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." 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.
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).
Posted at 01:18PM Jan 16, 2009 by Doug Iliff | Comments[1]
CAUTION! Read and follow all safety instructions
On December 3rd I listed six factors that figured into financial productivity. No. 2 was “How many problems can you manage in an hour?” This blog is about one thing you can do that will enable you to manage more problems in an hour. It doesn’t involve a behavioral, personality or intelligence change, so I know it is within reach of every family physician. Unfortunately, it runs counter to the fundamental, gut-level belief system of most docs in academic medicine, so I’m going to try to approach it delicately. Residents pay attention. This is a voice from the trenches. It won’t be news to veterans of private practice.
First, a four-item test:
Item one: This weekend I replaced 600 tiny bulbs on a long strand of greenery draping the stairs in my log home. I removed three small instruction tags from each of the strands, as well as a brochure from each box, which warns in large print, SAVE THESE INSTRUCTIONS. Unlike mattress tags, it did not warn of federal penalties for unauthorized removal.
For the first time in my life – I kid you not – I read these instructions. I now have been informed, for the first time, that I should not cover the lamps with cloth or paper. There are lots of other things I shouldn’t do, too, but I won’t bore you.
Item two: A new report notes, "the nation’s office-based system of primary care doctors is ill-equipped to deal with many health needs of adolescents, particularly issues related to behavioral and developmental issues. ... The 15-minute office visit offers little chance for probing teen concerns about their bodies and what they’re doing with them.”
Item three: I just heard during a third-quarter ad break, for the 100th time, that patients using Viagra should call their doctor if they get an erection lasting longer than four hours.
Item four: Mrs. X just became the 5,000th patient in my career to ask me for a diet.
Here’s the test: What do these four items have in common?
Here’s the answer: All of them involve a quasi-religious faith in the power of education to change behavior. In fact, there is good evidence that education can increase knowledge; some evidence, over a long period of time, that it can change attitudes; and very little evidence that it can change behavior.
There are some things that our patients really, really need to know. Those essential things can get lost in a wash of irrelevant information. The perfect is truly the enemy of the good. Maybe the good is the enemy of the mediocre.
I read the instruction manual on my chain saw cover to cover. I don’t (normally) read the instruction manual for Christmas lights or toasters or lamps. It would clutter my mind, which is already cluttered enough.
I don’t probe the minds of my adolescent patients for aberrant thought patterns. I did that, some, with my five kids, and there was never much payoff. If I sense weirdness, or if a kid wants to talk, they’ll find me open, honest and non-judgmental.
I tried to find out what to do if my patient has a four-hour erection. The PDR isn’t helpful; as best I can tell, they need an emergency operation by a urologist, or something bad will happen (gangrene?). If I ever get the call, I’d probably recommend soaking in ice water.
As a rookie FP, I printed up diet plans. No more. Now I just give a quick quiz, which I’m intending to research and publish in Annals of Family Medicine. It goes like this: Which is better for you, french fries or green beans? If they choose fries, I send them to Barnes and Noble, which has 100 linear feet devoted to diet education. If they choose beans, I send them to Weight Watchers. They need a little instruction, and a lot of accountability.
Don’t throw out the baby with the bath water, now. I’m not saying education is worthless; I’m saying you have to apply it with discretion, like antibiotics. Keep your powder dry; wait till you see the whites of their eyes; discern the teachable moment. Otherwise, save your breath, and your time.
I did an internship in psychiatry. I was the behavioral science coordinator on the faculty of a family practice residency program. I’m married to one of the best teachers in my city. I started a K-12 school in 1980 that produces National Merit finalists at ten times the national average. I edited a textbook for a two-year Great Ideas seminar. I’m not cynical about the value of education, and I’m not a virgin when it comes to the bio-psycho-social approach to family medicine – or life.
Concentrate on the bio. Trust me: You’ll address more problems, do more good, waste less time and make more money.
Now let me offer some perspective on what I have written.
1. Dr. Johnson (Samuel, not an MD) observed that men more often need to be reminded than instructed. That’s something you whippersnappers should bear in mind. When you teach, act like it is a reminder. It usually is, and it is less offensive than instruction.
2. The written word is a less threatening way to teach than the spoken word, just as the spoken word to a group (a sermon or a speech) is less threatening than a one-on-one conference. So make use of handouts, or (better yet) write your own. I give new patients a whole notebook of instructions on a variety of topics, photocopied from a dot-matrix original. It’s my way of saying that most medical truths go out of date very slowly.
3. Non-physician colleagues – whose time is less valuable from a monetary standpoint, and whose training and experience has specially equipped them – will often do a better job of depth education than I can. Agencies like Weight Watchers, diabetes learning centers or local gyms may have a miserable success rate, but it’s better than mine.
4. Last week a friend died unexpectedly, and prematurely. He was one of my long-term “knuckleheads,” an affectionate term reserved for patients who have persistently refused my attempts to systematically search for, and treat, preventable conditions. He needn’t have died. Is there something I could have said, or done, to persuade him to pay attention? That’s what haunts every veteran family physician, and it tempers my advice about wasting valuable time on face-to-face instruction.
Posted at 10:03AM Jan 05, 2009 by Doug Iliff | Comments[1]
