Remember Newton’s Second Law of Motion? To review, force = mass x acceleration. In other words, to determine the force of an object in motion, an observer must know the mass of that object multiplied by its change in speed over time.
Now, work with me. Imagine that the force is that which will shift a vector and that the vector, in this case, is the incentive system that drives rational physician behavior. At the present moment, that incentive system is designed to encourage one thing: volume of services and/or procedures. A doctor decides to do more for their patient and that doctor gets paid more for services rendered (usually no questions asked). This economic incentive is a powerful driver of cost and is largely responsible for the growth in health care costs, particularly when you apply the same incentive structure across the entire system to every provider of health care service widgets. Add to this economic scenario the increasing cost gap between procedural and cognitive services driven by the relative value unit (RVU)-based payment system, and what we have is a health care system that costs a lot without providing a lot of consumer surplus to the most important stakeholder in our health care industry: our patients.
Whew. Take a deep breath. That was a lot to digest (and probably brings back fond memories of studying physics for your MCATs).
Anyhow, let’s focus on that vector again. This volume-driven vector and its relation to cost (or payment in the health care provider’s eye) is what a health care executive (especially one whose title is a three-letter acronym that starts with a ‘C’ and ends with an ‘O’), or one of their bean counters, might use to measure a program’s value to an organization: those programs that provide the highest margin of revenue-over-cost survive whereas those that provide the lowest margin (or negative margin), should be cut. I would argue, however, that cost centers are not just cost centers; they provide health care services to real people and do, in fact, provide value beyond what is seen on a financial ledger.
The best example of this phenomenon of financial myopia and how to fight it occurred recently at Kern County Medical Center (KMC). In February, KMC CEO Paul Hensler decided not to allow the family medicine residency program to submit a rank list for the upcoming National Residency Match Program (NRMP). His rationale was that the medical center’s financial ledger showed a $5.5 million cost per annum related to operating the program. "We're looking at an increasingly difficult financial time,” Hensler said. “It's difficult to support a program that's not a necessary component to the hospital."
Boy was his accounting off.
Soon thereafter, a media and social media storm ensued. Twitter and Facebook were ablaze with furious posts regarding the proposed cuts. Word got to the Kern County Board of Supervisors and Mr. Hensler’s decision was publicly called into question. Community members and organizations banded together into a unified voice of stakeholders to decry what signaled the potential demise a family medicine program that clearly and loudly is a necessary component of Kern County (even if by Mr. Hensler’s calculations, the program is not a “necessary component of the hospital”). The storm of protest went on for three solid weeks. Then, on Monday, March 12, 2012, the Kern County Board of Supervisors “directed Kern Medical Center CEO Paul Hensler to bring in a new class of family [medicine] resident physicians, apparently determining that the program's $5.5 million annual cost was money well spent” according to the Bakersfield Californian.
What conclusions can be drawn? Fight force with force. Remember Newton’s First Law of Motion? An object in motion stays in motion until acted upon by an outside force. An object at rest stays at rest until acted upon by an outside force. Will we continue to allow volume to dominate health care delivery? What will it take for value to dominate health care delivery instead? And who will be the force for change?
In order for us to change the current vector of the health care market, we must force it to change. Let me rephrase: it’s time for us family docs to roll up our sleeves and act like we mean it even if that means we have to mess up the political dynamics in the proverbial sandbox of medicine and even if it means we have to “bloody our knuckles” (as I heard one family doc closer-to-retirement-than-me say at a recent county meeting) to get there.
So here is my revised Newton’s Second Law of Motion. Let’s call it: Family Medicine’s Second Law of Revolution: Family Medicine Revolution = Mass x Amplification
To generate sufficient Family Medicine Revolution force to change the current value trajectory in health care, we must increase our mass and/or amplify our voice. We are making progress on both accounts.
We have mass. This year, CAFP reached more than 8,000 members and AAFP surpassed 100,000 members. And if this year’s residency interview season was any indication of the quality and enthusiasm of tomorrow’s family medicine workforce, I anticipate a bright future.
We are just beginning to understand how to amplify our voice. The Kern County case is a living example of our possibilities. So if you aren’t already on Facebook or Twitter, join the growing community of family docs on social media and look for other #FMRevolution-aries. And if you are on social media already, make yourself known and help us amplify our family medicine voice. Long live the Family Medicine Revolution!