GME Funding for Family Medicine Residencies Must Be Preserved.. Now!

In a letter from the ACGME to the American Board of Medical Specialties, American Hospital Association, American Medical Association, Association of American Medical Colleges, and Council of Medical Specialty Societies, the ACGME warns of consequences that could occur due to proposed cuts in Medicare Graduate Medical Education (GME) funding. GME funding is the main source of financial stability for residency programs that train this country's medical interns and residents - the pipeline of production for physicians.

These cuts would threaten:

• The availability of residency positions to produce new physicians
• Access to care for the Medicare population
• Access to care for the underserved, underinsured, and uninsured
• Community-based primary care residency programs which produce primary care physicians that typically serve in rural and other underserved areas
• The distribution of primary care residency slots in multi-specialty institutions towards more lucrative sub-specialty training which reimburse the institution more for procedural rather than preventive care
• Residency training in general with the possibility of support from industry (insurance companies, pharma, etc) and/or implementation of tuition for residency training
• Entering clinical practice after one year of internship to repay student debt resulting in the undereducation of practicing physicians

The Association of American Medical Colleges provides a variety of resources explaining the importance of GME funding, including their advocacy to increase the amount of funding for GME in order to prevent/slow down a shortage of physicians. This includes a letter to President Obama sent on 5 July 2011 urging the President to preserve GME funding.

The American Association of Colleges of Osteopathic Medicine took it a step further by initiating a member-driven action alert. This alert allows members and non-members to submit emails and letters to their representatives in an effort to generate more than the usual auto-generated email response from our elected officials.  The AACOM also submitted a joint letter with the American Osteopathic Association to Congress opposing cuts to GME.

The American Academy of Family Physicians focus in on primary care, asking its members to take action on its Speak Out Grassroots Advocacy site by contacting legislators to specifically preserve primary care.

"The deficit reduction conversations continue. Lawmakers are re-thinking Medicare’s Graduate Medical Education (GME), and at this critical time, they should be reminded of primary care’s importance. Our representatives have an opportunity to change this program so that it encourages the innovations in primary care training that will help build a workforce our communities can count on."

So, where is the American Medical Association and the American Academy of Pediatrics?

Currently on the homepage of the AMA, they are worrying about the Independent Payment Advisory Board (IPAB) as well as a decrease in Medicare payments for diagnostic imaging.   It seems like CMS is starting to do the work that the RUC should be doing to decrease overvalued services?  Apparently this is more important than worrying about cuts to GME.  The AAP does not seem to be worrying about much of anything.  The ACP has submitted a letter to the President and Congress urging for a debt ceiling agreement which addresses GME, but nothing really focused on GME.

The AOA had no problem leading the way as one of the first medical organizations to take action.  The ACP continues its support for primary care, though it is easy to tell they do so very cautiously to keep its medicine sub-specialty members content.  Will the AMA step up at the sake of losing support from its specialty members to help save funding for primary care?  Or will they issue a blanket statement asking to preserve GME funding in general while still knowing that the preservation of GME funding does not necessarily mean the preservation of primary care training.  It may mean the shifting of more training towards specialties that get paid more for procedures...  who funds the RUC again?  Who makes money off of coding books with codes for procedures for which the RUC makes recommendations to CMS for reimbursement rates?  I digress...

Any cuts to GME that do not preserve funding specifically for primary care could be catastrophic, especially for programs that can barely get by with the current level of funding.  GME cuts that do not preserve or increase primary care residency funding will continue the current shift in our physician workforce that favors specialization and does not value primary care.  It is at times like these when I am most thankful for choosing a family medicine residency in the military - a health care system that actually appreciates and values primary care as its foundation for health care delivery.

Are We Providing Health Care, or Just Delivering Health?

