Guest commentaries: Family medicine trends to look for in 2017

With the new year come new thoughts on what may lie ahead.

Healio Family Medicine asked clinicians from some of the top family medicine programs in the country to discuss what they thought the top trends would be in their field this year, whether they be clinical, regulatory or political. Their answers follow:

Family medicine is in demand again, after decades of decline. Salaries are beginning to rise and a few more residencies and residency slots are appearing. As health systems regionalize, integrate, and prepare for value-based contracting, there is a growing need to “cover” populations with high-quality primary care. We are seeing more emphasis on payment for the quality of care and health outcomes in populations of patients, and less on raw visit or relative value unit productivity. This is having an interesting effect on how family medicine is practiced and how success is measured. We are beginning to see primary care practices with new methods of access, comprehensiveness, and self-management plans.

Frank V. DeGruy
Frank Verloin deGruy

Access: Partnerships with retail clinics and urgent care facilities are augmenting access to care. With shared records and a common panel of patients, this can be done in an integrated, non-fragmented fashion.

Comprehensiveness: Integration of behavioral health care into primary care is becoming more commonplace, and is more comprehensive and coordinated than referring out for those services. We are beginning to see statewide payment models for integrated care, including tele-mental health care.

Self-management: The most interesting and powerful change in family medicine is the emerging linkages with community and public health resources to produce community-based health solutions, such as elements of primary care moving from the clinic into community-based programs. For example, diabetes education might occur on Wednesday nights in the basement of a neighborhood church. Family physicians might use those occasions to meet with patients, even contribute to the teaching as part of their own patients’ personal care plans, and enter data from those sessions into the patient’s electronic health record. Or they may incorporate into the medical record data from apps that can measure depression or exercise status or weight at home or at work — and can track adherence to a self-management plan. This community connection is likely to become more and more important as care moves closer to home, into the community. It will drastically change the roles, structures, and activities of family physicians in the next few years.

Frank Verloin deGruy III, MD, MSFM,
chair, department of family medicine, University of Colorado School of Medicine

This year will be a great year for family medicine. A large driver will be new models of CMS payment from Medicare Access and CHIP Reauthorization Act (MACRA’s) quality payment program. The emphasis on value-based payments has made leaders more aware that a strong, highly functioning primary care base is required to provide comprehensive, high-value, low-cost population health. We will see family medicine residency programs grow and graduates have more choice than ever in their jobs, including the ability to maintain a broad scope of practice and career satisfaction. This is an exciting time to become a family physician!

Cristy Page
Cristy Page

Regardless of changes the new administration may make regarding Obamacare and Medicaid, family physicians will remain committed to improving the health of all people. Our leadership is critical for solving the complex challenges of modern health care. The trends of patient care, research, and education for 2017 will focus on innovations in care delivery, implementation science to help us study which care models and team designs work best to keep patients healthy and satisfied with their care, and in training family physicians for leadership in health care transformation. We will see enhancements in coordination of care to keep patients out of the hospital, extended hours, expansions of telehealth, and home visits, as some examples.

Cristy Page, MD, MPH,
interim chair, department of family medicine, University of North Carolina

The thing that strikes me about the future of family medicine is that every day, 10,000 baby boomers are turning 65 and entering into Medicare. How do we manage Medicare populations who are aging in a way that delivers comprehensive primary care services that coordinate not just for a person with a single illness, but also for those with multiple, chronic serious illnesses? I think that is going to be a major driving trend that’s going to continue for the foreseeable future. To me, the answer is the family medicine practice organizing around care delivery through teams for more complex patients. The leader of that team is the family physician since he or she is perfectly trained for that, because they are intimately familiar with the needs of their local community, the resources of their community, and they have excellent skills in communication and managing nurses and social workers to get the patient the help that they need. Making transitions in the practice to be able to deliver such care will increasingly be the wave of the future.

Paul Tatum
Paul E. Tatum

The second related issue that I think will impact physician practices is adaptation of several new billing codes from the CMS to help pay for this delivery care, including for chronic care management non face-to-face time, advanced care planning codes and new codes for cognitive evaluations. I think the question in the next year will be how do family physicians’ offices utilize those codes to help build the team systems we need to manage the older adult with multiple serious illnesses.

