventive care and evidence based care of chronic illness. We must also be willing to address that we do not have unlimited resources and engage in a public dialogue regarding what we as a society can afford to include in basic care, and what we cannot afford. Our current system of health plans can continue to offer secondary coverage to pay for care not covered under the basic health coverage.

Providing basic health care is not only a moral imperative, it is good public policy. The AAFP should further its efforts to be a leading voice in health system reform to achieve our vision: "The AAFP's vision is to transform health care to achieve optimal health for everyone."

Promoting the concept of the medical home including recognition of its importance and adequate supporting payment

For us family physicians it seems bizarre that the concept of the medical home is being discussed as a new and novel idea. We have been providing this service and practice model for many years. The problem is that patients, and most especially payers, have not recognized the importance and value of this service. Although it is frustrating that our provision of medical homes has not been recognized in the past, we must embrace the current discussion as being in the best interests of our patients, our practices, and our profession.

The patient-centered personal medical home has been demonstrated to provide better care more cost efficiently than uncoordinated subspecialty care. Although we have known this in our hearts and in our own experiences for years, there is now clear objective data to support this opinion. With this information in hand, we can advocate for health system reform that emphasizes the medical home and payment reform that adequately funds family physician practices to provide this service.

We all have slightly different ideas of what constitutes a patient centered personal medical home. In order to effectively advocate for this concept, we must be able to consistently define the features of this care model. Without a clear definition, we cannot expect private and public health care payers to provide payment for these services. We must work within the AAFP and with other primary care organizations to promote a consistent and understandable vision of the patient centered personal medical home. The "Joint Principles of the Patient-Centered Medical Home" released in February 2007 represents a solid consensus definition for this work.

We must seize this opportunity of the medical home being on the agenda of government and private payers. I will work to rally our members to embrace the Joint Principles definition and mobilize our grass-roots advocacy to make the patient-centered personal medical home a fully appreciated and funded reality.

Assisting our members in transitioning to the New Model

The New Model of Care is the result of the visionary work of the Future of Family Medicine Project, led by the AAFP. Much work has been already been done to lay the foundation for this transformation, but much more work remains to be done. The Academy must commit itself to seeing this process through to a successful conclusion.

Transition to the New Model represents a serious challenge for the practices of our members. Implementing electronic health records is expensive and involves learning new skills. Productivity is frequently decreased during implementation, adding to the financial stress. Building a complete healthcare team to deliver the complete basket of services is challenging, especially for small practices. Converting to open access scheduling represents a significant change for both the practice and their patients, and can involve a period of hard work and long hours.

The AAFP has already committed substantial resources to the study of how best to assist our practices in this transformation. TransforMed and the Center for Health Information Technology are great resources for our members. The information learned from these efforts will be essential in extending from the current pilot sites to all our practices. This will require a sustained commitment on behalf of the Academy to provide the necessary support and assistance to practices.

Throughout this process, we must work to assure that our strategy for implementing the New Model adequately considers the variation among our practices. From rural to inter-city, solo to large groups, we must be able to assist practices across this spectrum in successfully implementing the New Model.

The ultimate success in this transformation is critically dependent on health financing which support the costs of providing. The Academy must aggressively advocate with public and private payers for payment that recognizes and compensates the value of the New Model.

Cultivating a medical education system which nurtures interest in family medicine

Our American health care system needs more family physicians to achieve higher quality, patient centered, and more cost effective care. This process has appropriately been described as a "pipeline." The intake of the pipeline is prospective family physicians and the output is new family physicians serving where needed.

To achieve optimal success, I believe we must work to extend the intake for this pipeline. We must identify students as early as high school who have the aptitude and interest in family medicine. This is especially important in identifying those who may serve rural and underserved populations. Their interest must be nurtured through their college education with an effective pre-medical advising system. We must work to assure that students who are interested in family medicine are readily admitted to medical school. Furthermore, I believe the curriculum in our medical schools needs to provide a sequence of experiences for our students who are interested in family medicine that will not only maintain their interest, but will also provide the broad scope education that is necessary to become a successful family physician.

I also believe that we need to see more US medical school seniors entering family medicine residencies. Much of this will depend on medical schools admitting the right students, and then providing them with a curriculum that supports them throughout their educational pathway. Our Family Medicine residencies need to be exciting and dynamic learning experiences. Many of our residencies already fall within this category, but the AAFP and the state academies need to work hard to support their efforts. The education system for family physicians is truly the incubator for our future. If we do not support it, then we are risking the future of our specialty. Medical schools, especially those publicly funded, must be held accountable for the percentage of their graduates choosing Family Medicine and other primary care specialties.

We must address the impact of medical student debt on specialty choice. Tuition support, scholarships, and loan forgiveness programs need to be expanded. Family Medicine must be a financially viable specialty choice, appropriately recognized and compensated in our health care system. This is necessary to maintain the practice viability of us all.

So where can the AAFP and our members impact this pipeline? We interact with young people in the course of our practice and can promote Family Medicine as a career. Family physicians should seek the opportunity to serve on medical school admission committees and promote the admission of those interested in Family Medicine. Despite our frustration with current flawed and unfair payment for primary care, we must communicate our passion for our specialty and our optimism that the future will be better for Family Medicine. We have this opportunity in teaching and mentoring students and residents. And finally, we must work to make the vision of a health care system that appropriately values Family Medicine become a reality.

