Attempting to predict the future is always a risky endeavor. Attempting to predict the future of health care is particularly precarious. As Jon B. Christianson, PhD, recently said, “It is very difficult to predict how any system will evolve when in effect you are asking the system to do contradictory things.”

Being pulled in conflicting directions by health plans, physicians, “consumers,” purchasers and regulators, our health care system is without a doubt in turmoil. Few can agree on what's happening in the present, let alone the future, and no sure fixes loom on the horizon.

But while the future may be impossible to see fully, we can occasionally find glimpses of the coming storm or calm skies, as the case may be. So what will the next five or 10 years bring for family physicians?

For this first issue of Family Practice Management in the year 2000, we felt it appropriate to ask a number of family physicians and other observers of the health care scene to take the role of prophet for a moment. Our questions to them were twofold: What will be the biggest opportunity for family physicians in the next five to 10 years? And what will be the biggest challenge?

Doug Iliff, MD

Solo family physician Topeka, Kan.

As it has always been, the greatest challenge for family physicians will be to uphold the integrity of the profession by doing what is best for our patients, putting ourselves second. Patients will always be served best where the market is freest. In family practice, this would mean that the greatest number of patients have access to and choice among the largest number of physicians, who in turn have the utmost independence to decide among diagnostic and treatment options.

Of course, medical costs must be controlled. The discipline must come from the doctor, the third-party payer or the patient. Under fee for service, we tried the doctor. That failed, perhaps in part due to greed from certain specialties, but mostly because limiting care as a cost-saving measure is fundamentally contrary to our ethics and our instincts. Under man-third-party payer. That failed because it appears dictatorial and transparently unethical.

We haven't tried medical savings accounts (MSAs). Here patients have full responsibility and huge incentives to spend wisely, and here the family physician becomes a trusted counselor and colleague rather than a gatekeeper. The ethical dilemma disappears; both hypochondriac and skinflint can rest easily, the one satisfied with the abundance of care and the other with abundance of savings. If MSAs are ever to untie the Gordian knot, family physicians should lead the way.

David C. Kibbe, MD, MBA

Family physician, chief executive officer of Future HealthCare Inc., an Internet clinical applications and services firm, and contributing editor to Family Practice Management Chapel Hill, N.C.

The biggest challenge for family physicians will be how we manage costs. We're in a period in which reimbursements from all payers are shrinking. While patients will bear a large percentage of these costs, family physicians are going to have to find ways to become more efficient by understanding and implementing real practice management. We must manage our practices in a manner that satisfies our customers' needs for information, access and convenience because the consumer will be the driver in the health care marketplace.

The biggest opportunity for family physicians in the future is going to be how we reinvent primary care. We have the opportunity to redesign how patients receive primary care, how they interact with us and how they negotiate the referral system. We have a whole new set of information technology tools to accomplish this, if we so desire. This kind of information reformation — the ease with which patients can go directly to the Internet to gain information, for example — is something we can welcome, embrace, use to our advantage and offer to our patients. This is a huge opportunity — an opportunity that we forgo at our absolute peril.

Robert Graham, MD

Executive vice president, American Academy of Family Physicians Leawood, Kan.

The single biggest challenge for family physicians will be to continue to be able to make the case of the effectiveness and efficacy of the model of family practice services in a system that is fragmented and oriented toward short-term rewards. The single biggest opportunity will be to take a system that is in substantial disarray and that will be undergoing major changes in the way services are organized and financed and make the philosophy of family medicine central to the new system.

Karen Ignagni

President and chief executive officer, American Association of Health Plans Washington

Managed care will continue to evolve in diverse ways during the next five to 10 years, but where it heads will be guided by patient preference. At present, patients have expressed interest in increased direct access to subspecialty care. While the old gatekeeper model was at times challenging for primary care physicians, it did make them the key contact and coordinator of patient care. With today's consumer preferences, primary care physicians need to focus on new strategies aimed at increasing patient satisfaction. These include providing more high-touch service, such as telephone consultation and easier appointment availability, as well as high-tech services such as using e-mail for consultation and follow-up.