As a medical student I have come to appreciate two core goals of Health Care:

1) Health: The delivery of medical knowledge, assessment or treatment to a patient

2) Care: The compassionate approach to any patient

As a medical student I have also witnessed clinical medicine practiced across a spectrum of situations. Taking my time to reflect on these experiences, I am not certain we are meeting our goals. Too often I have watched a flurry of attendings rush from bed-side to bed-side, witnessed residents spend far more time in front of a computer screen than holding a patient’s hand. I am not arguing the nature and necessity of our modern system, rather I hope to ask a major question:

Do we get so caught up in the delivery of our health care, that we sometimes neglect the care itself? Are we providing health care, or simply delivering health?

Allow me to frame this in another way. Have you considered the definition of the word “care”? One that I rather like defines care as a “watchful attentiveness”. How often are you watchfully attentive to your patients? What can be said about the nurses, residents or staff working with you?

At the same time that medical advances allow immediate, efficient, and direct monitoring of patients, these same technologies can so easily disrupt our watchful attentiveness. New systems, with built in redundancies and alerts have the potential to incentivize complacency and interrupt the patient-physician relationship. I often overhear residents or attendings say, “Don’t worry about the patient in room 246 until the lab results come back. There is nothing we can do until then.” The consequence of this attitude represents a negligence to the value and importance of physician compassion.

Nothing we can do? What happened to kind words, reassurance, and the offering of a comforting hand? Sure the electronic record may show normal cardiorespiratory monitoring, no new nursing communications, and no updated lab results – but there still exists a patient, sitting in a hospital bed. Possibly alone, likely insecure, and almost definitely in need of your care.

Again, I am not arguing that our current system is ineffective in delivering health, nor am I contending the decisions of my peers and superiors. I have a profound respect for the urgencies and constraints of our modern health system. But I believe that, in any area of life, self-reflection is necessary for growth.

Somewhere along our medical journey, as we agreed to see more patients then we could handle, and developed advanced technologies that separate patients from caregivers – we may have lost sight of a simple fact. Fifty percent of our mission as physicians delivering health care is to provide that care to our patients. To be watchfully attentive over them. Consider – are we providing health care, or just delivering health?

Physician Communication: The Next Generation

Imagine using skype to contact your physician for a consult…..now stick with me….

In the midst of this rapidly progressing technologic era, our delivery of medical services is being transformed by Health Information Technology (HIT), Electronic Medical Records (EMR), and advanced telecommunications. In meeting criteria for “Meaningful Use”, physicians are driven to use these technologies to empower patients with communication through electronic medical records. A primary goal is to allow patients to obtain electronic copies of their medical records and share their health information securely over the Internet with their families. An overarching goal is to increase patient accessibility and communication with a physician to bolster continuity of care.

Communication. It all comes down to communication. This accessibility for patients to immediately communicate their worries of symptom or illness to a physician. The opportunity for physicians to instantaneously respond. As we embrace these technological opportunities of communication, physicians are open to new modalities for health care delivery – office visits can be supplemented not only by telephone calls, but now email, Skype, gchat, or any other imaginable resource or emerging technology.

Under the current Medicare payment system, a physician can only be paid for seeing a patient in the office. On my clinical rotations, I have witnessed an increasing number of physicians who respond to patient emails through secure health care portals. These emails promptly and conveniently enable a physician to address patient concerns. In the event that an email is not satisfactory to do so, the physician simply asks the patient to schedule an office visit. Our physicians should be reimbursed for this time.

CPT Codes exist for non-face-to-face services, including telephone calls, but these codes are not included in payment models through Medicare. Further, there is currently no established method of payment for any advanced telecommunications counseling or physician interaction.

Online physicians counseling has been increasing in the past five years – charging around 25$ for a five minute consultation – WITH the ability to provide personal prescription. These sort of interactions may be able to address simple patient questions, but really may go a long way towards harming the bond of the patient-physician relationship. Interactive care simply cannot be coordinated within the confines of a five minute video-chat.

