Tuesday, May 1, 2012

Is family medicine the only “pure” primary care specialty?

Brian Keppler writes that family physicians are the only "pure" primary care specialty, in a Kevin MD post railing against the decision by the American Academy of Family Physicians (AAFP) to remain in the RUC (RVS Update Committee).   So what does that make internal medicine, an impure primary care specialty?  (Brings back memories to me of the nuns in my Catholic parochial school, warning us to guard against impure thoughts—even when we were only eight years old!)

Keppler's point seems to be that because ACP represents internists who provide primary and comprehensive care, as well as IM subspecialists like endocrinologists and rheumatologists, we can't be expected or trusted to advocate for primary care.   Apparently, in his view, unlike AAFP, which represents only primary care physicians, because family medicine doesn’t have subspecialties.   Not only that, he makes the unsubstantiated claim that ACP (and AOA and AAP) are "dominated by sub-specialists, and so have been content with the RUC’s approaches."
(Well, if he was privy to the communications that I get from IM subspecialists who claim that ACP is too oriented to primary care and not doing enough for subspecialists, he might have a different view.  I also hear from IM specialists in primary care who say that ACP is too focused on its subspecialist members!  C'est la vie!)

The fact is that it was ACP that warned about the collapse of primary care in 2006, and it has been steadfast in advocating for policies to improve the lot of primary care physicians—internists, family physicians, and pediatricians.  At the same time, ACP tries to effectively represent all of internal medicine, which requires consensus and most importantly, balance, something that is in short supply in today's polarized political environment.

ACP has also worked diligently to reform the RUC, and we have achieved a large measure of success, with the RUC's decision to add another seat for primary care and another seat for geriatrics, which will add to the existing seats for AAFP, ACP, AOA, AAP and a rotating seat for IM subspecialties.  We also have advocated for establishing  an independent panel, outside the RUC, to identify potentially misvalued services.  

ACP’s record on the RUC and primary care isn’t the only thing that Keppler got wrong in his post: he called AAFP "the nation’s largest medical society" when actually ACP is the largest specialty society and AMA the largest physician society.

Keppler isn't the first one to refer to family medicine as the only "pure" primary care specialty.  Consider this AAFP video that encourages medical students to consider family  medicine this "versatile, pure primary care specialty."

Really, folks?  Internal medicine and family medicine, along with pediatrics and osteopathic medicine, have had a long history of working effectively together to help our members in primary care.  Do we really want to have a purity test about which specialty is the purest?  Or to assume that organizations like ACP that have both primary care specialists and subspecialists can’t advocate for the interests of both?  No primary care specialty can be effective if it goes its own way, jettisoning its alliances with its colleagues in other primary care fields.  

Plus, it isn't just primary care that is undervalued or in shortage.  The evaluation and management services of many IM subspecialists also are undervalued.  And with demand increasing, we need an "all hands on deck" approach to help all physicians who are involved in care coordination and who will be needed to take care of an aging population with more chronic diseases.  Not the divisive effort by Keppler and others to split primary care into "pure" primary care and, I guess, "impure" primary care specialties, like internal medicine.

Today’s post: What do you think about efforts to define family medicine as the only pure primary care specialty?


ryanjo said...

After reading Dr. Kleppler's post on KevinMD.com, it seems to me his comments were not really meant to start class warfare among primary care docs. He opposes "the RUC’s actions, including those that create incentives for unnecessary services, those that inhibit primary care’s moderating influence on specialty care, and those that undermine the development of an adequate supply of next-generation primary care physicians".

The AAFP leadership decided to continue to play ball with the RUC, despite these negatives, because “important strategic political partnerships outside the RUC could have been damaged if we withdrew, and that could have harmed the Academy’s advocacy efforts.”

Hmm -- how often have we critics of ACP leadership's coziness with the floundering health care reforms heard the same "seat at the table" explanation? Those 2 extra PCP seats on the RUC will surely cause a massive restructuring of primary care payments, once those 21 subspecialty members count heads.

To quote Pyrrus: "Another such victory ... and we are undone."

Arvind said...

All this shows the futility of persisting with CPT codes, RUC and the price-fixed system of reimbursement we have currently. The RUC battle will continue to divide physicians.

Let us all have the courage to ditch the CPT and RUC game and allow the free market and consumers of care (patients) to decide what primary care means to them and how much $ value they assign for such services. Like my barber, let us all put up a list of services with $ value in our waiting room or website, and allow patients to choose if it is worth for them. So long, CPT and RUC...

Ashok V. Daftary, MD, FACP. said...

Let them have it. The RUC is so entrenched and opposed to primary care that they are ensuring the demise of primary care

Jay Larson MD said...

Primary care – “the provision of integrated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal healthcare needs, developing a sustained partnership with patients, and practicing in the context of family and community”

Four main features of primary care services:
First contact access for each new need
Long-term person (not disease) focused care
Comprehensive care for most health needs
Coordination of care when it must be sought elsewhere

This is accomplished by physicians who have completed residencies in family practice, internal medicine, pediatrics, and OB/GYN and is not just limited to family practice.

The RUC will continue to serve the interests of the subspecialists represented and adding a couple more primary care spots will not change the overwhelmingly domination by proceduralists. Until the RUC substantially increases the value of the Evaluation and Management codes, all cognitive specialties and subspecialties will continue to struggle and Americans will continue to spend too much money for poor outcomes.