Family Medicine 2015: Our Moment in History John Saultz, MD Professor and Chairman OHSU Family Medicine.
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Family Medicine 2015: Our Moment in History John Saultz, MD Professor and Chairman OHSU Family Medicine 1. To share the story of how our discipline’s new strategic plan, Family Medicine for America’s Health, came about 2. To outline the plan’s core recommendations 3. To explain why this project is important for every person in this room and for those we serve 4. To describe the choices facing each of us when we return to our work next week Family Medicine as Reform Family Medicine’s creation myths The reports of 1966 (Millis, Folsom, and Willard) Family Medicine as counterculture reform A re-birth of general practice The family in family medicine The first decade: 1969-1979 Recognition and legitimacy Growth of residencies Reformist zeal “Since the days of Virchow, medicine has committed its whole heart to the belief that diseases are fundamentally protoplasmic in nature, and that if we could only understand the molecule, we could not only conquer disease but perhaps even death itself. Like a garishly glittering and fascinating, but increasingly obscene sideshow, medicine has become obsessed with its technological legerdemain. It does its tricks automatically and passionlessly, without noticing that the faces in the crowd show less astonishment than fear, less amazement than disgust, less pleasure than anger. Along the way, there have been some brilliant and gratifying successes using the man-as-machine research model. But now we are finding that our singleminded commitment to this ideology has produced a monster- a monster that has has at least as much power to harm as to help and that threatens to bankrupt us if we continue to worship it. Medicine has not noticed that the tides of its intellectual fortune have gone out in the past 75 years. Now it is grounded on a shoal and is alone because, in the euphoria of its halcyon days, it was guilty of overweening pride - what the theologians call hubris. Modern medicine has no philosophy of science or mind, no anthropology, no concept of history, no ethics- only power.” Stephens GG. Family Medicine as counterculture. Family Medicine Teacher 1979; 11:5. Achieving Recognition 1980-1990 Institutionalization in practice and in academic medicine Tempering reform with collaboration Expanding medical school curriculum Family physicians as residency teachers 1990-2001 Managed care: a story of false hope Residency expansion The rise and fall of student interest The Future of Family Medicine Project Little proof Accountable for outcomes Care coordination programs Team-based Expanded scope of practice Providers Communities Patients Contextual Coordinated Comprehensive Continuity access Lots of proof Expanded access The New Millennium 2001-present The patient-centered medical home Personal physician or practice architect? Rising costs and broken promises New collaborators The demise of the public sector Adaptation strategies in today’s world Employment Direct primary care Today’s Family Practices Independent practices: 20% Community Health Centers and other publicly supported practices: 35% Health system practices: 35% Academic practices: 10% Traditional comprehensiveness is shrinking when measured at the physician level Maternity care Hospital care Care of children Emergency care Nursing home care Office procedures Should we measure comprehensiveness by how we practice in teams? Should residencies be re-structured to conform to this new reality? New skills emerging in family medicine Data analysis skills Population care coordination using data registries Preventive care Chronic disease care Utilization management Defragmenting care Team leadership Integration of mental health 1961 US Seniors In 1983! Questions Facing our Discipline Which of our core principles should we keep and which should be changed? Are we here to fit into American medicine or to change it? What can we do to ignite student interest? Is our main goal population health or patient- centered care? Can we achieve both? What price are we willing to pay to make things better? Family Medicine for America’s Health Developed in 2013-14 by eight family medicine organizations Purposes: Re-define the role of the family physician Re-define the functions of the PCMH model Ignite a social revolution to reform the nation’s delivery system Increase the attractiveness of family medicine to students Implementation to take place between 2014 and 2020 2014 Role Definition Family physicians are personal doctors for people of all ages and health conditions. They are a reliable first contact for health concerns and directly address most health care needs. Through enduring partnerships, family physicians help patients prevent, understand, and manage illness, navigate the health system and set health goals. Family physicians and their staff adapt their care to the unique needs of their patients and communities. They use data to monitor and manage their patient population, and use best science to prioritize services most likely to benefit health. They are ideal leaders of health care systems and partners for public health. Phillips et al. Annals of Family Medicine 2014; 12(3): 250-5. Health is Primary: Family Medicine for America’s Health Phillips RL, Pugno PA, Saultz JW, Tuggy ML, Borkan JM, Hoekzema GS, DeVoe JE, Weida JA, Peterson LE, Hughes LS, Kruse JE, Puffer JC. Health is primary: family medicine for America’s health. Ann Fam Med 2014; 12(Suppl 1): S1-S12. Patients can expect that every Family Physician will: • • • • • • Give them the care they need when they are most vulnerable. Care for them regardless of age and health conditions, and work to sustain an enduring and trusting relationship with them. Be each patient’s first contact for health concerns. address all of their health concerns, and resolve most of them. Help with preventing, understanding, and managing illness. Navigate the health system with them, including coordinating with specialists and staying connected with patients before, during, and after time spent in a hospital. Set health goals that adapt to each patient’s needs as defined by them With the care team, use data and best science to prioritize and coordinate services most likely to benefit their health. Use technology to maintain and enhance access, continuity, and relationships, and to optimize patients’ care and outcomes. Patient can expect that every Family Practice will: • Provide the right care, at the right time, at the right cost. Ensure patients can be seen by their family physician or a member of the care team whenever they need to. Assist patients with all of their healthcare needs. Coordinate their care across settings; integrate care for acute and chronic illness, mental health and prevention; and guide access to specialist care when needed. Organize care within the care team in order to meet their needs and provide continuity of care across time. Use technology to maintain and enhance access, continuity, and relationships. Understand the effects of the community-level factors and social determinants of health on their well-being, and identify community resources available to meet their health needs. Care for them in the context of their family, and the ways in which the health of each family member impacts the others. The American people can expect that: 1. Family Medicine’s leadership will we