However, I believe that there is an ever-increasing potential for the integration of these video-chats, and other counsel through advanced telecommunication, as a compliment to the traditional office visit. Imagine the typical family physician that holds normal office hours for patients throughout the day. Suppose that from, say, 1-2pm each day that physician also chose to hold online “office-hours” for any of the patients within his practice. During this time, patients could address basic questions, initiate follow-up issues, or discuss health maintenance. Just think of the wonders of diabetic counseling!!! A family doctor would have the accessibility to voice chat with a difficult or non-adherent patient once each week for five minutes, with appropriate reimbursement for time spent.

Nothing can truly supplant the face-to-face relationship between a doctor and patient. That bond and the value of that interaction can not be underestimated. Nor do I believe that proper diagnosis or treatment can be duplicated across a platform like gchat. However, with ever-rising patient needs and increasing accessibility issues, physician time is increasingly valuable. Patients too may struggle in regularly scheduling and attending office visits. Ultimately, utilizing these technologies would be cost-saving, efficient, could reduce preventable hospital admissions, expedite the identification of acute care instances and decrease time to treatment. For those patients that choose to embrace this modality, this could improve quality and patient satisfaction.

Look out - your family doctor may be armed with a Dick Tracy watch for consultation soon. Calling Dr. Smith……Calling Dr. Smith…..

Home Visits - are they things of the past?

One day in the middle of my third year of medical school, I was walking home from clinic when I met the Assistant Dean for Academic Affairs of my school, a general internist, walking down my street. We struck up a conversation and, when I asked her what she was doing on my street, she mentioned that she was doing a home visit for one of her patients.

"Home visit?" I responded in surprise. "You mean doctors still do those?"

"Yes, for a few of my patients who are home-bound."

Even though less than 100 years ago most doctors only did home visits, I had thought that today the home visit was a phenomenon restricted to only rural areas. The reasons?

• Doctors just don't have the time nowadays.
• Doctors can't afford to do it financially!

Little had I thought that I'd see my Assistant Dean, an incredibly busy administrator and clinician, doing home visits.

Right now, a year later, I'm doing a geriatrics rotation. During my geriatrics rotation, I spend a couple of days in clinic, a couple of days at nursing homes and rehab centers and the majority of my days doing home visits. Our school's geriatrics department is structured such that all patients who are home-bound are seen in their home environment.

Last Tuesday, my first day doing home visits, I started the day questioning the value of home visits. It was over 90 F outside and humid and, as we trekked up a hill to my preceptor's first patient, she warned me that most of her patients didn't believe in or couldn't afford air conditioning. But as soon as our first visit began, my position started to change even though sweat was pouring down my face and arms. I learned that Ms. H was falling all the time because she had numerous rugs in her apartment. I talked with Mr. E's building manager about the numerous times Mr. E had flooded his apartment and how he was at risk for eviction. Despite Ms. M's assertions that she took her meds regularly, I learned that she didn't because months worth of meds were sitting on her kitchen counter.

And not only were we clinicians learning more about our patients, the patients were also much more comfortable in their home environment. Especially for elderly patients many of whom are hearing or sight impaired, navigating a hospital or clinic's reflective floors, fluorescent lights and white walls can be frightening.

So, can we, as future family doctors, incorporate home visits into our future practices? One half day a week for our patients who need it? I would challenge each of us to leave the comfort zone of our offices and clinics and enter into the homes and communities of our patients. It is there that we can best serve them!

Advice for a First Year Medical Student

I recently had quite a long conversation with a college senior that was just accepted into medical school for this coming fall. As a rising fourth year medical student myself, I would like to think that I have navigated the waters of academia and figured out both efficient paths to success and avoidance of roadblocks and setbacks. However, I was quite overwhelmed with the number of questions and concerns that this particular student had. But in retrospect, I can recall my own naivete and fear of the unknown that is medical school.

