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"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]