Paul E. Tatum, MD, MSPH, CMD, AGSF, FAAHPM,
department of family and community medicine, University of Missouri

1. The move to more quality-based reimbursement. It is likely that not only government-sponsored, but also other insurers, are going to move to more quality based reimbursement. In some ways this could be a positive change for family medicine, given the specialty’s interest in preventive care, primary care, and cost-effective care. However, exactly how the changes planned under MACRA, etc. are implemented, how small as well as larger clinics implement these changes, and how our hospital systems deal with less reimbursement for high cost care, is still very uncertain. We know from other ‘pay for performance’ systems that there are upsides and downsides of this form of reimbursement. Deciding what and how to measure are fraught with difficulty, and ensuring that family medicine clinics have the teams in place in order to improve care are critical.

Matthew Thompson
Matthew J. Thompson

2. The need for family physicians overall, and their distribution in rural and urban areas will continue to be a major challenge without changes to medical education and graduate medical education (GME). It is crystal clear that the U.S. is producing far fewer family doctors than needed, and that the system of GME is not meeting the U.S.’s health care needs. These need to change if we are to be able to care for our populations. Many smaller towns and rural areas will continue to struggle to attract providers, and without family medicine these communities will decline. Some states, such as Washington, are investing in new family medicine residency programs, and trying to ensure that osteopathic and allopathic joint accreditation is supported; other states need to follow this lead.

3. Research funding for family medicine and primary care has always struggled within the NIH. The emergence of Patient-Centered Outcomes Research Institute (PCORI) as a significant new funder of patient-centered research has been hugely significant, and underscores the need for research that meets all stakeholder’s needs, including patients, clinicians, insurers, medical technology industry etc. Support for PCORI as well as Agency for Health Research and Quality will be critical to generate evidence that patients and their doctors can use to provide the best quality care right now.

4. New technologies in family medicine. Many medical technology companies now see family medicine and primary care as valuable, and are investing in tools and technologies that attempt to improve this part of our health care system. In 2017, I expect to see further waves of new technologies that could (and emphasis on could) enhance the kind of care that family physicians provide. However, simply ‘throwing' new technology at family physicians and their patients is not the answer, and risks frustration and wasting money. Rather, we need to work with technology companies where appropriate to design, evaluate and implement new technologies that have demonstrated value to improve care.

5. Changes in health care coverage for patients in family medicine is certain to be a major issue for the coming year. It is unclear as yet what a replacement to the ACA will look like, but I know many family doctors have been able to provide better care (and be reimbursed for care) for many more patients who received coverage under the ACA. It is going to be essential that patients continue to have access to the high quality primary care that family physicians (and their teams) provide. No one will benefit if we lapse back into lack of insurance coverage for large swathes of our communities. The care that family doctors provide is an incredibly good value for money (preventing strokes, treating depression, detecting early cancer, avoiding the need for expensive ED visits etc.) that any new system must ensure that we can continue to provide excellent primary care.

Matthew J. Thompson, MBChB, MPH, DPhil,
professor and acting chair, department of family medicine, University of Washington

 

The future of family medicine will require expert preventive, acute and chronic disease care and will increasingly demand the care of populations. This care will be provided not only in person but via text and video communications. The historic pillars of family medicine will be sustained: accessible and accountable care provided in a continuous, comprehensive, and coordinated fashion. As we move increasingly toward value-based care, the reimbursement model will change to reflect this relationship and responsibility, increasingly being manifest as direct payment for primary care.

Steven Zweig
Steven Zweig

Exciting opportunities for family physicians will also include working with high-performance teams in caring for patients across all settings. Whereas service lines in health care will better serve single-organ health problems, the values and skills of family medicine will enable the comprehensive care of an aging population with its increasingly prevalent complex problems. Family physicians will be leaders in system-based practice, use of technology for improving quality, evidence based practice, and techniques for engaging patients and communities. Nevertheless, the human need for the personal physician will persist. Continuity relationships between patients and family physicians will provide the trust, accountability, and opportunities for healing experiences along the continuum of the life span. 

Steven Zweig, MD, MSPH,
professor in family and community medicine, University of Missouri School of Medicine.

Disclosures: DeGruy, Page, Thompson and Zweig report no relevant financial disclosures. Tatum reports receiving past funding from Health Resources and Services Administration geriatric academic career award and is currently a board member of the American Academy of Hospice and Palliative Medicine.

