Dittoheads of the world, unite!

I know I’m running out of things to say about practice management when I read a series of great articles in great publications – and all I can add is “ditto.” I never wanted to be a dittohead, and I don’t listen to Rush Limbaugh. But there are only so many valid points to make, and unless I want to make them again with different examples, or move on to some other subject, I’m reaching the end of my tether.

Dr. Mark Sklar, an endocrinologist and assistant professor of medicine at the hospitals of Georgetown and George Washington University, popped a good opinion piece in the June 23rd Wall Street Journal. Although he is a specialist and I am a generalist, the fact that we have both experienced academic bureaucracies and opted for private practice makes us blood brothers. Like this:

"Contrary to what you may have heard, my experience is that smaller practices provide better patient care than larger practices. There are no economies of scale in medicine. If you hire more physicians, you need to hire more support staff to deal with the increased work demands. Larger practices with less support per physician often end up providing worse service. They also require office managers, and sometimes even managers of managers, all of which just bloat costs."

Like I said before, doctors are really piece workers. There are no efficiencies in numbers. Have I mentioned that I don’t have an office manager, so I don’t have to pay my share of a $50,000 salary? That goes to my kids’ college fund. True, I have to make small day-to-day decisions between patients. Also true, I don’t have to meet with the office manager to go over those decisions, and check on the implementation later. I wouldn’t remember anyway. Short attention spans have their advantage, in the right setting.

"I worked in a university multispecialty practice for seven years before establishing my own private practice. At the university practice, I found that patients' requests often went unfulfilled. Phone messages didn't get to me, and charts and laboratory tests were routinely lost. In my own practice, my fingers are continuously on the pulse of my staff and patients. Because I can overhear how staff interact with patients, I can intervene rapidly if patients are not getting good service. We routinely have patients transferring to us from larger multispecialty practices where they often wait for hours to be seen, aren't called with their test results, and their phone calls are ignored."

My town is crawling with good doctors, including primary care – we had a family practice residency here for a long time, and lots of them stayed put. Every time I call my primary hospital, I listen to an advertisement for my competitors while I’m on hold; I read their full page ads in the paper; they dominate the evening news and the Yellow Pages. How is a solo FP supposed to compete? Like Dr. Sklar says. Our patients are treated like royalty. I was recently invited to join a large “concierge” organization, but there was a major problem: How was I going to offer VIP patients better service than they’re getting now for nothing?  

"Electronic medical records have been praised as a way to save money and avoid duplication of tests. It's true that electronic medical records will save some money, but not as much as you probably are counting on. In my practice, if a patient tells us he had a test performed, we call the physician or medical facility to retrieve the results…. When I refer a patient, I fax or mail over pertinent notes, lab work and radiology results so that the specialist knows the patient's problem and doesn't need to perform additional unnecessary tests. The specialists that I refer to either call me or write comprehensive consultation letters so that I am aware of their treatment plan and can coordinate future care with them."

When I read articles lauding EMRs, I feel like I’m in a parallel universe. You need an EMR to avoid duplication of tests and services? Like Dr. Sklar says, that’s what a fax machine is for. An EMR will save paper? Every time I get a “Practice Partner” five-minute office visit from one consultant, it occupies four pages of trees. An emergency room visit runs to eight single-spaced pages. It’s damn difficult to find the important stuff in all that computer-generated, ass-covering verbiage. If everyone shared a common platform, that would be one matter. But the government refused to mandate that a decade ago, and I’m paying for the results. Some day the Betamax/VHS, Blu-Ray/DVD, 8-track/cassette issue will be settled, and that’s the day I’ll shop for an EMR.

Don’t try telling that to the Patient-Centered Medical Home folks, though.

Posted at 12:22PM Jul 02, 2009 by Doug Iliff  |  Comments[1]

The health care debate heats up

On occasion I am brutally honest with patients about their differential diagnosis.  I tell them of several possibilities, but conclude that the most likely is “God Only Knows.”

This has been an active fortnight for news about reforming our health care non-system, highlighted, I suppose, by President Obama’s frank talk with the AMA and the Congressional Budget Office shooting Sen. Edward Kennedy’s plan out of the water.

As of this writing, and for the near future, God Only Knows is the front-runner.

What I look for is honesty about the real challenges.  And, lo and behold, we’re starting to get a little honesty.  

It started with Dr. Atul Gawande’s New Yorker article (see my June 1 blog post), which President Obama made required reading for White House staffers.  Then he mentioned it in his AMA speech. In his punch line, he referred to “…a system of incentives where the more tests and services are provided, the more money we pay. And a lot of people in this room know what I’m talking about.”

Throughout the speech, the president got a lot of nervous applause, and one standing ovation (“You entered this profession to be healers – and that's what our health care system should let you be"), but the line about incentives got stony silence.

If you want a useful and perceptive commentary, read Dr. Abraham Verghese’s article, “The Myth of Prevention,” in the June 20 Wall Street Journal.

If you don’t have access to these articles, or the time to read them, here’s an executive summary of the debate to date:

The CBO decided that Sen. Kennedy’s bill would cost roughly $1 trillion over 10 years, and still leave 37 million Americans without insurance.  That was a big "OOPS!" for congressional Democrats.

Dr. Gawande usefully observed that doctors make a lot more money when they decide to order tests and procedures which make them a lot more money.  He did not have a solution to this problem. The solution I favor, Health Savings Accounts, he dismissed by noting that no one shops for price when chest pain strikes in the middle of the night, which is true. He failed to point out that lots of people shop for price in the course of my routine office practice, which, to be fair, is completely outside his limited experience as a surgeon and author.

Dr. Verghese, an internist and infectious disease specialist, writes:

“Cut, poke, sew, burn, insert, inject, dilate, stent, remove and you get very well paid; if you learn how to do this efficiently, maybe set up your own outpatient center so you can do it to more people in a shorter time (which is what happened when this payment system was put in place in 1989) and you are paid even more. If, however, you are a primary care physician, and if, just like the young doctor who saw my parents yesterday, you spend time getting to know your patients, and are willing to play quarterback when your patient enters the hospital, so that you can herd the consultants and guide the family through a bewildering experience that gets surreal if you are in the intensive care unit, then you may have great personal satisfaction but you will make five to tenfold less than your colleagues in the doing-to disciplines.”