After answering all of his questions, I realized that many soon-to-be first years may not have the advantage of mentors or advisers. Lacking guidance, students are willing or forced to charge forward and hope for the best. These are the same students that suffer the inevitable fatigue and burnout. But I believe that there is a smart and efficient way to approach medical school. That is not to say there are any shortcuts or cheats. Rather, I wanted to share with you my advice on 5 easy steps to being a better medical student from day 1.

1) Be willing to be selfish

You must be willing to prioritize personal time and to continue to do the unique things that make you who you are. And trust me, the time can be found in any rigorous program. Doctors aren't robots, and you should never plan to train like one. Medical school must be a time for you to continue to develop your hobbies and your personality. These are the individual characteristics that will make your patients love you one day. More importantly, these are the activities that will keep you both sane and free from stress.

2) Get 8 hours of sleep

No debating this one. First the benefits – you will study better, be healthier, and feel happier. There are enough distractions and obstacles built into the medical education that you should not be adding to the list. Sleeping in class, rereading text, and mental sluggishness are not paths to engaging the curriculum. Turn off the light, set your alarm, and keep track of your sleeping schedule. After all – you are training to be a doctor who will one day advise patients on healthy practices. Limit the sacrifices you make in your own health along the way. Healthy eating and regular exercise follow, as well.

3) Subscribe to just one health policy daily email or news blog

Medicine, particularly in the modern world, has much importance beyond the realm of clinical information. As a doctor, you will one day be called to be a leader, and your understanding of health policy and health systems will drive your success. You do not have to understand every sentence, or even read every word. But be open to absorbing what you can so you will be better aware of health care on-goings. The future of medicine is in dynamic health delivery systems. While you're cramming over the Krebs cycle, take a five minute break to review the latest info on real-world medicine issues. ACOs are being built and discussed right now – embrace that change and learn as the systems are being designed. (Feel free to email me for the full list of my daily subscriptions – aaronge@pcom.edu). Read during rounds when your attending is off ranting about something esoteric and his back is turned. Read it while your on the bus or in the bathroom. Again, time can be found if you look for it.

4) Study Smart

There is a difference between studying for a test and studying to be a doctor. While these two goals sometimes coincide, they are often very different in nature. I find that, for some reason, medical students have difficulty wrapping there minds around this concept. Here is what I mean – medical students often look to prepare for exams as if they need to know everything about a given subject. Buying multiple textbooks and review guides is more than common. Gaining this knowledge is the right thing to do, and will make them a better doctor in the long run. But it may distract you from your goal of doing your best on given test – and worse, it may lead to burnout. If an exam has questions that are drawn from lecture, then information outside of lecture is irrelevant for the scope of that test. You need to make a personal decision as to how much supplemental information you need to be successful. I'm not telling you to take any shortcuts in learning medicine, I am telling you to be prepared for what matters. You have at least 7 years to go through medical school and residency, and then a lifetime to practice. You cannot possibly learn everything in a day, month, or year. Don't sweat the details during your first year, anymore than is already forced on you.

5) Smile

As easy as this simple act sounds, this may be the most difficult of my suggestions. But stick with me! I am a firm believer in the power of positivity and confidence. You will get through medical school. That is not in question. But you have a choice as to HOW you get through medical school – to complain, suffer, and grieve through the process.....or to enjoy the ride. I believe that smiling, appreciating the best that you have, and keeping a positive attitude effects you in two ways. In the first, you will have the advantage of internal confidence and lower stress. From a medical standpoint, you will be less rattled on test day and benefit from decreased cortisol - both can go a long way! The second effect of positivity is the external impact you will have on those around you. How do you think nurses respond to medical students that complain or look upset during morning rounds. I know that a genuine smile and greeting has led to nurses and residents that have been willing to go the extra mile to offer me support. How do you think an attending or residency coordinator will respond to the stolid student, versus the upbeat one? The truth is that letting in negativity and suffering through complaint are a means of externally expressing defeat. You do not want to be that kind of medical student. Smile, you are living your dream!

