Member Forum

1.  The future needs of FP

Posted 04-19-2017 09:12

The AAFP asked for input of how the organization can go forward.

I have attached my long letter to them.

Trying to keep it smaller  is often difficult as health care is convoluted and interdependent  on all the pieces.

I did not tackle how patients get insurance or be covered as that one is very hard to not get into ideology.  ( And we all know where that goes....)

Anyway these were just my thoughts...


AAFP Request

As a Family Physician for 40 years in 2 countries (Canada and USA) I have had the luxury of seeing different approaches over time. History is always important.  Health Care is very complex and has many interactive parts so any simple one liner fixes or just using "talking points" will always miss the mark. For those of us who have lived in the system for some time, know all too well that the fixes have often caused damage that was not expected or well thought out.  I have looked at this for some time, always from the point of view of my patients and my solo small town practice. This position is often an early warning system.  I am been involved with 4 pay for value contracts, both commercial and government and tried to modify my practice in several ways. These had made me very uncomfortable and sometimes put me in conflict of interest with my patients.  I am very loyal to my long term relationship with my patients so find the new system very disheartening. So here are some of my thoughts. I realize this is often ideal type thinking from my limited point of view but may help give a sense of direction to go. AAFP is already doing some of these but often gets into the compromise position that is not effective enough to get the end goal. Politics get in the way more often than not. Politics is not helpful.

1.       We need to increase FP income by 300%. We are a very small percentage of the overall health spending. Decreasing our income will have no net "win" for the system. Increasing our income by 200-300% using existing codes (? modified) will pay back the system many times over.  Suggest we have 2 codes for primary care only – one for simple and one for complex. Get rid of CCM and others like it. They come with too many rules and increased administrative load with not much real gain.  We have to make this specialty attractive again so that we can end up with the manpower that is needed.  Increasing the income dramatically ( for us but really not much for the system) and simplifying the paper work would send the right message. We need to get out of the AMA game that looks after specialists and procedures.  We do not need to "steal" from them as our work will pay for itself in the long run and then some.

2.       The real goal should be for every person to have a primary care physician and both sit in the center/driver's seat. One in that position is not enough. So all the arguments about the patient being in the center alone are not productive. Most of this is the corporate mind set who want to truly take over and have patients dependent on them.  As a family physician expert with lots of experience, it is still hard to navigate this health care arena, so there is no way that even an educated patient could do it successfully alone.  The relationship is still the critical element that makes it all work. It takes the two! Some may disagree but the independent FP is the one with the least conflicts of interest.  That has been proven by many studies now.

3.       Remove a lot of the administrative burden. We are not the police force of others to watch home care, DME, etc. and make sure they are doing the right thing. We are even asked to police ourselves with all the paper work "proof" of what we are doing. Enough. There must be a better way.  If we order it with the proper diagnosis and reasoning that could be adequate. There are enough other rules to catch the bad.  I have even tried to report a badly behaving corporate DME to CMS and was ignored.

4.       The concept of "skin in the game" is not good for primary care. Whether this is through high deductibles or donut holes or high co pays, etc. this only discourages patients from doing what is right. Avoiding good primary care with acute care in the office setting, chronic disease management, preventative work, etc. will only cost the system big down the road. If people truly believe that skin in the game approach will prevent abuse then they are under a big illusion. Again there is literature to support this. Steering patients to primary care rather than to ERs, hospitals and expensive care is certainly needed. Primary care is not a gate keeper but rather can direct to appropriate care when needed, plus do most to the work needed.  So exempt primary care from all of this plus the basic care needs we direct – meds, testing, etc. 

5.       Truly there is no competition in health care. FTC must stop all the mega mergers. Bigger is not better and in fact just becomes Godzilla fighting King Kong with all the collateral damages. Despite the rules that say they cannot talk and plan together, they do. It has been shown that small independent practices do better care, see more divergent groups and often serve where no one else does – small towns, rural area, special groups, difficult to manage groups, low social economic areas, etc.. This is usually dedicated long term docs rather than rotating staffing of a remote clinic with no local loyalty. However all the rules are really designed for the corporate world (see more, do more, bill more) and are killing the very practices that are already performing the desired approach. It is easier for the corporate world to keep up by just hiring more administrative people. This will need intensive work to change this mentality and must include in the design the very people that the regulations are destroying or forcing to join the big. Having a corporation (for profit or not for profit) be the insurer and provider without firm guidelines is frankly scary.

