Response to AAFP Board Candidate Forum
1. Do you concur with this information, these interpretations, values and views? If not, how do you differ?
Arnold Relman was right. It is interesting to read of the development of our current structure (evidence the excellent treatise by Niko Karvounis and Maggie Mahar on July 15, 2008 “The Managed Care Roller Coaster” http://www.healthbeatblog.org/2008/07/the-managed-car.html which described the evolution of managed care from Ellwood to current chaos. ) The Ellwood HMO model envisioned a long term continuity relationship funded by a monthly retainer with emphasis on preservation of health, prevention of illness and appropriate utilization of other levels of health care. Karvounis and Mahar then go on to describe the “profit-ization” and the “for profit” evolution of these plans with profit replacing care to maximize shareholder dividends rather than reward quality practices.
It has been shown that primary care adds value and quality from Starfield B, Shi L, Macinko J. (Contribution of Primary Care to Health Systems and Health -- Milbank Q 2005;83(3):457-502) to the recently released "Disparities in Health and Health Care Among Medicare Beneficiaries" conducted by the Dartmouth Atlas Project. and funded by the Robert Wood Johnson Foundation. While the former study proves the value of a primary care based health care system, the latter study acknowledged the benefits of using primary care physicians to manage chronic conditions and coordinate high-quality health care. "For conditions such as diabetes and hypertension, primary care physicians have been shown to provide care that is similar to (sub) specialty care in quality and lower in cost," the report said. "Adequate access to primary care can improve care coordination and reduce the frequency of avoidable hospitalizations." The report also said "studies have found that regions with a greater proportion of care provided by primary care physicians have both lower costs and higher quality." Family Medicine works. You are good – you are valuable – you deserve respect – Be proud to be a Family Medicine specialist – What better way to spend your life?
Business and, we hope, government are starting to recognize these facts. An article in the Washington Post http://www.washingtonpost.com/wp-dyn/content/article/2008/06/16/AR2008061602471.html?nav=emailpage outlines the think tanks developing health care plans for change - many with a new found old idea of the primacy of family medicine.
In his book, The Social Transformation of American Medicine (Basic Books; Reprint edition 15 May 1984), Paul Starr’s first line was “The dream of reason did not take power into account.” Later he wrote “But medicine is also , unmistakably, a world of power where some are more likely to receive the rewards of reason than are others.” I have always said that I do not fear government medicine which must, by its political nature, have some responsiveness to those from whom it derives its power. I do fear corporate medicine without ethics or values other than profit and dividend maximization. Relman was right. We have been drawn into the same episodic fee payment system that characterizes the partialists.
We need to support and lobby for ongoing payments that will mirror the values of our specialty – those values like caring, comprehensive, consistent, complete, collaborative, cooperating, competent. The value of family medicine cries for changes in our system - changes that reward comprehensiveness as well a complexity - changes that recognize the family medicine specialists as the true physicians that treat a number of problems in the same time and with better efficiency than one problem specialists - changes that reimburse the family medicine specialist for the coordination, documentation and implementation of comprehensive and continuing plans of management for patients with acute and chronic needs. Maybe Relman wasn’t the only one who was right – Ellwood is looking pretty good now. The recent advances at RUC (not yet finalized) as CMS gets RUC recommendations for Medical Home payment model (see http://modernhealthcare.com/apps/pbcs.dll/article?AID=/20080409/REG/751443597&SearchID=73317054443061 ) Further details of RUC medical home can be found in AMA news. http://www.ama-assn.org/ama/pub/category/18528.html.
2. What should AAFP begin to do differently in these matters? To what goal? Over what time frame? Who will be our partners in this reform?