I genuinely want all of you to do well, and to be great and successful doctors. After reading many other medical school advice posts on more tangible or “hard” skills, I wanted to offer a different perspective. As always, you have to do what works best for you, and everyone will find success with different methods. But I do hope that some of my advice gives you a different perspective on how to achieve that success. Good luck!

Thoughts from the 2011 Family Medicine Congressional Conference

Ok, I'll start out with a cheat sheet on the important issues and "asks" that we brought to Capitol Hill today. There was a definite sense of urgency to act, and our proposals focused on opportunities to incentivize primary care, without significant budgetary increases.

1) Fix the SGR. Stop kicking the can down the road and get realistic payment stability.
2) In regards to GME, consider a model that would secure a portion of funds specifically to primary care community and out-patient residency facilities.
3) Encourage investment in Title VII funding (specifically section 747) and further support for National Health Service Corps
4) Decrease the gap that exists between primary care and specialty salaries

Now for some reflections on the issues and discussions for family medicine here in Washington, D.C. at the FMCC:

7:00am: Wow, breakfast buffet is great! The AAFP really takes care of their own. Next, I walk into a room of over 200 family doctors convened and eager to descend on Capitol hill tomorrow and breakfast becomes an afterthought. Talk about wow - I'm speechless. I wish every medical student could be here for this program and for the good of the future of medicine.


Hot issues:

Monday, 8am: Models, models, model. You'd think with all the talk of models, their would be a Paris runway close by. Then again, I wouldn't complain if some Hawaiian tropic spokespeople walked through the doors right now.

In all seriousness, there is so much talk of models and systems. I can see that this sort of dialogue is important, as a means of establishing a strong foundation. The reality is that a 400+ pg proposal has been put forward, and we are still in the comment period prior to the final product. But the frustrating aspect is that family physicians function at the ground floor of health care delivery. Its tough to listen to mostly generalized and broad goals, when we all know how important the details really are. I do very much look forward to the proverbial "meat" at the heart of these proposed systems. I am eager to move forward and to see how these models function and to see them in place.

10am: AMA question and answer forum. This session quickly turned into a soundboard for comments. This tells me that family docs know the facts, and are more prepared to have their voice heard than the need to have questions answered. The people in this room have done their homework, and family doctors are hungry for parity and a successful balance in medicine. I'm encouraged by all of this discussion.

11am: Robert Phillips, MD, Director Robert Graham Center. This man is a visionary and his poise is inspirational. He first offers the difference between "Reducing costs vs restraining costs". This a perspective that isn't often considered. Everyone is looking for ways to lower cost, when in fact we should be looking for opportunity to curb spending growth.

Workplace continues to be framed in terms of supply and demand. Figures are often thrown around at the national level that "this many tens of thousands" of physician workforce shortage. The paradigm shift on this is to consider the implications of physician distribution. In fact, when you look at physician demographics, it is apparent that the number of physicians serving in areas of excess could cover the areas that demonstrate a shortage.

That said, it seems that the focus has shifted away from workforce and on to economic impact. That is fantastic news for the primary care front - their is amazing data on the number of local jobs, the economic impact, and cost effectiveness of family physicians. Most importantly, it has been shown that an increase in family physicians in a community led to a correlative decrease in readmissions. Every other specialty showed increases in readmissions with increased workforce in community.

Thought: data, data, charts, graphs and data. Proof and facts are the name of the game in directing change.

One thing that really sticks out to me is the continual rhetoric and future tense employed by many speakers. It seems that words such as "planning", "committee" "considering" "taking suggestions" "reviewing proposals" far outweigh any directions or indication of activity. Right now its a waiting and planning, and few seem to want to take the first step. Which is counter intuitive to the needs of medicine. We have an outmoded system that is functioning on an outdated payment schedule. In order to meet the demands of the modern health care climate, we need to stop the rhetoric and start the reaction. It was clear from the medical student voice, that we demand as quick resolve to act as any group.

