Posted 9/20/12 on Medscape Connect’s Care and Cost Blog
This week the American Academy of Family Physicians (AAFP) issued a new report describing its vision of primary care’s future. Not surprisingly, the report talks about medical homes, with patient-centered, team-based care.
More surprisingly, though, it makes a point to insist that physicians, not nurse practitioners, should lead primary care practices. The important questions are whether nurse practitioners are qualified to independently practice primary care, and whether they can compensate for the primary care physician shortage. On both counts the AAFP thinks the answer is “no.”
AAFP marshals an important argument to bolster its position. Family physicians have four times as much education and training, accumulating an average of 21,700 hours, while nurse practitioners receive 5,350 hours.
Relative to their specialist colleagues, primary care physicians have been generally passive about the politics that shape their professional lives, and they have been big losers. It is important for them to consider whether their societies are genuinely acting in their interests. I believe the evidence overwhelmingly reflects poor judgment by the societies that has diminished primary care’s prospects and, more importantly, caused significant harm to patients and purchasers.
Over at the ACP Advocate Blog on Wednesday, ACP Senior Vice President of Governmental Affairs and Public Policy Bob Dohertytook me to task for asserting that the American Academy of Family Physicians is the only “pure” primary care society. He’s right, of course, in the sense that the American College of Physicians (ACP), the American Academy of Pediatrics (AAP) and the American Osteopathic Association (AOA) have done yeoman’s work in the past few years in promoting the value of primary care. He’s also right, and I stand corrected, on my statement that AAFP is the largest society. The information on Wikipedia shows that ACP has 130,000 members while AAFP has less at around 100,000.
Last June the American Academy of Family Physicians (AAFP) sent a letter to the AMA’s Relative Value Scale Update Committee (RUC) demanding specific changes to the ways that the RUC conducts its business. Primary care has been severely compromised by the RUC’s recommendations, and there was an implicit threat that the nation’s largest medical society would withdraw if the demands were ignored.
I co-authored a Kaiser Health News article in January 2011 calling on AAFP and other primary care societies to quit the RUC. The campaign was given real teeth when six Augusta, GA primary care physicians filed suit last June in a Maryland federal court against the US Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS). The complaint charges that those agencies have refused to require the RUC to adhere to the stringent requirements of the Federal Advisory Committee Act, which ensures that policy is formulated in the public rather than the special interest.
First published 8/1/11 on Common Sense Family Doctor
Below is the text of a proposed resolution that will be submitted by the District of Columbia Academy of Family Physicians to next month’s Congress of Delegates of the American Academy of Family Physicians in Orlando, Florida.
WHEREAS family physicians rely on current, unbiased sources of evidence-based guidelines to select appropriate screening tests and counseling services for their patients;
WHEREAS the primary source of evidence-based prevention guidelines for family physicians is the federally-sponsored U.S. Preventive Services Task Force (USPSTF), whose recommendation statements commonly serve as the basis for AAFP clinical policies on preventive services;
This morning, the American Academy of Family Physicians, the largest and “purest” of the major primary care societies – the American College of Physicians (ACP), the American Academy of Pediatrics (AAP) and the American Osteopathic Association (AOA) are all heavily influenced by sub-specialists – announced that it has convened a national task force charged with identifying new, better approaches to value primary care services.
This initiative is nationally significant for several reasons. By definition, it challenges the methodology used for nearly two decades by the American Medical Association’s Relative Value Scale Update Committee (AMA RUC), which has drastically under-valued primary care services while over-valuing many specialty services. By taking on this effort, it not only announces that the fruits of the AMA RUC’s labors are unacceptable, but also points out that the methodology the RUC uses to value medical services – this is founded on the Resource-Based Relative Value Scale (RBRVS) “input” taxonomy developed by William Hsaio’s team in the late 1980s – is incomplete and outdated. For example, the RUC’s methodology for calculating value doesn’t consider whether a service produced a worthwhile benefit to the patient or society, whether it was evidence-based or even necessary. More on this in a future article.
Over the past four months, the germ of a long overdue primary care uprising has sprouted and begun to flower. When David Kibbe and I first tried to think through how to neutralize the RUC’s terrible influence on American health care, we realized the first steps had to be the primary care community’s refusal to continue “enabling” the RUC – we meant this very much in the clinical sense – through its continued participation and complicity. When the game is rigged against you, there is no benefit in staying at the table.
Primary care societies would visibly and noisily abandon the RUC, with the understanding that quietly walking away would be counterproductive in the extreme. It should be a highly publicized exit, filled with righteous indignation and clarifying for the American public how the RUC’s actions and relationship with CMS have shafted patients, primary care physicians, and the people who pay for health care in America.
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.
A few weeks ago, my writing partner David C. Kibbe and I ran an article on Kaiser Health News called “Quit the RUC!” that has caused some turmoil within the physician community, particularly in DC.
First, it noted that the RUC, the informal specialist-dominated AMA panel, has made recommendations for 20 years about the value of medical procedures within the highly arcane and jiggered Resource-Based Relative Value Scale (RBRVS). As the Wall Street Journal recently reported, CMS (and its predecessor, HCFA) has accepted some 90 percent of its recommendations, apparently almost without question. It shouldn’t surprise anyone that the vast majority of recommendations involve payment increases to specialists that have come at the expense of primary care.
Here’s an extraordinary development in the ongoing efforts to break down the barriers of a lack of interoperability standards and incompatible technologies!
The American Academy of Family Physicians has partnered with Surescripts, a firm that connects physicians with drug prescribing services, to announce a new collaboration, AAFP Physicians Direct, that will allow the AAFP’s physician members to easily and securely exchange information electronically.