By Jim Rickards, MD, MBA
Back in 2011, the state of Oregon was facing a massive budget deficit, primarily driven by rising Medicaid costs. Medicaid is government-supported health insurance for economically disadvantaged individuals earning up to 138 percent of the federal poverty level. About 25 percent of Oregon’s population, nearly 1 million individuals, are currently enrolled in Medicaid. This is a similar percentage to what is seen nationally. Not only did the deficit substantially impact the state’s overall budget for health care funding, but the potential impact on the lives of many Oregonians also weighed heavy on the medical community.
Typically, when states try to manage deficits related to Medicaid, they employ a combination of three strategies. For one, they will decrease reimbursement rates to hospitals and providers. This does not work very well because, ultimately, clinics will need to limit the number of Medicaid members they see since they are not financially viable, in turn creating access issues for patients. Second, the number and types of covered services can be restricted by the state. In Oregon, we had already employed the Prioritized List of Health Services for more than 20 years, which served as an evidence-based approach to prioritizing and limiting the availability of health care services. Limiting what was already on the list would not have been possible without denying many essential services. Finally, a state can decrease the number of individuals enrolled in Medicaid. This was not an option either, as Oregon was going to be an expansion state under the Affordable Care Act and would see its Medicaid population grow from 600,000 to a little over 1 million members within just a short time.more
By Travis Bias, DO, MPH, DTM&H
In his commencement address at Kenyon College in 2005, the late author David Foster Wallace told the story of two young fish swimming along. They pass an older fish swimming the other way who greets them: “Morning boys. How’s the water?” As they swim on, one of the younger fish responds to the other: “What the hell is water?”
Feeling and appreciating your body of water takes experience, maturity, and occasionally someone else making you aware of your daily surroundings. It was not until a few years into my career as a family medicine physician that I realized the furious pace at which American physicians learn to swim, insulated in a system that operates in stark contrast to that of other countries around the world.more
Janet Realini, MD, MPH
As is often the case in Texas politics, there was little agreement during the 85th Legislative Session on which steps are necessary to address the state’s many health care challenges. One area that did see agreement, though, was the recognition that far too many mothers in Texas get sick or die during pregnancy or within a year of a pregnancy ending. Unlike the decline of mortality rates internationally, U.S. maternal mortality rates have been increasing, and Texas’ maternal death rate infamously doubled between 2010 and 2012.
Thankfully, the Legislature moved during special session to extend the state’s Maternal Mortality and Morbidity Task Force, which plays an important role in identifying and addressing the core issues contributing to maternal death and severe illness.more
An excerpt from the inaugural speech of the new TAFP President
By Janet Hurley, MD
Greetings friends, colleagues, staff, and family members. It is my honor to stand before you as our next TAFP President. As I watched Dr. Elliott receive this medallion last year, I thought of all of the leaders in the past who have worn this medallion before us. I am honored to receive the responsibility today, acknowledging that this medallion has been around the necks of many giants along the way before me.
My first TAFP meeting was in the summer of 1997, ironically also here in Galveston. I was a student, wandering lost around the conference hotel. I was impressed to feel so welcomed by the TAFP staff and physician leaders, like Dr. David Schneider, who was among my first Academy mentors.more
By Tom Banning
Dave Chase, a friend of mine who was a longtime contributor to Forbes among other magazines, spent the better part of the last three years traveling the country documenting the multitude of failures of our health care system (pricing, contracting, lack of transparency, conflicts of interest), but more importantly identifying simple and tested solutions employers and some local governments have utilized to decrease their total health care spend.
His efforts have culminated in a compelling, must-read book, “The CEO’s Guide to Restoring the American Dream.” We’ve partnered with Dave on several physician–employer community events and in return, he has thoughtfully offered members and friends of TAFP a complimentary digital copy of his book. Below, I’ve provided a link to his TED Talk, “How Health Care Stole the American Dream,” as well as a link you can use to download a copy of “The CEO’s Guide to Restoring the American Dream.”more
What kind of system do we want?
