{"@context":"http://iiif.io/api/presentation/3/context.json","id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/iiif/319s17vp4p/manifest","type":"Manifest","label":{"en":["Dr. Jason Marker"]},"logo":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","metadata":[{"label":{"en":["Rights Statement"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine.  Disclaimer: The views presented in this broadcast are the speaker’s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice. \u003c/p\u003e"]}},{"label":{"en":["Description"]},"value":{"en":["\u003cp\u003eThe interview is primarily centered around the FMAH initiative and his thoughts on how it has changed, evolved, and benefitted people. He talks about how his job as practice core team leader was to develop a mature vision for the future of the Patient-Centered Medical Home. He talks extensively about the interworking’s of the organization and the structure of the initiative. In particular, him and his group were focused on how to create real change in the health care realm. He is optimistic for the future of health care in America and he thinks that real change in the future is possible. Dr. Marker also says that he believes the era of the private practice is not over, but he thinks that some might downsize in order to better serve needs of patients. He is not optimistic that the insurance companies can lead the change, he believes in will be business that leads the way into the correct path for medicine and private practice.\u003c/p\u003e (summary)"]}},{"label":{"en":["Date"]},"value":{"en":["2018-08-13 (created)"]}},{"label":{"en":["Type"]},"value":{"en":["Oral History"]}},{"label":{"en":["Agent"]},"value":{"en":["Dr. Herbert Young (Interviewer)"]}},{"label":{"en":["Format"]},"value":{"en":["Video file"]}},{"label":{"en":["Keyword"]},"value":{"en":["Family Medicine","Family Phsyician","American Academy of Family Physicians","Family Medicine for America's History"]}},{"label":{"en":["Subject"]},"value":{"en":["Jason Marker, MD (personal name)"]}},{"label":{"en":["Language"]},"value":{"en":["English (primary)"]}}],"summary":{"en":["\u003cp\u003eThe interview is primarily centered around the FMAH initiative and his thoughts on how it has changed, evolved, and benefitted people. He talks about how his job as practice core team leader was to develop a mature vision for the future of the Patient-Centered Medical Home. He talks extensively about the interworking\u0026rsquo;s of the organization and the structure of the initiative. In particular, him and his group were focused on how to create real change in the health care realm. He is optimistic for the future of health care in America and he thinks that real change in the future is possible. Dr. Marker also says that he believes the era of the private practice is not over, but he thinks that some might downsize in order to better serve needs of patients. He is not optimistic that the insurance companies can lead the change, he believes in will be business that leads the way into the correct path for medicine and private practice.\u003c/p\u003e"]},"requiredStatement":{"label":{"en":["Attribution"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine. \u0026nbsp;Disclaimer: The views presented in this broadcast are the speaker\u0026rsquo;s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice.\u0026nbsp;\u003c/p\u003e"]}},"provider":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/aboutus","type":"Agent","label":{"en":["Center for the History of Family Medicine"]},"homepage":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/","type":"Text","label":{"en":["Center for the History of Family Medicine"]},"format":"text/html"}],"logo":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","type":"Image"}]}],"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162442/file/295865","type":"Canvas","label":{"en":["Media File 1 of 2 - MarkerJason_01_Access.mp3"]},"duration":1857.4326,"width":640,"height":360,"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162442/file/295865/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162442/file/295865/content/1/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/295/865/original/MarkerJason_01_Access.mp3?1761141867","type":"Audio","format":"audio/mpeg","duration":1857.4326,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162442/file/295865","metadata":[]}]}],"annotations":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162442/file/295865/transcript/85501","type":"AnnotationPage","label":{"en":["Dr. Jason Marker interview transcript [Transcript]"]},"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162442/file/295865/transcript/85501/annotation/1","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Side 1\n\nDr. Young: This is side 1 of tape 1 of the oral history of Dr. Jason Marker, the leader of the practice core team of Family Medicine for America’s Health and we’re recording this on August 13, 2018. I’m Dr. Herbert Young, a volunteer at the Center for the History of Family Medicine. \n\nDr. Marker, may we have your permission to record this interview?\n\nDr. Marker: Yes, you may.\n\nDr. Young: Let’s start with your full name, if you would, please.\n\nDr. Marker: My name is Dr. Jason Marker.\n\nDr. Young: And what is your current title and position?\n\nDr. Marker: I am the practice core team leader for Family Medicine for America’s Health.\n\nDr. Young: And in terms of other professional work that you’re involved in now?\n\nDr. Marker: I’m currently an associate program director at the Memorial Hospital Family Medicine Residency program in South Bend, Indiana. I’ve had that role for one year. Prior to that I spent fifteen years in a small solo private practice that I opened upon completion of my residency. So over the course of my time with Family Medicine for America’s Health I concluded my time in private practice and made that transition into full time teaching.\n\nDr. Young: Can you share a bit more about your professional background, college and medical school and so forth?\n\nDr. Marker: After high school I went to Indiana University in Bloomington, Indiana and got a biology degree. I then went to the Indiana University School of Medicine in Indianapolis for my medical degree and then transitioned to the program that I am now a faculty in, Memorial Hospital in South Bend for my family medicine residency training. During my residency training I was the first graduate of a four year track that was developed shortly before my arrival that allowed me to get a masters degree in public affairs from Indiana University South Bend campus. And over those four years I did additional rotations in health systems management topics here at our hospital and in the local community.