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Family Medicine’s Agenda to Make Health Primary

Glen Stream, MD, MBI

(Fam Med 2015;47(8):595-7.)

“The American health care system is in crisis.” I’ve heard this refrain since I started medical school nearly 40 years ago. It’s probably been true this entire time but never more so than today. The United States spends far more per capita on health care than any other country, but we compare poorly in the health of our population, and we have serious health disparities. Hence the development of the concept of the Triple Aim: to improve health care, improve the health of our population, and decrease the burdensome cost.1 Additionally we face a crisis of dissatisfaction and professional burnout among physicians and other health professionals. The term quadruple aim has evolved to add the concept of professional satisfaction and sustainability.2

Family Medicine for America’s Health (FMAHealth) was developed to build upon the work of the Future of Family Medicine project3 and seeks to achieve the goals of the quadruple aim. Background on the development of this initiative has been published previously.4 The research findings informing the project development are clear. There is consensus across multiple stakeholders of the need to transform our health care system. Family medicine is best positioned to lead this transformation, and the time is now.

The articles that follow provide insight, recommendations, and challenges to the work of FMAHealth. Many of the authors were involved in the development of FMAHealth, some of them have continuing involvement on the FMAHealth board or tactic teams. Others have not been involved and bring valuable outside perspectives. During the 5 years of this project, the framework will evolve and grow, but these articles provide insight into the foundation from which we begin.

The vision paper provides a compelling vision of the health care system FMAHealth seeks to achieve.5 “Our vision is to transform the health of our country, not just its medical care.” A robust family medicine foundation is necessary but not sufficient to achieve this vision. Integrating primary care, mental health, and public health is critical if we truly aim to improve health.

The practice/payment article lays a foundation for transforming our primary care delivery system with necessary changes to the payment system to realize this transformation.6 There is strong data demonstrating that the patient-centered medical home (PCMH) model can deliver on Triple Aim. The authors outline a path to expand PCMH and to further enhance its performance. Critical to the further evolution and adoption of the PCMH is a payment system that provides the essential financial support for the entire PCMH care team. A comprehensive primary care payment system is best suited to this goal. Improving primary care payment and narrowing the gap between primary care and subspecialty physician income is the lynchpin of this effort.

Engaging with the patient community is essential to the FMAHealth vision of a truly patient-centered health care system. In the engagement article, the authors describe the current state of patient engagement and a future vision of increased collaboration.7 FMAHealth supports the concept that every practice has a patient advisory counsel or similar patient voice into the clinic’s management. Use of technology holds tremendous promise of enhancing the connection between patients and their health care.

Health information technology is rapidly evolving, and FMAHealth sees an important role for family medicine in enabling that technology to support better health and facilitate health care delivery. In the technology paper, the authors identify opportunities and offer recommendations toward this goal.8 Currently available electronic health records and other health IT is built around the current practice model and the fee for service payment system. FMAHealth seeks to impact the development of future solutions that support the evolving PCMH model and the emerging comprehensive primary care payment system. Consumer health technology is rapidly evolving and being adopted by consumers. Providing a meaningful connection between consumer health technology and the PCMH can be a powerful tool toward improving health.

There is growing understanding of the crisis in our primary care workforce but to date there has been insufficient progress in addressing this crisis. The authors of the workforce paper identify the challenges to producing the necessary workforce for the health system envisioned by FMAHealth.9 Medical schools need to be accountable for producing graduates destined to meet the primary care needs of the nation. It is an essential requirement to improving health. We must reform capacity and funding for graduate medical education to provide appropriate training to our new colleagues. The composition of this workforce must reflect the diversity and geographical distribution of our population as an important step toward achieving health equity. This is true not just in family medicine but across all the members of the health care team.

The concept of evidence-based medicine is firmly incorporated into medical practice. The American fascination with high-tech and subspecialty medicine has disadvantaged primary care. The authors of the research paper offer insights into the challenges facing family medicine research and provide recommendations for how those can be addressed.10 Enhanced research is needed into medical issues common in primary care that have a major contribution to health outcomes. Patients and primary care practices can take up a leadership role in this effort. We must assure the latest medical knowledge is available in the delivery of care, and technology tools are part of the solution. Evidence-based does not just relate to the science of medicine but also to the delivery of health care and promotion of health. Research is necessary to evaluate the transformation in care delivery and payment envisioned by FMAHealth so that it too can be continuously improved.

Our “Health is Primary” communication campaign is directed toward developing a deeper understanding among stakeholders, especially patients and communities, of the role of primary care in improving health. With this understanding we seek to engage them as advocates for transforming our system to the envisioned future.

The goal of FMAHealth is ambitious: to transform from our current poorly integrated, disease-focused, expensive, fee-for-service funded non-system to a highly integrated, patient-centered, primary care team-based, health promoting, disparity eliminating, professionally satisfying, and cost-efficient true system. Family medicine is taking a leadership role and seeks to work with like-minded groups of patients, providers, employers, payers and other key stakeholders to achieve the vision of a transformed health system. In this effort the ongoing work of the family medicine organizations sponsoring FMAHealth is more important than ever.

I encourage you all to engage in these efforts at the practice, local, or national levels. Working together we can achieve the transformed health system America deserves and where those of us working in health care feel proud of our work and professionally fulfilled.

On behalf of FMAHealth, I would like to express thanks to the authors of these articles for sharing their knowledge, expertise, and commitment to family medicine.

Corresponding Author: Address correspondence to Dr Stream, Family Medicine for America’s Health LLC, 11400 Tomahawk Creek Parkway, Leawood, KS 66211. Cell: 509-994-4097. Fax: 913-906-6089.



  1. Berwick DM, Nolan TW, Whittington J. The Triple Aim: care, health and cost. Health Aff 2008;27(3):759-69.
  2. Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: care of the patient requires care of the provider. Ann Fam Med 2014;12:573-6.
  3. Martin JC, Avant RF, Bowman MA, et al, Future of Family Medicine Project Leadership Committee. The Future of Family Medicine: a collaborative project of the family medicine community. Ann Fam Med 2004 Mar-Apr;2 Suppl 1:S3-S32.
  4. Phillips RL, Pugno PA, Saultz JW, et al. Health is primary: family medicine for America’s health. Ann Fam Med 2014;12(Suppl 1):S1- S12.
  5. Puffer JC, Borkan J, DeVoe JE, et al. Envisioning a new health care system for America. Fam Med 2015;47(8):598-603.
  6. Saultz JW, Jones SM, McDaniel SH, et al. A new foundation for the delivery and financing of American health care. Fam Med 2015;47(8):612-9.
  7. Howrey BT, Thompson BL, Borkan J, et al. Partnering with patients, families, and communities. Fam Med 2015;47(8):604-11.
  8. Hughes LS, Tuggy M, Pugno PA, et al. Transforming training to build the family physician workforce our country needs. Fam Med 2015;47(8):620-7.
  9. Phillips RL, Bazemore AW, DeVoe JE, et al. A family medicine health technology strategy for achieving the triple aim for US health care. Fam Med 2015;47(8):628-35.
  10. deGruy FV, Ewigman B, DeVoe JE, et al. A plan for useful and timely family medicine and primary care research. Fam Med 2015;47(8):636-42.

From Family Medicine for America’s Health LLC, Leawood, KS.

Copyright 2018 by Society of Teachers of Family Medicine