JM: Through the 1990s family physicians around the country were demonstrating significant frustration over the system in which they were practicing. The promises of managed care to truly manage care and create an environment in which family physicians can do what they were trained to do obviously has not been realized. More importantly, we heard frustration from patients: disappointment and anger at a very dysfunctional health care system. We began to notice that the future pipeline of primary care was also suffering, as students were saying, "I don’t want to work that hard for the limited amount of prestige and income. I want to go elsewhere." So the family docs, rather than just trying to look at how to retool and package, we decided we needed to go back to the American people and say, "You tell us what your needs, wants and expectations are. Do we have any role to play in this at all? What kind of system do we need to have that will create a better health care in this country?" That’s where the research project came from.

JM: The essence is that the primary care doctor is seen as a gatekeeper, which the American people see right now as a roadblock to get the kind of care that they want. There is a loss of trust that that physician will put them first, rather than the profits of the managed care company. There are limits on who patients can see depending upon the panel within their health plan. There is loss of communication among the various specialties and subspecialties, difficulties with different pharmacy formularies, differences in someone’s ability to pay for health care – those who are uninsured versus those who have high coverage. When you look at it that way, the whole system is dysfunctional.

JM: Although family physicians are very busy – they represent around 11 percent of physicians in this country and they see about 25 percent of the office visits – there is a trend that shows that the number of patients seeing primary care physicians, especially family physicians, is starting to diminish compared with visits to our subspecialty colleagues.

JM: My personal feeling is that managed care has created such a loss of trust in family physicians. There was a time when, if you lived in the community, you saw the same doctor year after year. A trusting relationship develops. Patients are smart enough to know now that, in most managed care, the less that is done for them the more the profit is. So, there is a push by the patients out of insecurity to want to make sure that they are getting the best care that they can, and the way they define that right now is the care of a subspecialist, or the care of the most modern up-to-date technology that’s available. As long as the family doc is relegated to a hamster wheel work mentality, seen as a gatekeeper adversary to patients getting into the health care system, is not allowed to practice the comprehensiveness that he or she was trained to do, and there continues to be decreased reimbursement value for what family physicians bring to the system, I think it will continue to be destructive.

JM: Absolutely not. I think what patients are looking for is to make sure they have confidence in the care that they get, and the gatekeeper model does not give them that confidence. If they feel like the family doc is refusing to do certain things that they want done because of the payment system of that particular plan, they’re concerned that they’re not getting the best care they can get and therefore they want to assure themselves of that by going straight to the subspecialist.

JM: Most people don’t put ob/gyn in that category. Ob/gyn wants access to women regarding primary care gynecological issues, but they’re not interested in the overall management of everyday medical problems that women have. Pediatrics and internal medicine have a pretty clear definition of who they are and what they do. Family medicine has not done a good job of promoting to the public who it is, what it’s training is and what it’s competently able to do. We felt that we needed to go back and find out, "Are we even relevant anymore? Do we belong in the health care system? Are we obsolete and need to go away?" That was actually one of the more powerful questions asked in this project. The public may have come back and said, "No, we don’t need you anymore."We were told that what we needed to be, we were. We just hadn’t promoted it well.

JM: We actually asked our subspecialty colleagues that exact question: "If you’re co-managing a patient and the person has a complex medical problem, would you rather have an general internist or a family physician helping you manage the patient?" By a very slight majority, they said, "We really don’t care, but if we had to make a choice it would be a general internist because we feel that their training is a little bit more in-depth." But then the question was, "What if the person has more than one complex problem at one time, would you rather have an internist or a family physician working with you?" Overwhelmingly they said, "Family docs do a better job of managing complexity and we prefer the best person be the one working with us in the care."

Pediatricians and internists do the exact same three years of training as family medicine does. The difference is, there is more subspecialty training in pediatrics, so pediatricians spend more time in the intensive care unit, more time in the critical care unit than do family physicians. So, for the critically ill child, I think that there very definitely is a role for the pediatrician to be the active caregiver in that case. In terms of internal medicine: similar argument, although family medicine has much more training in the intensive care unit and the critical care unit than they used to, so the subspecialty people said they feel that the family doc training makes them quite adequate to manage the same level of complexity as the internist.

JM: That’s what The Future of Family Medicine Project is all about. We need to develop a system that puts the patient back into the center of health care, that develops new strategies of how patient care is provided: Does it have to be face-to-face every time? Can it be improved? Can it be a synchronous process, like e-mail? Are there business models that will let that take place? It requires electronic health records. It requires office technology to make sure the care is high quality and safe, and yet it’s focused on the patient’s preferences and values. Training and education must take place and leadership must be developed to bring that system forward.

JM: We picked a national company that was well-known for producing valid marketing research. We had a qualitative project followed by a quantitative project. The qualitative part entailed a large number of focus groups in Boston, Minneapolis, rural areas around Minneapolis, and Los Angeles. Boston, because there was almost no family medicine present. Minneapolis, because it’s the most penetrated managed care market in the country. Los Angeles, because you can get many more cultures and diversity of different peoples’ background there. From all of those focus discussions we put together a detailed questionnaire that became the quantitative component that went to thousands of people across the country. Those participants included families who had a family doctor and those who did not have a family doctor. Those who had a family, those who didn’t have a family. Those who had chronic disease, those who didn’t. Those in the city, those in the suburbs, those in the rural areas. We got a very valid cross section of America in the study.