\n\nDr. Young: That sounds like an excellent and challenging addition to the usual family medicine clinical time.\n\nDr. Marker: It was nice to spread everything out over four years. I don’t think that I would have wanted to do it in just three. I saw it as an exciting opportunity to get someone else to pay for that masters degree, which was fairly unique at the time though not so much anymore. And the extra elective time that came by spreading everything out over four years I saw as an opportunity to prepare myself for private practice and pick up a few extra elective skills that I wanted to have as well.\n\nDr. Young: How did you get involved in Family Medicine for America’s Health?\n\nDr. Marker: I had been a one year member of the AAFP Board of Directors as a new physician member. And during my time with that board got to know Craig Doane (?), one of the vice presidents of the AAFP and the executive director of its foundation. He saw my aptitude for foundation work and we had several conversations about that. And upon completion of my year on the board of directors, I transitioned to a seat on the Board of Trustees of the AAFP Foundation. I really enjoyed the work, grew into leadership there, eventually was in their officer pool. And during the year that I was president-elect and president, it was at the time that the working party organizations of family medicine were deciding that it was time to renew the Future of Family Medicine project for a new era and I was selected to be part of the initial summit, the initial planning teams, et cetera. And then was asked if I wanted to apply for any of the leadership positions in what was not even yet called Family Medicine for America’s Health, but in the strategic process it was going to be developed. So my leadership within the AAFP Foundation found me at the start of FMA Health at just the right time and I was selected to be the practice core team leader during that time. \n\nDr. Young: Looking back on your professional development, what knowledge or skills do you feel have been particularly beneficial to your work with Family Medicine for America’s Health?    \n\nDr. Marker: Probably a couple. First, I was very interested in policy and physician leadership. We were rolling out a physician leadership program at the Foundation. I was really involved in the literature around physician professional development, particularly for students and residents. Second of all, I had done high level leadership as a board member for the AAFP. And additionally, I think the fact that I had committed myself to all of this leadership work from within the world of private practice without the financial safety net of other entities. And that skill set and willingness, at the same time, from private practice, I think got the attention of folks who wanted to make sure that that voice was heard around the table. Additionally, I guess I would say that I had not shied away from practice transformation activities within my private practice. And I think there could have been other folks with a private practice background chosen to do this, but the fact that I had done some practice transformation work within my own practice, it made me a suitable candidate for the practice transformation core team. \n\nDr. Young: You mentioned the Future of Family Medicine that had concluded some years ago. Perhaps now would be a time to ask how does Family Medicine for America’s Health differ from what was done for the Future of Family Medicine project and the carry on work that followed it?\n\nDr. Marker: It’s my impression, as a young physician who was not involved in the Future of Family Medicine project a decade and a half ago, that at its core both of these two projects are similar: Take the opportunity to sit down, take a high level view of where our specialty is and do the work necessary to chart a course into the future. So from that high level standpoint, I think there were not a lot of differences in why these two opportunities sort of took off. Now there were only two differences. This was organized as an LLC. It looked critically at what did not get accomplished in the Future of Family Medicine project; namely, a lot of public relations to multiple stakeholders, including patients, about what family medicine is and also to really tackle the payment transformations that did not naturally flow out of the Future of Family Medicine 1.0 project. \n\nDr. Young: And any comments in terms of what happened after Future of Family Medicine closed its doors?\n\nDr. Marker: From my standpoint, coming of age, if you will, in family medicine leadership in the midst of the Future of Family Medicine project, I believe that the growth of the Patient-Centered Medical Home as a known quantity to key stakeholders, including those in Washington, is one of the key outcomes of the Future of Family Medicine 1.0. The AAFP’s limited liability company TransforMED I think flowed from the Future of Family Medicine as well. And I guess in my limited view as a younger physician, those are the two biggies that came out of FFM 1.0.\n\nDr. Young: And turning to the state of healthcare in America today, what do you think needs to be done and how is Family Medicine for America’s Health addressing that need?\n\nDr. Marker: The two biggies for me are ongoing efforts at payment reform that allows physicians, whether they’re in private practice or in academic settings, some opportunities for financial stability. And, of course, in my background as a private practice physician, I really see that as being important for all those small shop family doctors that are out there who are still certainly the backbone of the U.S. family medicine healthcare system. So I think that’s a really important goal. Was and is an important goal of Family Medicine for America’s Health - to find some way to effect financial reforms within healthcare that are beneficial to the majority of family doctors. The second part for me, of course, as the practice transformation core team leader, is how do we prepare physicians and physician practices to do what needs to be done to justify those changes in payment model. And can they do those changes to their practice in a way that is not just able to capture those enhanced dollars but then leverage those into really important changes in care delivery for their patients while attending to the social determinants of health, working on anything that has to do with health equity in one’s community, and do it in a way that really accomplishes the Quadruple Aim, including physician satisfaction and physician practice satisfaction.    \n\nDr. Young: And it used to be the Triple Aim in the earlier parts of the materials I’ve read that became the Quadruple Aim. Can you talk a little bit about how that came about?     \n\nDr. Marker: From the first time I heard about Triple Aim I thought it was amazingly wise to put together our specialty into that context as the only specialty that can really have any hope of achieving the Triple Aim. As the literature around administrative burdens and physician burnout continued to build, it seemed logical to me even before I heard the phrase Quadruple Aim that there needed to be a fourth leg on that chair, which was something about joy in practice, physician satisfaction, keeping one’s practice life whole and lively and engaging. And then that came to be known as the Quadruple Aim. \n\nDr. Young: Let’s turn to your core team and then we can always revisit the broader aspects of Family Medicine for America’s Health. What was the charge to your core team?\n\nDr. Marker: Our core team had four charges right from the start. One of them was to imagine the world beyond the Patient-Centered Medical Home. So we were still at the start of this really in the midst of developing a mature vision of the Patient-Centered Medical Home and we were asked to look to what was going to be beyond that. So I liked that a lot. I like thinking about the future and how we can continue to evolve into something even better for our patients. We had a tactic that was based around understand measures, physician measurement in ways that would really actually matter to who we believe are the only two real key stakeholders – physicians and patients. So that was a tactic of ours from the start. So the tactic around putting together educational offerings. How can we best provide education to physicians that will help them do the practice transformation work that is necessary to be the best doctors they can be. And finally, a tactic around making sure that every person in America who wants to have a relationship with a family doctor has a way to do that. And everyone agreed that that was fairly nebulous. But it didn’t have a home other places and it was felt to be important by the board of directors. And it landed in the practice team because if you have practices that are really ready to take care of anybody in your community, then patients who want to be taken care of should be able to find a home in a family medicine office.   \n\nDr. Young: How were the tactics identified?\n\nDr. Marker: Very early on before there were any core teams at all there were just groups of folks getting together. And I was involved in many of those early conversations talking about what our specialty really needed to thrive a decade or two down the road. And all of the tactics for all of the core teams came out of those conversations and what was developing as a board of directors of sorts and before we had an organization to put a board to. This was mostly leadership of the Family of Family Medicine organizations that were doing this. So certainly they had an idea on what their own strategic plans were, what their own organization’s mission, vision of values were, what they saw as future challenges to their professional organizations and their membership. And those were sort of the groups that came together to put together these tactics for the core teams that would eventually be developed. It was certainly bigger than just the leadership of the key organizations because there were folks from all walks of life, including patient advocates and business folks and students and residents that were part of these early conversations as well. \n\nDr. Young: And you referenced that there was representation from the Family of Family Medicine. To what extent was there agreement versus conflict? Well, I shouldn’t say conflict – different viewpoints?\n\nDr. Marker: I recall very little conflict. And within the realm of differing viewpoints, that was always just a matter of having some robust discussions about where those viewpoints came from. And then I think very quickly everybody was able to get on the same page around those things. Most of it was just knowledge deficit – Oh, I didn’t know that was something your organization was passionate about, thanks for explaining that. I can see how that would fit into one of our tactics. \n\nDr. Young: So no surprises as such?\n\nDr. Marker: No, none from my standpoint. Of course, as a still relatively young physician, I tried to do my best to stay away from the politics of intra-organizational and inter-organizational conflict within the Family of Family Medicine. I don’t think that serves us well and has never been an area I’ve wanted to engage myself into too much. \n\nDr. Young: As the team leader how did you go about accomplishing the work? And you could also talk, if you would, a bit about who is on your core team.\n\nDr. Marker: Sure. Can you park that and let me back up to one thing that just occurred to me that I should say here? Go ahead and insert it. Okay. Fairly early on, after the core teams had been developed and were starting to do their work, there was a moment where we sort of paused and said do we need to do any sort of reboot on these tactics, on the core teams, and on the people engaged in the core teams. What I’m about to talk about fits in the gap between how we sort of came up with the tactics and then what my particular core team was working on. And what we did discover is that there did need to be some refinement of the tactics. Nothing major, but some rewording, a little bit of refocusing. And each of the tactic teams did that, mine included. This idea that our job was somehow to make sure everybody had a relationship with a family doctor sort of waned in relative importance amongst our tactics, knowing that if we accomplished the other tactics we’d be prepared to do that last one anyway.  There was the development of a health equity core team that was not an original core team that everyone recognized needed to be there. Once the core teams and their memberships sat down and looked around the room at one another and said, who put these groups together, there’s not nearly enough diversity here, we pushed back to the board and said we need to do something about this. And then each of the teams, by and large, got a little bit more diversity on it. And a special core team specifically assembled to hold our feet to the fire around health equity, social determinants of health and health equity issues in the work that we were doing.    \n\nDr. Young: Talk a bit then about how you progressed from there and how did you get your core team. Who are the members and all?\n\nDr. Marker: Really, it was mostly the board of directors who went about the work of assembling the teams. I, as a core team leader, was sort of picked at around the same time that the core team that I worked with was selected. So I was not, that I recall, really involved in who was going to be on that team. There were a few little side conversations here or there – Hey, do you know this guy. We’re thinking about putting him on your team. And over the course of just a few months, all of a sudden there was a team. We had a meeting, we got to know each other and carried on from there. My team has four folks on it in addition to me. Dr. Rebecca Etz, a PhD level anthropologist who works at Virginia Commonwealth and is a full time researcher in their Family Medicine Department. Sam Jones from Fairfax, Virginia who is a past ABFM president, I think, and an all around good guy who is one of the principles in a large group practice there that is affiliated with a residency in the sense that their practice is the residency clinic. Mike LaFevre, the department chair out of the Family Medicine Department at the University of Missouri in Columbia. And Jay Lee who has had a few different jobs along the way but currently works at Venice Health Clinic in Venice, California and is a real transformational change agent. A young physician, a social media guru for family medicine and all around deep \n\nthinker about the future of family medicine.    \n\n   \n\nDr. Young: And you had among those two people with PhDs, Lee and Etz, at least according to ...\n\nDr. Marker: Yes, I wouldn’t have told you right off the top of my head that Dr. Lee has a PhD, but that doesn’t surprise me.\n\nDr. Young: So how did you proceed now that you had your group together?\n\nDr. Marker: We proceeded by getting to know one another pretty well. We had some high level conversations about what we thought needed to happen in each one of our tactics. We surrounded ourselves with some staff members from T. Farr (?), the consulting firm that was hired to help us with the strategic planning process who we made sure understood our viewpoints and how we wanted to go about doing our work. And then we began to break down the tactics that we’d been given into some quantifiable parts, some projects that developed over time. It probably took a year of work for us to just sort of figure each other out and understand where we thought we were going with that and also in its relationship with the other core teams.\n\nDr. Young: Could you talk a little bit about some of that work in particular?\n\nDr. Marker: Sure. How do practices transform? Why do practices transform? When do they transform? What are the incentives to transform and not to transform? These are the questions that we chewed on for a while just in some very free-flowing, brainstorming kinds of work. And over the course of the year of doing that decided that there were some projects that we could work on that were finite enough to be doable in the time that we had, that were not so resource-intensive that would blow the budget that we had been handed to work on and that could be done with the skill sets that we had. So the idea that we would somehow have a role in practice transformation can be everything from understand past types of transformation to rebuilding the recently mothballed TransforMED organization. Where do we think that we would find an appropriate home for our organization within that concept of practice transformation? And I think all of the tactic teams really had to grapple with that right from the start because there’s so much you can do with these tactics and a finite number of resources considering we were all volunteers to do this. That we had to find our way in that to begin with. Yes, you could say that we want to restart TransforMED and how many millions of dollars do you need to do that. Or we could say maybe our job is to come up with some great ideas for how practice transformation education could be done. Really do what we needed to do to come up with a vision for that and then find out which of the sponsoring organizations had the aptitude, skill set and finances to roll that out and be the idea people and not maybe the doers of all things. \n\nDr. Young: And was that the direction you took?\n\nDr. Marker: And it was the direction that we took mostly. I will peel off a little bit some Measurements That Matter work that Dr. Etz was doing out of Virginia. She was already working on some of that when we stumbled across her. And she continued on the trajectory she was already on, but with some additional financial support from FMA Health and with some refinement of focus in some of the work that she was doing and some add on projects that we asked her to work on. But even as we unwind our part of Family Medicine for America’s Health, she continues on generally the path that she was on before she started working with us, but now with the new relationships that we’ve helped her get herself into that will guide her research work into the future of that. So that particular tactic team, as the core team leader I would describe to you as largely on auto pilot when we “found” it. That she contributed probably more to the work that we were doing than we contributed to the work that she was doing. And I didn’t have to do a whole lot more than some (I’ll say this in the best possible way and she wouldn’t be opposed to it), babysitting along the way of the things she was doing to make sure we knew what she was up to and could pass that on to the right people.