Family Medicine for America’s Health—4 Years Later, Heading Into the Future

In 2014, the eight leading family medicine organizations in the United States committed $20 million and representatives to Family Medicine for America’s Health (FMAHealth), a time-bound, goal-driven collaboration to promote and drive continued improvement of the US health care system and demonstrate the value of true primary care.1,2 The eight family medicine organizations are:

• American Academy of Family Physicians (AAFP)
• American Academy of Family Physicians Foundation (AAFP-F)
• American Board of Family Medicine (ABFM)
• American College of Osteopathic Family Physicians (ACOFP)
• Association of Departments of Family Medicine (ADFM)
• Association of Family Medicine Residency Directors (AFMRD)
• North American Primary Care Research Group (NAPCRG)
• Society of Teachers of Family Medicine (STFM)

The goal of FMAHealth is to transform primary care in order to achieve the quadruple aim (better outcomes, better patient experience, better cost, better provider experience4) by engaging all stakeholders to move the United States to a high-value system of health and health care. This goal will be achieved through practice transformation and the improved financial investment in primary care needed to support it in ways that achieve health equity—with the workforce, technology, and research needed to implement and sustain it.3

There are seven core strategies, each with a distinct purpose and tactic team to advance implementation1,2:

1. Engagement—Engage all primary care stakeholders to speak with one magnified voice about the value of primary care.
2. Health Equity—Reduce health disparities and increase the social accountability of primary care organizations.
3. Practice—Prepare for a future in which primary care teams provide comprehensive practice for comprehensive payment and strengthen joy in practice for all.
4. Payment—Move primary care away from fee-for-service reimbursement to comprehensive primary care payment.
5. Research—Demonstrate primary care’s ability to achieve the quadruple aim.
6. Technology—Put health information technology to work to solve problems facing primary care physicians and their practice teams.
7. Workforce Education and Development—Attract students to choose family medicine and strengthen supports to sustain practicing physicians’ passion for the specialty.

Health is Primary (http://healthisprimary.org) is the communication component of the project, meant to complement the work of the tactic teams.1

FMAHealth was a partner in the first Starfield Summit, held in 2016 to focus on what policy makers should know and where evidence was still needed to (1) measure and pay for the primary care function, and (2) train and deploy teams in primary care. The Summit’s success led to the Starfield Summit Series, an ongoing sequence of meetings for a diverse group of leaders in primary care research, education, practice, and policy to galvanize participants, generate important discussion for public consumption, and enable research and policy agenda-setting in support of primary care as an essential catalyst in health system reform.4

The formal work of the FMAHealth tactic teams will conclude in 2018-2019. This is an update that highlights some of the fruits of FMAHealth and the family medicine organizations related to the core strategies. This update also identifies which organizations will be involved in keeping the unfinished work of the tactic teams moving toward fruition.

Patients have been added to many of the boards of directors of the eight family medicine organizations. There is ongoing work exploring the best, outcome-improving ways to systematically engage patients in design and delivery of care. Legislative policy and advocacy work have been advanced. Collaboration with the Patient-Centered Primary Care Collaborative resulted in the development of the “Shared Principles of Primary Care,” which has been endorsed by more than 280 organizations encompassing physicians, educators, insurance companies, patients, and employers.5 The seven principles are6:

1. Person- and Family-Centered
2. Continuous
3. Comprehensive and Equitable
4. Team-Based and Collaborative
5. Coordinated and Integrated
6. Accessible
7. High Value

Health equity is so vital that the initial intention was to weave it throughout the work of all the tactic teams. However, it became evident that a dedicated tactic team could be more effective. The theme of Starfield Summit II was “Primary Care’s Role in Achieving Health Equity.” A resultant paper from Starfield II was accepted for publication in the Journal of the American Board of Family Medicine later in 2018.13 Family medicine organizations will intentionally highlight aspects of health equity throughout 2018-2019 and beyond. In 2017, AAFP started a Center for Diversity and Health Equity to address social determinants of health with the “EveryONE Project”7 to equip family physicians to address health disparities. Tools and resources are available at https://www.aafp.org/patient-care/social-determinants-of-health/everyone-project.html.