The reality is that Primary Care emphasis and thus our future relies on Payment Reform http://www.aafp.org/online/en/home/publications/news/news-now/professional-issues/20080227gaoreport.html . This must be done on a national level for federal health programs – Medicare, Tri-Care, and DOD and to a significant extent Medicaid. As I said before, to quote James Carville – “It’s the economy, stupid” (I’m not talking about you, Earl.) We need an Academy that advocates for the value of Family Medicine. We need an Academy that demands a seat at the table in the restructuring of American Health and Illness System. We need an Academy that aggressively pursues change or abolition of an outdated limited practice specialty biased coding and compensation system. We need an Academy that uses the Private Sector Advocacy to promote the keystone specialty that we are back to its primary location. We need an Academy that challenges our academic colleagues to continue to develop new knowledge in our specialty and to teach our students and residents cutting edge medicine expanding the skills they bring to their patients. We need an Academy that fights for a level playing field in contract negotiations so doctors and MCO's are on an equal footing in contract negotiations.
We have begun - steps have been taken by Academy leadership but the journey will be long and the effort intense - the battles will be tough and the losses frustrating - but we need to succeed - for the patients who rely on us over the course of their lives and the families who need us to help them when they need help, guide them when they are unsure and congratulate them when they are successful.
We need to join the upcoming change as a unified body - we need to go forward and be proactive - we need to go back home and bring our brothers and sisters out to join us in a stronger more visible force. We need to support the Board, the PAC, our trainees and our local, state and national political systems as they work through the change.
The American Academy of Family Physicians is the last great shining hope for American patients. They have been deserted by their specialists who are intent on generating new codes and churning the system. They have been deserted by their community hospitals that have become big businesses. They have been deserted by the pharmaceutical industry that requires the American patient to fund discounts provided to other countries and to fund the cost of a bloated sales program. They have been deserted by their government which promised them coverage and which is now trying to dump the bloated entitlement system it created back on American industry. This is the best opportunity ever to advocate for patients. We cannot and will not desert them. The AAFP is the strong medicine that this dysfunctional system needs.
Remember the words of John Kennedy “ Efforts and courage are not enough without purpose and direction.”
Led by the AAFP, we will fight for control of the coding system that discriminates against the value of the specialty of Family Medicine. Led by the AAFP, we will form stronger allegiances with our colleagues in General Pediatrics and those left in General Internal Medicine and with our friends in American industry to advocate for a balanced system where prevention and early intervention save money and lives. Led by the AAFP, we will turn inward to improve our specialty and enhance our skills – skills at wiser prescribing, skills at wiser referrals, skills at wiser contract negotiations and skills at developing new means of meeting the needs of our patients in the 21st century – and getting paid for them. Led by the AAFP we will develop systems where knowledge is discovered, validated as evidence based and disseminated to our family medicine specialists in record time. Led by the AAFP we will demand quality of ourselves so we can demand it of the system.
Evidence the challenge put forth by Pope John XXIII “ Consult not your fears but your hopes and your dreams. Think not about your frustrations, but about your unfulfilled potential. Concern yourself not with what you tried and failed in, but with what it is still possible for you to do. “
3. If you are elected, what will be your role?
My intention is to bring to the board experience in rural medicine, academic medicine, solo private practice, organizational skills of putting a 30 physician group together and keeping it alive when the partialists left, organizational skills putting together a physician, hospital and business collaborative, participation in the Academy at a state (two states in fact) and national level. I have significant experience in negotiation. My role will be as a team player with the other 90,000 + Family Medicine specialists who want the same thing – better patient care and greater personal satisfaction. If we don’t believe in that to which we have devoted out professional lives then where is the value of our time spent on this earth. I know the value of Family Medicine – I am ready to work to change this system to benefit our patients – I am ready to do the heavy lifting, to challenge the myths, to make things uncomfortable as we expose myths and complacency to the light of reality.
The greater danger for most of us lies not in setting our aim too high and falling short; but in setting our aim too low, and achieving our mark.
Michelangelo
4. a. Equally important, what should state chapters’ leaders be doing?
