Family practice in a failing health care system: new opportunities to advocate for system reform.

Medical practice, as well as the entire health care system in the United States, is in the middle of profound change. Managed care is past its heyday, and there is great uncertainty as to where the overall system is headed. Every specialty in medicine has been affected, with a resulting internal reassessment and speculation as to the respective futures of medical specialties in a time of unprecedented and unpredictable change. Such reassessment has been vigorous within family practice, as evidenced by the Keystone III Conference in October 2000 and the current Future of Family Medicine project sponsored by the American Academy of Family Physicians. Participants in Keystone III concluded repeatedly in their discussions that it is “hard to be a good physician in a bad system.” Many examples surfaced during the 4-day conference whereby valued goals of family practice could not be achieved because of system impediments. Family physicians, together with their colleagues in most other specialties, find themselves frustrated by an increasing bureaucracy and its attendant hassle factor. At the same time, in the last 20 years there has been a massive power shift from medicine to third-party payers. Furthermore, many of the values of medicine have been distorted by the steady growth of the investorowned, for-profit health care sector, in which the overriding goal is return on investment to shareholders rather than the public interest of patients. As part of this sea change of the health care system, physicians have lost professional autonomy, faceless bureaucrats have often infringed on clinical decision making, and the physician-patient relationship has been eroded in an increasingly fragmented system. In its own introspective reassessment, family practice is facing many basic questions, including those dealing with scope of practice issues (eg, inpatient skills, obstetrics, procedures) and style of practice issues (eg, office-based practice without hospital work, hospitalist without a primary care base, urgent care or part-time with limited or no continuity of care). How much differentiation within family practice is desirable to meet both the self-interest of the specialty and the public interest in a sick and failing system? Because the future of our specialty is inextricably intertwined with the overall system of which it is a part, internal reassessment requires a careful look at how the health care system is likely to evolve and, indeed, which system best meets the public interest and the values of family medicine. In view of the above, the purpose of this article is threefold: (1) to highlight the problems of our present deteriorating heath care system, with particular attention to access, cost, quality, and overall performance, as well as examples of their countervailing impacts on the goals of family practice; (2) to outline four major alternatives for health care reform, together with their feasibility and likely outcomes; and (3) to suggest some constructive future directions for family practice to take a leadership role in advocating for system reform.