Family Medicine 2015: Our Moment in History - PowerPoint Presentation

Slide1

Family Medicine 2015: Our Moment in History

John Saultz, MDProfessor and ChairmanOHSU Family MedicineSlide2

To share the story of how our discipline’s new strategic plan, Family Medicine for America’s Health

, came aboutTo outline the plan’s core recommendationsTo explain why this project is important for every person in this room and for those we serve

To describe the choices facing each of us when we return to our work next weekSlide3

Family Medicine as ReformFamily Medicine’s creation mythsThe reports of 1966 (Millis, Folsom, and Willard)

Family Medicine as counterculture reformA re-birth of general practiceThe family in family medicineThe first decade: 1969-1979

Recognition and legitimacy

Growth of residencies

Reformist zealSlide4

“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 single-minded 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. Slide5

Achieving Recognition1980-1990Institutionalization in practice and in academic medicine

Tempering reform with collaborationExpanding medical school curriculumFamily physicians as residency teachers1990-2001

Managed care: a story of false hope

Residency expansion

The rise and fall of student interest

The Future of Family Medicine ProjectSlide6

access

Continuity

Comprehensive

Coordinated

Contextual

Providers

Communities

Patients

Expanded access

Accountable for outcomes

Expanded scope of practice

Team-based

Care coordination programs

Lots of proof

Little proofSlide7

The New Millennium2001-presentThe patient-centered medical home

Personal physician or practice architect?Rising costs and broken promisesNew collaboratorsThe demise of the public sector

Adaptation strategies in today’s world

Employment

Direct primary careSlide8

Today’s Family PracticesIndependent practices: 20%Community Health Centers and other publicly supported practices: 35%

Health system practices: 35%Academic practices: 10%Slide9

Traditional comprehensiveness is shrinking when measured at the physician levelMaternity careHospital careCare of childrenEmergency care

Nursing home careOffice proceduresShould we measure comprehensiveness by how we practice in teams?Should residencies be re-structured to conform to this new reality?Slide10

New skills emerging in family medicine

Data analysis skillsPopulation care coordination using data registries

Preventive care

Chronic disease care

Utilization management

Defragmenting care

Team leadership

Integration of mental healthSlide11

1961 US Seniors

In1983!Slide12

Questions Facing our DisciplineWhich 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?Slide13

Family Medicine for America’s HealthDeveloped in 2013-14 by eight family medicine organizationsPurposes:

Re-define the role of the family physician Re-define the functions of the PCMH modelIgnite a social revolution to reform the nation’s delivery systemIncrease the attractiveness of family medicine to studentsImplementation to take place between 2014 and 2020Slide14

2014 Role DefinitionFamily 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.Slide15

Health is Primary: Family Medicine for America’s HealthPhillips 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. Slide16

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. Slide17

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. Slide18

Family

Medicine’s leadership

will

welcome

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:Slide19

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:Slide20

The American people can expect that:

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:

Lower

the

total

cost

of

care

for

the

patients

we

serve.

Continuously

improve the health and quality of care of the patients we serve.Continuously improve each patient’s experience of, and access to, care, emphasizing the patient’s definition of both. Slide21

The American people can expect that:

Family

medicine

will

collaborate

with

national

stakeholders

to

reduce

health disparities in the United

States.

 Family

medicine will lead,

through ongoing outcomes-based

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. Slide22

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:Slide23

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.

The American people can expect that Family Medicine will:Slide24

access

Continuity

Comprehensive

Coordinated

Contextual

Providers

Communities

Patients

Fully Integrated Mental/Behavioral

H

ealth

Accountable for outcomes

Robust Population/Public Health

C

apacity

Expanded Scope of Practice

Community Connections to Reduce Health DisparitySlide25

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.Slide26

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.”Slide27

Making FMAHealth a RealityAmerican 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.Slide28

Making FMAHealth a RealityMedical 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.Slide29

Making FMAHealth a RealityMedicine 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.Slide30

Access and ContinuityThe 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.Slide31

Coordination of care and Population HealthWith 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.Slide32

Comprehensiveness and Patient-centerednessWe 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.Slide33

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?Slide34

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 well-documented. 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. ”