\n\nDr. Young: And the other activities that you all …\n\nDr. Marker: The other activities. The first one that we started out with were some elevator speeches. They helped us really refine what we thought we were about and brought some other people to the table to help us make sure we were not off base. So we realized that if you’re a family doctor in this country, you may have a whole lot of people who think differently about what you do and how you fit within their world and that we needed to have some elevator speeches about what the future of family medicine looked like to us and why practice transformation was important that we could tell to an insurance person, a CEO, a patient, my receptionist, another doctor in my community. And we had a list of about twelve of those that we wrote up bullet points about what we thought the key points about practice transformation would be to get them on our side and agree with us that it was important. And then we turned those bullet point works into some pros that we actually thought here’s some important paragraphs. And even turned them into some scripting a little bit. Some back and forth about actual interactions you could imagine happening at each one of those environments. \n\nDr. Young: Any surprises in the development of what those points would be?\n\nDr. Marker: I think we were surprised that they needed to be so unique in their individual components. That the things you really needed to say to an insurance executive could be a very different list than what you wanted to say to a patient. Yes, there were common threads and basically things that would fit within the Quadruple Aim. But the specifics of why we were important to different groups was quite variable and that we needed to make sure that we were able in the practice transformation world to engage each one of those groups uniquely. \n\nDr. Young: Was there any pilot testing of these or any way of determining whether the insurance community, for example, thought differently? Or did you all have sufficient experience already with these audiences? \n\nDr. Marker: Because the nature of this was really just to help us crystallize what we wanted to do for some other next steps, we kind of shopped it around within the family medicine world and each of us sort of held to the standard of saying we’re our own experts because we got picked to come together in this way. We felt like we were able to acknowledge that these were close enough to the center of the target that they didn’t need any special work or justification out of the community that they were correct. I do think that in retrospect that could have happened, but we weren’t planning to use these for anything super profound. It was more about crystallizing our goals in the other tactics. So we took that for what it was worth. We talked through them at several of our Family Medicine for America’s Health meetings. I talked through many of them at my state chapter meetings. And getting no pushback, we proceeded into other projects. \n\nDr. Young: Take a moment, if you would, to talk about when you came together with the overall Family Medicine for America’s Health meetings and how you took advantage of that interaction.\n\nDr. Marker: A couple of times a year we had what we call all-hands meetings we got physically together in one room, all the tactic teams together with the board of directors to do a long weekend with some strategic planning. And some of that was just reporting out, where you were with your team. Some of that was co-meetings with other teams along the way. And these were opportunities for us to say, hey, here’s what we think, here’s some elevator speeches, what are your thoughts around that? And to a very limited extent people had some ways to refine some of them. But we basically got the green light that, yeah, these seem like reasonable ways that you would communicate with folks in other venues. Then as we went about actually communicating with folks in other venues, I at least tried to use a lot of that language when I could and found great advantage in it.\n\nDr. Young: And when you say all-hands meetings, does that mean that all the members of the core team came to these or was it just you as a leader of the core team?\n\nDr. Marker: All of the members of the core team. And we’re all busy folks and we’re all volunteers. We’re not paid to do this. So there were many occasions when it wasn’t every single person on my team, but more often than not we were all there together.\n\nDr. Young: And speaking of money, did you get the resources that you needed as you did any of the core team’s work?\n\nDr. Marker: Absolutely. Once I recognized that my team’s job was going to be about strategic planning and about thinking, we actually were able to be very fragile with the dollars that were entrusted to us. It’s my impression that probably the payment team to this point has used a fairly small percentage of the dollars of FMA Health. Now, we have one big project left on the block that we’re working on that has the potential to totally change that pledgetary (?) assessment of my work. But I never felt like we were pushing the envelope in the amount of money that we were spending. A lot of it for us went into just getting ourselves together, transportation costs, getting a few people to a couple of meetings they wouldn’t have otherwise gone to, some small dollar items like that.\n\nDr. Young: We’ll pause here and I’ll turn the tape over.\n\nSide 2\n\nDr. Young: This is side 2 of tape 1 of the August 13th, 2018 interview with Dr. Jason Marker, team leader of the practice core team for Family Medicine for America’s Health. \n\nTell us some more about the work of your core team.\n\nDr. Marker: We’ve talked about the elevator speeches which gave us something to do while we crystallized what we wanted to have as some overarching outcomes. We also worked on some bright spots that I’ll come to in a little bit. And also the state Interactive Resource Center idea at the end. But just a sentence or two more about Dr. Etz’s Measures That Matter work. She actually went about the business of evaluating physicians and patients and some other stakeholders, business owners and such, to understand from them how they thought doctors should be assessed, family doctors. What were their metrics for whether a family physician was doing a good job for them or not. And not surprisingly, especially what physicians and patients would like to see physicians being measured on is very different than the ways that we are measured and the metrics that are currently put together for assessment of our work. And so she has been doing a lot of research around making sure that her results are valid and the things that researchers do. But basically what it comes down to is that the ways that physicians are measured today do not reflect the way that either patients or physicians believe that physicians should be measured and that there needs to not just be a parsimonious list of science-based outcomes that are easy to acquire through electronic health records, but we need electronic health records that are able to acquire other types of data. And there needs to be valuative tools developed that break away from the current even parsimonious lists of physician measures and focus on the ways that are more patient-oriented. So that’s the work that she was doing. \n\nDr. Young: Can you elaborate a bit more such as what patients would like the physician to be measured on?               \n\nDr. Marker: Well, patients want to be heard. They want to feel like they were listened to. They don’t mind questions like I’m healthier because of my interactions with my family doctor. That’s a fine meda (?) metric for patients. They’re not opposed to that. Even some of the things that you see in consumer science around I would be willing to recommend this doctor to my family members are metrics that patients are very comfortable with as far as a valid indicator. And physicians like that too because tied up in those larger metrics are a lot of things about the work that we do. By and large patients don’t care that … Not that they don’t care. My blood pressure’s under better control is not as compelling for them as it might be for me as a family physician. But they’re not judging me based on how good their blood pressure control is because they know what I know, which a lot of that is under their control, not under my control. And so they want to be heard. They want access. And those are the kinds of measures that are more compelling to them.\n\nDr. Young: And are these measures unique to family medicine?\n\nDr. Marker: They probably are not, though this is family medicine researchers working on this work and they would be in iteration down the road to determine whether they’re generally applicable only within primary care or only within family medicine. My thought is that they might be a longer listen given all that family does compared to dermatologists say. Well, certainly we have different skill sets for sure. But if we say as family doctors that we are the doctors who take care of you in the context of your family and your relationships and that our relationship with you is at least as therapeutic as some very specific science-ey things that we will do for you, then I think us being assessed on our relationship building skill set is fair game. And if that’s more important to patients than what your hemoglobin A1C is then I’ll take it. Absolutely.\n\nDr. Young: Other comments on the work of your team?\n\nDr. Marker: We have been working in an area called Bright Spot (or that’s what we call it. It’s kind of generally called that within Family Medicine for America’s Health) where we said, okay, let’s not reinvent too many wheels here. If there are practices out there that have done robust transformation and now feel like they are achieving the Quadruple Aim and in many cases objectively are achieving the Quadruple Aim. Let’s go find them, talk with them, survey their work. Understand the steps they went through to be successful in that area and document that because we think those will be learning tools and teaching tools for doctors who have yet to embark upon that and it will help inform how they have worked within the current fee-for-service environment. And if they are already working in environments that are not fee-for-service, how they made that transformation. So Jay Lee became sort of the committee chair of our Bright Spots work. He had a relationship with Tom Bodenheimer (?) who certainly has been active in this area. He spent some time with Dr. Bodenheimer, then with some other assistance went about the work of identifying some key practices that had already transformed and gathering data through interviews that were transcribed and sort of parched and eventually videotaped so that we could use them in some other venues in other projects.\n\nDr. Young: The core teams had interaction for sure at the All-Hands meetings. Did your core team have any other core teams that you particularly worked together on?\n\nDr. Marker: At various times we overlapped some with all of the different core teams - by design, not surprisingly, but mostly at the All-Hands meetings. In the last eighteen months we have, by design, been growing closer to the payment core team just because it was known from the start of Family Medicine for America’s Health that the work of the Payment and Practice core team was going to be critical to how we were viewed in the final analysis of Family Medicine for America’s Health. If we couldn’t find ways to both transform our practice delivery models and our financial models, that we would not be successful. So Tom Weida, the payment core team leader, and I spent many opportunities talking, just the two of us, about the work of our two teams and bringing our two teams together even in some venues where it was just our two teams. \n\nDr. Young: And any comments on the particular activities when you were together, outcomes, et cetera?\n\nDr. Marker: Excellent, robust conversations. They had plenty say about our work. We had plenty to say about theirs. We probably, to a certain extent, nudged each other’s teams into slightly different trajectories. But I don’t think were any radical differences in what we were doing based on those interactions. It was more about knowing what approach they were taking to payment transformation so that we could make sure to model the language, if nothing else, that we were using around the language they were using and vice versa. That our vision of practice transformation matched what they saw as necessary for payment transformation and that our visions of payment transformation sort of were in good alignment with what they were working on as well. We didn’t want to end up at the very end of the project with our own vision of what payment transformation needed to be that was different than theirs. \n\nDr. Young: And where is your core team currently in terms of its life?\n\nDr. Marker: Our core team is designed to sunset at the end of this calendar year 2018 and to turn over the remainder of its work to be done to the sponsoring organizations. The elevator speech work was done a long time ago. The Metrics That Matter work looks like it will be primarily honed as The American Board of Family Medicine where there are some like-minded researchers looking at metrics that will be a good fit for Dr. Etz. We did a project about physician readiness we can talk about that is completed now and simply in form. The last big project was our Interactive Resource Center. \n\nDr. Young: So looking to the future it sounds like at least one member of the Family of Family Medicine, the board, is going to carry forward that project. What’s your prediction or plans for everything else?