番茄社区

On October 27, Alabama family physician Steven Furr, MD, will be sworn in as the new president of the American Academy of Family Physicians (AAFP). 番茄社区 (MPT) Washington Editor Joyce Frieden talked with Furr about what his priorities will be when he takes over and what challenges and opportunities he sees ahead. The interview, which was conducted online with a public relations person present, has been edited for length and clarity.

MPT: Hi, Dr. Furr! Tell us a little about yourself.

Steven Furr, MD: I'm in a small town -- a little bit less than 5,000 people, and I'm a board-certified family physician. [Our practice] started with two physicians; now we currently have three physicians and two nurse practitioners working with us.

We do the whole spectrum of care -- we used to do obstetrics, but we stopped doing that about 10 years ago -- but short of that, we do everything else, from taking care of babies to admitting people to the hospital and taking care of them in the nursing home. In fact, a few minutes ago I left from the nursing home where I made rounds and did my quality assurance meeting at the nursing home.

MPT: How did you get involved with family practice on a national level?

Furr: Well, I started at the state level and I was invited to be on the family practice board there, and I came to realize there was a lot of things I could do in my office, but there's a lot of things that we have to deal with, as far as regulations, that affect both the doctors and the patients -- and that's done on the legislative and advocacy side.

So once I finished my time on the family practice board, then I got involved in the medical association. While I was doing that, I also worked on my state medical board as well as my board of public health, and I saw the influence physician leadership could have there, so then it was just a natural step to move up to the national level.

MPT: What are your top three priorities for your first year in office at AAFP?

Furr: First off, we need many more family physicians. There's a shortage already, and as our workforce is getting older, our population that we serve is also getting older, and we need more medical students and residents [to] go into family medicine. There's actually supposed to be a shortage of over 14,000 primary care physicians by 2034.

So we not only need more of them out there, we also specifically need them in certain areas, such as rural areas and underserved inner city areas. You can put some specialists in there, but nobody can do what a family physician does. In a rural area, they might not be able to support certain specialties, but generally they can support a family physician who does multiple things and can take care of multiple problems.

Along with that we need Congress to expand the National Health Service Corps -- it's kind of like a Peace Corps for doctors. I actually started as a National Health Service Corps person; that's where they help pay for you when you go to medical school and then you agree to serve in an underserved area. And also we have "teaching health centers," where family physicians are actually trained in smaller communities in rural areas. [What] we know is most people tend to stay within 100 miles of where they're trained, so we need to train them more in the areas where we really have the need.

The second thing that goes along with that is that we need to increase reimbursement for family physicians. Primary care physicians are some of the lowest paid specialties, not because they do less work -- they actually do more work. But our payment system is often geared towards paying for procedures and not taking care of patients. And our argument is we should be paid for taking care of patients and managing our patients.

One of the things we're advocating for right now is add-on billing code , which would actually pay us for the comprehensiveness of care we do with our patients. For example, just the other day I saw a patient who had flayed open his thumb on a table saw. So I sewed him up and made sure he had his tetanus shot, and while he was here, I treated his hypertension, made sure he had prescription refills, and made sure he had his flu shot. That's the kind of comprehensive care we give rather than just having him go into the ER [emergency room] and get sewed up. We take care of that whole patient while they're here, and we need to be rewarded for that and paid at that level.

The third issue is administrative burden -- the things that keep us from taking care of our patients. For instance, I might have a patient on a diabetic or hypertensive medicine and they're well controlled, but their healthcare plan decides they're not going to pay for that medicine any more, or they want to use a cheaper alternative -- might be just a few cents cheaper. So then they deny that medicine, and I've got to spend time trying to find out what medicine is covered and what works for the patient, and make sure we keep them under control.

There are all kinds of little administrative things that actually started out as good things but are now actually negative. The reason that we started out with prior authorization was to make sure that things that were really expensive, like a PET scan, [were really necessary]. That was what prior authorization was meant to be, but now it's morphed into this thing where we're doing prior authorization for generic drugs and things that aren't that expensive.