Since so much of our movement is now economic and, since most insurance is regulated at the level of the several states, it is incumbent for the state chapter leaders to take very active roles. These roles involve legislative activities to correct the more grievous components of the insurance industry. It is incumbent for state leaders to lead by example, seeking out issues from members, formulating legislation and then pursuing its successful passage for the benefit of our patients. Each state president/board chair/legislative chair needs to get on a first name basis with their insurance commissioner. Finally, state leadership must organize the ability (PAC’s) to provide financial support to those who are friends of Family Medicine to insure that the needs of the patients are expressed at the state capital. We have many challenges ahead of us. Scope of practice is about to heat up again as evidenced by the Wall Street Journal on the Doctor Nurse programs (http://www.marketwatch.com/news/story/making-room-dr-nurse/story.aspx?guid=%7B2425D486-50B5-4594-86D6-C3A1BC84D6EB%7D&dist=TNMostMailed ) and tort reform. If you thought that tort reform was done, look again. We need to organize now for strong and vigorous alliances with business to strategize for the rationalization and reform of the legal system.
These are not dark days: these are great days - the greatest days our country has ever lived.
Winston Churchill
4. b. Equally important, what should individual members like me be doing?
These above thoughts above are well and good - but remember, the Academy is us. Waiting for the AAFP to win the day means you are waiting on yourself - so it is time to act. Depend on others to do your talking for you and you will get their solutions. Don't depend on our "brother" specialists to speak out for us. They haven't before - they won't now - until their position is comfortable and then it will be too late for us. They may actually fight our solutions while benefiting from our victories.
This is the year when we elect a President, 1/3 of the senate, all the house. Next year - nothing. Now is the time - we need to get change for our patients' sake - now is not the time to settle for a paltry 1 % that bites deeper into our ability to survive. Get to the candidates - ask the tough questions - donate to those who understand and will work to meaningful solutions (GET RID OF SGR, etc.) - work to defeat those with lousy track records. Now is the time - if we complain and moan and don’t get active, we have no one to blame but ourselves. Congress is available and responsive now - they will be in their home communities- - find out their phone numbers and call them. Get active in the Academy. Get your colleagues to join and get active also. If you read one thing, read the Verden Report on Cost vs Profit in Managed Care today http://www.osma.org/files/public/CostvsProfit.in.Managed.Care.Today.pdf
This is no time for ease and comfort. It is time to dare and endure.
Winston Churchill
Earl, thanks for the opportunity to respond to your positions. The sign of a true teacher is that he/she teaches as he/she questions and probes. You have done that. I am pleased to have you as a colleague Family Medicine Specialist.
Arnold Relman was right. It is interesting to read of the development of our current structure (evidence the excellent treatise by Niko Karvounis and Maggie Mahar on July 15, 2008 “The Managed Care Roller Coaster” http://www.healthbeatblog.org/2008/07/the-managed-car.html which described the evolution of managed care from Ellwood to current chaos. ) The Ellwood HMO model envisioned a long term continuity relationship funded by a monthly retainer with emphasis on preservation of health, prevention of illness and appropriate utilization of other levels of health care. Karvounis and Mahar then go on to describe the “profit-ization” and the “for profit” evolution of these plans with profit replacing care to maximize shareholder dividends rather than reward quality practices.
It has been shown that primary care adds value and quality from Starfield B, Shi L, Macinko J. (Contribution of Primary Care to Health Systems and Health -- Milbank Q 2005;83(3):457-502) to the recently released "Disparities in Health and Health Care Among Medicare Beneficiaries" conducted by the Dartmouth Atlas Project. and funded by the Robert Wood Johnson Foundation. While the former study proves the value of a primary care based health care system, the latter study acknowledged the benefits of using primary care physicians to manage chronic conditions and coordinate high-quality health care. "For conditions such as diabetes and hypertension, primary care physicians have been shown to provide care that is similar to (sub) specialty care in quality and lower in cost," the report said. "Adequate access to primary care can improve care coordination and reduce the frequency of avoidable hospitalizations." The report also said "studies have found that regions with a greater proportion of care provided by primary care physicians have both lower costs and higher quality." Family Medicine works. You are good – you are valuable – you deserve respect – Be proud to be a Family Medicine specialist – What better way to spend your life?
Business and, we hope, government are starting to recognize these facts. An article in the Washington Post http://www.washingtonpost.com/wp-dyn/content/article/2008/06/16/AR2008061602471.html?nav=emailpage outlines the think tanks developing health care plans for change - many with a new found old idea of the primacy of family medicine.