\n\nDr. Marker: The Physician Readiness project, as I said, was just about understanding how physicians self-describe themselves as readiness for change and fed directly into the Interactive             \n\nResource Center. The Interactive Resource Center is envisioned to be a freestanding place, probably a website or other mobile application that would be an easy access congregation point for physicians interested in practice transformation. It is currently being evaluated by the AAFP for logistical feasibility studies and will be discussed here in early August at the working party meeting as a potential high dollar program to be rolled out of perhaps the AAFP but in conjunction with the other Family of Family Medicine organizations as a one-stop shop for practice transformation education. \n\nDr. Young: As a faculty member, what do you see coming out of the work of your core team, but more broadly Family Medicine for America’s Health, that will impact what goes on in your residency education process?  \n\nDr. Marker: I firmly believe that today’s medical student and resident is partly in our specialty because they see the opportunity to impact social determinants of health in their communities and practice in a way that is very intimately involved in the patient’s well-being and provides a high level of high touch care for their patients in ways that leverages their relationship building in ways that were not part of my education in family medicine but which I find great affinity to as well. The payment and practice delivery models that allow that to happen are the ones that the Family Medicine for America’s Health organization are advocating for. And if we can see those transformations happen, there will be a happy home for tomorrow’s medical students and residents as they become family medicine doctors. So I’m passionate about it. I was passionate about it before I became a faculty member. But now, as I really get to engage with these young folks and see what they’re passionate about and how they want to deliver care, it’s not the current fee-for-service, in your office payment and practice model. It’s a syncronis care with prospective payment that can support you financially in ways that allow you to prevent burnout and provide a high level of care for your patients where they know you care about them individually and that they’re not just some widget flowing through your office.\n\nDr. Young: You mentioned early on that the small practice is a bedrock within family medicine in America today. We are in a time of great change in a variety of ways. What is your prediction in terms of say the employed physician versus the independent practice? And are we ending up in several different camps, direct primary care being one model, being employed in a large Kaiser-like or Geisinger model is another - where are we going?\n\nDr. Marker: I am very optimistic that small private practices are not going away. They will probably be rebranded and some of them will see direct primary care practices and some of them will be larger groups that in the future break apart into smaller groups because it’s easier to be nimble and be attentive to specific community needs when you’re in a small group. But I actually think that the 40% of practices that are still small private practices will probably get smaller before they rebound. But I do think that they will rebound. They may rebound under different payment models and different practice delivery models but I think we’re going to get there. I honestly believe that direct primary care is a temporarily interesting idea that is borne out of the backlash against fee-for-service and that once we finally -- fee-for-service out of this dysfunctional payment model that we have in America, that some of these direct primary care practices will start to look a lot more like my practice did for fifteen years in a small rural community in private practice again. So I’m very optimistic that there will be a day that looks a lot more like 1975 in how it is embedded within communities and how it takes care of its patients. But it will have an entirely different feel of how it is financed and the goals with which it assesses whether it’s getting communities healthier or not. \n\nDr. Young: Who needs to make these decisions? What structures within the healthcare payment system, both federal and private, not-for-profit? How does this change come about? Who needs to be doing what when?\n\nDr. Marker: My prediction is that it will be business that ultimately makes the call that there is a better payment model for them that preserves their profits. Or even in a non-profit, that preserves their residuals at the end of the year that they can reinvest in their not-for-profit entity. And that they will then perhaps drag the insurance industry along with them into some new era of payment reform. I do not yet have confidence that the insurance industry has the incentives to lead this charge. The government will have a role to play in that. I’m sort of a mildly less leading moderate. I don’t know that government can solve all of these things and I don’t mind some free market private business interests thriving in practice transformation and in the leadership of how healthcare is financed. I think that the house of medicine has to be ready to provide medical care that fits the needs of patients, particularly those that are the employees of the employers who can pay for a lot of this. And that some of the work that we’ve done in DPC (?) to put the payment onerous onto patients themselves will probably fade as businesses can do a better job of this perhaps. \n\nDr. Young: And is this regardless of the size of the business?\n\nDr. Marker: I think there can be ways for even small businesses to accomplish some of this in ways that they can’t if they have to buy insurance for their employees. And it may actually be small businesses that are in the best opportunity to advocate for some of this. Initially I think it’s going to be some of the big boys, IBM and others, Amazon, Microsoft who say we’re spending way too much money on insurance. We’re going to directly contract with some groups of primary care doctors and we can really save a lot of money. And they will. And then either the insurance companies will come up with products that kind of look like that, that make it administratively simpler for the businesses or they’re going to fall by the wayside. I think that’s just going to be a reality for them, if they can’t keep up in that way. Or they’re going to independently come up with products that look like that, that they can sell to businesses that aren’t forward thinking enough to do it on their own. \n\nDr. Young: You mentioned the big guys. Do you think that they as organizations, some of them think differently about their employees and it’s sort of a natural that this other approach that you’re talking about would make sense to them?