Task Force Report 5. Report of the Task Force on Family Medicine’s Role in Shaping the Future Health Care Delivery System

Patients

Data from around the world have shown that a continuing relationship between patient and physician is an essential component of the most successful health systems with the best outcomes.⁴ Physicians have been reluctant to enlist patients in larger social issues, such as health care reform, but their awareness and support are crucial if positive change is to occur.

Family Physicians

Major initiatives by family medicine must first pass the reality check of practicing family physicians. Without their support, such efforts are likely to be misdirected and to fail.

Primary Care Physicians

Family physicians have much in common with other primary care physicians (ie, general internists and general pediatricians). Whereas there are important differences between the respective primary care disciplines, success is much more likely when other primary care groups are recruited to the cause. Other physician groups look to family medicine as the natural leader on primary care issues. This leadership is a responsibility family medicine should embrace.

Other Physicians

Although physicians in other specialties may fear that they have much to lose in a reformed system that better supports primary care, they are also frustrated with the current system, which is expensive, fragmented, and under-performing. Common ground can be found most often when efforts center on the welfare of patients rather than on financial self-interest.

Local Communities

The FFM research⁵ identified the contributions of family physicians to their communities as the “best kept secret” of the discipline. Communities are powerful potential allies and a largely untapped resource that should be mobilized on behalf of their local primary care clinicians and the community’s health.

Health Care Professionals

Many nurses, physician assistants, various types of therapists, public health workers, and other health care professionals share a desire for a reformed health care system. Family physician anxieties about being replaced by nonphysicians have not borne out; everyone in primary care has more than enough to do. Such fears reflected an incomplete and inaccurate understanding of the comprehensive care provided in the primary care setting, the importance of teams to address more effectively the increasingly complex needs of patients, and the valuable contributions offered by the various members of the primary health care team.

Professional Organizations

Associations such as the American Medical Association (AMA), the American College of Physicians, the American Academy of Pediatrics, the American Academy of Physician Assistants, the American Nurses Association, and others can be important partners for health care reform. While each organization will have a different perspective, they share a common belief that the system is in need of transformation.

Change Agents and Organizations of Influence

Several national organizations, such as the Institute for Healthcare Improvement (IHI) and the IOM, have become forces for change in American health care. Commercial interests, such as pharmaceutical companies, with their considerable market influence, may be considered organizations of influence and potential partners. Certain foundations, such as the Gates, Kellogg, and Robert Wood Johnson foundations, also exert influence through their funding and programming priorities. While some may debate whether medical schools and academic medical centers are change agents, they do have influence and must be addressed. In this regard, the Association of American Medical Colleges (AAMC) is another important potential partner. Family medicine should develop special relationships with these influential organizations through shared projects. For example, the task force’s recommendation to develop and report on quality measures for each of the 6 IOM aims would make for a natural partnership for IHI, IOM, and family medicine.

Health Plans

The managed care movement of the 1990s showed the considerable influence that can be exerted by health plans. Jockeying for market niche, health plans have demonstrated variable commitment to and support of a primary care medical home model. Americans have not appreciated fully the potential harm of a fragmented and reductionistic approach to health care, nor have they realized fully the potential benefit of primary care. The improved outcomes, satisfaction, and efficiencies offered by a primary care model must be communicated more effectively to the American public and to health plans through better data and better performance.

Employers and Labor Organizations

The rising costs of health care are of concern to both employers and workers. Management and labor share a desire for better value and service for their health care investment. Their growing disquiet with the current health care system provides an opportunity for family medicine and primary care to form an alliance with employer and labor groups to respond to their concerns.

Government Policy Makers

Government funds nearly one half of all health care spending and is an important determinant of US health policy. The decisions of federal and state legislatures and agencies have an impact on health care through the health plans they administer (eg, Medicare, Medicaid, the Federal Employee Health Benefits Program, and the Department of Defense health care system), as well as through the direct services they provide through the Indian Health Service, the Veterans Administration health system, the National Health Service Corps, and public health hospitals, clinics, and nursing services. In addition, government funding through such agencies as the National Institutes of Health (NIH) shapes public health policy and opinion. Supportive government policies have great importance for primary care.

