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[2]

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[5]

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]

Promise and peril of being TransforMED-II

As promised in my previous post, now it’s time to find the pony in the horse manure of the Patient-Centered Medical Home (PCMH) and TransforMed.

I’m going to follow the lead of Dr. John Rogers (read his article here), who divides the Joint Principles of the PCMH into two categories: “practice infrastructure principles” and “patient care principles.” For the sake of clarity and economy, I’m going to redefine those as “inputs” and “outcomes.”

Outcomes are the objective results that measure the quality of our care. They are based on medical evidence, and change as research produces better evidence. All of us should want to know the average HgA1c of our diabetics, the average blood pressure of our hypertensives, and the average LDL of our hyperlipidemics. That’s how we measure quality of care, and that’s how we measure improvement in our practice habits.

Inputs are the methods and practices that produce the outcomes. Inputs exist to serve outcomes, and only to serve outcomes; inputs are not an end in themselves. Perhaps we promote huddle groups every morning to focus our mission, or maybe our office is so small that a freewheeling huddle occurs all day long. Perhaps our personalities are best suited to one-on-one patient instruction or group instruction, or writing patient education materials or printing materials from the Web in the exam room.

Outcomes are few and objective and measurable. Inputs are legion – as legion as family physicians and the varieties of practice experience.

My first experience with this dichotomy came when I started a private school almost 30 years ago. I investigated state accreditation, assuming that accreditation would focus on outcomes: standardized test scores, fitness tests or contests in math, spelling or history.

Boy, was I naive.

Accreditation, in those days, was based entirely on inputs. As shorthand, I came to refer to the standards as the “urinals per student ratio.” There were lots and lots of ratios, but if you get that picture in your mind, you get state accreditation. (With the advent of No Child Left Behind, things have changed.)

Why, if the students at your school were excelling on performance measures, would it matter whether you had 10 students for every teacher or 30? Why, if your average HgA1c is 6.5, would it matter if you instructed your patients one-on-one or in a group?

Beats the hell out of me, but a bureaucrat understands.

Inside the mind of every bureaucrat operates what Charles Dickens called the “circumlocution office,” where paperwork passes from box to box, desk to desk, hand to hand, until it arrives back at its origination, extensively annotated but essentially unchanged. The bureaucratic mind is what Thomas Friedman calls “sand in the gears.” It produces friction, heat and noise, and this is mistaken for work.

Back to elementary physics: Work, you remember, equals force times distance. If there is no movement, there is no work. There may be buckets of sweat, bulging muscles and engorged veins – but if it doesn’t move, no work has been done.

Now we’re ready to understand the problems and perils of TransforMed.

If you read Dr. Rogers' article several times, you see that what worries him is that TransforMed is all sweat and no work. It is thick with inputs – in fact, it is clear from the TransforMed Evaluators’ Report that the TransforMed inputs are positively exhausting to the people trying to run a family practice – and thin on outcomes.

Let me add to Dr. Rogers’ quotations from the Evaluators’ Report. Italics are my translation.

“Implementing the technical pieces of the TransforMed model of care has been enormously difficult, requiring heroic efforts and faith on the part of the practices.” It may not have been door-to-door in Baghdad or Paul on the road to Damascus, but for the folks in the physicians’ office, it looked like blood in the streets. And that was with facilitators working for free, and discounted equipment and software.

“Despite this assistance, implementation of the model has strained even these exemplar practices, because change is demanding and rife with unexpected setbacks. … An important role of the facilitator has been helping the practices stay on course and manage change fatigue.” It was all we could do to keep herding these exhausted sheep toward the Promised Land. A few died along the way.

“Successful implementation of new model components does not automatically lead to the relationship-centered organization, necessary for sustained change and learning. … For the most part, practices that are relationship centered were so in the beginning.” No matter how much we hectored, badgered and cajoled, the damn zebras refused to change their stripes.

