By Guy L. Culpepper, M.D.
During his recent NFL Hall of Fame induction speech, running back Emmitt Smith affirmed that refusing to let others define him was critical to his success. This simple, yet powerful advice has been a core value shared by champions throughout history. Success begins with a clear vision of one’s abilities and goals. Defining identity must not be swayed by the ever-present naysayers. This principle holds true across all spectrums of life; in faith, in business, and certainly in medicine.
Nicholas Pisacano, M.D., the founding director of the American Board of Family Practice, faced a multitude of naysayers and roadblocks when he led the efforts to have family practice recognized as the 20th medical specialty in 1969. To achieve that recognition required meticulous documentation and high standards of definition as to the training and responsibilities of the family physician. In other words, family physicians defined themselves. And Dr. Pisacano understood the importance of defining ourselves.
The clear vision provided by our specialty’s founding leadership has resulted in remarkable success. As we look back over the past 40 years, one of the greatest strengths in medicine has been the family physician. Our specialty, family medicine, is a jewel in the crown of the health care system. Multiple studies have acknowledged the critical role that the family physician offers in both the prevention and early detection of disease, consistently creating enormous impact and savings for our patients and our country. For all of the concerns regarding our country’s health care crisis, there is agreement that family medicine is part of the solution, not the problem. Family medicine remains the highest calling in health care.
It is not a surprise that every plan of action proposed to improve health care delivery and to reduce cost revolves around primary care. The family physician is the greatest value in medicine. Business leaders and politicians are anxious to develop systems that further capitalize upon the successes of primary care. But no one except the primary care physician really understands just what it is that we do to achieve that success. No one else is aware of the demands, the sacrifice, and the commitment that is required to deliver high-quality primary care. The flawed reimbursement system, which fails to adequately reward primary care, is proof of that ignorance.
The patient-centered medical home has been proposed as one system to accentuate comprehensive patient care, as well as reimburse primary care physicians for some of the myriad services provided in that pursuit. Much of the cost savings to be found in health care reform is based upon reducing the utilization of resources. There is no one in a better position to decide which resources may not be necessary to use than a personal family physician when reviewing that decision with a patient.
Additional significant savings can also be derived from cost effective referrals. The need for primary care physicians to be independent in making these cost-saving referral decisions is obvious. In order to lower costs, the referral choice cannot be restricted to only the hospital or specialist with whom the primary care physician has a business relationship. True cost savings, and often quality enhancement, comes from the competition for those referrals. Again, this positions the family physician in a place of substantial control. Understandably, the potential empowerment of primary care physicians through a medical home model has been recognized with concern by some hospitals and specialists.
It is this concern over losing market share, referrals, or power that has led many health care corporations, hospitals, and specialty groups to quickly embrace the new buzzword in medicine, the Accountable Care Organization. Based in Washington, D.C., the Brookings Institute and researchers at the Dartmouth Institute for Health Policy developed the model of the Accountable Care Organization as a part of health care reform efforts. While this model naturally emphasizes the importance of primary care, it also facilitates and encourages the development of large hospital-based, single-tax-number corporations.
The rapid popularization and political support of the Accountable Care Organization model has been propelled by those recognizing an opportunity to control a market by quickly employing that region’s primary care physicians. It is clear that whoever controls the majority of family physicians will control the area’s health care dollars. Scare tactics are being used in many parts of our country, frightening primary care physicians into becoming employees under the guise of national policy inevitability. The message conveyed is that you have no choice.
The family physician is being told that our only future is to be an employee, one who can effectively manage a bevy of mid-level providers by using an electronic medical record. The family physician of this model may not even see the patient, but instead review each case’s management for efficiency. Instead of rewarding family physicians, the new model plans to replace us with mid-level providers and prescribing pharmacists. The Accountable Care Organization is not the patient-centered medical home. It is just a policymaker’s latest idea to define our profession.
When you hear naysayer opinions, stop and remember the clear vision of our founders. Family medicine is critical to the success of cost-effective health care. We are the key to the successful Accountable Care Organization and we can define the model of the Accountable Care Organization. Primary care and the mission enhanced by the patient-centered medical home are at the core of the Accountable Care Organization. Independent family physicians can develop the Accountable Care Organization, lead the changes, and remain true to that mission.
We must not let others define us. The vision of politicians and policymakers cannot define family medicine. We, the family physicians, just as the champions who founded our specialty, must instead define ourselves and proudly guard our future. Our country’s health care depends on it.