September 27, 2016

ORLANDO, Florida — John Meigs Jr, MD, inaugurated president of the American Academy of Family Physicians (AAFP) here at the annual Congress of Delegates, is chief of staff of a 25-bed hospital in Centreville, Alabama, population 2718.

Dr Meigs gave up his solo practice of 31 years to become a hospital employee in 2013. With fewer administrative hassles and better backup coverage for his patients, he said he now has more time to devote to academy work.

The 62-year-old also serves as chair of the governing committee for the Alabama public health department. During monthly meetings, a broad portfolio of concerns is addressed, including the Zika virus, ambulance service, telemedicine, septic tanks, and childhood immunizations.

When it comes to the antivaccine movement, "I guess fear and anger trump truth and fact," he told Medscape Medical News. "The vaccines are safe and they keep people safe. The science is there."

Dr Meigs is also a member of his state's medical board, policing his own profession.

Dr John Meigs Jr (Source: Sheri Porter/AAFP News)

"We don't intentionally try to put folks out of business or out of practice," he explained. "But if somebody is doing unwise, foolish, and unnecessary things, they put the public at risk. We're obligated to protect the public and, yeah, sometimes it will make you not very popular."

Dr Meigs spoke with Medscape Medical News in Orlando as a physician-at-large for both Alabama and the United States.

Medscape: Is the Medicare Access and CHIPS Reauthorization Act (MACRA) a case of good intentions and bad regulation? Can the average family physician master almost 1000 pages of regulation?

Dr Meigs: Well, understand that all we've got right now is a preliminary rule. The final rule hasn't come out. And also realize that MACRA replaces the sustainable growth rate formula (SGR). If we didn't have MACRA, we would still have the SGR. The pay cuts were probably three times as steep under the SGR.

Medscape: It could have been a disaster.

Dr Meigs: You don't have to master all of the MACRA regulations. You have to learn the concepts and play by the rules. MACRA offers a couple of different pathways. Initially, the majority of physicians will probably end up in the Merit-based Incentive Payment System (MIPS) because it's going to be harder to get qualified on the other side — the Advanced Alternative Payment Models (APM) side.

We sent 107 pages of comments back to the Centers for Medicare & Medicaid Services (CMS) on the proposed rule. We talked about how we needed to delay the onset of the performance year (set for 2017). There's evidence that CMS has listened. Last year, Acting Administrator Andrew Slavitt announced a "pick your pace" policy on the CMS blog.

With pick your pace, folks can participate for a few months and test the system. We're encouraging folks to do that because you will not be subject to a penalty in 2019. Physicians who want to participate for the whole year, who think they're ready, will have to deal with the potential upside risks and the downside risks.

 
I guess fear and anger trump truth and fact.
 

Medscape: Many physicians who oppose the Affordable Care Act (ACA) say they were "sold down the river" by medical societies, such as the AAFP, that supported the law. What would you tell those physicians?

Dr Meigs: Part of it goes back to fear and anger trumping truth and fact. A lot of things have been blamed on the ACA that aren't really part of the ACA. But 20 million more people now have insurance, you cannot be denied because of pre-existing conditions, and your children can stay on your insurance until they are 26.

It has been a longstanding policy of the AAFP that we support healthcare for all. We know the ACA is not perfect; we think there is plenty of room for Congress to improve it. But it did expand coverage. There are good parts of an imperfect law.

Medscape: A lot of the work of organized medicine has helped practitioners running a private independent practice. What can the academy offer hospital-employed physicians, who have different concerns?

Dr Meigs: I don't know that I totally accept that premise. I realize that around 64% of our membership is employed. But half of those are employed by physician groups. They are not all employed by hospitals and large systems.

When I went into practice in 1982, there were probably only about 25% to 30% of physicians employed; everybody else was in some sort of private-practice situation.

Medscape: They were owners?

Dr Meigs: Owners. And that has shifted. But even though that's shifted, our membership has grown. We must be providing something for our members.

One of the things we provide that is always rated highly by our members is continuing education. And we handle the reporting of CME, which is required for AAFP membership and by the government and insurance companies for quality measures. So CME is a big deal.

Medscape: Many physicians lament the disappearance of independent practitioners.

Dr Meigs: We are in a changing system. When you go through a period of transformation, a lot of folks are uncomfortable. Some folks may have gone into an employed situation to bring stability and certainty in an uncertain world.

 
We are in the middle of the chaos of living in the fee-for-service world while trying to get into the value-based care world.
 

