A prescription for the success of family medicine

We should treat our practices and our specialty like we treat our patients

By Christopher Crow, M.D.

If anyone ever feels the need for a good dose of doom and gloom, visit your local doctors’ lounge. There one can hear plenty about how the good old days are gone. Expenses are up, revenues are flat or down, insurance companies have the upper hand and we are completely regulated by the government. I don’t dispute these as facts one bit, but how did we get into this mess?

The question begs a complicated answer but there have been forces working against our profession for the past several decades that have slowly eaten away at the doctor-patient relationship and allowed decisions to be made by non-physicians. The last 40 years have seen the health care industry take up more and more of our nation’s gross domestic product. As the industry grew, it made economic sense for many entrepreneurial third parties to enter our arena in search of profits, like insurance companies, drug companies, hospitals, trial lawyers — you know the list. Government responded throughout with more regulation. As these changes occurred, most physicians remained hard at work in their offices. Traditionally, we have tried to stay out of any political discussions that didn’t involve patient advocacy. We felt politics were for lawyers and lobbyists, not for doctors.

Our inactivity has led to our current conditions. The questions for the future are: 1) will we learn from our mistakes and not let history repeat itself, and 2) can we buck some of the current trends so we can keep our offices open to care for our patients who need us?

As a young physician who hopes to have many years ahead of him, I choose not to be pessimistic. In fact, I see opportunity, especially for family physicians. And why not? The need for physicians is not decreasing any time soon. Primary care is the entry point into the health care system for over 80 percent of the population. More and more studies are showing not only our cost effectiveness but our patients improvement in morbidity and mortality compared to those of our specialist friends. With more of the costs of health care being placed on the consumer and the coming tidal wave of pay-for-performance, who is in a better position than family physicians to provide the most value for services such as preventive care and chronic disease management?

So if we do not want our future to look like our recent past, what is our prescription for success? Let’s use the treatment of diabetes as an analogy. Just as diabetes is a high-maintenance and complex disease, so are the problems we face as physicians. To successfully treat diabetes, patients need to participate in their own care by taking responsibility for how they live their lives. They need to monitor their sugars and blood pressure, take their medicine as prescribed and practice good habits including diet, exercise and not smoking. Furthermore, to keep their diabetes under control, the patient relies on a care team that may include several doctors, support staff or other resources in the community. This care team monitors patients and helps communicate when changes need to be made and they provide disease education. Diabetic patients have to make internal changes and they have to interact with external resources to achieve maximal health.

What are the internal changes we as physicians need to make to achieve maximal health for our practices? First, we can run our offices better. Health care is by far the most inefficient industry in America. According to the Medical Group Management Association, the average physician office has $25,000 of administrative waste per doctor. Take a step back and see if your practice needs a tune up. Maybe even hire a consultant. Do not be afraid to talk to other physicians about their triumphs and pitfalls in running their practices. We could learn so much from each other if we would communicate about our business issues as much as our clinical ones. There are so many cheap ways to make sure our offices run more efficiently and provide better customer service, both of which should add to a practice’s health.

The second and more important change we can make is to take better care of our patients. There is plenty of evidence showing patients receive around 50 percent of the services needed in this country for preventive care and chronic diseases such as diabetes. Then there are the numerous preventable medical errors, which have been highly publicized. These facts are exactly why pay-for-performance programs were born. The payers of health care in this country — government and employers — are tired of paying exorbitant amounts in health care costs and not getting quality back. I don’t blame them. If I paid my cable TV bill every month but only got half the channels I bought, I would be really upset.

The evidence shows we’re not measuring up because of a lack of information at the point of care. Without it, patients often do not receive the care they need such as a HgA1c in a diabetic. As every other industry has known for years, information is king. If you don’t have good information about your business and the care you provide your patients, you can’t make a convincing case in negotiations with those who do have it, i.e. insurance companies and government programs like Medicare and Medicaid. Most other industries have implemented technological solutions to provide better service to customers and so they achieve greater profits. Think of the banking industry before ATMs and online checking. Besides using technology for diagnosis, physicians have been slow to adopt technology to improve their practices. While EHRs may not be a panacea, if utilized correctly, they can make drastic improvements in the quality of our patient care. Furthermore, they can make your office exponentially more efficient and thereby provide an outstanding return on investment. It is time for all physicians planning to be in practice for the next 10 years to strongly consider making the switch.

What are the external changes we need to make? To use the diabetes analogy, we need a “care team” led by organizations such as TAFP. In my mind there are two very important ways TAFP should provide care for its members. First, it needs to market the attributes of our specialty. Insurance companies, employers, patients, the media, other health care providers and elected officials need to know that family physicians provide the highest quality and most cost-effective care to our patients. Along this line, I applaud TAFP for its current dialogue with the major insurance companies in Texas to help them design their inevitable pay-for-performance programs. Hopefully this endeavor will lead to reimbursement that better reflects our value to patients and the health care system as a whole. Further marketing needs to be done in the academic centers. Medical students need to have a better idea of the benefits of being family physicians. TAFP is already very involved with the Statewide Preceptorship Program, but it needs to connect even more students to family physicians.

The second way TAFP can provide better care is by getting members engaged in the political process. I realize TAFP already tries to accomplish this, but the network needs to go deeper to reach more of our physicians with timely information as well as guidance on how to participate. Politics is a dirty game but it is where most of the regulations and laws are made that affect how we run our businesses and care for our patients. If doctors choose not to be involved in the discussion of how health care is delivered and reimbursed, then we should expect more of the same conditions that we face today. As physicians we need to become involved by getting to know our elected officials and helping those who are friendly to our cause with time and yes, even money. TAFP should help facilitate these relationships.

Remember that diabetes is a chronic illness and so are the problems we face today as practicing physicians. It is great that we all banded together to pass tort reform in 2003, but that does not make us cured. This past legislative session in Texas was like many. We physicians had to defend ourselves against others wanting to make changes that would hurt our patients and our practices. Winning these unheralded battles is similar to the diabetic who never has kidney failure due to work that was done years before. Since our adversaries will remain persistent to advance their causes, TAFP and its members must remain vigilant and ready to preserve our profession. We must strive for continuous improvement and look for opportunities internally and externally to make meaningful change on behalf of our esteemed profession and our beloved patients.

The prescription for our success is waiting to be written. The question is, when are we going to write it?

Christopher Crow, M.D., practices family medicine in Plano, Texas. Contact him at crowchristopher@hotmail.com.