No argument there. But aside from “behavioral things – eat better, lose weight, exercise more, smoke less, wear a seat belt,” he is skeptical about preventive medicine. Primary prevention through the use of statins may not be cost-effective (unless you are careful to use generics when possible); there are lots of technological gimmicks, like CT scans for coronary calcium, which don’t add much except anxiety.  

Dr. Verghese is also skeptical about electronic medical records: “…an electronic medical record (EMR) may or may not save money (it won’t be anywhere as much as is projected) but what it will do is ensure that we doctors, nurses, therapists, particularly in hospitals will be spending more and more time focused on the computer, communicating with each other, ordering and getting tests, buffing and caring for our virtual patient – the iPatient is my term for this phenomenon – while the patient in the bed wonders where everybody is. Having worked exclusively for the last seven years or so in hospitals that have electronic medical records (EMR), I have felt for some time that the patient in the bed has become an icon for the real focus of our attention, the iPatient. Yes, electronic medical records help prevent medication errors and are a blessing in so many ways, but they won’t hold the patient’s hand for you, they won’t explain to the family what is going on.”

He asserts “the single most important fact about health care in America that you or I need to know. ... all of us – doctors, hospitals, pharmacists, drug companies, nurses, home health agencies, and so many others – are drinking at the same trough which happens to hold $2.1 trillion, or 16% of our GDP. Every group who feeds at this trough has its lobbyists and has made contributions to Congressional campaigns to try to keep their spot and their share of the grub. Why not? – it’s hog heaven. But reform cannot happen without cutting costs, without turning people away from the trough and having them eat less. If you do that, you have to be prepared for the buzz saw of protest that dissuaded Roosevelt, defeated Truman’s plan and scuttled Hillary Clinton’s proposal."

Our leaders in the AAFP are, at this moment, trying to shoulder their way into this trough. And I wish them well, I really do, because their ideas are better than the proceduralists’ ideas. In a perfect world their proposals would be enacted. This is not a perfect world.

Meanwhile, I know this from personal experience: If I am given complete control of medical dollars through a full-capitation model, I will make a lot of money, because I practice evidence-based, cost-effective medicine. If I am simply scored against my peers based on costs that pass through my fingers, even if there is no monetary incentive, I will rank high for the same reason.

For around $200 per patient per year, you can have all of my services, including office visits, labs, x-rays, and obstetrics. My Job One, except for delivering babies, is to keep patients out of the hospital. I'm good at it, Dr. Verghese. Prevention works for me.

Based on proposals he has entertained thus far, President Obama is suffering from delusions about what it will take to reduce health care costs. I am not.

What we need is a system in which patients trust their family physicians, internists and pediatricians to direct their care in a cost-effective, patient-centered, wise and humane manner. This system should not interpose itself between me and my patient, and it should not raise questions about my motives. The inevitable and necessary rationing decisions must be made by patients and their families with the advice of their personal physicians, not by insurance companies or government commissions.

Aside from a universal system of Health Savings Accounts with refundable credits for the poor, I am waiting for alternative proposals that meet these criteria.

But this is beyond my pay grade. In the meantime, I’m Making It just fine, and you should be too.

Posted at 10:41AM Jun 27, 2009 by Doug Iliff  |  Comments[3]

Whatever happened to hard work?

As often happens, it was advertisements that made me think.

Two arrived the same day from Merritt Hawkins & Associates, the headhunters. Both were looking for family physicians and offering $300,000+ earning potential, which would be at the 90th percentile for our specialty. 

Shouldn’t that be enough to allow a modern medical student to consider family medicine? Or was there a catch?

The first flier offered a $240K salary with a production bonus, a four-day work week, no state income tax, no non-clinical hassles, golf at the 29th toughest course in the nation, a host of outdoor sporting activities in “the high-desert playground of the Mountain West” and a 13 percent lower cost of living than the national average – what’s not to love?

The second was to take over the practice of a retiring physician. The starting salary was $200K, with a $40K signing bonus and $10K relocation allowance, and you could keep your lab and x-ray revenue. The community was “safe and friendly” and “a great place to raise a family,” which probably translates to “boring,” which is why it also offered an “easy drive to two metropolitan areas.”

The former specifically noted “average three to six deliveries per month.”  The latter specifically noted “25 to 35 patients per day.”

There you have it. That’s the catch.

Both practices expect to hire, and I’m sure will hire, family physicians whose knees don’t shake at the thought of 60 deliveries or 7,000 patient visits per year.

Numbers like that would not have intimidated my great-grandfather Dan. He would have considered $12K (the equivalent of $300K in 1900 dollars) to be a princely sum, and as for the four-day work week – well, had he died and gone to heaven?

Even in my era (now we’re fast-forwarding to 1980) $116K would have made me salivate. And 60 deliveries per year? I trained for a couple of Boston marathons, raised four kids and started a private school while I was doing that.

Is this the real “crisis” for which the Patient-Centered Medical Home provides the “solution”?

In order to become one of the top 10 percent of earners in family medicine, do you just have to work about as hard as I expected in 1980, or half as hard as Dr. Dan in 1900?

It’s a question worth asking, because if that’s the answer, God help the AAFP in wringing enough money out of the federal health budget to lure more students away from urology.

Posted at 11:24AM Jun 19, 2009 by Doug Iliff  |  Comments[4]

PCMH meets the real world

The “preliminary” report on TransforMED is out, and it isn’t pretty. It also isn’t much different than Evaluators’ Report #5 from over a year ago. If you’ve never heard of the Patient-Centered Medical Home (PCMH) or TransforMED, I’m not going to help you today. See old blogs here and here, which will link you to the big picture. 

First, some perspective.   

The AAFP deserves a lot of credit for at least three reasons. First, it recognized several years ago that the specialty was in trouble and came up with an action plan. Second, it put its money where its mouth was, to the tune of $8 million, and funded an experiment to see if its plan was workable. Third, when the results weren’t pretty (see below), it didn’t flush them, and we know that that has proved to be a big problem in medical research. 