Nongovernmental Policy Makers

Numerous private organizations, such as the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Graduate Medical Education (ACGME), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the Liaison Committee on Medical Education (LCME), shape health policy through their accreditation decisions. Family medicine should know and be known by these nongovernmental policy makers.

Nature and Role of Leadership in Transforming Health Care

Effective leadership is an essential ingredient that will determine, to a large extent, the success of family medicine in advocating for needed change in the health care system overall and in the specialty. In the context of this report, leadership can be defined as persuading others to act through a compelling vision, and taking risks to achieve that vision.

Speaking about the nature of leadership, singer and activist Marian Anderson once said, “Leadership should be born out of the understanding of the needs of those who would be affected by it.”⁶ Family physicians are the only physicians distributed across the United States in roughly the same proportion as the population. Family physicians care for all generations in all settings; they bridge personal and public health issues. Few health care professionals are better situated to understand the individual and collective health care needs of Americans than are family physicians. The ongoing relationships family physicians have with their patients, families, and communities enable them to understand those needs. It must be those needs that form the basis for creating a vision of the preferred future US health care system. While a compelling vision for the health care system has yet to gain widespread acceptance, this task force believes it should encompass the 6 IOM aims and should include measurable medical and service outcomes, patient values, and costs.

Much of the discussion about health care reform has centered on the financing of care. Equity and efficiency demand that every American should have adequate health care coverage. Yet, coverage is a necessary, but insufficient, element of an improved health care system. Equally important is a reordering of the organization and delivery of American health care. US health care is focused excessively on rescue medicine at the expense of preventive, primary, and restorative care. Noted historian Rosemary Stevens has written that American medicine “historically was geared to produce specialists for acute, interventionist, high-technology medical care, targeted to a focused problem area, rather than support of patients through long periods of disability and multiple conditions.”⁷

Changing the financing and delivery of American health care will require a special kind of leadership. There are different types of leaders: status leaders, such as a president of a country, who influence through their position; service leaders, such as Mother Teresa, who motivate through their selfless efforts for others; charismatic leaders, such as the Rev. Martin Luther King, Jr, who inspire through force of personality; and transformational leaders, who lead by empowering others to achieve a shared and compelling vision. As Henry Miller described, “The only way in which any one can lead us is to restore to us the belief in our own guidance.”⁸

Family physicians are status leaders in their communities and, to some extent, the nation. They also are service leaders, by the nature of their work. Some family physicians are charismatic leaders. In matters of health care reform, it is vital that family physicians become transformational leaders. By understanding the needs of those they serve, by helping to shape a compelling vision for a better system, and by working with the many individual Americans whose lives they touch, family physicians offer the best hope for transforming the US health care system. For individual Americans, the complexity, expense, and politics of US health care can appear daunting and immutable. As transformational leaders, family physicians can show the public a path to a better system. In the end, it will be the collective decisions of individual Americans that will transform American health care.

The transformational leadership called for in this effort must be completely, even brutally, honest. This honesty must extend to family medicine itself. Family physicians must point out that some of what physicians do is wasteful, ineffective, and even harmful. The discipline must identify its own flaws and improve its practices. Family medicine must embrace clear and valid performance measures for all health care professionals, including physicians, and must demand patient-centered accountability. The discipline also must advocate for a health care financing system that provides universal coverage and controls medical inflation. By engaging their patients, communities, and leaders in a dialogue about health care, family physicians can change the nature of the American health care debate. Encouraging patients to discuss the system’s strengths and weaknesses, supporting their attempts to challenge substandard care and service, and advocating a patient-centered system, all reflect transformational leadership in action.

Advocacy in pursuit of a reordering of health care priorities and a shift in the traditional medical paradigm in the United States poses a risk for the discipline of family medicine. Having labored mightily to gain entry to the hallowed halls of medicine, family practice has determined that the structure needs major renovation. Challenging the status quo means that family physician leaders may risk the disapproval of their family medicine colleagues, other physicians, and those with a vested interest in the current system. The task force believes that now is the time and that family physicians are the leaders to step forward and take those risks. Nothing less than the health of the American people is at stake.