By Tricia Elliott, MD
In his seminal book “The Signal and the Noise,” renowned statistician, Nate Silver, examines the world of prediction, investigating how we can distinguish the truth — the signal— from the noise, which he describes as a universe of ever-increasing information, relatively little of which is useful.
Any candid observer of the now nearly decade-long effort to reform our health care system will readily admit that the health care debate we’ve been engaged in has generated a lot of noise and useless information for political gain. Our elected leaders, on both sides of the aisle, have been busy creating this noise and are now trapped in a political vise of their own making. They’ve sadly left the public with a binary choice of whose health care solution is better, that of the Republicans or the Democrats.more
A model whose time has come
J. Stefan Walker, MD
Luke Fildes’ portrait “the doctor” epitomizes the primary care physician that our younger selves aspired to become.That kind of doctor-owned practice is now slipping away as quickly as the business model supporting it. Where $300,000 per year is the new benchmark for employed primary care positions, the prospect of starting or joining a private practice only to tread water in a sea of acronyms (MACRA, HIPAA, HMO, ACO, etc.) for margins that barely cover overhead no longer makes sense to most family physicians. No wonder that in 2016, for the first time, less than half of American doctors partly or fully own their practices.
As the care of inpatients became a separate field, primary care was mostly sidelined into a 9 to 5 office job in a role now shared with mid-level practitioners, retail clinics, and telemedicine services. Unlike many other specialists still seeing patients during nights and weekends, primary care is now conspicuously absent in that important space, further putting pressure on family physicians to justify the level of reimbursement that can support independent practices. Now a rarity, small primary care practices — even those now thriving — risk succumbing to this tide of obsolescence, not unlike local department stores and indoor shopping malls.more
By Jean Klewitz
Do you have a specific interest in rural medicine? Want to learn how to face challenges as a rural physician or a maternity care provider? This active section can help you work through those challenges. The integration of full-spectrum maternity care in rural family practices is their focus and they seek to create more opportunities for growth in these remote communities.
The section also works with AAFP’s Rural Health Member Interest Group and AAFP’s Reproductive Health Care Member Interest Group to provide opportunities for rural medicine and maternity care education, training, support, interest, and involvement for physicians, students, and residents.more
By Jonathan Nelson
Direct primary care practices are cropping up across the country as physicians grow more frustrated by administrative burdens inherent in a fee-for-service third-party insurance market. But some regulatory obstacles block many people from joining DPC practices. The Direct Primary Care Coalition — of which TAFP is a steering committee member — has called on physicians to ask their representatives in Washington D.C. to sign on to federal legislation that would remove those obstacles.
In DPC practices, physicians charge patients a monthly, quarterly, or annual fee — like a retainer or membership fee — that covers a broad set of primary care services and patients typically enjoy greatly enhanced access to their physician. IRS rules interpret these DPC payments to be like paying premiums for health insurance rather than just a different way to purchase a set of services. Even though Texas and 17 other states have passed laws defining DPC arrangements to be outside of state insurance regulation, the IRS interpretation bars individuals with health savings accounts paired with high-deductible health plans from using their HSA funds to pay DPC fees.more
By Perdita Henry
Congratulations go to the family medicine interest groups at the University of Texas Medical Branch at Galveston, Texas College of Osteopathic Medicine, and the Paul L. Foster School of Medicine for winning the first annual Texas FMIG Program of Excellence Award. Last year TAFP’s Commission on Academic Affairs voted to create the award to celebrate and support FMIGs for their work to inspire medical students to consider the specialty of family medicine.
FMIGs are student-run organizations with faculty and departmental support. They provide a forum in medical schools for students interested in family medicine. FMIG programs across Texas applied for the new award and a subcommittee of the Commission on Academic Affairs reviewed the applications and selected the winning programs. Award winners receive cash prizes to help cover student travel costs to AAFP’s National Conference of Family Medicine Residents and Students.more