The AAFP also deserves three Bronx cheers. First, it has tirelessly promoted the PCMH model (as defined by TransforMED) to its membership without having the evidence to back it up. Second, it is allowing TransforMED to sell its non-evidence-based services to members. Third, it is failing to provide a forum for the vigorous debate that needs to take place immediately. 

What follows below is a cut-and-paste summary of the “Initial Lessons” from the researchers' report with my brief commentary in italics. 

Rush to Judgment; Unintended Consequences; Hold Your Horses: "The PCMH represents an innovative and exciting national conversation that melds core primary care principles, relationship-centered patient care, reimbursement reform, new information technology, and the chronic care model. Unfortunately, the rush to demonstrate operational and financial feasibility of the PCMH, proceeding apace with the recognition process of the National Committee for Quality Assurance (NCQA), risks premature closure of the larger PCMH conversations and potentially stifles evolution of the PCMH to meet important patient, practice, and system needs. … The pressure toward widespread adoption of this model is gaining momentum so rapidly that we feel compelled to share our observations and summarize the early process-evaluation lessons. … The NCQA has taken the lead in defining some essential components and creating a 3-tiered, implementation process for recognizing a PCMH. We fear the details of the recognition process may have reached premature closure, however, before the rich data have emerged from the NDP and other current demonstrations."

A one-size-fits-all approach is usually a bad idea, and TransforMED has proved it. The PCMH is ideally suited to large practices where bureaucracy has created layers of separation between providers and patients. For small group or solo practices, which constitute the bulk of the AAFP membership, the PCMH prescriptions are an insult. (If you’re not insulted, take the TransforMED Medical Home IQ test. You will be.) The authors are pleading for a re-evaluation of the concept. A good starting point would be the proposal by well-known researcher Barbara Starfield, MD, MPH.

Demoralization; Emotional Exhaustion; Financial Disaster: "In the process of working with these practices, our team has seen the day-to-day reality of changing community-based practices into the current idealized model of the PCMH. We have already learned enough from the NDP to identify some potentially dangerous red flags fluttering over the demonstrations just getting underway. Our early analysis raises concerns that current demonstration designs seriously underestimate the magnitude and time frame for the required changes, overestimate the readiness and expectations of information technology, and are seriously undercapitalized. We fear that with current assumptions, many demonstrations place participating practices at substantial risk and may jeopardize the evolution of the PCMH as unrealistic expectations set up demonstrations and evaluations for failure. … All the well-supported NDP-facilitated practices were challenged financially by the project." 

At the AAFP's annual meeting in Chicago two years ago I buttonholed Terry McGeeney, TransforMED's president and CEO, and Jim Arend, its CFO and practice facilitator, and asked them about the lack of “before and after” financial data for the participating practices. Their response: “It’s too hard to gather.” So now we know from the researchers' report that the practices were “financially challenged,” but we have no idea how badly. Somebody in authority needs to know what is going on.

Loss of Focus; Perils of Transformative Change: "Most current practice models are designed to enhance physician workflow. The PCMH should be designed to enhance the patient experience. This shift requires a transformation, not an incremental change. … The work is daunting and exhausting and occurring in practices that already felt as if they were running as fast as they could. This type of transformative change, if done too fast, can damage practices and often result in staff burnout, turnover, and financial distress. … Do not be surprised if the situation seems worse after the first 6 months to a year; the experience of benefits often takes at least 2 years."  

In a one-horse practice, “the patient experience” is right in your mug all day long. If you miss it, you’re too dense to profit from the PCMH experience anyway. In a big group practice, if you can hold your breath for two years you might be OK, except that all of the TransforMED practices were heavily subsidized financially; so while you’re holding your breath, you’d better be applying for Robert Wood Johnson Foundation grants. And get ready to suffer the consequences of staff burnout and turnover.

EMR Idolatry: "The hodgepodge of information technology marketed to primary care practices resembles more a pile of jigsaw pieces than components of an integrated and interoperable system. … For example, it is possible and sometimes preferable to implement e-prescribing, local hospital system connections, evidence at the point of care, disease registries, and interactive patient Web portals without an EMR. … New Web-based technologies, electronic clinical information systems, and telecommunications are finally nearing accessibility and utility for both health systems and primary care practices. … Future PCMH recognition and certification processes should focus more on patient-centered attributes and the proven, valuable key features of primary care than on the disease management and information technology features of the PCMH." 

Challenges to the politically expedient push for EMRs are now rolling in from all directions. If you already have one, keep and improve it; if you’re starting practice, research and buy one. If you’re well established, an EMR is not going to make you more money, and will cost you a fortune in purchase, maintenance and lost productivity. 

Productivity and Efficiency: "We should be wary of industrial-like schemes and excessive use of the language of productivity and efficiency. Primary care, like healthy food, works best at a local and personal level."

There are two metaphors for productivity: the factory and the farm. To a good family physician, you cannot view your patients as widgets rolling off an assembly line; they are crops to be nurtured. You can’t hurry the growth of a plant, but you can nurture it more productively. That’s the metaphor this blog is about. On the other hand, the PCMH is more like an industrial operation than anything else; and a bad one, to boot. TransforMED proves it. Now it’s time to move on to greener pastures.

Posted at 10:13AM Jun 11, 2009 by Doug Iliff  |  Comments[1]

The roots of medical inflation

The fault, dear Brutus, lies not in our stars but in ourselves.  

In the June 1 New Yorker, Dr. Atul Gawande tackles what he calls the medical “cost conundrum,” to wit: Medicare costs bear no relationship to quality of care outcomes.

He approaches this delicate subject by examining the medical society of Hidalgo County, Texas, which has the lowest household income in the country. It also spent $15,000 per Medicare enrollee in 2006, roughly double the payola in the home counties of the Mayo Clinic and Duke. It is also double the cost of El Paso County, 800 miles up the border, which is demographically identical.

Why? You won’t be surprised.

Hidalgo County physicians are nothing if not entrepreneurial. Dr. Gawande posits a case for a group of them over dinner. A 40-year-old woman comes in with chest pain after a fight with her husband. An EKG is normal. The chest pain goes away. She has no family history of heart disease.

