To bring about the changes the authors deemed necessary, they proposed the development of a new model of family medicine, an idea that became the centerpiece of the FFM final report and recommendations, published in a supplement to Annals of Family Medicine last April. As Task Force One described it, the new model would be a medical practice “for people of all ages and both genders that emphasizes patient-centered, evidence-based, whole-person care provided through a multidisciplinary team approach in settings that reduce barriers to access and use advanced information systems and other new technologies.” The new model would provide better, more consistent care for patients and it would have to make the practice of family medicine more rewarding for physicians.
The new model requires redesigned offices, retooled scheduling strategies and new avenues of patient/doctor communication, not to mention the implementation of electronic health record systems. With practice margins stretched to the breaking point, the question many family physicians have is how are we going to pay for all of this? That’s also the question AAFP has been working to answer since before the FFM report was published. A sixth task force was commissioned early this year to work with health care consulting firm, The Lewin Group to construct a financial model that would sustain the new model. The chair of the new task force was Texas’ own Steve Spann, M.D., chair of the Department of Family and Community Medicine at Baylor College of Medicine and one of the report authors of Task Force One. The much-awaited Task Force Six report should be published in the November/December issue of Annals of Family Medicine, but the prognosis looks good.
Spann says if you take a practice today with the current reimbursement system and you implement all of the elements of the new model, the task force estimates you should see an increase in physician compensation by about 26 percent.
Part of the increase comes from adopting open access scheduling. “One of the issues that we talk a lot about in the new model is elimination of barriers to access,” Spann says. If a patient can call today for what he or she wants today, the models show the intensity of the visit codes should rise and the number of no-shows should decrease. Physician Web portals will allow patients to view the day’s availability and schedule their appointments online. Patients should also be able to download education materials and find links to trustworthy medical information on the Web portal.
Adding asynchronous communication, like secure e-mail, can increase office efficiency as well. The physician could review symptoms for a cold, bladder infection or other simple problems that could be solved without examination through an
e-consultation and still get paid. Facilitating prescription refill requests online could boost efficiency, too, especially if the physician is using an electronic health record.
According to the FFM report, the new model depends on EHRs. “We really see the EMR as the central nervous system of the new model practice,” Spann says, using the term electronic medical record instead of electronic health record. “We believe that the EMR ultimately can make docs more efficient, can for example cut down on medical records staff, medical records cost, paper cost, eliminate transcription cost, can improve
E-and-M coding — so there’s evidence out there that using an EMR actually can improve the bottom line.”
Along with shoring up the financial viability of family practice, these changes help fulfill one of the central tenants of the new model — putting the patient at the focal point of the provision of care. Of course most family doctors would probably argue that they’re already providing patient-centered care. According to James Martin, M.D., of San Antonio, chair of the AAFP Board of Directors, the new model requires a paradigm shift. “Right now, everything – doctor/patient contact – is totally based on the physician’s schedule, the physician’s preferences,” says Martin, who has spearheaded the FFM project and the initial implementation efforts during his term as AAFP President and in his position as board chair. Open access scheduling, e-mail communications, phone consultations, group visits and expanded clinic hours should allow patients to have more say in when and how they receive care.
Patient-centered care in the new model definition also means that care will be culturally and linguistically appropriate. “The key is that the family physician or whoever is doing the new model has to be very aware of the patient’s preferences and value system,” Martin says, adding that physicians have to help patients become active participants in their care. “Let’s say for example, someone comes in with high cholesterol. In the past, most doctors routinely just say, ‘Here, start taking statin and I’ll see you back in X period of time.’” In the new model, doctors will access reports and graphs online to show patients the anticipated results of different alternatives. “Here’s the percentage of success if you exercise and diet. Here’s the percentage if you take niacin. Here’s the percentage if you take Lipitor, so that the patient has more information to help be a partner in making those decisions,” Martin says.
The 26-percent increase in physician reimbursement that Task Force Six estimates for new model implementation assumes there is no change in the way physicians are currently paid, but the task force has been working on another financial model that includes some new twists for the U.S. health care system. Martin says along with traditional fee-for-service reimbursement plus payment for
e-consultation and group visits, the Academy is pursuing a blended payment model including patient management fees, chronic care management fees and pay for performance initiatives.