“Rather than acquiring specific details about a practice’s finances, this form is intended to measure the practice’s overall knowledge and understanding of their finances. It is a subtle difference …” between knowing whether the New Model made us more money per hour versus understanding the philosophy of practice finance without seeing the books or depositing the checks.

“Much credit goes to the NDP facilitators and their tireless effort to collect comprehensive financial data from the practices. However, the data which have emerged will simply not permit analysis of the financial implications of implementing either the components of or the total TransforMed model.” Though we tirelessly worked to collect the information which every MD files with the IRS every year, we failed. So in return for your blood, sweat, toil and tears, you will have the undying appreciation of Secretary Daschle and President Obama. Don’t worry about catching up with the cardiologists in income.

“… implementing components of the original TransforMed model does not automatically lead to a patient-centered medical home. … this focus on technical innovations has competed with efforts to address relationship-centered patient care within the practice.” Tapping on a keyboard rather than making eye contact is NOT interpreted as attentive or caring by patients. All those damned Inputs competed with our ability to achieve Outcomes.

“Since there may be a time lag between implementation of TransforMed components and patients’ perceptions, the final patient survey will be delayed as long as possible.” We’re going to drag our feet, and hope for a miracle.

“TransforMed is a knowledge company. The most critical ingredient for its success is knowledge capital. Other additions, such as tailored marketing and strategic alignments, may be very helpful as TransforMed goes forward as a commercial enterprise.” We didn’t learn anything useful, but if we talk the talk, hire the right advertising agency, and position ourselves for a buyout, we may be able to sell it to family physicians!

The fundamental flaw in TransforMed is that, in pursuit of the Patient Centered Medical Home, it is rigid about Inputs and fuzzy about Outcomes, rather than vice-versa.

Let me say that again. TransforMed should have focused like a laser beam on Outcomes, both medical and financial, and should have been as flexible as silly putty regarding Inputs. Instead, a great concept was co-opted by the bureaucratic mindset.

You don’t have to take my word for it. Subject yourself to several modules of TransforMed's Medical Home IQ self-test. There is some really good stuff in there that challenges my practice and we all ought to strive for. But there is a whole lot more horse manure.

Here’s an example. The introduction to the Practice Management module makes this over-the-top proclamation: “the practice management module assesses the operational tools and processes that must be in place and functional for sustaining and growing the practice.”

Well, I’ve had a thriving practice in a very competitive environment for 22 years, and I only scored 29 out of 64. I guess I'll have to wait and see if anyone shows up Monday morning.

When the module asks about my accounts receivable aging, it is requiring that I know critical Outcome data. When it asks if I have a documented business plan [“The plan document describes the Mission and Vision of the practice and the values on which the practice is based. The plan provides (at a minimum) a description of the practice and the services provided, the market in which the practice exists, the financial background, management structure and personnel, strategic goals and objectives for the future and the resources needed to accomplish these goals and objectives, and a risk analysis”] it is requiring that I manufacture an Input which, for me, would be a never-again-to-be-viewed waste of time. It might be critical for someone else; that’s what I mean by Inputs needing to be flexible.

I hope you know how to swim.

Posted at 03:56PM Feb 02, 2009 by Doug Iliff  |  Comments[4]

Promise and peril of being TransforMED

Sometimes the title says it all. Such is a recent article by Dr. John Rogers, a recent past president of the Society of Teachers of Family Medicine, writing in The Journal of the American Board of Family Medicine:  "The Patient-Centered Medical Home Movement – Promise and Peril for Family Medicine."

My next two blog entries will depart from my avowed subject (making money like a specialist without a change of politicians or health care policy) to examine the risks and benefits of the PCMH, specifically as promoted by the National Demonstration Project (NDP) of the American Academy of Family Physicians (AAFP) through its LLC, TransforMED (TFM).

As we contemplate the GDP for FY2009 we must remember that TFM LLC may adversely impact the net revenue (NR) of AAFP, leaving the NDP high and dry. This may be a problem for both NCQA and the PPC-PCMH Recognition Program (PPC-PCMH/RP), which means the P4 initiative goes right down the rat hole.