What did they do 15 years ago? Send her home. Maybe an outpatient treadmill. And today? A stress test, an echocardiogram, a mobile Holter monitor and a cardiac catheterization.

“Young doctors don’t think anymore,” the family physician said.

“There is overutilization here, pure and simple,” the general surgeon said.

I see the same thing in my town. Thinking – that is, making a medical judgment that a test or procedure is not cost-effective – is dwindling. And why should that be a surprise? Every procedure earns a fee for some physician. And if you question the rationale? “You’re rationing care!” is the cry.

This is not family medicine’s problem. It is not primary care’s problem. Primary care’s problem is that entrepreneurial specialist colleagues have so padded their wallets over the past 15 years that medical students – no dummies, they – won’t choose our calling.

We are now under the direction of a new administration, which seems to be more serious about the coming bankruptcy of Medicare than the previous administration. “Nearly thirty percent of Medicare’s costs could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level in low-cost areas,” says Peter Orszag, President Obama’s budget director.

He’s right, too. That would push back the bankruptcy maybe a decade.

The solution proposed by the primary care societies is the Patient-Centered Medical Home, with pay-for-performance incentives that will jack up our salaries into the procedurist stratosphere. That’s the basket we’re putting all our eggs in.

In which case bankruptcy comes a decade earlier.

If you believe that’s going to happen, I have a house in Colorado I’d like to sell you.

The solution is going to be rationing by a government agency like Britain’s NICE commission, or self-rationing by the market in the form of Medical Savings Accounts. You can take that prediction to the bank.

In the meantime, we honest family physicians need to do what we’ve always done, which is care for patients in a cost-effective manner – informed by the best medical evidence, and with a close eye on their medical expenses and our administrative expenses.

Which is what I’ve been saying all along.

Posted at 02:43PM Jun 01, 2009 by Doug Iliff  |  Comments[4]

Who cares?

An article in the New York Times on April 26th ("Shortage of Doctors an Obstacle to Obama Goals") was full of fascinating quotes from the best and brightest of our solons. Taken as a whole, and assuming their mouths bear even a tangential relationship to their minds, it verifies my April 23rd comment that family practice ought to be in the catbird seat when it comes to the negotiating table.

If you don't have time to read the whole thing in the New York Times, here's a sampler:

We’re not producing enough primary care physicians. The costs of medical education are so high that people feel that they’ve got to specialize. (President Obama)

The primary care physician workforce shortage is reaching crisis proportions. (Sen. Orrin Hatch, R-Utah)

Primary care physicians are grossly underpaid compared with many specialists. (Sen. Max Baucus, D-Montana)

Maybe they're just posturing, which would be habitual. Or maybe it really is dawning on them that there isn't enough primary care capacity in the the country to do what the president wants to do. And this would be the fault of ... whom? 

Well, the Relative Value Scale Update Commission (RUC), for starters – an AMA goon squad dominated by procedurists, which calls the shots with the federal Center for Medicare & Medicaid Services, which is wholly responsible for the increasing spread between primary care and specialist incomes. The Times article says the Medicare Payment Advisory Commission, a congressional advisory committee, has recommended a 10 percent increase in primary care payment at the expense of the specialists.

The specialists beg to differ. 

Now the food-fight begins. And it's about time. This one could be fought in public, rather than behind closed doors in a mahogany-paneled conference room. This is a fight the AAFP ought to win.

Who cares?

Let's look at some numbers. There are roughly 220,000 generalists in active practice in the United States, and 400,000 specialists. Of the generalists, more than 90,000 are family physicians, 60,000 of whom are "active" AAFP members. So roughly one in three physicians are generalists, one in seven are FPs, and one in 10 are active members of the Academy. Furthermore, most Americans see one of these generalists every year, and rely on these physicians to shepherd them through a health care system they find perplexing, if not frightening.

That ought to add up to a heckuva lot of clout, but it doesn't. There are lots of reasons.

Not long ago, the four generalist societies got together to figure out an action plan. Rather than howling for financial incentives and administrative simplification for their overworked constituents, they signed onto a concept called the Patient-Centered Medical Home, with a burden of bells and whistles only a bureaucrat could dream up, and love. It might be a painful net gainer for the 25 percent of family physicians laboring in a group of eight or more, but for the rest of us, it just looks like pain, period. Clearly, it was pain to the 36 practices participating in the TransforMed national demonstration project, according to the researchers' first report.

But those of us in the trenches share the blame. When the RUC meets, the specialists have spent a fortune to demonstrate why their procedures are going to save the world. We don't contribute the money that is necessary for effective lobbying.

And then there's the issue of apathy, or resignation. I recently read that almost a third of family physicians had never heard of the Medical Home. If true, that's almost unbelievable. You'd think from reading a few excellent blogs from family physicians (see bar to right) that we know the score; but we're talking mostly to each other, and a relatively small coterie of enthusiasts.

So who cares?

Posted at 03:12PM May 12, 2009 by Doug Iliff  |  Comments[3]

No-man's land

At the moment I am attending a seminar sponsored by the Kansas Medical Society entitled “Revitalize Your Medical Practice: Creating a High-Performance Work Team.” The nationally-known speaker is a guy like me – about my age (60), and a graduate of a family practice residency and teaching fellowship. The differences are that Harvard Medical School turned me down, and I returned to family medicine after six years in the emergency room. He stayed.

He makes a number of well-researched points that are worth considering in detail, but here’s an important one: The four critical competencies for physicians in 2009 are clinical ability, productivity, teamwork and bedside manner.

This blog is dedicated to the second of those four, and he mentioned in passing that some office-based physicians seem to be under the misimpression that they are owed a living for seeing 10 patients a day. This echoed something TransforMed’s Jim Arend told me a couple of years ago: that some of their test practices thought they could make it in family medicine averaging 16 patients per day per doctor.

They can’t. Here’s why.

Aristotle’s Golden Mean (like Jesus’s Golden Rule, Kant’s Categorical Imperative, Mill’s Utilitarianism, and all other deservedly “great” ideas) is only true most of the time. When it comes to practice staffing and structure, the Golden Mean isn’t desirable.

Between micropractice and full speed ahead is no-man's land, a place where you have all the pains of modern clinical practice, and none of the rewards.

