Friday, June 5, 2015
by Gary Buckholz
I practice full time palliative care, but I am also a strong advocate for family medicine and primary care. I volunteer a significant amount of my time serving on the Family Medicine Review Committee for the Accreditation Council of Graduate Medical Education (ACGME). While most family physicians don’t specialize, the American Board of Family Medicine (ABFM) offers Certificates of Added Qualification (CAQ) in some areas of medicine. Hospice and Palliative Medicine (HPM) and geriatrics, for example, are natural extensions of family medicine. Twelve years ago I pursued HPM training directly after family medicine residency training, however family medicine continues to serve as the foundation for my palliative medicine practice. As many family physicians say—“once a family doc, always a family doc”. I suppose this is also why I will always need to maintain my board certification in family medicine in order to maintain my CAQ in HPM.
When the Institute of Medicine (IOM) report on Graduate Medical Education (GME) financing came out last year, I agreed with the recommendations and thought to myself that primary care specialties as well as the subspecialties of HPM and geriatrics stand to do well if these recommendations are implemented. Dr. Kyle Edmonds nicely summarized the details of the IOM recommendations and the context for HPM.
The American Academy of Family Practice (AAFP) took advantage of this report and released a document or position statement on GME financing as well: Aligning Resources, Increasing Accountability, and Delivering a Primary Care Physician Workforce for America This release came with additional supporting documents:
These documents describe how family medicine meets the needs of our population in the context of a shortage of family medicine physicians. They advocate that GME financing should align with the needs of the population rather than hospitals. I completely agree with that!
However within these documents, the first of five recommendations is to “Limit payments for direct graduate medical education and indirect medical education to training for first-certificate residency programs.” Interpretation = Don’t fund fellowship programs (including HPM and geriatrics). I was extremely disappointed to see the wording of this specific recommendation.
Are HPM and geriatrics really in a significantly different ballpark as compared to Family Medicine? The ABFM offers CAQs in both of these fields. HPM and geriatrics have documented significant shortages of trained physicians and both meet the needs of our aging population. Both view and care for the patient in the context of their family and the community. You might argue that HPM and geriatrics don’t provide primary care, although the geriatricians I know provide primary care for the most complex patients and when I worked for a hospice, I assumed primary care (at the request of the referring physicians) for many of the most complex patients. Additionally, HPM and geriatrics fall in line with family medicine when it comes to the goal of increasing value and the triple aim of better care, better quality, and lower costs. When compared to family medicine, there are many similar goals and quality outcomes for our patients. However, HPM and geriatrics require additional training because there are additional skills needed for our patients that are not taught within family medicine (or other primary care) training programs.
The AAFP statements ignored recommendations from an IOM report in 2008: Retooling for an Aging America: Building the Health Care Workforce. And ironically, the same month the AAFP released their statements, the IOM released another important report: Dying in America: Improving Quality and Honoring Preferences Near the End of Life. This important report calls for a number of changes to enhance our population’s quality of life and contribute to a more sustainable health care system. In addition to calling for general palliative care skills to be required for training of all clinicians caring for advanced serious illness (including primary care training), the report calls for increasing the number of and funding of HPM fellowships.
The AAFP statements say that subspecialties don’t need funding for training programs because subspecialist trainees are allowed to bill for their services. This is incorrect. GME departments that support training programs do not allow subspecialist trainees to bill due to Centers for Medicare and Medicaid Services (CMS) scrutiny. Since GME departments receive federal funding for some training positions and provide some level of support to all training positions, they do not allow any trainees to bill. CMS policies would need to shift significantly for this to change.
Why then, as the AAFP statements point out, have many fellowship programs developed since 1997 that don’t get financial support from Medicare? These programs depend on funding through private-sector philanthropy or institutional support (departments or hospital budget). Just over 100 mostly small HPM fellowship programs in the United States have scrapped together money in this fashion. Unfortunately that does not come close to meeting the workforce needs of our population.
I am aware that some family medicine residency positions have also been funded without government Medicare funds (over the cap). However, that does not mean it is a sustainable model to grow family medicine to meet workforce needs. While this isn’t a good model for family medicine, HPM, or geriatrics, it might work for some subspecialties with higher department budgets and faculty billing revenue.
A friend of mine who is a Family Medicine Residency Program Director had trouble understanding my dismay regarding the AAFP position. She said, “Well, can’t HPM develop their own advocacy for GME funding separate from family medicine?” The simple answer is “sure”, but it doesn’t make sense to me that any advocacy will be in direct opposition to AAFP. Additionally the AAFP stance is currently one that isolates family medicine instead of building strategic partnerships.
The American Academy of Hospice and Palliative Medicine (AAHPM) and American Geriatrics Society (AGS) are doing important work to grow and retain the HPM and geriatric workforce. A number of collaborative efforts have been undertaken around education and advocacy including a joint outreach to AAFP with AAFP holding firm on their stance for now.
For those of you who are family physicians, I encourage you to reach out to AAFP and tell them how you feel about these position statements and specifically the wording of their first recommendation. I hope there will be a shift over time. It makes sense that AAFP would be a partner in advocacy to meet the needs of our current and future patients and their families. Please leave your thoughts here as well.
American Academy of Family Physicians
Telephone: 800-274-2237 Fax: 913-906-6075
American Academy of Family Physicians
P.O. Box 11210
Shawnee Mission, KS 66207-1210
Gary Buckholz, MD, FAAHPM is an Associate Clinical Professor at UC San Diego and part of the Doris A. Howell Palliative Care Service. He co-directs the UC San Diego and Scripps Health HPM Fellowship Program. These are his personal opinions and may not represent the views of UC San Diego, Scripps Health, AAHPM or ACGME.