Leadership in the Past: Lessons for the Future

Leadership is part of the heritage of family medicine. Past leadership successes by the discipline provide important lessons that can be instructive as family physicians begin advocating for needed changes.

Established in 1947, the American Academy of General Practice innovated a requirement that every member obtain 50 hours of continuing medical education (CME) each year. In 1969, the transition from general practice to the specialty of family practice set a new standard when the American Board of Family Practice (ABFP) conditioned diplomate status on the successful completion of a board-certification examination (ie, there would be no grandfathering) and required that every diplomate must pass a recertification examination no less than every 7 years. More than 3 decades later, some specialty boards have only begun to move toward these educational and testing standards. The American Academy of Family Physicians (AAFP), the successor to the AAGP, has embarked recently on a program to require that CME presenters reveal the source and quality of the evidence used when making practice recommendations. While laudable, these 3 innovations—annual CME requirements, board certification and recertification standards, and the evidence basis of CME—represent endeavors within the control of family medicine. The only audiences affected directly, and in need of persuading, were family physicians. A better test of family medicine’s leadership will be its ability to influence those outside the discipline of family medicine.

An example of the influence of family medicine outside of the discipline can be found in the insinuation of family medicine into medical schools. Beginning in 1969 there were no departments or divisions of family medicine in medical schools; there are now such departments or divisions in 114 of the 125 allopathic medical schools. The story of this achievement suggests a leadership model for other family medicine initiatives.

First in public and then in private medical schools, family medicine used a multipronged approach to secure its place in academic medicine. Local efforts were combined with state and national resources to focus on each school. Practicing family physicians often donated their practices as they joined the faculty and helped start a new residency that served as the beachhead for family medicine at a school. State academy chapters lobbied their legislatures to secure funding for the nascent programs. Statewide, family physicians directed their referrals to schools that were supportive of family medicine. At the national level, resources such as the Residency Assistance Program were founded to start up and assure the quality of training programs. School visitations by national family physician leaders impressed on local medical school leaders the importance of family medicine at their institution. Schools without academic units of family medicine were targeted for special efforts. Using this multipronged strategy of local champions, statewide commitment, and national resources, the number of target medical schools without academic units of family medicine was cut by half from 22 in 1990 to 11 today. A similar level of success, using similar strategies, was achieved with the current requirement of a family medicine clerkship that exists in 85% of US allopathic medical schools.

The lessons of past leadership success include the importance of identifying a shared priority across the discipline of family medicine and combining targeted resources and coordinated efforts at multiple levels. Thus far, family medicine has concentrated on initiatives that are focused primarily inward (eg, CME, board certification, academic units); the challenge will be to achieve similar unity and momentum around issues that are focused outward (eg., health system reform).

Harold Geneen, who transformed International Telephone & Telegraph into a worldwide business superpower during the 1960s, once said, “Leadership cannot really be taught. It can only be learned.”⁹ Leaders who changed the fundamental direction of society come readily to mind in such areas as achieving self-governance through civil disobedience (eg, Mahatma Gandhi) or reengineering for quality (eg, Jack Welch). Such change leaders have not been as identifiable in health care generally or primary care specifically.

Even if leadership cannot be taught, it can and must be recognized, nurtured, and supported. Investment of resources and cultivation of talent will be needed for such leaders to emerge. This task force believes it is vitally important to groom leaders within family medicine who will change the health care landscape, as well as to create venues where policy makers and influence leaders can look beyond their usual constituencies and horizons to a comprehensive view of health care.

Identification of Key Policy Initiatives and Implementation Strategies

The FFM project has provided an important impetus for the identification of key priorities across the discipline. Ultimately, however, for the FFM project to be deemed a success, implementation steps will need to be identified and prioritized. This effort should involve family physicians and their organizations, as well as foundations, industry, and other potential funders.