Establishing family physicians as the experts in ambulatory information technology including EHRs

Family physicians individually, and the AAFP as an organization, have been leaders in implementing Electronic Health Records (EHRs). Early adopters had the true pioneer spirit to endure the challenges of incompletely developed EHR applications. Their experiences have enabled those now implementing to avoid many of the pitfalls. But implementing an EHR remains a stressful and expensive endeavor.

The AAFP's Center for Health Information Technology (CHIT) has done wonderful work to collect and evaluate information about different EHRs and the experiences of those using them. The resulting resource can greatly assist a practice in evaluating, selecting, and implementing an EHR. I support the continued work of this essential AAFP resource.

EHRs are a cornerstone component of the New Model of care. We must expand upon our current efforts to assist our members in the EHR process. Community-wide EHR collaborations are one means by which EHRs can be made more affordable. The AAFP can be a resource for practices interested in this model.

A recent national AAFP survey, as well as my own survey of Washington family physicians, shows that as many as 30% of our members do not plan to implement an EHR. We cannot allow this large percentage of our members to be left behind as we move forward. These members are not likely to come to meetings to discuss the advantages and implementation of EHRs. We must commit to an outreach effort to convince them of the value of the New Model including EHRs, and then assist them in the transformation.

Implementing an EHR is expensive. I do not believe the small amount of grant money currently available will make even a small dent in what is necessary to fund this technology in our practices. It is also inherently unfair to provide grants to practices now implementing EHRs but not recognize the investment of those early adopters. I support a time-limited program where care delivered and documented in an EHR is paid an extra fee on a per-claim basis. With such a program, practices that have already invested in an EHR will recoup some of their investment, and practices implementing an EHR will have a guaranteed revenue stream to pay for their EHR. A payment of $1 to $2 per claim for a period of four to five years would greatly help speed EHR adoption. As a member of your Board I will advocate for such a program.

Implementation of electronic health records is challenging. One of our own members was quoted describing this process as "a walk to paradise over hot coals." From my experience, he understated the pain of this process. But rather than shy away from this difficulty, I believe we should embrace this challenge. Use of clinical IT is essential to better coordinate the comprehensive care of our patients. I believe we need to make utilization of clinical IT a core competency of our specialty. Family physicians are uniquely positioned to influence the refinement of clinical IT to best benefit the patients and communities we serve. We care for the full spectrum of health care from prenatal to end of life care. We provide care across the full spectrum of locations where care is delivered. The values of Family Medicine are critical to preserving the caring and compassionate aspects of patient care through this technologic revolution that has only just begun. For these reasons I recently completed a Master of Biomedical Informatics program, with emphasis on ambulatory clinical IT. My knowledge and experience in this area will be extremely valuable on the AAFP Board.

Continuing to promote the health of the public through programs such as Tar Wars and AIM

The health of the public must remain a high priority of the AAFP. I believe we must maintain AAFP support and funding for AIM (Americans In Motion) and Tar Wars. These two public health programs are ideal for furthering the AAFP's goal of improving the health of patients, families and communities. The public health approach to health is a proactive approach, identifying factors associated with health problems and intervening, countering tobacco advertising in the Tar Wars program and facilitating individual behavior change with AIM . Family Medicine is all about prevention and both of these programs do that. Stopping smoking is very hard for many individuals and Tar Wars focuses on eliminating that struggle, keeping kids from starting smoking. We are all seeing our patients live longer and struggle with the impact of chronic diseases such as diabetes, heart disease and arthritis. The AIM program works to lessen the incidence of these diseases and enhance patients' health and lives as they age. AAFP support for the AIM program provides the information for our members to become fit themselves and positively affect the fitness of their patients. For the Tar Wars program, the AAFP provides the teaching material and directions for the post er projects, and facilitates local, state and national recognition and rewards for the students participating. This AAFP investment enhances our members' ability to increase the health of all in their communities.

These are also opportunities for family physicians to be visible in the schools and the communities where they practice. Surveys have shown that many people do not understand or appreciate what Family Medicine brings to health care. Being a guest presenter in a classroom, working with teachers and schools to promote healthy behavior, and being out in the community personally exercising provides opportunity for our members to be known and spread the news about Family Medicine. These opportunities could go away without AAFP support.

An additional impact of these programs is the personal benefit for the family physicians participating. The current health care environment for family physicians is highly stressful with long hours, new technology, and challenging reimbursement issues. It is associated with low morale for many of our members. Every day we advocate for our patients to get healthy and stay healthy through healthy behavior. The best way to change behavior is to be an example of that behavior, e.g. becoming a fitness role model with the AIM program so our patients will be more likely to "do what we say and do." This also means better health of our members, less heart disease, diabetes, etc. Exercise also is highly effective in countering stress and we all can do with some "exercise highs" on a daily basis. Taking a break from the office, donating some time to the community and spending time with kids can also have a positive impact on how our members feel about themselves. "Physician, heal thyself" is often quoted to us and these two AAFP supported public health programs promote just that.

As an AAFP Board member I will work to maintain these programs so you can help increase the health of your patients, families, and communities.