The patient-centered primary care home is evolving. Tasked with preparing for the time when primary care means prepared teams able to provide comprehensive practice for comprehensive payment, the practice team used the Annals of Family Medicine 2014 family physician definition:

…personal doctors for people of all ages and health conditions. They are a reliable first contact for health concerns and directly address most health care needs. Through enduring partnerships, family physicians help patients prevent, understand, and manage illness, navigate the health system and set health goals. Family physicians and their staff adapt their care to the unique needs of their patients and communities. They use data to monitor and manage their patient population, and use best science to prioritize services most likely to benefit health. They are ideal leaders of health care systems and partners for public health.8

They focused on Primary Care Measures That Matter, a 2-year project to identify quality indicators that matter and were involved in Starfield Summit III, Shared Principles of Primary Care, evaluating and advancing PRIME Registry, and identifying exemplars of practice transformation. Much of the metric and measurement activities of the practice team will be transitioned to the ABFM Foundation’s Larry A. Green Center for the Advancement of Prima­ry Health Care for the Public Good, established to advance the work of defining and promoting meaning­ful metrics in primary care.3

Payment reform is vital to the success of the other strategies. Achieving comprehensive, coordinated care delivered in a patient-centered manner means moving reimbursement away from fee-for-service. The payment team developed a comprehensive primary care payment calculator (CPCP Calculator—https://fmahealth.org/resources/comprehensive-primary-care-payment-calculator) that can be used by practices, employers, and payers to provide an example of how a comprehensive primary care payment can be structured.3 To enhance stakeholder understanding of primary care, the team formed the Primary Care Innovators Network to bring together practices and payers to learn more about the value of the CPCP Calculator.

Initially it was necessary to divide and conquer the multiple objectives. As progress was made, increased collaboration and communication developed so this left hand and right hand could start to clap. This is just one example of the many overlaps within the FMAHealth tactic teams’ work, eg, there is a business case for health equity, and payment reform has workforce ramifications.

The focus of Starfield Summit III was specifically “Meaningful Measures in Primary Care.” NAPCRG will continue to lead the Mapping Primary Care Research Project, designed to engage all eight family medicine organizations in advancing family medicine’s research efforts and infrastructure by analyzing, mapping, planning, and coordinating research efforts to identify overlaps, gaps, and/or synergies, as well as describe current and future research priorities.3 In 2017, the FMAHealth Board established an FMAHealth research fellowship. The current fellow is supporting works that bridge many tactic teams: Starfield III—Meaningful Measures for Primary Care, Bibliometrics on Family Medicine Research Productivity, Family Medicine Research Bright Spots, and Mapping Research Capacity Across Family Medicine.3

“Vision for a Principled Redesign of Health Information Technology” was published in Annals of Family Medicine.9 STFM’s Conference on Practice Improvement has brought together an innovator community of health technology entrepreneurs and family physicians to address practical problems and improve health through innovations in technology. Alliance for eHealth Innovation, a cooperative effort to align innovative physicians and industry leaders to improve workflows and address gaps in needed functionality, has transitioned to AAFP where it will focus on discovery, deployment, development, and data. ABFM is using its PRIME Registry to improve population health by enhancing and easing family physician quality reporting and improvement efforts.10,11

Within the context of competency-based education, entrustable professional activities (EPAs) were developed to describe the knowledge, skills, attitudes, and behaviors that each family medicine resident physician must acquire in order to graduate competently. The EPAs were vetted and edited by ABFM, ADFM, AFMRD, and STFM. AFMRD will lead continued work with the EPAs. The Preceptor Expansion Initiative is a multipronged approach led by STFM to obtain and retain more quality clinical training sites. It was discussed in greater detail in the April 2018 issue of Family Medicine.12

Encouraged by the work of the FMAHealth tactic teams, the eight organizations have adopted the audacious goal of 25% of medical students choosing family medicine as a career by the year 2030 (25x30). The AAFP has taken responsibility for this shared goal that will require the continued engagement of all eight organizations. Nearly all aspects of FMAHealth directly or indirectly support 25x30.

FMAHealth is a bold endeavor, the first of its type for the family of family medicine organizations. It is now in a transition phase in which different members of the family are assuming various levels of leadership, responsibility, and accountability for curating, maintaining, and advancing FMAHealth products and by-products.

In addition to lessons learned and mutual understandings gained from this significant collaboration, there will be other legacies related to the work of the tactic teams. The Shared Principles of Primary Care, EPAs, CPCP Calculator, Starfield Summits, Preceptor Expansion Initiative, continued health equity emphasis, and 25x30 are all endeavors that will have lasting positive impacts on family medicine and America’s health.