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]