Quite apart from the evolution of managed care, primary care physicians have an important educational job to do. For over two years the political discussion in Washington and throughout the United States has equated high-quality care with direct access to subspecialists. Indeed, virtually every specialty society has a mandate proposal and a champion in Congress. But primary care physicians have done relatively little to educate the public about what's at risk if there is far less reliance on physicians who have been trained in general medicine. Primary care physicians are in danger of seeing legislation passed that bypasses their important contribution. If that happens, it will limit innovation in the design of health care plans and potentially shrink patient choice by limiting the scope of primary care options.

William D. Soper, MD, MBA

Family physician and member of the Family Practice Management Board of Editors Liberty, Mo.

For our patients' sake, all physicians are going to have to take back control of medicine, and I think the family physician is in one of the very best positions to do that.

To regain control, we have to recognize why we lost control in the first place. The greatest reason of course was cost-effectiveness; a lesser reason was because doctors were —and are — unwilling to band together for the sake of medicine. The insurance companies were able to take over simply by dividing and conquering the physicians.

In the future, the family physician is going to be called on increasingly to fall into the role of coordinator, the person who makes the decisions about what needs to be done for the patient and by whom. The family physician has to be a counselor, helping the patient sort out what are often varied recommendations, and is going to become the ultimate consultant and patient advocate.

Alice G. Gosfield, JD

Health care attorney, principal of Alice G. Gosfield & Associates, PC, chairman of the Board of Directors of the National Committee for Quality Assurance, and member of the Family Practice Management Panel of Consultants Philadelphia

The biggest challenge facing family physicians today is realizing that there is no one single biggest challenge but rather a different challenge or set of challenges for every group —and that every group needs to find its own set of solutions. There is no perfect answer. There is no model. Only by being ruthlessly self-analytical and acknowledging that there is no absolute answer can any group find its way. That said, it is possible to list the major types of challenge that many groups face, and if I had to focus on one, I would say that learning how to be efficient without worrying about defensive medicine has to be really, really high on the list. After all, there are two ways of making money: You can raise your fees or lower your expenses. In this environment, it's going to be lowering your expenses — and physicians are very bad at doing that, even though there are ways of doing it that actually promise to improve the quality of care.

I would have to call that the biggest opportunity family physicians have today. Focusing more on better clinical management of patients so that you can lower expenses, monitor what you're doing and improve the quality of care is an enormous opportunity for a win-win solution —particularly in light of an underappreciated antitrust safety zone outlined by the Federal Trade Commission and the Department of Justice in 1996: A network of otherwise competing physicians who don't have to be financially integrated, who don't have to take capitation, who can bargain collectively over fees if they integrate clinically.¹

Lee N. Newcomer, MD

Senior Vice President for Health Policy, United Health Group Minneapolis

Family physicians are going to be held accountable for their performance by managed care, the government and the public. People will want to know how well physicians are able to do things, and they'll need to be able to show that when they treat people with this or that disease they do it right. This tremendous challenge also leads into the opportunity: Once we develop ways of measuring that performance, we're going to make some quantum leaps in how well we improve the care that we give.

I think we'll see payment systems continue to change to reward people who perform better. And I think we'll see public dissemination of performance information. Consumers, led by baby boomers, will care more and more. You're going to see an explosion of interest in how well physicians perform.

Nancy W. Dickey, MD

Immediate past president of the AMA and professor in the Department of Family & Community Medicine, Texas A&M College of Medicine College Station, Texas

In the future, family medicine may be perceived as a threat to the more narrow-breadth specialties. We do a broad range of care, and we increasingly demonstrate the importance of having one physician be the central repository of information and referral. As family physicians, the relationship with our consultant colleagues is important, including their valuing the contributions of primary care physicians in the care of patients.

Some of the other challenges we face are the growing number of nonphysician providers and the need to demonstrate the difference in quality and cost of family physicians vs. nonphysician providers; the anger patients feel about the “gatekeeper” concept and the need for family physicians to communicate the usefulness of a primary care physician as an entry point not as an obstruction; and the increasing public discussion about the patient's right to access “specialist” care, which indicates a lack of appreciation of the value and skills of primary care specialists.

The greatest opportunity for family physicians is to demonstrate daily our commitment to our patients. We're here to advocate for them in the health care delivery system. We need to demonstrate the importance of continuity to cost and quality; otherwise, why should patients believe it's important? We need to show our patients and our consultant colleagues the value of having a personal family physician — through research and by our actions as superb partners and referring physicians.