6.       Malpractice as it is currently run needs to go. Instead deal with patient harm with no fault insurance. Bad physicians should be dealt with by licensing. But first by with education, retraining and rehab, then with their ability to practice if needed.  We are generally a trainable lot and to just destroy individuals who just need education is a disservice.  There are just better ways that have track records of working well. In addition this approach lends itself to better systemic analysis and fixes when things go wrong. More often than not problems are a series of events and not fixable by pointing a finger at one and punishing that target. There is very little evidence that the current make money approach actually makes things better. Often does the reverse and costs the system dearly with all the defensive approach that has become standardized.

7.       It must be recognized that facts are the lowest argument that convinces anyone (other than us) . The continuing issues with vaccinations are a perfect example.  Stories always overcome facts. Unfortunately in today's electronic world stories spread like wildfire. The one thing that will overcome a story is a good patient/family physician relationship. This must be recognized as critical. A "relationship" with a corporation does not work.  Back to the vaccination issue as an example.  A lot of the new CDC rules with expensive requirements and limited reimbursement have ended up with drug stores now being the bigger vaccine giver. No relationship there to make the magic work. More people are now not vaccinated because of the rules and the destruction of that needed human relationship.

8.       High tech with instant intensive (and expensive) testing with multiple specialty care plus protocol following is perceived as the ideal route to good care. We all know otherwise. The American public needs to hear this message but so do the media, government and others who are in decision positions. Hard sell but it is the only way to stop the high costs/poor quality US health care system from going bankrupt.  It is not having more people in the middle, making profit nor is it tech things like EMRs as "the answer". We have to get away from this as a solution. Yes they are useful tools if designed right for the end users, but certainly not the sole solution needed to drive the system in the direction we all know it needs to go.

9.       Big pharm and generics are also too big and have too much power. However so do insurance companies with the power and freedom to do as they wish. The under the table rebate system between these two is a key element in overpricing medications. It is not talked about much and the details are hidden from view. It is ridiculous that the list price is not the real price. Stopping this additional Godzilla versus King Kong war is paramount to fixing the US system. This may be one of the reasons why other countries have more reasonable prices. The simple approaches of just blaming pharm ignore the intricacies of the current corporate dynamics that is so unfriendly to patients who end up paying for it. Looking at the whole system of pricing is the way to approach this rather than just pointing fingers at single agents.  The way that drugs get their patents discourages good studies as those have economic impacts in delaying meds to market and thus driving excessive pricing. It would be better to have the patent start when the drug is approved rather than as it is now. That way outcome studies could become more standard without driving prices sky ward. Placing a lot of attention on the drug rep / physician interaction is a good distraction for those who do not want the system changed.  It only leaves those with power now to have more. The generic international industry is a difficult entity to define an approach but they are certainly not the good guy that they were promoted to be.  They sometimes have become even better at playing the for profit corporate game.

10.   Quality measures, rigid standards of practice, guidelines and the even more utiltized protocol approach to patient care are a disaster.  Population health at a practice level is good helpful way of thinking. However all of the above needs to modified for each and every distinct patient. This must be acknowledged that a thinking full trained brain is needed to do this. Primary care is the expert at doing this and should be. Being a good doctor by high rates of compliance with quality measures and protocols does not always result in a good outcome. This is why you need real working, independent thinking docs both in the clinical fields and on all the advisory groups. ACO/PCMH, etc. have some good concepts but the administrations of these have turned it all into a nightmare. Bottom up always works better than top down.  Having a BP of 138/88 versus 140/90 as being good, does not fit anything clinical or even up to date thinking. Having the last measure of the year being the measure, ignoring all the others during the year is not logical as a good standard. Especially when you add things like the donut hole, formulary change, patient's ability to afford drugs that time of the year, etc.. Successful awarded docs will be great at cherry picking their patients and the ones doing the hard work will be punished. Not a good design.  Keeping the system revenue neutral in the way that this is being done now by rewarding the "top" performing docs by taking from others is a terrible design that lends itself to those with lots of administration to do what they do best. Make it look good on paper. So the academics, policy experts, big business and others that do not do the job have done a lot of damage with their designed approach. It needs to change.


