乌鸦传媒

The American Academy of Family Physicians (AAFP) installed Sterling Ransone, Jr., MD, as its new president on September 28. Ransone, a third-generation family physician in Deltaville, Virginia, spoke with 乌鸦传媒 Washington Editor Joyce Frieden about his plans as president, his concerns about the healthcare system, and his experiences with COVID-19 and vaccine hesitancy. This conversation has been edited for length and clarity.

乌鸦传媒: Dr. Ransone, thank you for taking the time to talk with us today.

Sterling Ransone, MD: I'm happy to.

MPT: As AAFP's new president, what are your priorities for the coming year?

Ransone: I'm going to start with kind of the big, audacious, hairy priority that we're going to shoot for -- we need to shoot for an outpatient primary care-centered healthcare system focused on having a family physician for every person. And it's a big goal, but I think this is how we will be able to best take care of the citizenry of the United States.

Right now we have a healthcare system that's an excellent sick-care system. We do a great job of taking care of people once they become ill, but what we really want in the healthcare system is basic primary care where we can take care of issues before they become big. I think that if we can expand the pipeline of family physicians to get more family physicians, out into the community, we can save lives. Studies show that if you put a primary care physician in the community, that people live longer. This is what we need for the nation.

MPT: What about other types of primary care physicians, such as internists?

Ransone: All primary care physicians are wonderful, but in small rural communities, we need people who can do a little bit of everything. That's what family physicians do; we take care of patients from cradle to grave. My internist friends who take care of folks who are 18 until they're in their 90s, they're wonderful. We absolutely need them. The problem that we see with some of our internists is once they finish an internal medicine residency, they decide to specialize and do more niche medicine, and relatively small percentages -- anywhere from 10% to 20% -- of internists go on to do general internal medicine, but it's that primary care-focused physician that I think we need in our community. And that's what family physicians do.

MPT: What are some of your other priorities?

Ransone: We need to reduce administrative work for all physicians, especially family physicians. One way to do that will be to help develop and leverage technology and electronic innovation so that we can use that technology to take care of a lot of the burden that we currently have to do, and return our time and focus to taking care of patients. Right now, over half -- and in some places, two-thirds -- of our time is spent with administrative tasks. We're not doing what we're trained to do, which is take care of patients. If we can find innovative ways of having technology do that for us, we can in turn spend that time with patients, and I think that's what the patients want.

For example, I have tons of paperwork -- I was away last week at the AAFP installation; when you come back from vacation, that's when you wish you had not taken time off, because you have too many stacks of paperwork to fill out. A lot of what I have to fill out is things I have to look up on my electronic medical records, fill out on a paper form, and then send that form to the people who need this information so my patients can get the care they need. There has to be some way that we can standardize that paperwork and standardize the little blanks, so that my electronic medical record, where the information resides, can automatically fill in the paperwork, and I can print it up and sign it, send it off. There have to be electronic ways that we can do it.

The third thing that I'll throw out is we have to develop a payment structure that pays family physicians and primary care physicians in a way that appropriately reflects our value and worth to our society. I think the way to do that is by scrapping the antiquated fee-for-service method that we're paid under now -- which is based on volume and procedures -- and switch to a more value-based method of payment, where we're rewarded for keeping our patients healthy. If we can do that, I think that's one way that we can feed our pipeline and get more people into a primary care-centered healthcare system.

MPT: Well, it looks like Medicare also wants to move everyone into value-based payment too.

Ransone: Moving payments into that realm will free up a lot of our time, where we can do things like telemedicine and be adequately paid for the time we spend taking care of our patients. In the past, we had to bring patients down to the office. I'm in a rural area, and I have patients who, in order to come to be seen for their chronic medical conditions, they have to take a half day or a full day off of work in order to come in.

I don't always have to see them in the office. There are things we can do that I can handle via telemedicine and take good care of their health, but prior to the pandemic we weren't reimbursed for any of those services. So in order to be reimbursed for the time and effort that we've spent on that care, we have to bring them into the office. I think if we change to more of a value-based system, we'll be able to more creatively use technology to give better care to our patients, and not have to worry about that "churn and burn" in the office.