In his book, The Social Transformation of American Medicine (Basic Books; Reprint edition 15 May 1984), Paul Starr’s first line was “The dream of reason did not take power into account.” Later he wrote “But medicine is also , unmistakably, a world of power where some are more likely to receive the rewards of reason than are others.” I have always said that I do not fear government medicine which must, by its political nature, have some responsiveness to those from whom it derives its power. I do fear corporate medicine without ethics or values other than profit and dividend maximization. Relman was right. We have been drawn into the same episodic fee payment system that characterizes the partialists.
We need to support and lobby for ongoing payments that will mirror the values of our specialty – those values like caring, comprehensive, consistent, complete, collaborative, cooperating, competent. The value of family medicine cries for changes in our system - changes that reward comprehensiveness as well a complexity - changes that recognize the family medicine specialists as the true physicians that treat a number of problems in the same time and with better efficiency than one problem specialists - changes that reimburse the family medicine specialist for the coordination, documentation and implementation of comprehensive and continuing plans of management for patients with acute and chronic needs. Maybe Relman wasn’t the only one who was right – Ellwood is looking pretty good now. The recent advances at RUC (not yet finalized) as CMS gets RUC recommendations for Medical Home payment model (see http://modernhealthcare.com/apps/pbcs.dll/article?AID=/20080409/REG/751443597&SearchID=73317054443061 ) Further details of RUC medical home can be found in AMA news. http://www.ama-assn.org/ama/pub/category/18528.html.
2. What should AAFP begin to do differently in these matters? To what goal? Over what time frame? Who will be our partners in this reform?
The reality is that Primary Care emphasis and thus our future relies on Payment Reform http://www.aafp.org/online/en/home/publications/news/news-now/professional-issues/20080227gaoreport.html . This must be done on a national level for federal health programs – Medicare, Tri-Care, and DOD and to a significant extent Medicaid. As I said before, to quote James Carville – “It’s the economy, stupid” (I’m not talking about you, Earl.) We need an Academy that advocates for the value of Family Medicine. We need an Academy that demands a seat at the table in the restructuring of American Health and Illness System. We need an Academy that aggressively pursues change or abolition of an outdated limited practice specialty biased coding and compensation system. We need an Academy that uses the Private Sector Advocacy to promote the keystone specialty that we are back to its primary location. We need an Academy that challenges our academic colleagues to continue to develop new knowledge in our specialty and to teach our students and residents cutting edge medicine expanding the skills they bring to their patients. We need an Academy that fights for a level playing field in contract negotiations so doctors and MCO's are on an equal footing in contract negotiations.
We have begun - steps have been taken by Academy leadership but the journey will be long and the effort intense - the battles will be tough and the losses frustrating - but we need to succeed - for the patients who rely on us over the course of their lives and the families who need us to help them when they need help, guide them when they are unsure and congratulate them when they are successful.
We need to join the upcoming change as a unified body - we need to go forward and be proactive - we need to go back home and bring our brothers and sisters out to join us in a stronger more visible force. We need to support the Board, the PAC, our trainees and our local, state and national political systems as they work through the change.
The American Academy of Family Physicians is the last great shining hope for American patients. They have been deserted by their specialists who are intent on generating new codes and churning the system. They have been deserted by their community hospitals that have become big businesses. They have been deserted by the pharmaceutical industry that requires the American patient to fund discounts provided to other countries and to fund the cost of a bloated sales program. They have been deserted by their government which promised them coverage and which is now trying to dump the bloated entitlement system it created back on American industry. This is the best opportunity ever to advocate for patients. We cannot and will not desert them. The AAFP is the strong medicine that this dysfunctional system needs.
Remember the words of John Kennedy “ Efforts and courage are not enough without purpose and direction.”
Led by the AAFP, we will fight for control of the coding system that discriminates against the value of the specialty of Family Medicine. Led by the AAFP, we will form stronger allegiances with our colleagues in General Pediatrics and those left in General Internal Medicine and with our friends in American industry to advocate for a balanced system where prevention and early intervention save money and lives. Led by the AAFP, we will turn inward to improve our specialty and enhance our skills – skills at wiser prescribing, skills at wiser referrals, skills at wiser contract negotiations and skills at developing new means of meeting the needs of our patients in the 21st century – and getting paid for them. Led by the AAFP we will develop systems where knowledge is discovered, validated as evidence based and disseminated to our family medicine specialists in record time. Led by the AAFP we will demand quality of ourselves so we can demand it of the system.
