Highs and lows of the AAFP convention

Every two years I go to the annual AAFP convention, almost without fail in my long career. This gives me the benefit of perspective, which I will now pass along.

This year’s event in Boston was exceptional. If you’ve never gone, you should. It might become addictive.

Since the Chicago convention in 2007, there has been a major change in format. Previously there were “headline” presentations in a huge hall, with a confusing variety of other talks in several formats – lectures, demonstrations, conversations, etc. The schedule was so overlapping and confusing that I sometimes missed events I wanted to hear, or could only work in half of the presentation.

All that chaos was junked in 2009, hopefully for good. All the events, except for fee workshops, were one hour in length with 30 minutes between. Many were repeated, so I didn’t have to wish I could be in two places at one time. The half-hour intervals provided plenty of time to breeze in and out of the exhibition hall, if I wanted to, which I didn’t. But that’s just me, this year. In the past I enjoyed the dog-and-pony shows.

For the first time I stayed at the hotel attached to the convention. You have to book early. The advantage was the ability to easily stroll down to the optional breakfast and dinner meetings, which were useful and also provided a free meal – a good one, in all cases. I could even get in a quick workout in the exercise room between lectures, which is impossible if you're using the shuttle buses.

The result was that I arrived Wednesday around noon, left Saturday morning after running in the 5K race and squeezing in one more lecture, and accumulated 40 hours of group CME credit. Many of the presentations gave 2-for-1 hourly credit because they were “evidence-based,” even if they weren’t really (listen to the popular "Am I Hungry?" diet talk, and you’ll see what I mean). That’s a bargain.

The presenters are uniformly qualified and useful. Once upon a time most of them were experts in other specialties. Now we've grown our own, and they think like family physicians. When I sit down for the lecture, all I want to know is if I should be doing something different. My habits are well established; that's the advantage of being a veteran. When a family doc presents evidence that I should change a habit, I usually do. The result is that I leave the convention with a few things that I want to change back home. 

So kudos to the Academy. The annual meeting is as good as it gets.

Now for the downside.

I missed the annual town-hall meeting with AAFP leadership, which apparently happened during the early part of the week when only the poo-bahs were gathered for their Order of the Moose convention. [Editor's note: This is referring to the Congress of Delegates.] You can tell them by their suits and the decorations on their assembly badges, which make them look like South American military dictators.  

Although I poke fun (partly because of my aversion to committee meetings) and although their aspirations do not make my heart glow, I can appreciate their willingness to be active in the political process – unless the political process is all they do, because they work in academic centers. In that case, it's a paid vacation.

I just think we're overdue for an honest, no-holds-barred discussion about the direction of our dying specialty. Enough with the happy faces and glitzy promotions. We need a town-hall meeting that isn't buried in safe territory and that offers members not only a chance to speak but also a chance to cross-examine perfunctory answers.

The president of the Academy came to speak at the Kansas meeting this summer on the patient-centered medical home. I asked those in charge if we could make it a debate. The answer was no. I could, however, drive to Wichita to ask one question at the town-hall meeting. That was too much driving to get one answer.

As I was taking cover in the Boston chill prior to the Saturday race, my ear was bent by a political aspirant from the midwest. He had lost his bid for a seat on the board, and he was lamenting that no one represented people who really ran full-time family practices.  

I don’t know if that’s true. But the few folks like him who are willing to make the sacrifice – because their service comes right out of the bottom line – are the salvation of the specialty, if it can be saved.

Posted at 01:59PM Oct 29, 2009 by Doug Iliff  |  Comments[0]

The economics of the health care industry

On Sept. 25, I referred readers to an article I wrote on the health care debate for Front Porch Republic. It was an overview, and as such made no attempt to provide background material supporting or clarifying my views. It sparked a healthy debate, revealing to me how woefully ignorant even intelligent Americans are about the economics of our profession.  

Following a recommendation from reader Dan Schmidt, I just read a long article from The Atlantic entitled “How American Health Care Killed My Father.” Don’t be put off by the title; it isn’t a rant. Rather, it is as close to perfection as anything I’ve ever read on the subject of health care economics. Every point and every example rings true to my experience.

If you have any interest in the subject, which will determine the future of our profession and now controls 18 percent of our economy, please – read this article.  

When you do, you’ll realize the futility of any attempts to shoulder family medicine to the front of the federal trough. Oh, I know; at the moment, current legislation will give me an 8 percent raise in RVU compensation next year, probably to be snatched away the year after. Instead, our specialty's leaders should be the voice in the wilderness crying for a free market in health care services, where we would quickly demonstrate our indispensability.