With the new year come new thoughts on what may lie ahead.

Healio Family Medicine asked clinicians from some of the top family medicine programs in the country to discuss what they thought the top trends would be in their field this year, whether they be clinical, regulatory or political. Their answers follow:

Family medicine is in demand again, after decades of decline. Salaries are beginning to rise and a few more residencies and residency slots are appearing. As health systems regionalize, integrate, and prepare for value-based contracting, there is a growing need to “cover” populations with high-quality primary care. We are seeing more emphasis on payment for the quality of care and health outcomes in populations of patients, and less on raw visit or relative value unit productivity. This is having an interesting effect on how family medicine is practiced and how success is measured. We are beginning to see primary care practices with new methods of access, comprehensiveness, and self-management plans.

Frank V. DeGruy
Frank Verloin deGruy

Access: Partnerships with retail clinics and urgent care facilities are augmenting access to care. With shared records and a common panel of patients, this can be done in an integrated, non-fragmented fashion.

Comprehensiveness: Integration of behavioral health care into primary care is becoming more commonplace, and is more comprehensive and coordinated than referring out for those services. We are beginning to see statewide payment models for integrated care, including tele-mental health care.

Self-management: The most interesting and powerful change in family medicine is the emerging linkages with community and public health resources to produce community-based health solutions, such as elements of primary care moving from the clinic into community-based programs. For example, diabetes education might occur on Wednesday nights in the basement of a neighborhood church. Family physicians might use those occasions to meet with patients, even contribute to the teaching as part of their own patients’ personal care plans, and enter data from those sessions into the patient’s electronic health record. Or they may incorporate into the medical record data from apps that can measure depression or exercise status or weight at home or at work — and can track adherence to a self-management plan. This community connection is likely to become more and more important as care moves closer to home, into the community. It will drastically change the roles, structures, and activities of family physicians in the next few years.

Frank Verloin deGruy III, MD, MSFM,
chair, department of family medicine, University of Colorado School of Medicine

This year will be a great year for family medicine. A large driver will be new models of CMS payment from Medicare Access and CHIP Reauthorization Act (MACRA’s) quality payment program. The emphasis on value-based payments has made leaders more aware that a strong, highly functioning primary care base is required to provide comprehensive, high-value, low-cost population health. We will see family medicine residency programs grow and graduates have more choice than ever in their jobs, including the ability to maintain a broad scope of practice and career satisfaction. This is an exciting time to become a family physician!

Cristy Page
Cristy Page

Regardless of changes the new administration may make regarding Obamacare and Medicaid, family physicians will remain committed to improving the health of all people. Our leadership is critical for solving the complex challenges of modern health care. The trends of patient care, research, and education for 2017 will focus on innovations in care delivery, implementation science to help us study which care models and team designs work best to keep patients healthy and satisfied with their care, and in training family physicians for leadership in health care transformation. We will see enhancements in coordination of care to keep patients out of the hospital, extended hours, expansions of telehealth, and home visits, as some examples.

Cristy Page, MD, MPH,
interim chair, department of family medicine, University of North Carolina

The thing that strikes me about the future of family medicine is that every day, 10,000 baby boomers are turning 65 and entering into Medicare. How do we manage Medicare populations who are aging in a way that delivers comprehensive primary care services that coordinate not just for a person with a single illness, but also for those with multiple, chronic serious illnesses? I think that is going to be a major driving trend that’s going to continue for the foreseeable future. To me, the answer is the family medicine practice organizing around care delivery through teams for more complex patients. The leader of that team is the family physician since he or she is perfectly trained for that, because they are intimately familiar with the needs of their local community, the resources of their community, and they have excellent skills in communication and managing nurses and social workers to get the patient the help that they need. Making transitions in the practice to be able to deliver such care will increasingly be the wave of the future.

Paul Tatum
Paul E. Tatum

The second related issue that I think will impact physician practices is adaptation of several new billing codes from the CMS to help pay for this delivery care, including for chronic care management non face-to-face time, advanced care planning codes and new codes for cognitive evaluations. I think the question in the next year will be how do family physicians’ offices utilize those codes to help build the team systems we need to manage the older adult with multiple serious illnesses.

