A Family Physician’s Manifesto

Paul M. Fischer

As a third-year medical student in 1977, I joined the American Academy of Family Physicians (AAFP).  In those culturally tumultuous years, it was a way to declare my belief that America needed physicians who cared for the whole person, family and community. It was also a declaration that, in choosing the primary care path in a field ripe with tempting medical specialties, money was not my primary goal.

For much of my 33-year membership, I have considered the AAFP to be “my” organization. However, there is a time when one must step back and declare independence from organizations that have lost touch with their members.  The AAFP does much that supports my day-to-day life as a busy family doctor, but for 33 years, its leadership has failed to fix the central problem for primary care in America: poor reimbursement.

I deal every day with complicated health problems of complex patients who are insured by companies singularly focused on limiting even the smallest cost.  In return for managing these patients, which often involves critical and life-or-death decisions, I am paid by Medicare 60% less per hour than is a dermatologist, who, for the most part, treats trivial disease that involves no nighttime emergencies and little intellectual challenge.

The AAFP has implicitly supported this payment fiasco through its membership in the RUC, a committee of organizations focused primarily on defending surgical and specialty fees while ignoring the growing challenges and costs of the practice of primary care.  Because the RUC advises Medicare on physician reimbursement, the AAFP’s involvement is tacit agreement with a reimbursement plan that undermines the health of primary care and, hence, the health of the country.

In light of the organization’s failure to effectively advocate through the RUC on behalf of its members for crucial change in physician reimbursement, I strongly urge the AAFP to immediately withdraw from the RUC and work to establish an alternative means of impacting Medicare’s physician payment decisions for the good of primary care and American health care.

Fellow primary care physicians who wish to communicate the same sentiment to their societies may find a prepared letter here.

Paul M. Fischer, MD, AAFP #1925120 practices at The Center for Primary Care in Augusta, GA.

7 thoughts on “A Family Physician’s Manifesto

  1. Dear Dr. Fischer,
    For a very long time I as my wife’s Practice Manager have been all too aware of the collusion of the AAFP, AAP and other Primary Care Organizations in continuing the horrible financial conditions that primary care has been stuck in for years. I agree with your basic theory that the RUC and the Relative Value System has distorted the illogical, unethical and out of balance financial reimbursement between primary care doctors and their much better paid brothers and sisters in the multitude of sucessful specialists. Further I also support the basic thesis that the present set up is intentionally imblanced in favor of the “Stacked” panel that is the commitee’s make-up. I even support your concept that the relationship between the Government as in CMS and our Congress in basically accepting the recommendations of the RUC at over 90% of the time is a sure sign of the unhealthy nature that seems like a form of “Anti-Trust” like “Collusion” between the parties involved.

    Bravo and Well Done in your efforts in attempting to properly spread the word and inform the greater base of Primary Care Doctors about these unethical relationships and inequalities. And I thank you as well.

    BUT, might I suggest that most of the time when great concepts and theories such as your attempt to work from within the system too much they almost always get “Co-Opted”, leaving them watered down and only making modest if little real noticable gains. President Obama’s attempts at working with all of the “Stake Holders” (i.e. all the present piggies feeding at the trough who will not go away quietly and will always insist upon having a sizable portion of the resources at the table to be divided up, never allowing themselves to made obsolete or minimalized) in the present insanity is a great example of good intentions that get ruined by attempting to stay within the present set-up with the old players of the old rules game. He tried and bless him for his attempts but this ballon won’t fly because all it does is move those deck chairs around on the soon to be underwater Titanic. It was a well intended exercise in futility that maintains the status quo.

    It is the shared belief of mine and my wife’s, along with hundreds of similar minded friends hardworking Primary Care Doctors and their all too often “Family Based” management like myself, that working within the AAFP and or the AAP is a worthless time wasting exercise. Everyday more and more of us discuss our “Dropping Out” of the AAFP and what a waste of our money and time, how disconnected the present organization has become from those that it claims to represent. In attempting to stay afloat and viable they have abandoned the majority of the potential membership, mostly small and solo primary care doctors and the values that we are attempting to keep as our guiding principles as we struggle for even basic survival no less viability or success.