When that research was done, a series of taskforces were developed. Taskforce number one was to find out: what people needed, wanted and expected from the health care system; what attributes physicians would need to meet those expectations; and what kind of system would be best developed that would allow that to take place. Taskforce two said, "How do we train the next generation of physicians to have those attributes and work in that system?" Taskforce three asked, "How do we educate current physicians to have those attributes, work in that system and continue to be high-quality throughout their career?" Taskforce four looked at promotional aspects of how to move the changes forward. Taskforce five looked at leadership of family medicine and primary care within the health system. As the work was done each of the taskforce chairs approached me privately and said, "Jim I will be able to deliver what you wanted in terms of the charge of the taskforce. But if we cannot change reimbursement mechanisms for family physicians, we’re wasting our time because none of the things that we’re seeing in the research that need to happen can occur if family physicians are not valued more in the health care delivery system." So, a sixth taskforce was developed to look at reimbursement models and business plans.

JM: Audiences are multiple. First of all, our patients. We’ve been very gratified with the project’s media coverage, which included the Wall Street Journal, The New York Times, The Washington Post, U.S. News and World Report, Jim Leherer News Hour. Many of these media, which are focused on the consumer, have said that the public is encouraged by this radical, yet simple way of turning the care back on being patient-centered again. The second audience has been family physicians, who are beaten down and frustrated that the system in which they work doesn’t let them do what they were trained to do. It gives them hope that we can develop a system which will allow them to have the relationships they want with their patients again. And thirdly, we want the policy makers and stakeholders to be a part of that. Managed care and the insurance companies are obviously audiences; they’re actually what makes up all of that sixth taskforce. Obviously, our hope is that they will see the value of making the change in the system to get them the credibility back that they want. Also we thought it would control some the escalating cost of care in this country.

JM: Finding number one is that there needs to be a new way of providing health care in this country that includes the development of a personal medical home, the use of electronic health records, use of appropriate technologies in doctors’ office settings, use of a team approach in the management of patients based upon their preferences and their values, and a set basket of services that must be provided. That was the biggest set of findings from this project. The second one had to do with future education, to make sure that residents in training are taught the new model so when they begin their practices – and there are about 3,000 to 3,500 that graduate each year in family medicine – they are already very comfortable with the new model and can help push that tipping point where all the practices in the country begin to implement it. The third finding has to do with using the model to improve the quality, safety and provision of health care for this country.

JM: There’s a confluence of events happening in the country right now that I think will make this happen much sooner, rather than later. First and foremost, patients and the majority of physicians are unhappy with the health care system that they’re in. So, there’s increasing public and professional frustration. Number two, managed care has not delivered on what it said it was going to do. It has managed costs. It hasn’t done a whole lot to address care, and it’s lost a lot of its credibility because of this focus on its stockholders. That’s not lost upon patients; it’s not lost upon physicians. There’s a frustration over dramatically rising costs of health care in this country. Employers now are going to say, "I can’t afford your health care plan anymore. I’m going to give you the money. You become your own consumer and do your own decision making." That’s going to force patients to have to look at how they want to pay for that care. You’ve got the Congress telling NIH to start making their research more relevant, to start bringing it out to the practice level. So, there are these tremendous opportunities for re-looking at the system and choosing the system that we know will be effective.

Family medicine has moved forward with a series of parameters to try to encourage our members to develop electronic health records, which we see as such a central element in the system. We’ve been fairly successful, in terms of the number of vendors who are willing to be a part of the program, and we recognize that the majority of family physicians in this country really want electronic health records. They recognize that they are going to have to spend the money, and they want help to do it right – to get a system that really will work and that’s not going to be obsolete in a couple of years. Insurers are coming back with their own data that says, "We have found that when we do have that trusting continuity relationship, patients’ satisfaction is better, the care is good, the outcomes are good and it’s not nearly as costly to us." So, they are also willing to start looking at pilot projects to pay family physicians to do these additional roles, to offer synchronous e-mail communication, to have group visits. They feel that, in the long run it will lead to a healthier outcome and a healthier bottom line for them. The fact that all of these are occurring all at one time is very exciting to me and provides the synergy that I feel will make this very successful.

JM: First and foremost, the family physicians of America will need to buy into this. They’re going to have to say, "We like this model. We think this model will work. We will start to make the changes in our own practice to make that occur. Give us the business plans, the technical support, so we can get that done." That will be an Academy function, at least initially so. The second group that has to buy into this are the payors. They have to see a value to them by developing this type of system, which will give them more credibility by putting money where they will get the best quality outcomes, that also protects their bottom line. When that’s in place, the patients have got to like it. They’re the third part. They’ve got to be able to come in and say, "Yes, this is exactly what I want from health care because it delivers it in the way that I want it, in a timely manner." Those three elements have to come together. The people that I thought would be hesitant to see this work – the payors, the other stakeholders, the other parts of the medical community – have all said at least thus far, "We love this. Somebody needs to stand up, become the leader and move this forward into a good system, and logically it’s the family physicians and we will work with you." I think that’s the most exciting part. They all said, "We’re behind you, go do this."