Healthcare delivery keeps changing, but patients’ need for lifelong care coordination from a family physician does not, says AAFP president.
The American Academy of Family Physicians celebrates its 75th anniversary this year. Founded in 1947, today it represents 127,600 physicians and medical students. Family physicians conduct approximately one in five office visits – 192 million visits annually, and they provide more care for America’s underserved and rural populations than any other medical specialty, according to the Academy.
But like all healthcare providers, AAFP members face change. Seventy-three percent of AAFP members are employed, over half of those by a hospital or health system. Many family physicians find it difficult to provide home-based care, transitional care, behavioral health counseling and other primary care services under today’s fee-for-service payment system. And they question how and when value-based reimbursement will be fully implemented.
“We face great challenges in healthcare, and it will take the entire healthcare community, working together, to improve our system,” AAFP President Sterling Ransone, M.D., FAAFP, told Repertoire. “I have high hopes for the future of the Academy because I have seen the difference it has made in the lives of family doctors, their patients and communities over the last 75 years. I fully expect exponential improvement over the next 75.”
Dr. Ransone, a third-generation family physician in Deltaville, Virginia, recently responded in writing to a series of questions from Repertoire about AAFP and the profession of family medicine.
Repertoire: In its proposed program requirements for graduate medical education in family medicine, the Accreditation Council for Graduate Medical Education (ACGME) pointed to several components of the family medicine specialty, including that family physicians are generalists who care for diverse individuals in the context of their families and communities, are adaptive learners, and are social justice advocates for their patients and communities. Would you add anything else?
Dr. Sterling Ransone: No other specialty treats a person prenatally, then from birth, through childhood and adolescence, and into adulthood. They coordinate care with other healthcare clinicians and community agencies; diligently stay current on research, practice, and clinical guidelines; and advocate for their patients so they have access to the most appropriate care when and where it is needed. Often a family physician provides this care for multiple members of the same family. Family physicians are integral members of their communities and provide referrals to other medical specialties, social services, and community resources.
Repertoire: On its website, AAFP addresses 1) transitional care management, i.e., the handoff period between the inpatient and community setting, and 2) care management and coordination, i.e., patient education, care planning, managing medications, risk-stratifying populations and managing data, and coordinating care across the health system. Why are these two concepts important to AAFP and its members?
Dr. Ransone: Patients who are diagnosed or hospitalized with serious health conditions often need support from their family physician during the recovery process. Family physicians are the “quarterback” of each patient’s care team, connecting the dots among all care providers and helping implement cohesive strategies for optimum health. Transitional care management, as well as care coordination for chronic conditions, are important components to ensure patients get the comprehensive care they need. In addition, family physicians are now able to bill for these important services, which frequently were not covered by insurance in the past.
Repertoire: AAFP points out that the shift to value-based payment (VBP) often focuses on physicians taking on more financial risk. Are AAFP members prepared to do that? What challenges might they face in transitioning to VBP?
Dr. Ransone: Some AAFP members are prepared to take on financial risk as they shift to more value-based payment. Family physicians face multiple challenges in transitioning to VBP, but there are a few significant challenges I’d like to focus on.
In many respects, VBP requires a different approach (e.g., new delivery models) than traditional fee-for-service payments. Therefore, transitioning to VBP may mean redesigning the practice, which can be a challenge, especially if some payers don’t offer VBP.
Practices may also face lack of alignment among payers. Think of it this way: The typical family physician contracts with multiple payers. Often, each payer has its own complicated set of rules, performance measures and approach to VBP. This lack of alignment on key elements of VBP makes it challenging for family medicine practices to shift to such models.
Another challenge is that VBP models are unlikely to work if only a small subset of a practice’s patient population is included. Covering just a portion of patients with value-based payment while the majority remain in traditional fee-for-service does not provide enough investment to build advanced functions of primary care, like VBP.
Repertoire: When you say that value-based payment may mean redesigning the family physician’s practice, what do you mean?