    I implore you to simply read the next in to surely come, in any issue now, article about how to add another patient or two a week or day to our already insane schedules or how to make sure you don’t leave those last few pennies on the table by proper coding which most of the healthcare industry (the private carriers spit upon and reject anyway…. Lying and Bundling their way to increased profits and our financial demise even though CMS and CCI Edits clearly Support our coding methods and point out the cheating flaws in their rules and policies) already understand that private carriers reject as their bean counters calculate ways to change it to their personal profitable advantage, and you will see all you need to know that attempting to change this sluggish old ship in this ice field without enough Rudder to properly steer her clear of the real issues is an futile exercise for sure. The AAFP’s time has come and gone and their opportunity to see and read ahead started to come to end way back when they supported other failed concepts that should have been clear as day as the old HMO’s and other Managed Care concepts from so many years past now.

    The answer is for those of us who clearly “Get It” is to create something new with better and clearer vision based in part upon the lessons learned of the many failed years of overly manipulative political interventions in medicine. Further I would say I agree with educating employers who are presently the ones overly funding our failed system. But that two we must educate the end consumer of our actual services, the patients, the American Public if we care to bring about real and meaningful change. In most other small, day to day personal relationship service businesses and industries like our 0wn, it is the consumer at the end of the service who in relationship with the service provider what is the “Value” of the services the consumer is purchasing and the service provider is about to provide. That Super Critical aspect of medicine in general no less in something as personal as the “relationship” based parts like primary care as been destroyed and totally severed. Imagine the cost disconnect, the lack of understanding and ownership of the value of services purchased and rendered and growing dissatisfaction in HVAC, Carpentry, Plumbing, Vet’s, General Contracting, Auto Body or Mechanics, and The Law if such services were to be purchased and paid for in a manner anywhere similar to those that we in primary care healthcare find ourselves in today. I promise you that those industries especially seeing how less life and death most of them are most of the time… that they would have fallen off the end of the economic earth had they attempted to survive and do business under the conditions we present work under. It is shear maddness.

    At the same time there are others in the Medical Profession who they too have been pushed to the brink, retired early and many of the young intelligent next generation are also chosing NOT to enter their once valued fields of practice. These are our Brothers and Sisters in other Office Visit, E&M coded, low or no procedures to be done specialties. Specialties such as Endo come to mind. It is the devaluation of what many of us have come to refer to as “Cognitive based Medicine” that is at the heart of the matter.

    As anyone knows there is strength in numbers. It is my proposal that those of us like minded folks in primary care attempt to join forces with these other abandoned and forgotten Cognitive based specialties in combination with the final end consumer of our services the Patients, the American Public as well as the employers who are presently being swindled supporting the failed system. We need to create a new organization which represents all of the “Real” interests, the Real Stakeholders, Patient Consumers, Cognitive Based Specialities lead by those of us in Primary Care who so Get It and refuse to be fooled again or to allow these other less ethical, blinded by their own greed and vested interests, those Stake Holders, including our own already Rudderless and Co-Opted AAFP and AAP like organizations. Those ships are already adrift and goind down, never stopping and considering the real impact upon everyday small and solo doctors or their patients the insane impacts of the newest quality proposals, they are sorry and lost to the currents band wagon jumpers with blinders on and I for one refuse to follow their continued misguidance a moment longer. They have lead us on this road to ruin and I and my fellow independant thinkers know it is time to unfortunately let them fl0under, run adrift or sink under their own misguidance and poor foresight and management. Anyone who thinks primary care is best served by striking deals with the likes of Coke Acola has shown themselves to obsolete and probably beyond salvage and repair.

    So let’s get together with our customers, our patients, the American Public and our fellow Cognitive Based friends and allies to form a new and separate organization founded on the principles of returning the “Real” stake holders to the valuation negotiation table…. the hard working cognitive based medical specialties, especially primary care in combination with the people who need and consume our services, our patients, our customers, the American Consumer….

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