2pm: Panel on health reform movement. After spending the better part of the past year and a half focused on health reform, it seems that their is a general health care fatigue on Capitol Hill. On top of this, the magnitude of the funding deficit makes any movement in the positive direction extremely challenging.

Two of the COGME recommendations that struck me: to adequately meet the needs of American health care, it is recommended that the physician workforce be composed of at least 40 percent primary care. The second recommendation was to encourage enhancement in medical school social accountability in training. See my most recent post on this site for some of my thoughts that are right in line with this.


Some other random thoughts:
1). Check out Wellmed a non-hospital aco based in san antonio that is producing outlier numbers in reduced mortality, cost saving, and family physician salaries. (http://www.wellmedmedicalgroup.com/)
2). Its inspiring to meet and see all of the energetic and engaged medical students here. Debt is a huge issue, but these passionate students are willing to sacrifice for the goals of primary care. More apparent is the medical student urge for activity. We are saying, we can't wait, we can't put things off - we need to act now.

Leading New Models of Practice - Accountable Care Organizations

ACO - the newest mysterious acronym from Washington. Just when most of us were getting familiar with the last big organizing acronym, PCMH. Maybe we weren't actually familiar with the 7 joint principles of the Patient-Centered Medical Home (PCMH) and their implications, but we were at least getting comfortable throwing the term around in discussions, networking sessions and conferences, hoping that no one would ever ask us: "So, what is a PCMH?" Now we've been hearing about the Accountable Care Organization (ACO)... is this just the newest street language in health policy or is there more to it than that?

Last Wednesday, I attended a full-day workshop sponsored by the Society of Teachers of Family Medicine on the ACO. We started by reviewing the basic premise of the PCMH: central places to coordinate care focused on patients’ needs and relationship-building. Industry leaders who were fed up with poor care options in America created the concept of the PCMH, which was jointly supported by all national primary care organizations. The PCMH model emphasizes a strong primary care foundation in which primary care providers take responsibility for providing, coordinating and integrating care across the health care continuum. Pilots of the PCMH have shown improvements in quality and reductions in spending when implemented in large provider settings.

The conceptualization of ACOs is separate from the PCMH but there are many parallels. ACOs are organizations that can use payments:

• to incentivize physicians and hospitals to provide care coordination,
  
• to invest in infrastructure and redesign care processes and
  
• to provide high-quality and efficient services.
  

Patient-specific metrics are being developed to evaluate outcomes and quality. An example of a metric would be A1c <9% in those with diabetes or providing a post-discharge physician visit. Participation in ACOs is optional. Providers and hospitals that participate would be accountable for a defined population across care continuum. Benefits for participating? You would also get a share in the cost-savings from this model.

You may be thinking right now - this all sounds great. But what you've given me is a bunch of fancy concepts. Where are the examples? Well, the answer is that there aren't really any good examples yet. The ACO is a new model that was outlined in the Affordable Care Act. ACO rules were just released last month by the Center of Medicare and Medicaid Services (CMS). These rules are still open for comments until June 6, 2011 and then are to be implemented by January 1, 2012. Providers and hospitals at that point can apply to be ACOs.

What does this mean for family medicine and for the PCMH model that we helped develop?

It’s an opportunity to get involved! The weakness of the PCMH model is that there is no incentive for specialists and hospitals to get involved because they don’t participate in the savings. Secondly, there’s little financial incentive for even primary care doctors to get involved because the money saved on emergency room visits, tests and procedures isn’t reflected directly in the pocketbooks of primary care doctors unless payment structures are transformed from the traditional fee-for-service to more innovative payment mechanisms. The ACO model helps align these incentives to achieve much of what the PCMH model desires.

However, the ACO model makes no explicit mention of the centrality of primary care. As future primary care doctors, we must lead in the development and implementation of ACOs if we are to remain relevant in the 21^st century and to continue serving our patients.