Telemedicine, as part of a patient-centered medical home, is an incredible tool that we'll be able to use over the next few years to help take great care of our patients. These patients who I have known for 25 years, I can use telemedicine as a tool to help take care of them, just like my stethoscope. I'm a little concerned about potential venture capital companies coming in, thinking that they can take care of patients without physically seeing them. That touch, and that getting-to-know-someone is an incredibly vital part of patient care, and I don't want to see that get lost.

MPT: What about issues like prior authorization?

Ransone: Prior authorization is one of the largest headaches that we have in medical practice. A lot of it is frustration -- what we see as needless paperwork in order to give our patients the care that they deserve.

I will never forget having a patient who did not get her blood pressure medication, and I tried to figure out why. Her insurance company had put up a roadblock; we had to fill out a prior authorization form, it was about three pages long. She eventually got her medication within about a week, although she needed her medicine sooner than that. The medicine involved was lisinopril, which is a generic ACE inhibitor which had been on the market for over 20 years. And if she had gone to the local big box store across the way, it was there for $4, but she wanted to use insurance that she paid for, and it took her days in order to get a generic medication, and I still don't understand why that roadblock was put up for her.

A friend of mine had a similar case. He had written for a generic antidepressant that had come on the market in 1997. This was 2 years ago. He got a prior authorization, filled out the paperwork, but he got a little miffed, because when it came back they said the patient can have it for 3 months and that they would reassess. Now, this medicine had been on the market for 20 years. He wrote quite a long letter and they sent him a note back, and they approved the generic medication for a timeframe -- until the year 3000. Yes, they approved their insurance-holder's medication for 980 years.

Now, if you're going to approve something for 980 years, why do you ask us to fill it out in the first place? He actually wrote a letter back saying, "I appreciate you think I'm going to take such good care of this patient that she'll live for 980 years." But just the constant barrage of these things chips away at the soul. And that's on top of the medical practice; now with the pandemic, I'm spending a third of each office visit discussing patient's concerns about the pandemic -- concerns about vaccination, concerns about mask-wearing and distancing. All these little things piling up are leading to a lot of burnout, a lot of compassion fatigue in my colleagues. I'm concerned about the health and welfare of the medical community due to all these burdens being placed upon them.

MPT: You mentioned insurance -- what would AAFP like to see in terms of health insurance reform?

Ransone: We believe that any method that the United States can use to make sure that all patients are covered, is something we would support. We have not put all our eggs in one basket, be that single-payer, be it whatever. We want to see all of our patients with some type of health coverage so we can keep everybody healthy. Whether or not that is separating out primary care into its own basket, where we have universal primary care and everything else is employer-based, or however we as a nation decide the best way to cover our citizens is. We just want to make sure that we have universal coverage for all patients, however we might arrive at that goal.

MPT: What do you see as AAFP's role in helping members with the pandemic, including the fatigue and the burnout?

Ransone: The first thing that I'd like to say to all your readers, is realize that you're not alone. I think in these days where we have had to switch to virtual care, we have had to isolate ourselves for our own safety, for our patient safety and our staff's safety, we don't have as much interaction with people. And I think when you look at our society, we're seeing a lot more mistrust in authority. We're also seeing people who are acting out somewhat and when you watch the news and you go online, especially, you see see a lot of people who are venting their frustrations in unhealthy ways. I want your readers to know that as physicians, we're not alone. A lot of us are going through this together.

The AAFP is doing a lot of different things to try to help all physicians deal with the stressors of the pandemic. The first is education. We have an excellent ; we have the most up-to-date recommendations regarding the pandemic. We found about a year and a half ago that there was so much misinformation and so much contradictory information that a lot of physicians really didn't know where to turn to get good, non-biased info. So we decided that was something we're going to do. On our website we have special COVID-19 pages where we can go and get the most up-to-date information.

We've also had town halls for our members, where they can get together as a virtual group and ask experts questions regarding the pandemic and ask one another how they are doing and how they are managing to deal with issues that we all have in managing a practice. The academy has also made a few changes in our CME structures that help physicians get continuing medical education.