Sometimes it takes a famine for people to appreciate farmers.

Fascinating excerpt: “Let’s say you’re a 22-year-old single employee at my company today, starting out at a $30,000 annual salary. Let’s assume you’ll get married in six years, support two children for 20 years, retire at 65, and die at 80. Now let’s make a crazy assumption: insurance premiums, Medicare taxes and premiums, and out-of-pocket costs will grow no faster than your earnings – say, 3 percent a year. By the end of your working days, your annual salary will be up to $107,000. And over your lifetime, you and your employer together will have paid $1.77 million for your family’s health care. $1.77 million! And that’s only after assuming the taming of costs! In recent years, health-care costs have actually grown 2 to 3 percent faster than the economy. If that continues, your 22-year-old self is looking at an additional $2 million or so in expenses over your lifetime — roughly $4 million in total.”

And on the other hand, we have a Wall Street Journal lead editorial that can’t discern its terminal colon from a terrestrial excavation.

The editors are upset that the Senate Finance Committee bill authored by Democrat Max Baucus would increase primary care compensation at the expense of specialists. This is an assault on the free market, they opine, blissfully unaware that it was federal regulators who created the income disparities that Sen. Baucus is attempting to scale back.

Tell you what: Sometimes the ignorance of educated friends makes me want to weep.  

However, I’m sure the AAFP leadership has ripped off a stunning riposte to the Journal, which is always willing to print a letter from the loyal opposition. I’ll let you know how it turns out next week.

Posted at 12:30PM Oct 12, 2009 by Doug Iliff  |  Comments[3]

RVU ramblings

In the “Practice Pearls” section of the latest Family Practice Management, Kent Moore cites the Medical Group Management Association (which gives us the more reliable health statistics in America) on the average work RVUs generated by family physicians not doing obstetrics in 2007.

After a sentence like that, take a deep breath. The figure is 4,600.

That got me wondering how many RVUs I generate per year, since I’m often prattling on about productivity. Right on time, Blue Cross sent me the rolling report on my efforts for the last three years, reproduced here:



If you divide my RVUs for this three-year period by three, and divide by 0.85 (Blue Cross is about 85 percent of my business), you get roughly 8,000. Admittedly, this includes about 20 obstetrical deliveries per year, which is hardly a back-breaking number. Remember, too, that including obstetrics (since I have given the hospitalists my inpatient work) I only work about 40 hours per week, 220 days per year, with about eight weeks of holidays and vacations.

I’m talking to medical students and family practice residents here. You know, those of you who told the Admissions Committee you wanted to go into primary care, or actually chose to do so. Now you’re wondering if it’s a viable choice.

Here are random thought bearing on that choice.

1. If I can generate 8,000 RVUs per year working the same hours as a state employee but enjoying the stimulation of intellectual challenge and terrific personal relationships, avoiding the administrative burden of the patient centered medical home while providing a place where every patient knows every one of my employees and vice versa, and while earning as much money as the average cardiothoracic surgeon, what’s not to love about this specialty?

2. What’s wrong with the practices of all those other family physicians?

3. In his blog, Kent Moore also asks why (based on a Health Affairs article) a family physician would choose to spend an average of $65,000 to comply with the diktats of insurance companies. My answer: That’s half of my expenditure for salaries, so it must be nuts. Where do people get these figures? My nurses must spend at least 90 percent of their time doing meaningful service for my patients.

4. I’ve done my level best to charge Blue Cross for every legitimate 99214 or procedure (thank you, Kent and Cindy, for an excellent column). Still, I keep proving to be 18 percent more efficient than my peers – the ones, I assume, doing only 60 percent as much work as I do. How can this be?

5. I wrote about an old friend and an old student in a recent blog post. The former quit doing OB 10 years ago and is coasting toward retirement with an aging patient panel; the latter doesn’t plan to do OB at all, which is increasingly common among FP residents. I know that OB can be inconvenient, and scary. In the last 24 hours I did a delivery at 3:30 a.m. and a vacuum extraction at 4:30 p.m (followed by a shoulder dystocia resulting in a fourth-degree laceration requiring careful repair). My question: If family physicians give up OB, and therefore a preponderance of potential pediatrics, why choose family practice over med-peds?

As I draw near the end of a year’s worth of blogs, I understand much better why I am successful, and what other family physicians need to do to be successful.  

But I am losing confidence that family practice will survive.

Posted at 02:19PM Oct 02, 2009 by Doug Iliff  |  Comments[3]