Keep doing what you do best; change what needs to be changed

Tags: president, ragle, president's letter, health care reform

An adaptation of the 2014-2015 incoming president’s address

By Dale Ragle, MD
TAFP President, 2014-2015

It is an honor and a privilege to serve my fellow family docs as TAFP President. There is no other group of people that I would rather serve and give my time to than you. I represent all of you, whether you are a solo, rural doc in west Texas where you may be the only doctor within 70 miles, a doctor in a big multi-specialty group, a resident in training, or a medical student aspiring for a career in family medicine. You all deserve my service and attention and you all shall get it.

The last three members to serve as president of our organization have initiated their terms with inaugural speeches about change and reform of our health care system. I too will tell you that our health care system is indeed changing and we are going to have to adapt in some way. The forces driving this change are bigger than TAFP, they are bigger than AAFP, and they are bigger than the AMA.

The Medicare program is a case in point. Our population is aging and the baby boomers are entering their Medicare years. At the same time, fewer and fewer taxpayers are paying into the Medicare system, putting the program in an untenable financial dilemma. Without some sort of change our Medicare program will go bankrupt. Now, different prognosticators give different dates on when this will occur, but, suffice it to say this is an economic reality facing our political leaders.

Something has to be done. Change and some sort of reform are coming, whether we like it or not. It is not the role, as some would like, of our professional organizations to try to stop reform or to slow it. Rather, I believe the role of our Academy is to be a voice which will guide reform and offer constructive solutions and alternatives.

Total health care expenditures are continuing to rise. And it is very likely, in the near future, that the fee-for-service reimbursement model will fade away and will be replaced by a new payment model that emphasizes quality over quantity. Medicare is likely to move away from the widely unpopular SGR formula for reimbursement to some sort of pay- for-performance model. Private insurance is sure to follow.

In talking about all of this, it is important to point out that the amount of health care dollars spent on primary care, relative to the amount spent on hospitals, costly procedures, and specialty care is still miniscule. Exact numbers are difficult to obtain, but I saw one calculation which took the total average payments to primary care practices and divided it by the average number of total patients in a primary care practice. Using this calculation methodology, the average primary care practice gets about $144 per patient per year. When you consider that most insurance premiums are around $7,000-$10,000 per year or more, and Medicare dollar spending per beneficiary is around $10,000, that would amount to roughly 2 percent of the insurance premium going to primary care practices.

Even if these calculations are off by 50 or 100 percent and the real number is 3 or 4 percent, that is still a drop in the bucket of total health care costs. It is suffice to say, that primary care expenditures are not significantly contributing to Medicare’s or the private payer’s budget crises. For years now our organizations have trumpeted the many studies that clearly show that areas with higher concentrations of primary care physicians relative to specialists have lower health care costs than areas where the reverse is true. Hence, better access to primary care services lowers health care costs.

It does not take a rocket surgeon (to mix metaphors) to see that in this era of revamping payment methodology, if payers and policymakers want to reduce overall health care costs, they should invest in expanding primary care.

It’s a very simple concept. Sort of like purchasing a fuel efficient car to reduce your transportation costs. Family medicine offers a very efficient vehicle to deliver health care. Expanding access to family medicine provides a great value for policymakers and payers to improve the health of the nation and lower health care costs. In this vein, we need to promote expansion of our family medicine workforce. We must redouble our efforts to promote family medicine in our medical schools and encourage students to choose our specialty. We must also advocate for robust funding and expansion of family medicine residency training slots. It’s a message that needs to be carried loud, clearly, and often. I encourage you to continue to contact your state and federal elected officials with this message. Using the car analogy, this is sort of like promoting the manufacture of more fuel efficient cars. I give you my permission to use that analogy when talking to policymakers.

I believe that the value of family medicine lies in the fact that we know our communities and our patients better than anyone. Simply speaking, you know that lady who comes into your office complaining of headaches had a husband pass away a year ago, has a pregnant teenage daughter at home, and may not need a brain MRI. You know that 35-year-old guy coming to you with heart palpitations has a seriously ill child at home, works at a local company undergoing layoffs and may not need an extensive cardiac workup. No one knows your patients and your community better than you do. Maintain that pulse that you have on your patients’ lives and let it be the beacon that guides you, whatever changes the health care system throws your way. Keep doing what you do best. Change what needs to be changed.

Those of you in solo and small group practice may ask yourself the question, “why can’t I just go on doing what I have always done?” After all, I have always done well by my patients, and I believe that you have. Unfortunately, the cold hard truth is that whenever someone else is paying for health care, whether it is the government, private payer, or an employer, we are not totally independent. Change was and is inevitable as we cannot really expect for someone else to continually pay the bills and not eventually exercise oversight in how their money is spent.

We recognize that the current plight of the physician in solo and small group practice is difficult. I’ve been there. However, because of your value to our health care system, we also have a great opportunity to promote our profession to policymakers and payers with the goal of providing positive changes and opportunities for you.

TAFP is here to help you navigate these waters and assist you in your progress. For example, our board of directors recently commissioned a task force on payment reform. The major charge of this task force was to provide TAFP with ideas to help you navigate these changes, whether you are in solo practice, large group practice, or are employed. AAFP is doing similar things on a national level. The task force has completed its report and I have read it. One of the ideas being bandied about is a concept known as direct primary care. This delivery model essentially eliminates the burden of public and private payer systems by targeting services directly to the patient as purchaser. There are practices thriving today by charging small, affordable monthly fees – often $30 to $40 per month – to patients in this direct primary care model. The details of setting it up are well beyond the scope of this column, but stay tuned. Your state and national organizations will be able to help you explore this idea in the near future.

For those of you interested in navigating other models of delivery coming down the pike, such as the pay for quality model, we will be here to help you with that as well. We plan to develop toolkits to help you monitor quality in your practice. We will also promote communications and organization between colleagues in your communities and provide access to mentors who can assist you with practice and infrastructure transformation. Whatever model eventually lands in your practice, keep doing what you do best. Change what needs to be changed.

I believe that the physician who took care of me when I was growing up was a doctor like you. I remember him always being there for us on a moment’s notice. In today’s parlance, that would be known as same day appointments or acute care visits. I remember him politely chastising my mom when we showed up at his office about 30 minutes after she called with him knowing that we lived 40 miles away. I guess he calculated that we would have had to have traveled an average of 80 mph to get to his office in that time frame. He then proceeded to tell her not to get us killed just so we could come to him and try to get well. It’s important to note, that he did this in an era before there would have been a check box in an electronic health record attesting that he had counseled the patient about automobile safety. He did this because he cared about us, wanted us to be safe and wanted us to know that he would have been available, even if we showed up to his office a few minutes late. It just came naturally to him because he cared. I’m sure that 99 percent of you are like him.

I want you to keep being that doctor. We will do everything in our power to enable you to do that. Caring comes natural to you. It is the essence of your value to the health care system. It is what you do best. Keep doing what you do best. Change what needs to be changed.

Dale Ragle, MD, practices family medicine with the group Dallas Family Doctors in Dallas, Texas. He received his medical degree from the University of Texas Medical Branch in Galveston and completed his postgraduate training at the Baytown Family Medicine Residency Program affiliated with University of Texas Health Sciences Center at Houston. He has been a member of TAFP since 1991 and has been a member of the AAFP since 1987. During his tenure at TAFP, he has served on the TAFP Board of Directors, Executive Committee, Commission on Legislative and Public Affairs, Commission on Health Care Services and Managed Care, and TAFP Foundation Board. He is also a member of the Texas Medical Association and the Dallas County Medical Society.

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