We are beginning the transition from fee-for-service to what we call "value-based care." We are in the middle of the chaos of living in the fee-for-service world while trying to get into the value-based care world. Physicians are looking for stability — "I have to play in both worlds, so let me work for somebody until it gets all sorted out, and then I'll see what I want to do."

Medscape: Are you seeing the opioid overdose epidemic in your community?

Dr Meigs: It's everywhere. Everybody sees it.

Back in the 90s, we were told we were undertreating pain. And you had governmental agencies and regulatory agencies saying pain is the fifth vital sign. And then you had pharma companies advertising their latest, greatest, expensive painkiller, saying how it was safe and not addictive. I think their credibility rates are right up there with the tobacco companies that said cigarettes weren't addictive.

But the pendulum swung too far. We went from undertreating to overtreating. Now we are trying to get the pendulum back to what's reasonable. Pain is real, but abuse is also a problem.

Medscape: Is your medical board disciplining doctors for overprescribing?

Dr Meigs: About every month.

Medscape: And are some of the physicians before the board taking the pills themselves?

Dr Meigs: About every month.

Medscape: Wow. You know, Tom Frieden, MD, director of the Centers for Disease Control and Prevention, has said this is a "doctor-driven epidemic."

Dr Meigs: Yes. And I want to push back. It is not a doctor-driven problem. It's a societal problem. It's the whole problem of addiction. Whether you're talking about prescription drugs, illegal drugs, or alcohol, society has a problem.

Medscape: Is physician morale as bad as the media portray it, or are news stories exaggerated?

 
You want to know the leading cause of physician burnout? The administrative hassles of modern medicine.
 

Dr Meigs: You want to know the leading cause of physician burnout? The administrative hassles of modern medicine. All of the rules, regulations, precertifications, and prior authorizations.

If you come to see me, I spend a few minutes getting to know you, examining you, diagnosing your problem, and writing you a prescription. And then the drugstore calls and says, "the insurance won't cover that." But the insurance won't tell me what they will cover sometimes, and maybe the drug they cover is not appropriate for you. Or we've tried it before, and they say, "Well, you can't have this drug until you've tried at least two or three of these."

I spent my 30 minutes evaluating and treating you. And now I'm spending more time — when I could be seeing somebody else — redoing what I've already done.

We haven't even talked about the hassle of dealing with the electronic health record. Ten or 15 years ago, I routinely could see about 30 patients a day, now I can routinely see about 22 to 24.

The current system is making me an expensive secretary and data-entry clerk. The burnout comes from the fact that I want to practice medicine, I don't want to treat a computer and interact with an insurance company.

This is a major problem. But it's not just in my age group. We've seen burnout in medical students, residents, folks in their early careers. If people start cutting their careers short, you make the workforce issue that much worse. Do you realize that most family physicians work into their 70s? They don't retire at 65.

In my state, we did a physician manpower survey. General internists retire in their early 60s. Pediatricians retire at about 65. Family physicians retire at 74, on average.

For most family physicians, this is not just a job, it's a calling. We do it because we care. And a lot of times, if there is nobody to replace you, you say, "I'm going to have to keep practicing."

If we get burned out and folks who would have been working until they were 74 are leaving the practice at 54, you lose 20 years of productivity. That really hurts the workforce.

Medscape: Is there anything you would like to tell Medscape readers?

Dr Meigs: There is value in a long-term relationship with a primary care physician you know and trust, and who knows you and provides comprehensive care, coordinated cared, continuous care.

Medscape: In other words, the centrality of primary care.

Dr Meigs: Certainly there are times when we need the specialist, when we need the surgeon. Many a time I've had patients who have been to see the surgeon, the oncologist, and they make an appointment with me. We discuss their options and treatments.

This happens a lot with patients with prostate cancer. They talk to the surgeon and he wants to do a prostatectomy. Then they go to the oncologist and he wants to put them on chemo. They get confused. And then they come to me and we hash it out.

For some patients, surgery is the right answer; for some, it's not. If I've known somebody for years, I know how they respond to illness, how they respond to treatment.

What do patients do if an oncologist they do not know says, "Well, if we do X, you've got a 60% chance of survival. If we do X and Y, you've got a 63% of survival. But overall, you're going to be dead in 5 years. What's your choice?" They want talk to somebody who knows them as a person and is not looking at them as a disease.

I treat people. People who have problems and diseases. That's whole-person care, comprehensive care. The longer I've done this, the more I see the value of what we do.

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