Number two is the payment issue. The academy wants to make sure that we are reimbursed for the services that we provide. We're actively advocating to Congress to continue payments for telemedicine services. We're also strongly recommending that we continue to be paid for audio-only services for our patients who don't have the availability of broadband, or the knowledge to use a lot of the available telemedicine services.

And third would be safety. The academy has partnered with some folks to get personal protective equipment (PPE) for our members. We had a huge problem at the beginning of the pandemic, where a lot of family physicians, especially those in small practices, could not get PPE, and what we could get was of poor quality. So the academy is partnered with groups that will allow us, especially the small groups, to go into group buying to access PPE to keep them and their staff safe.

I guess the last thing is health. We've got a lot of services at the academy to help with burnout and compassion fatigue.

President Biden, about a month ago, in a speech to the nation regarding the pandemic, he said, "And to the nation's family physicians, pediatricians, and GPs: you're the most trusted medical voice to your patients." There are several studies out there that back this up, and I'd like to reiterate to all primary care physicians, we're the most trusted voice. As frustrating as this can get, and as many times as we've had to repeat what the truth is regarding the various subjects around COVID-19, our patients listen to us, and it's worthwhile to take that time to sit and talk with patients regarding the concerns that they have with what they've seen or heard, either from relatives or on social media. And when we combat this information we can give good service to our patients, and we can save lives. So realizing that we're not alone, we can do this together and we will prevail, is my message.

MPT: Have you seen a lot of vaccine hesitancy in your area?

Ransone: It comes and goes in waves -- in the spring and early summer, absolutely. There were a lot of things that were out there that people just had questions about. And we could sit and answer them, and give good advice, and people would listen. We have some folks who they've become entrenched in their thought processes, in their position, they've stated it loudly on social media and to other people, and they've felt that they were almost boxed into a corner. I think it was a pride issue; they could not see themselves changing their mind, despite evidence showing that what they thought wasn't exactly right.

I don't think demonizing or belittling their opinions is the way to go, but we can say, "This is how the data, the information has changed over time. And this is why I think that what you thought then might not be the case now." And that's a way that, for me, I've been able to get some people to change their mind and become vaccinated.

Right now, I've got a patient who is 41 years old and he's in the ICU on a ventilator. I'm really worried about him. We had a long conversation back in July regarding vaccinations. He steadfastly said he did not wish to do that, and it just breaks your heart when you see these folks and know that were they vaccinated, they would not be in that situation. When I first saw it, my heart dropped and I felt really sad, but what it's really done is it made me redouble my efforts to get my patients good health information and combat misinformation so they can be safe.

I always ask my patients, if they're not vaccinated, why, and what are their concerns, and try to be open to hearing what they've said. But last summer, I saw a patient grab one of my staff persons, and I rushed up to see what the issue was. The patient had heard on social media that the temperature-checking device that we use, the little infrared scanner, they had heard on social media that that was what we used to activate the chip they got in their flu shot last year.

It took me quite a while to sit down and talk about it, to say that is not something that happened or could happen, but they were just kinda scared. They had read this and didn't know enough science to know it wasn't the case.

My first thought was, "How could you think that?" But my second thought was, "We just need to sit and talk about what they've read, and why that's not true." And eventually he got the point, but from a physician standpoint it can be frustrating. I'll read social media, and I'll shake my head. It'll get my blood boiling. But I do it so I know what misinformation is out there so I can help my patients and counter the bad stuff that's out there. Every once in a while, I'll have to take a break for a couple of days, because I can't handle it. But then I go back and read what the current misinformation is, to try to help my patients overcome some of their concerns.

We have to realize people are scared. Thank God the numbers in our area are plateauing and starting to decline, but what the pandemic has shown to me as much as anything is that we need to redouble our efforts on public health education and on science education in general, so when the next pandemic hits, people will understand why we do what we do and that way we can keep our populous healthy.

MPT: Thanks very much for talking to us today.

Ransone: Thank you. Have a great afternoon.

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