So what can the AAFP do for me? Stop the madness. Do not be afraid to take a stance and say no more. Keep promoting primary care especially now with the federal mess. The free market competitive dynamics are just not in health care for all the reasons you know. So promoting that as the solution is just as fool hardy as ignoring all of the above.  Rewards of 0.5 - 3% with more added paperwork are not anything close to a victory. Do not be proud of that.  Making quality concepts (not hard core measures) softer and more reality oriented. Not having every payer with their own. We need to own these and not have others do these for us.  We are at a cliff's edge. Getting closer to falling off every day. To wait years to inch things forward has not worked.  Doing more of the same at the "table" has not worked enough. The burnout and suicide rates are an indication of how bad things are. Yes we are a diverse group and rightly so. But there are common threads and needs plus core values that should not put us in competition with each other for your attention. Political statements using the one liners or usual talking points have not been helpful. Rigid thinking has not been helpful. We need to solve the problems using the strength and quality of the family physicians of this country before they are gone,  burnt out, replaced by others as just a widget in the health care for profit corporate world.  


Scott Macleod, MD

Solo independent Family Medicine

Small town

Old guy.

Takes a lot of energy and time to do these.





Scott Macleod, MD

Solo, Independent FP

Highlander Family Medicine

Woodstock, Virginia


2.  RE: The future needs of FP

Posted 05-03-2017 21:04
Very well thought out, Scott.
I never pictured you as an old guy - Ha!

I,too, was asked for feedback by AAFP as I made my Jerry Maguire like exit and I wrote them briefly.

  • I have too many practice expenses and this is one that had to get cut. I would have stayed for half the price it is just to keep accessing AAFP articles. I cut out my disability insurance too! 
  • I've used many of the benefits over the years and valued the articles about evidence based management of specific conditions. However, I still have the pay ABFM every year regardless of the AAFP CME. It seems like the AAFP costs do not go towards anything that is "required to practice medicine" i.e. DEA license fee, state license fee, county privilege license fee, CLIA fee, AFBM fee, malpractice. The live CME requirement was difficult for me as a solo doctor and North Carolina licensure and ABFM do not require that. 
  • Lastly, I feel the AAFP jumps on board too much with the current/latest healthcare climate - what I refer to is Patient Centered Medical Home, quality metrics and various seemingly unproven "practice transformations", retail health clinics,  I don't feel it's about individual doctors and individual patients whereas my personal philosophy is more the Ideal Medical Practice model. 

I agree, Scott. I think they should have taken a stand at times. They are well run - they always answer e-mails, have snazzy materials, answer the phone. We are all probably slightly to blame for being too busy to be involved but for the price we pay, you'd think it could go towards more advocacy and more logical advocacy.
Agree - malpractice reform seems like it should be included out but not sure if it's included in the bill going to the house tomorrow.

Mamatha Agrawal, MD
Family Doctor CaryNC
Cary, NC
Live in Raleigh, NC
Solo since 2012
Practice Fusion and NueMD

3.  RE: The future needs of FP

Posted 05-04-2017 06:01
I love this letter of yours and am entirely with you on these suggestions!
Thanks for taking the time to write this down and giving the AAFP a piece of your mind. I know you are not alone in your concern but you had the courage and made the effort to speak up and I salute you.

There is no such thing as failure. Only the distance you are willing to travel in pursuit of a dream.
Gregory Sharp
Ideal Family Healthcare
Manitou Springs CO

4.  RE: The future needs of FP

Posted 05-08-2017 19:34
Scott, I agree 100%, but I have the feeling of "Who will bell the cat?"  crossed with, "But, doctor, we need the eggs!"  With the debate in Washington going in the direction of how much can be cut, there's little interest in paying anyone more, even if it would save money.
Reducing the cost of health care would cut insurer's profits, so if they did cut costs, the people doing it would be eliminating their own jobs. THEY won't do it.
Ditto large health systems.

One place where interests align, AND it's possible to do something about it, is between employers/municipalities/unions who want good care but also lower costs, and primary care.  Paying for more comprehensive primary care would save them money...if we could just get their attention away from all the folks selling them "Big Data" and wellness programs.

Anyone have any ideas how to do that?

Peter Liepmann
My mission is to fix US health care
Bakersfield CA