And sometimes we just can't get clear authorization, so then we have to send them to the specialist and waste their time, and then they order the test when we could have ordered the test, gotten the diagnosis, and moved forward. I think that's part of why we're seeing such a problem with fatigue and burnout; doctors still love taking care of their patients -- that's where we get our joy -- but it's all the extra time we have to spend doing these things not involved in direct patient care.

MPT: On a related note, do you think enough is being done to encourage primary care physicians?

Furr: I think Congress has realized that is a huge issue, and when you look at the other developed nations, 50% of their physician workforce is primary care, where here it's more like 20% to 25%, and you can tell by their outcomes they're doing much better than us. So I think Congress is starting to realize that we really got exactly the opposite of what we needed. We need more primary physicians to take care of multiple problems and hopefully prevent problems as they go along. If our primary care workforce even deteriorates more, then people are just not going to get the care they need, and when they do go in to get care, they're going to be sicker, more debilitated, and have worse outcomes.

MPT: Are you concerned about patients' level of trust in physicians and public health officials?

Furr: I think that's why it's so important that we get more family physicians out there, so that people have their primary care physician who takes care of them and that they can trust. So at my level, we don't see [a trust issue] because my patients have known me for over 30 years. So when they come in, and they say, "Would you take the COVID vaccine, and I say, "I've taken it, my mother's taking it, and my mother-in-law's taking it," and they trust me.

Now there are some that are still not going to take it no matter what, but that's not surprising because they didn't take the flu shot either. Some people just don't take vaccines and they'll tell you that they just don't do it. But they still...it's funny -- they might say, "No, I don't want to take the COVID vaccine," but they'll let me take a lesion off their arm, so you can say they don't trust you, but they really do. There are just certain things they're not comfortable with.

You've just got to talk with them and understand where they're coming from. When you look at the vaccine rollout, if we'd have gotten more of the COVID vaccine early on into doctors' offices -- into their primary care and family physicians, where they could talk to them -- rather than trying to do mass immunization, I think we would have had a better uptake than the way we did it. We did the best we could under difficult circumstances, but I do think that could have made a difference.

MPT: What about other issues, like reproductive healthcare?

Furr: What we've tried to focus on there is that it needs to be between the patient and the doctor. We're concerned any time legislation is trying to tell doctors and patients what they need to do. We really don't want legislation impacting what goes on in the exam room.

MPT: Another issue in the news has been the high cost of prescription drugs. How are you feeling about current efforts to lower those costs, such as the Medicare drug price negotiations?

Furr: Well, it's early to tell how the Medicare price negotiation will work. There's a limited amount of drugs so it's too early to tell on that; we hope that will bring down some costs. Certainly, some of the new drugs are very expensive, and we do have supply issues on some drugs. We've had an issue with attention deficit drugs and even some of our pain medicine drugs. So we work hard with our patients, trying to see what's on the formulary, what works well -- we give them cards, give them discounts, and that type of thing, but it is an issue. And some of it's just supply and demand.

MPT: And what are your thoughts on another Medicare initiative: trying to get more doctors into accountable care arrangements?

Furr: We're strongly supportive of that. And we've also focused on not just taking care of just individual patients, but improving health for groups of patients. There are some real positive things as we move physicians -- particularly family physicians -- toward value-based care, so that you reward them for their comprehensive care.

But there are also some pitfalls there too. You've got to make sure the reimbursement is adequate, and that's one area where you have to be real careful -- sometimes the bar can be set so high in some of these plans, that it's almost impossible to reach those goals.

MPT: Is there anything else you'd like to add?

Furr: I just want to end on a positive note. Despite all the things you've heard about, it has never been a better time to be a family physician. I want people to hear that loud and clear. We can do more for our patients than we've ever done. We've got vaccines to treat diseases that we didn't have treatments for, and we've got new drugs that can do wonderful things. We've got diagnostic abilities that we've never had. So if we can get some of the administrative burden out and go back to focusing on our patients, we can do more for our patients and help them have better health than they ever had before.

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