\n\nDr. Marker: I absolutely think that’s true. And those that have been hiring their own doctors because they have enough patients-employees to justify doing that, I think some of them have known this for a long time, they’ve just been keeping it to themselves because they haven’t had to have anxiety around it like other companies that were buying insurance. I think that some of the political changes in the landscape over the last three administrations has created a lot of business angst as they have seen their premium structures increase within the traditional insurance markets and that they are not going to take that anymore and they’re looking for alternatives that we’d like to educate them about the importance of family medicine as they look at what their alternatives are. \n\nDr. Young: Anything else that you’d like to comment on regarding Family Medicine for America’s Health, the healthcare system as we’re seeing it continue to evolve, et cetera?\n\nDr. Marker: I’ve been very concerned about what the legacy of Family Medicine for America’s Health is going to be because I think we’re in a time of rapid change within healthcare and some of the things that we envisioned as being really good future ideas at the beginning of this just sort of happened to American healthcare during the course of this long five year strategic planning process. I think when MACRA came onto the scene, a lot of folks thought that we should just shut down because that’s a brand new payment model that looks like it has some good future legs if it continues to be modified properly. So it may be that some folks in retrospect feel like there hasn’t been a lot accomplished, but I don’t feel that way. In many cases we were part of some of the decisions that were made that are good for U.S. healthcare right now. And I think that a lot of the things that family medicine organizations who are sponsoring us have done internally over the last few years have been done in part because we were leading some charges that they happened to be privy to. We kept them up to date with what we were doing along the way. And they just began to naturally incorporate some of those things as business as usual, not waiting for us to be done at some arbitrary date in the future and then say, oh, what a bunch of great ideas, we should do that. They’ve been incorporating some of that along the way. And so I think there is a tendency then for folks to say that we didn’t do a lot because it just sort of happened organically within each of the organizations along the way.\n\nDr. Young: So the impact of Family Medicine for America’s Health may not be as visible to some looking at it from the outside because they don’t recognize the influence that you all have been able to have on the various organizations?\n\nDr. Marker: There are people who will want to take credit for things that are happening good in family medicine and I think that Family Medicine for America’s Health has reason to take credit for some of those things. But as a big group of volunteers, at least my team decided early on we don’t care to take any credit for anything specific that comes from this. If the specialty grows and is better and patients are better taken care of because of some of our work, I really don’t care who gets the credit for that. I’m not looking for somebody to come back in ten years and say, oh, that Jason Marker, wow, what great work he did on that practice core team; we have this thing going now because of his work. If that thing, whatever it is, is happening well because of the work my core team did, I’m happy as a clam about it and no one needs to mention my name. One, I will say for posterity here in this particular venue is if you look at who are the leaders of the eight Family of Family Medicine organizations, if you look at the diversity around those board tables and the ways that those boards are talking about social determinants of health and social justice and health equity, none of those were conversations before Family Medicine for America’s Health. And I believe that the things that we espoused and believed were important as we worked to build Family Medicine for America’s Health into a strong strategic planning organization rubbed off in very visible ways in those boardrooms and in what they are finding important to advocate for. And I believe that FMA Health should take a big hunk of credit for that, not the individual organizations always. \n\nDr. Young: Any other comments that you would like to make?\n\nDr. Marker: I think it’s been an exciting time. There has been within Family Medicine for America’s Health sometimes some tension with the sponsoring organizations as we found ourselves out in front of them by necessity and asked to be there by them. There’s also been friction sometimes with our strategic planning partners at C-Far (?) and how they did their work and led us through that. It’s been, as a totally side issue, very educational for me, as a physician leader, to watch and be part of some of the interactions where we’ve sorted out our relationships with our sponsoring organizations and with our strategic planning partners. And there were days when I felt that was what I was mostly getting out of FMA Health, was seeing how organizational dynamics were playing out in some really big organizations with some high dollars at stake. I think that’s an intangible thing that I learned along the way. Some of the folks who started along with me in FMA Health as leaders aren’t part of the leadership of FMA Health. They got tired of it or fed up or burnout or whatever and moved on to other projects in life. And I had certainly opportunities to do that and probably times when it wouldn’t have been a bad idea. But I’m glad that I hung in there to the end and find that there was great value for me personally and professionally in not just the things that I was doing for my specialty but learning within leadership.\n\nDr. Young: Dr. Marker, thank you ever so much for allowing us to interview you.\n\nDr. Marker: It was my distinct pleasure. 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