Jeff Goldsmith, PhD

President, Health Futures Inc., and associate professor of medical education at the University of Virginia School of Medicine Charlottesville, Va.

The single biggest challenge for primary care physicians will be maintaining the focus on the patient despite the distractions of the health care payment system and the delivery system. I think that's going to be a lot easier for primary care physicians who, unlike some of their specialty care colleagues, never really got all that far away from the patient.

I think mastering Internet communication is the biggest opportunity for physicians. When physicians get past their concerns about an unmanageable volume of communications and some of the medicolegal issues, they'll discover that e-mail, in particular, will give them a whole array of options for answering patient questions and making more efficient use of their time.

U.S. Rep. Tom A. Coburn, MD, R-Okla

Majority member of the Committee on Commerce, vice chairman of the Subcommittee on Health and Environment and practicing family physician Muskogee, Okla.

What our patients know and don't know about health care, and how we respond to it, is going to markedly change. A number of our patients will be gathering information from the Internet, and they're going to walk into our offices knowing that they have a certain disease. Our compassion and patience are going to have to be at a level where we're not offended when we don't know something that our patients know. It's projected that by 2001, 80 million people will have access to the Internet, so our patients are going to be much more informed. Through this new medium, they're going to help us become much better doctors.

Bruce Bagley, MD

President, American Academy of Family Physicians Albany, N.Y.

The single biggest challenge family physicians will face in the next five to 10 years is the transformation to computerized medical records. We have to make the transformation in order to support quality care.

I believe the health care system has figured out that family physicians provide the most cost-effective care. The system will come to value what we do, as family physicians, in a way that it really hasn't in the past. We have a wonderful niche market: We offer continuous quality care, care for entire families and we handle many different problems. No other specialty provides what the people of America want — a personal physician who cares about them as a whole person.

Douglas E. Henley, MD

Family physician, co-chair of the AMA's CPT Editorial Panel and past president of the AAFP Fayetteville, N.C.

Family physicians need to continue their tradition of adapting to change. The key to meeting the challenges the environment will continue to create for us will be maintaining clinical competency, empathy and concern for patients as well as a positive attitude. I think any family physician who does these things is going to continue to thrive, both economically and in terms of enjoying what he or she is doing.

Electronic medical records will create tremendous opportunities for family physicians in the years ahead. EMR systems will help us to enhance patient care and efficiency, for example, by decreasing concerns about drug interactions and helping us to manage multiple drug formularies. I also think physicians will have to be more attuned to performance measurement in the future, and EMRs can help us to demonstrate our performance to patients and health plans.

U.S. Rep. John D. Dingell, D-Mich

Co-sponsor of the Bipartisan Consensus Managed Care Improvement Act of 1999 (the Patients' Bill of Rights, as it's commonly known, has been committed to a House-Senate conference committee), minority member of the Committee on Commerce and the Subcommittee on Health and Environment Dearborn, Mich.

Family physicians will have two challenges. The first will be to continue to provide high-quality care to the families they serve — in a way that they and their patients want. We need to pass legislation that will help them to accomplish this. The Patients' Bill of Rights would see to it that patients and doctors decide questions of medical necessity, and it would give patients the ability to sue to see to it that their quality-care rights are protected.

The second challenge for family physicians will be to assure access to this kind of care. How are we going to cover the 40-some percent of Americans who don't have any health care insurance, and how are we going to stop insurance programs from eroding in terms of the quality of care provided and the amount of care available. Unmet health care costs result in huge financial, social and emotional costs for the country and its people.

David Satcher, MD, PhD

Family physician and Surgeon General Washington

The biggest challenge that family physicians will face in the next 10 years is the changing demographics of a country in which the population is growing older overall and how we will deal with that in terms of health care financing and delivery. This challenge will provide the opportunity for leadership from family physicians, who can take the lead in a number of areas, especially in mental health, where we desperately need to improve early detection, treatment and referral of mental health problems. More than half of the people who could be helped by treatment do not receive it. I recently returned from a visit to Australia, a country that has made significant progress in addressing mental health problems and destigmatization. They were very successful in getting primary care physicians involved in early detection and treatment.