Over my career, the American Academy of Family Physicians, my primary professional society, has made some colossal mistakes in what it has chosen to advocate for. It has learned from its past mistakes, but only a little. They’re about to screw it up again with their call for payment reform, but more on that later. First, let me provide a brief historical perspective.
Almost from the moment I became a board-certified family physician, the AAFP started into its first major mistake. This was the early to mid-1990s, the era of the rise of HMOs and managed care. The big insurers and federal government essentially came to the AAFP and said, “We want you to be the gatekeepers for the healthcare system of the future.” Family medicine basically responded crying out, “You mean you’ll love us if we let you call us gatekeepers instead of family physicians? OK!”
This was the era of the mandatory referral, when a patient had to see a “PCP” for permission to see an ologist (this was the time when that godawful acronym PCP was popularized). It was not unusual for a patient visit to start with a family physician asking the patient “What can I do for you?” and the patient responding “Fill out this form so I can see a cardiologist and this other form so I can see a dermatologist.”
“Why do you need to see them?”
“I have high blood pressure and acne.”
“I can take care of those problems,” beamed the naive family physician.
“I’m sure you can,” responded the patient snarkily. “Now fill out those forms.”
The managed care era was a disaster for many other reasons. I won’t expand on them at this time other than to say that the insurance company suits and government bureaucrats knew that there was evidence that family physicians delivered better care at a lower cost. They just had no clue WHY family physicians delivered better care at a lower cost. Patients heard “gatekeeper” and they interpreted it to mean that the HMO and their family physician lackeys were “keeping” them from the best care. We got absolutely no support from the government, insurance companies, patient advocacy groups, or anyone else, emotional or financial. The average income of family physicians relative to the ologists actually got worse in the managed care era. When the American people very justly forced the end of the managed care era, family physicians got tossed out with the dirty bathwater and medical student interest in family medicine, which had been climbing through the 1990s, completely collapsed. And the AAFP mostly stood by, fighting back with all the energy of a grazing sheep. We didn’t even have a PAC back then.
The next major screw up happened about 10 years later. There was a big study and subsequent report called the Future of Family Medicine (FFM) Project. It’s final report came out in 2004 (if you’re interested, there were about 6 papers published in the Annals of Family Medicine). There was no real call for payment reform. Instead, the FFM report called on the electronic medical record (EMR) to become the linchpin on which the future of family medicine would rest.
And how the dreamers dreamed. One of the FFM findings was that the American people dissed family medicine because they could not identify us with a technology such as 3D images of a brain spinning on a computer screen or the latest laser treatment. Some FPs actually thought that our patients would start to love us more because we would be seen as the experts in the technology of the EMR. They dreamed that EMRs would make our lives simpler and easier and that all this important medical information would flow freely, allowing us to take even greater care of our patients. To be fair, it wasn’t just the AAFP. Lots of other people thought that EMRs would save us.
Instead, the reality of EMRs is that there is no great evidence that they have improved overall quality or safety for patients, or lowered costs. They have increased the work burden on family physicians (and other physicians) and have led to fewer patients seen per hour and more family physicians having to take more work home just to document in their EMRs. They are associated with higher rates of physician stress and burnout. Instead of the EMRs making our work easier, they have made us their slaves. We have to work harder just to make the clunky EMRs work at all.
And the most important features of family medicine — comfort with uncertainty, providing a comprehensive basket of services, for example — were hardly mentioned in the years after the FFM report came out. Instead other EMR fanatics helped push the AAFP into thinking the Patient Centered Medical Home and other deviations from traditional family medicine (the model that for nearly 40 years has been associated with better care and lower costs) were the direction we needed to go.
Now, about 10 years later in 2014, came the Family Medicine for America’s Health program. To its credit, the AAFP actually showed it grew a spine, a little one at least, and it explicitly recognized that a dearth of American medical students want to be family physicians because of the huge payment bigotry between family medicine and ologist services. To give you some round numbers, in the rest of the developed world, about 40-50% of medical students become family physicians. In the U.S. it’s about 10%, less if you just count allopathic students. The FMAH report also explicitly mentioned that the comprehensiveness of family physicians to provide a wide basket of cognitive and procedural services has declined over the managed care and EMR eras, and says this is a problem that should be reversed. Good for them.
But then they started screwing up their payment reform plans.
It will take me several posts to fully explain how the AAFP came off the rails, again. Here are the links to 2 documents if you’d like to start checking them out for yourselves: an executive summary and longer Alternative Payment Model. The bottom line is that my national organization was a contributor to the continued anemic position we hold in the U.S. healthcare system, and I’m not going to let the last phase of my career be screwed up once again, at least not without a fight. Wish me luck.