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]