Paul E. Tatum, MD, MSPH, CMD, AGSF, FAAHPM,
department of family and community medicine, University of Missouri

1. The move to more quality-based reimbursement. It is likely that not only government-sponsored, but also other insurers, are going to move to more quality based reimbursement. In some ways this could be a positive change for family medicine, given the specialty’s interest in preventive care, primary care, and cost-effective care. However, exactly how the changes planned under MACRA, etc. are implemented, how small as well as larger clinics implement these changes, and how our hospital systems deal with less reimbursement for high cost care, is still very uncertain. We know from other ‘pay for performance’ systems that there are upsides and downsides of this form of reimbursement. Deciding what and how to measure are fraught with difficulty, and ensuring that family medicine clinics have the teams in place in order to improve care are critical.

Matthew Thompson
Matthew J. Thompson

2. The need for family physicians overall, and their distribution in rural and urban areas will continue to be a major challenge without changes to medical education and graduate medical education (GME). It is crystal clear that the U.S. is producing far fewer family doctors than needed, and that the system of GME is not meeting the U.S.’s health care needs. These need to change if we are to be able to care for our populations. Many smaller towns and rural areas will continue to struggle to attract providers, and without family medicine these communities will decline. Some states, such as Washington, are investing in new family medicine residency programs, and trying to ensure that osteopathic and allopathic joint accreditation is supported; other states need to follow this lead.

3. Research funding for family medicine and primary care has always struggled within the NIH. The emergence of Patient-Centered Outcomes Research Institute (PCORI) as a significant new funder of patient-centered research has been hugely significant, and underscores the need for research that meets all stakeholder’s needs, including patients, clinicians, insurers, medical technology industry etc. Support for PCORI as well as Agency for Health Research and Quality will be critical to generate evidence that patients and their doctors can use to provide the best quality care right now.

4. New technologies in family medicine. Many medical technology companies now see family medicine and primary care as valuable, and are investing in tools and technologies that attempt to improve this part of our health care system. In 2017, I expect to see further waves of new technologies that could (and emphasis on could) enhance the kind of care that family physicians provide. However, simply ‘throwing' new technology at family physicians and their patients is not the answer, and risks frustration and wasting money. Rather, we need to work with technology companies where appropriate to design, evaluate and implement new technologies that have demonstrated value to improve care.

5. Changes in health care coverage for patients in family medicine is certain to be a major issue for the coming year. It is unclear as yet what a replacement to the ACA will look like, but I know many family doctors have been able to provide better care (and be reimbursed for care) for many more patients who received coverage under the ACA. It is going to be essential that patients continue to have access to the high quality primary care that family physicians (and their teams) provide. No one will benefit if we lapse back into lack of insurance coverage for large swathes of our communities. The care that family doctors provide is an incredibly good value for money (preventing strokes, treating depression, detecting early cancer, avoiding the need for expensive ED visits etc.) that any new system must ensure that we can continue to provide excellent primary care.

Matthew J. Thompson, MBChB, MPH, DPhil,
professor and acting chair, department of family medicine, University of Washington

 

The future of family medicine will require expert preventive, acute and chronic disease care and will increasingly demand the care of populations. This care will be provided not only in person but via text and video communications. The historic pillars of family medicine will be sustained: accessible and accountable care provided in a continuous, comprehensive, and coordinated fashion. As we move increasingly toward value-based care, the reimbursement model will change to reflect this relationship and responsibility, increasingly being manifest as direct payment for primary care.

Steven Zweig
Steven Zweig

Exciting opportunities for family physicians will also include working with high-performance teams in caring for patients across all settings. Whereas service lines in health care will better serve single-organ health problems, the values and skills of family medicine will enable the comprehensive care of an aging population with its increasingly prevalent complex problems. Family physicians will be leaders in system-based practice, use of technology for improving quality, evidence based practice, and techniques for engaging patients and communities. Nevertheless, the human need for the personal physician will persist. Continuity relationships between patients and family physicians will provide the trust, accountability, and opportunities for healing experiences along the continuum of the life span. 

Steven Zweig, MD, MSPH,
professor in family and community medicine, University of Missouri School of Medicine.

Disclosures: DeGruy, Page, Thompson and Zweig report no relevant financial disclosures. Tatum reports receiving past funding from Health Resources and Services Administration geriatric academic career award and is currently a board member of the American Academy of Hospice and Palliative Medicine.