IT'S NOT ABOUT US: MOVING THE FOCUS TO THE TEAM AND THE PATIENT

1. Moving the Money Focus from Docs to Teams/Infrastructure

Is it time to shift the national primary care conversation on reimbursement from “family doctors don't earn enough money” to “family doctors don't have the help they need to create systems that work for patients and populations”? Family medicine needs to promote payment models like global capitation, value-based care and pay-for-population that will facilitate infrastructure development needed to effectively serve patients, families, and communities. This would require a departure from focusing on the income of physicians to support for the team, the system, and ultimately the patient and the population. Creating the infrastructure for transformed health care, whether patient-centered medical homes (PCMHs) or Accountable Care Organizations (ACOs), is critical to meeting the triple aim (better outcomes, better patient experience, lower costs) and cannot come too soon. Recently published articles, such as the article by Nocon, et al in JAMA,¹ have verified that practices which become patient centered medical homes cost more to run. Increased funding/alternate payment schemes are needed for practices and systems undertaking this transformation.

2. Changing the Ratio of Primary Care Physicians to Specialists

Is it time to change the conversation from “we need more family physicians” to “we need the right mix of primary care to specialty care to improve the health of the nation and lower health care costs”? The Council on Graduate Medical Education's and most work force analyses estimate that the ratio of primary care to specialists needs to be at least 40% to achieve these goals. Rather than talking about the need for more Graduate Medical Education (GME) slots for family medicine, we should be advocating for a rational process for determining both the number and distribution of GME slots; a process that is based upon the needs of the nation as opposed to one that preserves the status quo or protects certain specialties.

3. Finally Marrying Primary Care and Population Health

Our discipline has never quite fulfilled the promise of joining public and population health, though not due to lack of effort. Valiant efforts to achieve such a union have been attempted through community-oriented primary care (COPC), through adding public health, community, and preventive medicine to our departments and many important grant-funded initiatives. But a failure to complete this integration appears to be increasingly unacceptable. We cannot address the root causes of chronic illness without relying on public health—primary care partnerships that are sustainable, responsive to communities, and effective. One of the key barriers to integrating these 2 disciplines is the chronic underfunding of both. As called for by the Institute of Medicine, it is time to finally achieve the elusive goal of integrating public health and primary care.

The rhetoric of our discipline should change to reflect the evolution of our aspirations. Our messages should derive from our best efforts to define changes in health care delivery and payment mechanisms that are urgently needed to improve health. We need to “take the high road” and continually and loudly advocate for what is best for the health of our patients and for the nation. We need to persistently advocate for what will help our health care system achieve the triple aim of improved health, better patient experience and lower costs. We need to change the conversation from what we believe we need as a discipline to what is best for the country. It is not about us, it is about the health of our patients and the nation. We can, however, take an active role in helping lead the way.