Micropractices are the Amish of family medicine: They enjoy the simple pleasures, and accept a lower salary. They are rarely under time pressure, but they file their own insurance claims and empty their own trash.

Most of us see the appeal of that style, but for one reason or another have chosen a different path. We hire people to answer the phones, file the paperwork, and check patients into rooms. The pain comes from managing those people. The rewards are financial, we hope.

With that payroll comes a moment of truth every payday. You, or another person you hire, write a bunch of checks and live on what is left over. The problem with family medicine is that there is not enough left over to attract medical students into our specialty.

Physicians don't get rich unless they manage insurance or pharmaceutical companies. We are all – specialists and generalists alike – piece workers, just like teenagers stitching together Nikes in Sri Lanka. Our "pieces" are charge codes or, as a matter of shorthand, our patients. If we manage physician extenders, we may profit to a small extent from the labor of others. But not much. It's mostly on our backs.

Now the key question: How many patients a day do you have to see before you earn your first nickel? That is, how many patients does it take to simply pay your bills? 

The answer to that question depends on a number of variables, but in general it will be in the low teens; say, for the sake of argument, 13. When you get to 14 a day, you're making (a little) money, maybe $100. That's $2,000 per month, right up there with a full-time Wal-Mart greeter.

Bump it up to 18 a day, and you're an average family physician at $120,000 per year. You're keeping the entire profit from those extra five patients. The rent is the same, the staffing is the same; your supply costs went up a little, and everyone is working harder. The medical students still aren't interested.

But let's say you could average 25 per day. Now you're going to need a bigger office, and at least one more nurse, so the break-even is up to 15 patients from 13. But your profit from patients 16 through 25 is $240,000 per year. You can bank it, or you can take more vacation with a lower salary – or you can hire a mid-level, book 30 or 32 patients per day, take more vacation and earn more too.

The medical students are starting to sniff around. You're looking more like a dermatologist every month.

If any financial lessons are learned from TransforMed, this will be one of them. Of course, we knew it all along. 

However, somewhere on the road between the wild, woolly and entrepreneurial days of family medicine 40 years ago, and the present-day experience of family practice residency, this commonsense knowledge was lost.

Because I left academic family medicine in 1980, I don't know how we lost it. My residency director semi-retired from a busy practice in upstate New York, where he saw 30 to 40 patients per day. I doubt many STFM members have that sort of experience; what they know and teach is important, and good, but it has not translated into financial success from their disciples.

I have two very close friends from my early years in medical school and private practice, both dentists. They got a thorough schooling in the business of dentistry. They both were grateful for their payback time in military service, because it gave them a chance to build up their practice speed (as they put it, how to turn the burr) before taking out big loans to start their businesses.

I'm afraid that young family physicians still don't get much practical help with business, and to make matters worse, they no longer have mentors who assure them that they can turn the burr without sacrificing the joy of personal relationships. So they join multispecialty and/or hospital-owned groups where their pay has little direct relationship to productivity – and it doesn't matter, because their service is only a loss-leader, a pipeline into the procedural roundabout. Worse, the lack of entrepreneurial incentive makes them resent that same-day patient who really needs to be seen today.

That's a shame. I wish I knew a way out of this wilderness, where I seem like a voice crying. The present incarnation of the Medical Home may help to sort out the inherent problems and inefficiencies of large groups, or it may not. The lobbying efforts of the Academy may wring a 10 percent increase in payments from Medicare or big insurers, or they may not.

All I know is that I'm having a good time in solo practice, and have for 23 years. Come on in; the water's fine!

Posted at 09:39AM May 05, 2009 by Doug Iliff  |  Comments[4]

Shortcuts

"I work long hours, half of which are essentially unreimbursed."

So writes a passionate advocate of the patient-centered medical home in a newsletter dedicated to promoting the concept. By testimony of others, he is an excellent family physician.

My goal is to work short hours, and be reimbursed for all of them. This blog is dedicated to shortcuts – the kind that save time, without sacrificing quality.

The first shortcut that I specifically remember came from a staff neurologist at Womack Army Hospital, where I did my training. In a noon lecture he advised that when you get a woman who complains of a bitemporal headache that progresses to a hatband distribution and goes down the neck, you can stop listening. 

He's the same guy who advised that when a staff physician writes "WNL" in a note, it stands for "We Never Looked." He was kidding. He always looked, and we knew it.

Remember the "medical school physical"? The eight-page form with printed body parts that taught us the skills of physical diagnosis? The hour and a half that it took to perform? And the waste of time it would represent at our present level of experience? The key to a happy and productive practice is learning the corners we can safely cut.

Would anyone argue, with a straight face, that civilization has progressed by figuring out ways to do the same job, only slower? Of course not. But where is the research on productivity, or efficiency, in family practice? 

Many family physicians are demoralized because they feel like they're on a "hamster wheel."  When TransforMed tries to turn them into a patient-centered medical home, it seems to get worse. 

I don't feel that way. But I can't get a handle on why I'm such a distinct minority. Surely this is a more gripping problem for FP research than yet another survey tool designed to detect closet alcoholics. Lacking a research base, all I can do is make educated guesses about what makes me un-stressfully productive.

Could it be that from my first year of practice, I decided that I was going to work no more than 220 days? There are 262 Monday through Friday workdays in a year, so that's like 8+ weeks of vacation. Research: How is vacation time related to job satisfaction and productivity?

Could it be that I hire only experienced RNs, and pay them well? That way my turnover is extraordinarily low, I virtually never talk on the phone, and my histories are thoroughly documented when I walk on stage. Research: How is staff continuity and education level related to job satisfaction and productivity?

Could it be that I refused to dictate notes in the beginning, and refuse to adopt an electronic medical record now? That way I never had to read transcriptions after office hours, and I never look at a keyboard while giving patients my full attention. I use a check-box system (manual macros) and my notes are very cryptic – just enough so everybody knows what's going on. (For a really clever essay on this subject, see "Charting Then and Now" by Mitchell Cohen, MD.)  Research: How is time spent looking at or creating a medical record related to job satisfaction and productivity?

