Let’s be bold for family medicine

Tags: hurley, perspective

By Janet Hurley, M.D.

It’s time for boldness in family medicine. As I turned to hug Jim Martin, M.D., at the last TAFP C. Frank Webber Lectureship, I was touched by his heartfelt concern. He and other dedicated leaders before me have endeavored to set the stage for family medicine to have its time in the spotlight. Yet many family physicians do not seem willing to demonstrate the leadership skills or “fire in the belly” during this pivotal time of health care change.

In the past, family physicians were seen as feeder mechanisms for the procedural and hospital cash machine. We were disrespected in the academic centers and our value was minimized by payers and the Relative Value Scale Update Committee. Specialists desired our referrals for lucrative procedures that are reimbursed under an inflated fee-for-service price. The hospitals have been hiring family physicians to ensure referral sources to their admission beds, imaging centers, and operating rooms. But the day of reckoning is coming for that payment methodology.

The common enemy to us all in health care is one simple concept: cost. In the next five to 10 years, we will continue to see changes in reimbursement moving away from fee-for-service toward value-based purchasing, bundled payments, and shared risk models. Payers, employers, and the public are looking for treatment methodologies that are practical, cost-effective, and evidence-based. Care coordination is needed to reduce the duplication of services, the readmission rate, and the ordering of unnecessary high-cost imaging tests and procedures. Who is the best person to coordinate that care, counsel patients about evidence-based guidelines, and steer patients toward quality specialists who do good work but don’t order unnecessary tests and procedures just because they can? The opportunity is here, and the time is now for family physicians to rise to this challenge with boldness and candor.

It fills me with indignation when medical students report back to me that academic specialists still look at family physicians as just a “cheap alternative” for quality specialty care. As a community physician and health care leader, I know community specialists, payers, employers, and, most importantly, patients appreciate the value they receive when they come to see me and my family physician colleagues. Patients want to be treated by someone who cares not only about their health but also their pocketbook. Every medication I prescribe, test I order, and referral I request takes money out of the patient’s personal budget. The copays are high enough now that patients don’t want any of this stuff if it does not really add true value to their care. That is not cheap care or poor quality care, it is compassionate and practical care, and acknowledges our responsibility to be good stewards of health care resources.

The time is now, but are we ready to lead? I enjoyed hearing from Doug Curran, M.D., in Athens, Texas, whose patient fell victim to an unnecessary procedure by a nearby specialist. We need more doctors like Curran, who picked up the phone and called the specialist directly to express his dismay. This is the kind of “fire in the belly” our profession needs.

I know some family physicians have learned how to be profitable in the fee-for-service world either through high volumes or smart employment contracts with hospitals. But if we are to bend the cost curve in health care, we have to change service paradigms, work toward medical home certification, invest in new technology, and transition to population management philosophies. It won’t be easy and it won’t be comfortable, but we have to hold ourselves and our colleagues accountable for duplicated services and unnecessary procedures. To be clear, I’m not asking my colleagues to have superpowers and fix all of these problems. What I’m asking is for family physicians to be engaged and to lead.

Many excellent leaders have spent sweat and tears to bring our specialty to this pivotal moment. Will we lead this charge in our community hospitals and clinics, or will we permit ourselves to be marginalized again? We’ve already been down that road. Let’s get the “fire in the belly” to stand up for our patients and our specialty.

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