Evidence the challenge put forth by Pope John XXIII “ Consult not your fears but your hopes and your dreams. Think not about your frustrations, but about your unfulfilled potential. Concern yourself not with what you tried and failed in, but with what it is still possible for you to do. “
3. If you are elected, what will be your role?
My intention is to bring to the board experience in rural medicine, academic medicine, solo private practice, organizational skills of putting a 30 physician group together and keeping it alive when the partialists left, organizational skills putting together a physician, hospital and business collaborative, participation in the Academy at a state (two states in fact) and national level. I have significant experience in negotiation. My role will be as a team player with the other 90,000 + Family Medicine specialists who want the same thing – better patient care and greater personal satisfaction. If we don’t believe in that to which we have devoted out professional lives then where is the value of our time spent on this earth. I know the value of Family Medicine – I am ready to work to change this system to benefit our patients – I am ready to do the heavy lifting, to challenge the myths, to make things uncomfortable as we expose myths and complacency to the light of reality.
The greater danger for most of us lies not in setting our aim too high and falling short; but in setting our aim too low, and achieving our mark.
Michelangelo
4. a. Equally important, what should state chapters’ leaders be doing?
Since so much of our movement is now economic and, since most insurance is regulated at the level of the several states, it is incumbent for the state chapter leaders to take very active roles. These roles involve legislative activities to correct the more grievous components of the insurance industry. It is incumbent for state leaders to lead by example, seeking out issues from members, formulating legislation and then pursuing its successful passage for the benefit of our patients. Each state president/board chair/legislative chair needs to get on a first name basis with their insurance commissioner. Finally, state leadership must organize the ability (PAC’s) to provide financial support to those who are friends of Family Medicine to insure that the needs of the patients are expressed at the state capital. We have many challenges ahead of us. Scope of practice is about to heat up again as evidenced by the Wall Street Journal on the Doctor Nurse programs (http://www.marketwatch.com/news/story/making-room-dr-nurse/story.aspx?guid=%7B2425D486-50B5-4594-86D6-C3A1BC84D6EB%7D&dist=TNMostMailed ) and tort reform. If you thought that tort reform was done, look again. We need to organize now for strong and vigorous alliances with business to strategize for the rationalization and reform of the legal system.
These are not dark days: these are great days - the greatest days our country has ever lived.
Winston Churchill
4. b. Equally important, what should individual members like me be doing?
These above thoughts above are well and good - but remember, the Academy is us. Waiting for the AAFP to win the day means you are waiting on yourself - so it is time to act. Depend on others to do your talking for you and you will get their solutions. Don't depend on our "brother" specialists to speak out for us. They haven't before - they won't now - until their position is comfortable and then it will be too late for us. They may actually fight our solutions while benefiting from our victories.
This is the year when we elect a President, 1/3 of the senate, all the house. Next year - nothing. Now is the time - we need to get change for our patients' sake - now is not the time to settle for a paltry 1 % that bites deeper into our ability to survive. Get to the candidates - ask the tough questions - donate to those who understand and will work to meaningful solutions (GET RID OF SGR, etc.) - work to defeat those with lousy track records. Now is the time - if we complain and moan and don’t get active, we have no one to blame but ourselves. Congress is available and responsive now - they will be in their home communities- - find out their phone numbers and call them. Get active in the Academy. Get your colleagues to join and get active also. If you read one thing, read the Verden Report on Cost vs Profit in Managed Care today http://www.osma.org/files/public/CostvsProfit.in.Managed.Care.Today.pdf
This is no time for ease and comfort. It is time to dare and endure.
Winston Churchill
Earl, thanks for the opportunity to respond to your positions. The sign of a true teacher is that he/she teaches as he/she questions and probes. You have done that. I am pleased to have you as a colleague Family Medicine Specialist.
posted by George W. Shannon, MD at
10:07 AM
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