Many believe that America’s obsession with high-technology acute care medicine, at the expense of preventive and primary care, is due in part to the loss of the voice of primary care amid the cacophony of media hype and industry advertising that show only the promise, and rarely the peril, of organ- and disease-centered medicine vs relationship-centered medicine. The growth of complementary and alternative medical practices is partially the result of a failure of mainstream medicine to address adequately the many other important aspects of health (eg, prevention, nutrition, pain management, end-of-life care). The various primary care disciplines have all been involved in recent efforts aimed at self-reflection and redirection. To bring the health care system into better balance, however, the leaders of primary care must develop a stronger and more unified voice. Primary care is poised to reassert its primacy in health care. Convening a summit of primary care leaders will be a crucial first step toward a stronger and more unified voice.

Family Medicine and Primary Care Leadership Center

Even after common ground and mutual priorities are established, there will remain a need for continuing collaboration and advocacy across family medicine and the other primary care disciplines. A leadership center for family medicine and primary care is needed to provide a focal point for cross-disciplinary research on effective leadership strategies, to coordinate leadership development and advocacy efforts, and to cultivate resources for leadership programs and research.

Promoting Family Medicine Leadership

Strategies will need to be developed to promote family physicians and other primary care advocates as leaders in their communities, in government, and in other influential groups, particularly the AMA, AAMC, ACCME, ACGME, IHI, IOM, JCAHO, LCME, NIH, and National Quality Forum (NQF). Such strategies should include the identification of possible positions and candidates for those positions, the active promotion of those candidates by allies in target organizations and through campaigns for their selection, and the creation of networks of successful candidates to identify, mentor, and place additional primary care advocates.

Blue-Ribbon Panel of Key Stakeholders

Traditional efforts to create change in health care typically have involved large groups of putative experts or politically derived representatives and have resulted in proclamations that ultimately had little impact on the experience of health care in America. Existing entities, such as the IOM, the NIH, and the NQF, offer important perspectives on health care, but they often function in isolation or have agendas that are too narrow to effect meaningful change. Family medicine should advocate for the creation of a blue-ribbon panel of key stakeholders from advocacy groups, business, government, health care professionals, health-related industries, health plans, and labor. The panel should be charged with addressing comprehensive health system reform and articulating a compelling vision for health care in America.

Recommendation 1.1.

That the discipline of family medicine target by 2004 a few major policy initiatives and employ a multipronged approach for their implementation.

Recommendation 1.2.

That a summit of family medicine and primary care leaders be convened in 2004 to identify major policy initiatives.

Recommendation 1.3.

That a leadership center for family medicine and primary care be established by 2005.

Recommendation 1.4.

That explicit strategies be developed by 2005 to promote family physicians and other primary care advocates as leaders in their communities, in government, and in other influential groups.

Recommendation 1.5.

That family medicine advocate for the creation of a blue-ribbon panel of key stakeholders by 2006 to address comprehensively the American health care system and articulate a compelling vision for its transformation.

Recommendation 2.1.

That steps be taken to ensure that every American will have the opportunity to choose an identified personal medical home by 2010.

Recommendation 2.2.

That efforts be initiated to enhance health literacy among patients, including an information campaign beginning in 2005 on the value of a personal medical home.

Recommendation 2.3.

That standards for an electronic health record be developed by 2005, which promote the use of a personal medical home and encourage research in practice improvement.

Recommendation 3.1.

That family medicine develop by 2005 and begin by 2006 regular reporting for all family physicians their performance on at least 1 measure for each of the 6 IOM aims of high-quality health care: safe, timely, effective, equitable, patient-centered, and efficient.

Recommendation 3.2.

That family medicine residencies by 2006 track and report regularly the performance of their graduates over time against the 6 IOM quality measures and modify their training programs to improve the performance of their graduates.

Recommendation 4.1.

That steps be taken to ensure every American has health care coverage by 2009 which assures adequate funding of basic health care services and protection against extraordinary health care costs.

Recommendation 4.2.

That tools be developed by 2008 to help patients make informed decisions about a personal medical home and health care coverage.

Recommendation 5.1.

Reimbursement models will be developed by 2006 that sustain and promote primary care practices so that they may thrive and serve as personal medical homes.

Recommendation 6.1.

That a National Institute for Family Medicine and Primary Care be established by 2009 to foster, coordinate, and fund research in family medicine and primary care.

Recommendation 6.2.

That funding be provided by 2005 to encourage academic and other institutions to pursue research on the value of a personal medical home.