That pretty much says it all for the professors in my audience. The rest is directed to hoi polloi who never served in the acronym-larded, jargon-infested swamps of the U.S. Army or academic family medicine. They may determine how the rest of us will live out our careers.

This isn’t for students or residents, either. You will of course be fully up-to-speed on electronic records coming out of your training and will use them starting with patient #1, as you should.

But for all of you fellow war-horses in the practice of family medicine, under the illusion that you are providing a medical home for your many established patients, the following will be a translation in plain English. I’m going to go get a beer.

There. Here we go.

Primary care is dying. In the words of Dr. Johnson, this has powerfully concentrated the minds of the big four primary care organizations: the AAFP, the American Osteopathic Association, the American Academy of Pediatrics and the American College of Physicians.

Their response was the Patient Centered Medical Home, a great concept because it captures the essence of primary care. Robert Frost once wrote that home is the place where, when you have to go there, they have to take you in. That’s what we are.

The AAFP then did something bold and beautiful. They created an expensive experiment, the National Demonstration Project, to drastically overhaul volunteer practices into PCMHs. TransforMED is the agency created by the AAFP to implement this experiment.

What is the definition of a PCMH? It’s pretty complex, involving a number of elements. The primary care specialties supported the National Center for Quality Assurance (NCQA), an organization dedicated to defining and measuring quality heath care, in developing a set of standards (available here) for the Medical Home.

There are 30 discrete elements, 10 of which are “must passes.” Practitioners can aspire to one of three levels (I-III). Level I requires 5 of the 10 must pass elements (“Uses paper or electronic charting tools to organize clinical information”). Any of us can achieve Level I without breaking a sweat. Levels II and III, however, require all 10 must pass elements and points from the NCQA schema.

How difficult is it to achieve the upper two levels? Given the fact that I use electronic prescribing and have bureaucratic BS-ing experience, I could make Level II by next week. Level III is virtually impossible without a full-fledged electronic health record.

What difference does it make? Nobody knows. The primary care organizations are using the Medical Home as a public relations or “branding” exercise to capture the political imagination of Poo-Bahs in Washington. I think it’s great, for that purpose. The challenge is to wrest control of the money levers away from the specialists, who give America mediocre results for an astounding price, and who are sucking the blood out of primary care.

Now we get to the problems.

If you run an experiment, what happens if it fails? Do you publish the results, or quietly slip your journals into the shredder? We all know what generally happens. Positive results get published, negative results get shredded, and clinicians get confused.

When the AAFP and TransforMED (an independent, fully-owned LLC subsidiary) set up the National Demonstration Project, they went “all in.” The subject practices were subjected to the Full Monty, the full-court press of transformations. You gotta admire their guts.

What were the results? The latest Evaluators’ Report (#5) is dated Feb. 5, 2008. No kidding. Almost a year ago.

So I emailed Terry McGeeney, the CEO of TransforMED, and Jim Arend, the financial guru. I trust them, and I like them, and so I thought I might get readers a heads-up. Not to be. Terry informed me that the results were almost compiled and would be going to press (hopefully in the Annals of Family Medicine) in late spring. He also noted that no less than five (5) academic departments of separate institutions, headed by Carlos Jaen of the University of Texas, were involved in the production.

Since I’ve been a member of the world’s largest HMO (U.S. Army) and a faculty member and have worked through the peer-review process before being published, allow me a prediction: Don’t look for TransforMED results in 2009.

What we have is the Evaluators’ Report. It isn’t pretty. Even with modest spin control, it is clear that being TransforMED was a very painful experience for the subject practices.

However, if you go to the TransforMED Web site, what you see is all butterflies and flowers. The letters from subject practices are uniformly positive. Furthermore, the services of TransforMED facilitators are for sale.

On Oct. 29, I wrote that much of this New Model stuff was horse manure, but there must be a pony in there somewhere.

Next time we’ll try to sort the manure from the pony.

Posted at 01:18PM Jan 16, 2009 by Doug Iliff  |  Comments[1]