Could it be that I chose independent rather than salaried practice, so my take-home pay is influenced by every patient I see and every item I charge? That seems to help my attitude when I'm tired, and concentrates my mind on coding and business decisions. Research: Controlled for group size, how is salary structure related to job satisfaction and productivity?

Could it be that my determination to be physically fit contributes to the speed of my decision-making, and my stamina when examining the 26th patient of the day? Research: How is physical conditioning, measured by peak METs on graded exercise testing or the timed one-mile walk related to job satisfaction and productivity?

I have more questions, but that's a good start. And it makes me wonder: After four decades of academic family medicine, why don't we have more answers? If family practice goes down the tubes for economic reasons, the dearth of productivity research will be a root cause.

In the meantime – I'm not holding my breath – some of you might report on your anecdotal experience with my hypotheses (or your own). And you rookies might try testing them for yourselves.

Posted at 03:54PM Apr 27, 2009 by Doug Iliff  |  Comments[4]

Boston Tea Party for family physicians

A California family physician, and frequent contributor to the AAFP practice management listserv, recently noted: "On April 1st United Healthcare reduced our reimbursement schedules to 2008 rates." [For background, read the post by Kent Moore.]

"So, the company that has hired TransforMed to help them become more PCMH friendly has concluded that being friendly means an 8 percent reduction in our 99213 rates," he writes. "The AAFP has written letters. ... Why haven't I received a written letter from the AAFP whereby they suggest a nationwide boycott against UHC?"

His frustration is palpable, and understandable. When it comes to a national response, what should the AAFP do?

The times they are a changin', and we'd better broaden the discussion.  Let's start with postulates.

First: There are not enough primary care physicians to provide cost-effective, quality service to the American population. Even if you add in nurse practitioners and physician assistants, it's still not close. And  if education policy and funding changed immediately, it won't be close for at least a decade. 

Second: In a free market, the price of any scarce commodity, good or service rises. Medicine is far from a free market, but neither has it been nationalized by a socialist state, yet. This means, by (normally) inviolable laws of economics, that family practice ought to be in the catbird seat.

Third: For the last two decades, the inflation-adjusted income of generalists has been stable, while that of specialists has risen dramatically. This has priced primary care out of the market for medical students. Furthermore, the rise of specialist income bears no relation to the difficulty or demands of their occupations; it is wholly a function of pricing decisions emanating from a Council of Elders responsible to Medicare and the American Medical Association. (See "What Every Physician Should Know About the RUC.")

Fourth: The hardest jobs in medicine are those of general surgeons, general internists and family physicians. Some of the work of these physicians could, it is true, be supplanted by ancillary personnel. But nearly all the work of many highly paid specialists could be similarly supplanted. Could a dexterous high school graduate perform colonoscopies? Of course; it is a simple manual exercise. How often does the nurse anesthetist ($120K/year) call in the anesthesiologist ($400K/year)? Hardly ever. But no "physician extender" can juggle the complex mix of stuff that comes through my door every day like I can. 

Now, granting that, how in the world has primary care been painted into this corner?

One hypothesis is that we are represented by the worst negotiators since Neville Chamberlain met Hitler and proclaimed "Peace in Our Time." This requires believing that the American Academy of Pediatrics and the American College of Physicians are also limp-wristed at the long table. Could be. I hear that surgeons can be really nasty people in a closed room.

Another hypothesis is that primary care, representing the largest groups of American physicians, nevertheless has a minority of votes on the Relative-Value-Scale Update Committee. The natives were restless at the 2008 Congress of Delegates in San Diego, insisting that the Academy consider other strategies, including withdrawing from the RUC. An AAFP director responded that "the Academy has no intention of rushing headlong into any situation that might prove untenable."

If family medicine is sliding into the abyss – well, we wouldn't want to do anything untenable, would we?

A few months ago, I read The Strategy of Conflict by Thomas Schelling, a 1960 book on game theory that won him a belated Nobel Prize in 2005. It considers nuclear war at length, but we won't go there. More to our situation, he spends a chapter discussing labor-management negotiations and makes a fascinating point. (Just to be clear, despite what the law says about our being independent competitors, we're labor.)

When a union chief sits down with a CEO, he has an ace in the hole if he has lost control of his membership. If the members are rioting at the gates, he can credibly say, "Look, Mr. Big, I'm trying to negotiate in good faith and make compromises – but those people are crazy mad. They've had it. I can't tell them what to do. Nobody can tell them what to do. If you don't make concessions now, they're going to burn the damn place down."

It's an interesting idea. The AAFP isn't a union, and it can't threaten a strike. But what would happen if month after month more and more family physicians were opting out of, say, Medicare? Not because the AAFP told us to – they wouldn't – but because we've had it, too.

Just a thought. Here's how.

Posted at 08:30AM Apr 23, 2009 by Doug Iliff  |  Comments[7]

Where did the Medical Home go wrong?

I’ve been cogitating on this issue for months.

I’ve been reading family practice and primary care blogs, and the AAFP practice management listserv discussions (which are unanimously Bronx-cheering). I’ve scanned the family medicine literature, which is turning critical, or at least concerned. I’ve studied the monograph by the Graham Center, editorials in Kansas Family Physician, information on the TransforMED Web site, and the brutal truth in the NDP Evaluators’ Reports.

I got far enough in my understanding to recognize that the NCQA approach to the PCMH was heavy on inputs, and light on outcomes, even though results are supposedly the sine qua non of evidence-based medicine and the scientific method in general. And I am satisfied that the ballyhooed “evidence” supporting the PCMH is phony; it touts the discrete elements taken in isolation, not the concept applied as a whole, and even then it is weak.

But I couldn’t get a handle on what churned my guts.

Then the author of "Musings of a Dinosaur" punched the button on March 29 in her blog post entitled “The Emperor’s Fashion Show” when she said this: "IT'S A WAY TO MAKE LARGE GROUP PRACTICES WORK MORE LIKE A SOLO DOC!"

I think she's onto something. The NCQA and PCMH proponents want documentation that patients see their PCP, because the large group has lots of PCPs. My patients virtually always see me.

The PCMH proponents want surveys of patient satisfaction, because the office manager sits behind a closed door one floor up and doesn't get patient feedback directly. I am never more than 40 feet from the patients talking through the window to my receptionist, and often less than 10.

