Although my practice is thriving, it’s hard to escape the conclusion that my specialty is not – and this despite my conviction that family-centered, longitudinal, preventive-oriented medicine is the best model for most patients and our health care system. For many months, I have been cautiously hopeful about the Future of Family Medicine project. I found much to praise in the initial report, despite its overly idealistic and academic tone.¹ However, I questioned two unexamined postulates of the project: that American health care consumers respond to the quality of the product rather than the price, and that American health care payers respond readily to long-term quality rather than short-term costs.

As I awaited the Task Force Six report on financing the New Model of family medicine, which I considered the linchpin of the entire initiative, I formulated the following questions and, where possible, my own answers:

1. Why is it easier to fill training slots in gastroenterology, radiology, ob/gyn or orthopedic surgery than family medicine?

   Since the vast majority of medical school applicants profess a longing for primary care, the most tenable answers are (a) the influence of mentors and (b) monetary rewards. I choose (b) as the cause and (a) as the rationalization.

2. When family physicians have committed to electronic medical records and evidenced-based practice, and research is humming along at thousands of small laboratories, will the demand for prestigious family medicine training slots exceed supply?

   In this imaginary scenario, the quality of family medicine will be the highest in history, but family physicians’ income will have shrunk still further due to unreimbursed technology costs and continuing reductions in health plan reimbursements. Students will therefore tender their admiration for family medicine and request a colonoscope for graduation.

3. Will Medicare, Medicaid and insurance companies, recognizing the cost savings of family medicine, reimburse cognitive services on a par with procedures?

   When hell freezes over.

4. Since every new screening test, drug, procedure or technique trumpets its global cost-savings, why is the cost of medical care once again spiraling out of control as managed care wanes?

   Those are wink-and-a-sneer confabulations, and we all know it. Coreg vs. atenolol? TPA vs. streptokinase? Plavix vs. aspirin? Most modern drugs offer a 5 percent increase in efficacy at a 1,000 percent increase in cost, and we must remember that 86-year-old nursing home residents now receive triple-bypass surgery and hip replacements on demand.

5. Does controlling medical inflation involve somebody making a cost-benefit decision and saying “no” to a test, drug, procedure or technique? If so, who?

   Yes. Government, insurance companies, physicians or patients. Any volunteers?

6. Under whatever form of universal health care envisioned by the AAFP, who would make the rationing decisions?

   Perhaps Task Force Six would answer this one, I thought.

7. When universal health care is operative, does the Academy imagine that it will muscle family physicians to the front of the reimbursement line more effectively than under the present system?

   Here’s another one I couldn’t answer.

8. Why do my patients, who have had the benefits of open-access scheduling, office staff who know them as friends as well as patients, and a doctor who has always provided the “medical home” advocated by the Future of Family Medicine, leave this practice due to a change in insurance that might cost them an additional $5 or $10 per office visit?

   American consumers are exquisitely price-sensitive. I think my patients truly appreciate the “home” we provide, but not as much as they appreciate the $5 or $10. This is not to say they couldn’t be sold on my ability to save them money if they had real money at risk, which almost all insured patients do not.

9. If all cost-benefit decisions were in the hands of patients and those patients stood to benefit financially by wise purchasing decisions, could family physicians compete with other groups of physicians and non-physician providers in a truly open marketplace?

   I wish I knew the answer to this one, too. I know I would be eager to compete; I am certain that I effectively handle more problems per dollar spent on my services than physicians in other specialties. Back in the halcyon days of full capitation, I collected several annual bonus checks in the $60,000 to $80,000 range as a share of the money left over in my pool at the end of the year, but many of my family medicine colleagues did not fare so well.

   Do we really believe in ourselves, or not? The implications are enormous. If we believe our own propaganda, then we want the patient in full command of the money decisions, as with health savings accounts, because this will produce high demand for our services. If we don’t, then we need to vastly increase our contributions to political action committees – in order to shoulder our way to the front of the trough.

   I still believe we’re ignoring the real problem: our patients.

10. Believing that we will inspire our patients to make desperately needed lifestyle changes, the AAFP is promoting the untested hypothesis that family physicians should shape up and become better role models. What percentage of patients will be moved to sustained action, lacking any financial incentive or disincentive to do so?

We all know that lifestyle choices are killing our patients. I don’t know what works, but I’m pretty sure I know what doesn’t. I’ve been a perfect role model my whole career, right down to running two Boston marathons and winning an AAFP convention 5K. I’ve preached diet, exercise and smoking cessation for three decades. Out of 4,000 active patients, at least 400 are in desperate need of overhaul; I pioneered and extensively publicized a program called Basic Training (http://www.iliffbasictraining.com), and six patients signed up (none of them were among the 400 I targeted). In one form or another, we’ve all tried wheedling, cajoling and pleading. Personally, I think it’s time to hit them in the wallet. Only health savings accounts, among all the ways of financing health care, bring the full bore of moral hazard to bear on this desperate situation.

Afterthoughts

Task Force Six was not assigned to answer my questions, so it’s not surprising that they didn’t. I had assumed that they would assume the otherworldly expectations of the Academy regarding universal health care. To their credit, they did not. Their report^2,3 does rely heavily on models of reimbursement (translation for lay persons: optimistic speculations) purporting to show that implementing the new model of family medicine will result in a 61 percent increase in reimbursement, at least when insurance companies finally acknowledge the value of our services and design their reimbursement methods accordingly. Color me skeptical.

One reimbursement innovation that the report predicts is pay-for-performance. If health plans indeed implement pay-for-performance programs, and if they reward excellent performance with additional money rather than simply punishing poor performance by withholding money, some family physicians will do well. But I doubt this is how it will play out. It’s not that I’m cynical about insurance companies; most of my experience is with the local Blue Cross plan, and I think they do an excellent job and really care about their enrollees. But every day I say something like this: “Look. I can fix your problem for $500 a month in drugs, or you can tackle your lifestyle.” Either way, I will hit my performance target. But 98 percent of the time, the insurance company is going to pay the freight. And I’m supposed to believe that they’re going to reward me, year in and year out? It strains my faith in human nature and corporate decision making.

Besides, I still believe we’re ignoring the real problem: our patients. They are the only ones who can make the rationing decisions in question six, at least in American culture. Health savings accounts are criticized because they are a better deal for healthy patients than sick ones. Bully! I do not have a moral problem with making bad drivers pay more for auto insurance or parachutists pay more for life insurance or smokers pay more for disability insurance. Until there is moral hazard built into health insurance, I don’t think Americans are going to pay attention to our advice, work with us to make cost-effective decisions or become full partners in the wholistic system envisioned by the Future of Family Medicine. Of all the financing schemes – past, present or future – only health savings accounts fit with the individualistic spirit of Americans. That’s where the AAFP and the rest of the family medicine community need to start the promotional campaign.