Making choices about the scope of family practice.

At Keystone III, a dialogue about family practice after 30 years of development in the United States, a futuristic view of the potential failure of family practice suggested that family physicians could fail because they abdicated their functional domain to other providers.In this issue of the JABFP, Rodney and Hahn focus on the functional domain of family practice by assessing the financial implications of deleting selected procedures and hospital services from the scope of family practice in an urban setting. Given the turmoil that frontline practice is in at the moment, these findings are timely, and they fit into a succession of domaindefining research that should inform debate concerning the redesign of family practice. Rodney and Hahn describe 1 year’s experience in a teaching practice with about 30,000 visits per year, a financial case mix that was 84% MedicaidMedicare, and net collections of 45.2%. They show that, after deducting direct and opportunity costs, both hospital care and procedural services were financially rewarding even with low collection rates. These findings are based on prudent rather than extreme assumptions. The authors coped explicitly with capitation issues, conducted tests of both internal and external validity, and reached across outpatient and inpatient settings. Even though the data are drawn from one practice, are subject to unknown variations associated with valuation and accounting practices, and doubtless excluded some costs, the strengths of their findings are sufficient for this study to be taken seriously. In short, this study shows that even with a poor case mix and low collection rates, a positive effect on the bottom line can be attained by including in family practice selected procedures and hospital services that many patients need. Evaluating and debating what procedures should be taught and done are not new to the landscape of family practice. Studies cited in the Rodney and Hahn article and others found that training programs were providing training in more procedures than were done routinely by practicing family physicians. With the addition of this careful analysis of economic implications to the literature, a prudent conclusion is family physicians can learn procedures and hospital skills that are relevant to the needs of their patients, they can provide excellent service, and they can be financially rewarded for doing so. To a large extent, those procedures and hospital work to be included in the domain of family practice are choices to be made by family physicians. There are aspects of this report that reveal why some family physicians might choose to abdicate procedures and hospital care to others. Two thirds of the hospital activity in this study occurred before 8:30 am and after 5:00 pm. The hundreds of hours spent doing procedures and hospital work displaced alternative uses of professional and personal time. Making these services available and maintaining the skills necessary to do them well is hard work and requires a commitment of personal and financial resources. Furthermore, family physicians are trained to provide many nonprocedural, outpatient services that are also needed and important and that compete for their time and effort. Finally, there is evidence family physicians do make choices about their domain that exclude procedures and hospital work. According to survey data collected by the American Academy of Family Physicians (AAFP), only 6.7% of Florida family physicians provided obstetric services in 2000 (lowest in the country). This situation exists even though Larimore and Sapolsky reported that Florida family physicians who provided obstetric care found it both financially and psychologically rewarding. Nationally, only Submitted 28 January 2002. From The Robert Graham Center: Policy Studies in Family Practice and Primary Care (RLP, LAG), Washington, DC. Address reprint requests to Robert L. Phillips, Jr., MD, MPH, The Robert Graham Center: Policy Studies in Family Practice and Primary Care, 1350 Connecticut Ave NW, Suite 950, Washington, DC 20036.