The PCMH proponents ask for huddle groups, because they assume that nurses and medical assistants are pooled, and the same group may not work together for another week. My two nurses have worked with each other, and me, on 90 percent of business days for the last two decades.

The PCMH proponents require evidence of collaboration, and safety, perhaps because many large practices utilize MAs to check in patients. I use only RNs. They cost more, but I don’t have to look over their shoulder every hour. And they work right under my nose, anyway.

Now I’m getting it. 

The Medical Home is a great idea. It can still be salvaged. But as currently defined, it is a gigantic bureaucratic jangle that addresses the inherent problem of the large group: As a practice grows arithmetically, the communication problems grow exponentially. No wonder the PCMH scoring system seems so absurd to those of us who work within speaking range of our staff.

Does this make sense? Do you agree or disagree, and why? I'm listening.

Posted at 11:24AM Apr 10, 2009 by Doug Iliff  |  Comments[6]

Saving it

I’m meandering my way through six questions that will determine your productivity as a family physician, to wit:

1. How fast do you work and think?
2. How many problems can you manage in an hour?
3. How much time do you spend on non-paying medical activities?
4. How much do patients trust you?
5. How efficient is your collection system?
6. How much attention do you pay to coding?

This week I had occasion to divert my reading into the Journal of John Wesley, who once said, “Make all you can, save all you can, give all you can.”

This inspired a diversion from “Making It” into “Saving It,” because, of course, some day all of us will retire. And after the economic events of the past year, that may be problematic. The only people who are unconcerned work for the government and have defined benefit pension plans.

For the rest of us, intelligent saving will be more important, over the long run, than salary negotiations. So this blog is devoted to all of you who will retire on your own investments; and the younger you are, the closer you should attend.

I’m not going to tell you where to invest your money. That would imply that I am a prophet, and I’m not. There are lots of lamebrains and goofballs out there who will assume that role, and if you want to throw in your lot with them, be my guest. I’m going to stick with what is demonstrably, historically and mathematically true.

First: No financial advisor, stockbroker, or hedge fund advisor can claim, going forward, that he is going to beat the returns of an unmanaged index fund. Historically, the odds are overwhelmingly against him.

If you put a gun to my head and made me turn over my retirement funds to an individual, I would pick Warren Buffett. Everything about his investment philosophy, his demeanor, his performance and his way of life, ring true. But the Sage of Omaha won’t make any promises, and he’s having a hard time figuring out where to park his cash right now.

Second: If you invest $10,000 per year in an IRA that earns the historical average of 6 percent after inflation, and you work 40 years, you’ll have $1,750,000 (inflation-adjusted) at retirement. That ought to be enough.

Third: If you are completely unnerved by the recent shenanigans on Wall Street, be assured that you don’t have any good alternatives. Put you money in a mattress, and inflation will steal its value year by year. Buy gold, bury it in the back yard, and hope for hyperinflation? Over the long haul, that hasn’t proved to work. Real estate? That’s a hoot. Certificates of deposit? Bonds? Plan on giving up 2 percent per year, and over 40 years your retirement fund drops to $1,000,000.

Fourth: If you can’t call Vanguard or Fidelity and ask them to help you set up a SEP-IRA (it takes about 10 minutes) using index mutual funds that charge about one-tenth of one percent per year as a management fee, then you’re going to have to use a financial advisor, or worse, a stockbroker.

The stockbroker will earn a commission every time he sells you on a hot tip. The financial advisor will earn a percentage of the funds he manages. So will our Academy, if you use their investment services. If you are lucky, that will only cost you an additional 2 percent per year. See above. And if the stock market only earns 4 percent, half your earnings go to the advisor.

Here’s the only hot tip you ever ought to take: Call Vanguard or Fidelity and invest in an index fund that approximates the entire U.S. stock market, or maybe the whole world stock market. Write your check every year, and don’t pay any attention to the ups and downs of Dow Jones or Nasdaq.

Fifth: Don’t get divorced, and don’t invest in businesses started by friends or family. Trust me on those.

Here’s more good advice from John Wesley, off the subject:

“Do all the good you can,
By all the means you can,
In all the ways you can,
In all the places you can,
At all the times you can,
To all the people you can,
As long as ever you can.”

Posted at 09:47AM Apr 02, 2009 by Doug Iliff  |  Comments[0]

The lesson of Officer Krupke

The subject of this blog is how to (1) run a financially successful practice, (2) earn as much money as the anesthesiologist sitting behind the curtain thinking about his dinner plans, (3) not miss your kids’ soccer games and school plays, and (4) work 40 hours a week. All at the same time.

I can write about it because I’ve done it. My experience is that (3) and (4) are way more important than (1) and (2).

However, in the spirit of cognitive dissonance, my focus is on financial success. The reason is that the Match results are in, and once again family practice residencies attracted fewer American medical students than the year before. The extinction continues.

The reason is net income. So I return to the subject of money, the love of which is the root of all evil. While I continue to wait for the angel of charity to slash the unwarranted incomes of less challenging specialties, let’s address collection policies.

Every time I go to a medical convention, a management consultant has a couple of sessions in a noisy, curtained venue that will tell you in 45 minutes what I’m going to tell you in six words: You’ve got to dump the deadbeats.

Some of you have been brainwashed by social workers (on government payrolls, with defined-benefit retirement plans) into believing that deadbeats should be objects of mercy, not justice.

They believe, with the delinquents confronting Officer Krupke (see Stephen Sondheim, West Side Story):

“Dear kindly social worker,
They say go earn a buck.
Like be a soda jerker,
Which means like be a schumck.
It's not I'm anti-social,
I'm only anti-work.
Gloryosky! That's why I'm a jerk!”

“I’ve tried to be human about debts. Anybody who tries to make arrangements to pay, and then follows through without our badgering, will make us happy. I don’t care if your monthly payment will never retire the debt. Just don’t make us keep sending you bills. That’s all we ask.”

“Our office policies do not prevent us from forgiving debts. It is only when patients neglect to discuss arrangements with us, or fail to abide by agreements, that we terminate service for financial reasons. It simply wastes too much time to chase patients with past due bills. Our office policies do not allow for dismissal based on the patient’s type of insurance or medical needs.”