AAFP recently adopted a new policy position that could help bring about a blended payment system. The policy has been published in a document called “The New Model of Primary Care: Knowledge Bought Dearly,” which is acknowledged as a synthesis of existing literature and new analyses by the Robert Graham Center: Policy Studies in Family Medicine and Primary Care. The document describes the burden of chronic care on the Medicare system and some devastating predictions for the near future. Currently, less than 20 percent of Medicare patients have five or more chronic diseases, yet that population accounts for more than two-thirds of Medicare spending.
“The purpose of the Graham study was to demonstrate that if you have a family physician managing the chronic disease of a patient, then A.) the patient satisfaction goes up; B.) the quality is extremely high; and C.) it costs less,” Martin says. The document backs up those claims, showing possible savings of over $50 billion to the Medicare system if family physicians serve as the usual source of care for Medicare patients with chronic diseases.
In a letter to AAFP chapter presidents that accompanied the document, Martin writes: “Effective delivery of care requires consultation with the patient, organization of the patient’s care and encouragement of the patient to become a partner in that care. Our payment system penalizes physicians for taking each of those actions.” The document goes on to recommend that changes be made to the way family physicians are paid that would include the adoption of a patient management fee and a chronic care management fee.
Martin says the argument is bolstered by a recent article published in Health Affairs by two Dartmouth professors entitled “Medicare Spending, the Physician Workforce, and Beneficiaries’ Quality of Care,” which compares Medicare spending and quality of care among the states. The study reports that in states with higher Medicare spending and a higher concentration of specialists delivering the care, the quality of care and the level of patient satisfaction are lower and the cost is higher than in states where primary care physicians deliver more of the care.
Other AAFP initiatives are working to interest payers in providing financial incentives to physicians for reaching a set of quality standards. “If the physician is able to lower the cholesterol to certain standards or lower the hemoglobin A1c to certain standards, then there are extra payments, bonuses paid to the physician for doing those things,” Martin says.
Dr. Spann believes the use of advanced information systems championed in the new model holds the promise of greatly improving the quality of care family physicians deliver, particularly in cases of chronic disease and prevention. “We believe that in the long term, insurance companies are going to be willing to reimburse us for practicing better quality, and so in the long run, we think that will reap revenues,” Spann says.
According to Martin, payers are interested in the possibilities proffered by the new model. He says he’s had talks with insurance company representatives who are so impressed with the new model that some may give support to a number of clinics as part of a demonstration project. And it’s not just insurance companies that are interested.
“We’re getting just tremendous response,” Martin says, even in Washington, D.C. “There are members of the Senate who think the FFM new model is where they should be going to correct health care disparities rather than [Federally Qualified Health Centers]. There are just some very powerful people that are looking at this and coming back and saying, ‘go forward.’”
For Drs. Martin and Spann, the question now is how does the Academy begin to implement the new model and do it in a cost effective way. Task Force One’s report called for the development of a national resource center that might use demonstration projects, or new model beta sites to fine tune the practice, and then package the parts in a turnkey solution that would make implementation easy and seamless. AAFP’s Board of Directors asked Spann to serve as a consultant to a team that has been working on a business plan for the national resource center and they should present the plan to the board at their annual meeting this October.
Martin’s term as board chair will end at that meeting and he says as his swan song, he is hoping the board recommends to the AAFP Congress of Delegates that the national resource center be developed. The purpose of the center after the initial demonstration project is over would be to act as a consultant service, helping family physicians or whoever else is interested in transitioning to the new model. For some practices already meeting many of the new model requirements, the resource center might do as little as pass on some tips via e-mail, or it could start from the ground up for other practices, providing software and intensive training. Martin says the resource center would have to be financially viable, so the service wouldn’t be free, but part of the center’s purpose would be to make sure the new model improves a physician’s bottom line. He believes that if the board approves what’s in the works today, the center could begin to take shape in the next six months to a year.
Martin says the new model is necessary to the success of the U.S. health care system, and certainly that of family medicine. “Yes, this is a mountain we have to climb, but it’s doable. And the tools will be provided to help get there, but it’s not something that we’re going to have the opportunity to pick and choose on.”
He says that in this case, the old adage “I’ll believe it when I see it” has to be turned on its head. “I’ll see it when I believe it,” Martin says. “I think that if we are at a point where we believe this can happen, it will.”
Links:
Future of Family Medicine Report — Plus the task force reports published in Annals of Family Medicine
AAFP Care Management Policy — The New Model of Primary Care: Knowledge Bought Dearly
InterNetCME — Access audio and slides from Dr. James Martin’s FFM presentation at TAFP’s 2003 Annual Session and Scientific Assembly.
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