l c o m e collaboration with patients, employers, payers, policy makers, other primary care professionals, mental health providers, and public health to enhance the value and benefits of primary care, particularly the contribution that family physicians make, in meeting the health and healthcare needs of people throughout the United States. The American people can expect that: 2. Family medicine will work to ensure that every person in the United States understands the value of, and has the opportunity to have a personal relationship with, a trusted family physician, or other primary care professional, in the context of a medical home. The American people can expect that: 3. Family medicine will, in collaboration with our primary care partners, be accountable for increasing the value of primary care for the patients we serve; This means we will, using specific measures: o Lower the total cost of care for the patients we serve. o Continuously improve the health and quality of care of the patients we serve. o Continuously improve each patient’s experience of, and access to, care, emphasizing the patient’s definition of both. The American people can expect that: 4. Family medicine will collaborate with national stakeholders to reduce health disparities in the United States. 5. Family medicine will lead, through ongoing outcomesbased research, the continued evolution of the Patient Centered Medical Home to ensure it is the best way to deliver comprehensive, patient-centered care to the patients, families, and the communities we serve. The American people can expect that Family Medicine will: 6. Family medicine will work to ensure that the country has the well-trained primary care workforce it needs for the future through expansion and transformation of training from pipeline through practice. The American people can expect that Family Medicine will: 7. In order to give patients the comprehensive and coordinated care and attention they deserve, family medicine commits to moving primary care reimbursement away from fee-for-service and toward comprehensive primary care payment* as quickly as possible. Accountable for outcomes Community Connections to Reduce Health Disparity Expanded Scope of Practice Robust Population/Public Health Capacity Providers Communities Patients Contextual Coordinated Comprehensive Continuity access Fully Integrated Mental/Behavioral Health Julian Tudor Hart “ Real social change depends on the mobilization of those social groups who will gain from it, against those who will (or think they will) lose; the effect of publications, heroic personal examples, and all the rest, depends entirely on the extent to which they assist in such a mobilization” “In general, the expectations of new recruits to primary care are still going to collide with a reality which they themselves must change” Hart JT. Relation of primary care to undergraduate education. Lancet, October 6, 1973. Julian Tudor Hart “The new departments should be teaching a disciplined anger, not against people, but against attitudes and situations that impede the effective delivery of medical science to sick people. Without such anger, the new young doctors will be brought up by the areas of gracious medicine; and anger without discipline is mere cursing.” Making FMAHealth a Reality American medicine is in greater need of reform than ever before and we are still in a perfect position to lead this reform. To do this, we must truly empower our patients and communities to demand change. This will require instilling disciplined anger in them, not just demonstrating it ourselves. We must embrace the Triple Aim as the delivery system’s primary objective and use it to measure our progress. Making FMAHealth a Reality Medical schools have broken their social contracts with the public and should not be the primary focus of our reform efforts. But medical students are essential to our future and we must not abandon them. Many family physicians are being co-opted by health plans and health systems in ways that are contrary to the public interest. Health systems that are focused on the welfare of hospitals and medical groups rather than the health of the public should not be condoned. We must not be afraid to break ranks with them. We have focused too much on observing and teaching about what is wrong with health care and not enough on inventing and testing solutions. Making FMAHealth a Reality Medicine will cease to be a healing art if we continue to allow biomedicine and commercialism to define its agenda. We must not remain silent about this. We cannot accomplish needed delivery system restructuring without comprehensive payment reform. Apparently this will require drastic actions on our part. We should not shy away from taking these actions. Our five core principles remain essential. Access and Continuity The care we provide must become more accessible. To be relevant, we have to be available when patients need us. Care teams can be used to improve availability, but for critical events in patients’ lives, we must be personally available. Communication technologies can greatly expand our personal availability if we learn to use them more systematically. Coordination of care and Population Health With electronic information systems, we finally have the tools needed to master population health for our communities. We need to understand much more about how to measure and improve population health. This will require mastery of information technology beyond our current skill set. Comprehensiveness and Patientcenteredness We must not abandon a comprehensive scope of care, but comprehensiveness can be achieved by teams and by partnerships with specialists. Family medicine must remain committed to the contextual care of people in continuous personal relationships over time. We care for people, not just their diseases. Are we willing to: Make a personal commitment to patients and their families that we will be available when they need us? Have difficult conversations with our partners to achieve consensus about basic practice values? Insist on payment reform and empower patients and communities to lead this effort? Find a balance between collaboration and reform in our day-to-day interaction with the rest of the health care system? Make a personal commitment to the next generation? May 1978 “A review of the literature published in the past 2-3 years on family practice reveals an incredible rate of growth for this newest branch of medicine. This growth is largely due to a very real public demand not only for more primary care doctors, but also for doctors who are willing to have closer personal relationships with their patients. Family practice is already having a major impact on career choices by American medical students and is providing a real alternative to sub-specialization. It is my opinion that family medicine can effect a major change in the health care delivery system of the United States. Whether or not it reaches this potential depends largely on the quality of its educational programs and on its ability to coexist with other medical and surgical specialties. There can be little doubt about the economic benefits of this new system, and the patient satisfaction is welldocumented. Finally, family medicine offers a unique opportunity to advance the quality of primary medical care. It is a specialty that will be built largely by today’s generation of doctors. Such an opportunity may not soon arise again. ”