Posted at 10:46AM Mar 25, 2009 by Doug Iliff  |  Comments[10]

Trust me. I'm your doctor.

I’m meandering my way through six questions that will determine your productivity as a family physician, to wit:

1. How fast do you work and think?
2. How many problems can you manage in an hour?
3. How much time do you spend on non-paying medical activities?
4. How much do patients trust you?
5. How efficient is your collection system?
6. How much attention do you pay to coding?

I do this under the (challengeable) conviction that when family physicians have met the enemy, he is us; that we can make specialist-level incomes if we pay attention; that the bio-psycho-social model is a time waster, and caters to the lazy or lackadaisical; and that, as TransforMED discovered (in perhaps its only useful return on an investment of millions), you can’t make a living seeing 15 patients a day – unless you choose the micro practice model, and you’re willing to empty your own trash and serve as an insurance clerk part-time.

Let’s walk into a minefield: Why does it matter how much patients trust you?

When I started in family practice, I was a big believer in patient education and informed patient choice. I’ve already told you how I discovered that most patients need an ounce of willpower more than a pound of knowledge. Since I believe in Original Sin, that wasn’t a big surprise.

The big surprise was that they really wanted me to be God.

I don’t like people who think they’re God. Many CEOs are ordinary people; but when I encounter a godlike CEO, I can’t get rid of them fast enough. (“Yes, you really do need to go to the Mayo Clinic for your $3,000 annual physical.” “No, I won’t see you at 6 in the morning.”) Give me honest, hard-working, unpretentious, blue-collar folks any day.

What I found with experience was that long-winded, derriere-shielding discussions with patients about the risks and benefits of ingrown toenail removal, including death, were promptly met with “What would you do, Doc, in my situation?”

Maybe my practice is eccentric. But that’s what I’ve found. My patients want to know what I would do. That shouldn’t be confused with What Would Jesus Do. But I’ve had to get over the discomfort of answering that question honestly.

It really isn’t the same as wanting me to be God. I was exaggerating. What they are doing is trusting my judgment, which is exactly the same thing I would do in their situation. After all, if I didn’t trust the judgment of my physician, wouldn’t I choose another?

So I got over it. I don’t have a dictatorial personality (at least in person), and learning to simply be grateful for the trust I am granted makes me a lot more productive. I don’t have to listen to myself talk, unless requested. A lot of problems are handled in a lot less time.

Trust has to be earned. It takes time, and exposure. I work with an excellent PA, but I decided early on that I wasn’t going to reroute routine colds and pains to my mid-level; those encounters are trust builders.

It takes honesty, including the humility to say, “I don’t know.” Be well-informed, and shoot straight. Sincerity is important, and eye contact is important. I have seen evidence that tapping on a laptop doesn’t hamper relationships, but I don’t believe it.

Here’s a pearl: Review the chart, including labs and the last visit, before you enter the exam room. Don’t pull it out of a slot on the door; then the patient knows what you’re up to. The point is to make them think you’re smarter than you are, or at least that you care enough to devote full attention from the moment you cross the threshold.

Kathy Saradarian, a family physician with a micro practice in New Jersey, recently wrote, “The PCMH die-hards are not allies. They are so caught up in this high-tech, low-touch, doctor-manager definition that they have forgotten who we are.”

That’s the ticket. There’s the danger. And it may not pay well, either.

Posted at 09:37AM Mar 16, 2009 by Doug Iliff  |  Comments[0]

Chronicles of wasted time

To review: This blog is about financial productivity. It is directed at medical students (to give them hope regarding a career in family medicine), residents (to give them insight into the business of family medicine) and family physicians of all ages who are still learning and growing.

Posted at 10:09AM Mar 09, 2009 by Doug Iliff  |  Comments[2]

The paradoxes of open-access scheduling

When I opened my private practice in 1986, I decided that I would never fall behind my workload. As I wrote in 1998, “If you need an appointment today, you get an appointment today.” If you wanted a database physical in a week, you could get it in a week. That just seemed like common sense.

Access, I think, is the most important factor in family practice management. I’m surprised that the “medical home” folks give it so few points (9 out of 100 in the NCQA's medical home scoring system). An accessible physician is better than a smart physician, if you have to choose. For that matter, an accessible NP or PA is better today than a smart FP tomorrow.

The “open access” movement came along about 14 years later. “Advanced access” scheduling means the patient is not only seen today but by his own doctor as well. There is evidence that as the percentage of patients seeing their primary care provider rises, so do average charges. In solo practices, like mine, that percentage is very high.

Here are the paradoxes (G.K. Chesterton: “truth standing on its head”) of just-on-time medical care, as seen by someone who has been doing it for 22 years.

1. It ought to result in a lower income, due to open appointments. But it doesn’t. I won’t review the theories why, but it works.

2. It ought to result in scheduling chaos, but it doesn’t. Patients never panic. They know they can be seen when they need to be seen, so they don’t reserve an appointment 10 days down the line in case they are still coughing – and then no-show when the cough is gone.

3. It ought to result in spoiled, dependent patients who call the doctor at the first hint of trouble, but it doesn’t. My home phone is in the book. Patients can reach me 24/7 through a live operator (never a phone tree). They just don’t. I average one page every other night. When patients know they can interrupt your life at any time, they respect your privacy.

4. It ought to result in a healthier population of patients, and it does. In a recent audit of type-2 diabetics treated for over a year in my practice, 40 percent had an A1C less than 7 at diagnosis. But your insurers will decide that this is a result of good luck or covert selection bias, rather than quality care delivered on time.

5. It ought to attract patients to your practice, and it does. That ought to prompt other area practices losing those patients to shape up and quit delaying physical exams for six months. But it doesn’t. I guess working off that backlog is too much trouble.

6. It ought to save your nurses time on the phone. But it doesn’t, because when your patients can’t get through to their neurologist, surgeon, dentist or veterinarian, they call you to find out what’s going on. (Refuse, politely.)

Take-home lesson: Do it right, from the start.

Posted at 02:58PM Feb 27, 2009 by Doug Iliff  |  Comments[2]