Dr. Ransone: Practices shifting from a volume-based, fee-for-service system to value-based care and payment models must home in on the five key functions of the medical home: access and continuity, planned care and population health, care management, patient and caregiver engagement, and comprehensiveness and coordination. Physicians and their care teams are increasingly held accountable for cost and quality of the patients assigned or attributed to them, which requires a more proactive, population-health-focused approach.
This includes knowing who your patients are, understanding their risks and managing their care. Practices engaged in a fee-for-service payment model may also implement the medical home functions and may be paid for them through fee-for-service. However, practices in value-based payment arrangements, particularly those with prospective payments, have increased flexibility to innovate and implement care delivery reform.
Repertoire: AAFP has defined behavioral health integration as “a patient-centered approach in which primary care and behavioral health physicians and other clinicians work together with patients and caregivers to improve the physical and mental health of the patient.” Is behavioral health integration becoming more important to AAFP members? How prepared are they to implement it in their practices? What are the barriers to doing so?
Dr. Ransone: Integrating behavioral health with primary care aims to increase access as well as reduce the stigma associated with seeking mental health treatment. Without a system in place to routinely screen for behavioral health conditions and substance use disorder in the primary care setting, we will miss opportunities to address problems that threaten the health and well-being of our patients, families and communities.
According to a new paper from the Robert Graham Center, primary care physicians provide 45% of visits for patients with depression and/or anxiety, of which about half are co-managed with a non-physician, behavioral health clinician.
While behavioral health integration is a solution to our country’s mental health crisis, there have been barriers to progress. Payment reform must allow for flexible delivery models, shared medical records and dedicated physical space for behavioral health staff. The U.S. is also experiencing a shortage of behavioral health providers, making it increasingly difficult to hire needed staff and/or refer patients. Flexibility will be key to implementation.
Repertoire: How prepared are AAFP members to implement home-based primary care in their practices? What barriers do they face?
Dr. Ransone: Approximately 13% of AAFP members make at least one house call per week. Some of the barriers to implementing home-based primary care include payers; those still locked in a fee-for-service model often do not compensate physicians for travel time. Additionally, home-based primary care may involve practice redesign, which is not universally supported by payment models. Practices may also face technology issues, such as broadband access and cell phone coverage, which may be a barrier in some areas of the country.
Repertoire: We see acquisition of independent physician practices by health systems, payers, even private equity firms; and expansion of primary care services by companies such as CVS, Walmart, Walgreens, and Amazon. Is AAFP seeing a growing number of its members becoming employed by these larger entities?
Dr. Ransone: Family physicians are increasingly practicing in employed settings, with over 73% of AAFP members employed as of 2022. Over half of those employed are in a hospital or health system. Over the last two years, the percent of physician practices owned by corporate entities has risen from around 14% in 2019 to 27% in 2022.
Repertoire: How might this affect the family medicine profession?
Dr. Ransone: It’s a bit of uncharted territory. We’re still learning more at this point and working on examining how this will impact family medicine.
Repertoire: AAFP is celebrating its 75th year. What will the Academy look like when its centennial rolls around in 2047?
Dr. Ransone: The American Academy of Family Physicians has endured as the champion of family medicine for 75 years, and I fully expect our role as advocate and clinical authority to continue and grow. My own history with the AAFP is proof that the scope of the organization is broad and the benefits to family physicians are numerous.
As I imagine the AAFP and the state of family medicine in 2047, I envision a future where behavioral health is fully integrated into primary care, allowing our patients to receive the mental health care they need regardless of their location and socioeconomic status. I look forward to reduced administrative burdens and improved, equitable physician payment that provides family doctors with the time and resources needed to coordinate care with other healthcare providers and engage with their community’s leaders to address patients’ social needs.
I look forward to a future where health inequities are lessened – a future where race, gender and geography do not directly determine health outcomes. Additionally, I look forward to a robust, diverse workforce that reduces physician shortages and allows family doctors to practice self-care, which will allow them to serve their communities and patients even better than they do currently.