PCMH meets the real world

The “preliminary” report on TransforMED is out, and it isn’t pretty. It also isn’t much different than Evaluators’ Report #5 from over a year ago. If you’ve never heard of the Patient-Centered Medical Home (PCMH) or TransforMED, I’m not going to help you today. See old blogs here and here, which will link you to the big picture. 

First, some perspective.   

The AAFP deserves a lot of credit for at least three reasons. First, it recognized several years ago that the specialty was in trouble and came up with an action plan. Second, it put its money where its mouth was, to the tune of $8 million, and funded an experiment to see if its plan was workable. Third, when the results weren’t pretty (see below), it didn’t flush them, and we know that that has proved to be a big problem in medical research. 

The AAFP also deserves three Bronx cheers. First, it has tirelessly promoted the PCMH model (as defined by TransforMED) to its membership without having the evidence to back it up. Second, it is allowing TransforMED to sell its non-evidence-based services to members. Third, it is failing to provide a forum for the vigorous debate that needs to take place immediately. 

What follows below is a cut-and-paste summary of the “Initial Lessons” from the researchers' report with my brief commentary in italics. 

Rush to Judgment; Unintended Consequences; Hold Your Horses: "The PCMH represents an innovative and exciting national conversation that melds core primary care principles, relationship-centered patient care, reimbursement reform, new information technology, and the chronic care model. Unfortunately, the rush to demonstrate operational and financial feasibility of the PCMH, proceeding apace with the recognition process of the National Committee for Quality Assurance (NCQA), risks premature closure of the larger PCMH conversations and potentially stifles evolution of the PCMH to meet important patient, practice, and system needs. … The pressure toward widespread adoption of this model is gaining momentum so rapidly that we feel compelled to share our observations and summarize the early process-evaluation lessons. … The NCQA has taken the lead in defining some essential components and creating a 3-tiered, implementation process for recognizing a PCMH. We fear the details of the recognition process may have reached premature closure, however, before the rich data have emerged from the NDP and other current demonstrations."

A one-size-fits-all approach is usually a bad idea, and TransforMED has proved it. The PCMH is ideally suited to large practices where bureaucracy has created layers of separation between providers and patients. For small group or solo practices, which constitute the bulk of the AAFP membership, the PCMH prescriptions are an insult. (If you’re not insulted, take the TransforMED Medical Home IQ test. You will be.) The authors are pleading for a re-evaluation of the concept. A good starting point would be the proposal by well-known researcher Barbara Starfield, MD, MPH.

Demoralization; Emotional Exhaustion; Financial Disaster: "In the process of working with these practices, our team has seen the day-to-day reality of changing community-based practices into the current idealized model of the PCMH. We have already learned enough from the NDP to identify some potentially dangerous red flags fluttering over the demonstrations just getting underway. Our early analysis raises concerns that current demonstration designs seriously underestimate the magnitude and time frame for the required changes, overestimate the readiness and expectations of information technology, and are seriously undercapitalized. We fear that with current assumptions, many demonstrations place participating practices at substantial risk and may jeopardize the evolution of the PCMH as unrealistic expectations set up demonstrations and evaluations for failure. … All the well-supported NDP-facilitated practices were challenged financially by the project." 

At the AAFP's annual meeting in Chicago two years ago I buttonholed Terry McGeeney, TransforMED's president and CEO, and Jim Arend, its CFO and practice facilitator, and asked them about the lack of “before and after” financial data for the participating practices. Their response: “It’s too hard to gather.” So now we know from the researchers' report that the practices were “financially challenged,” but we have no idea how badly. Somebody in authority needs to know what is going on.

Loss of Focus; Perils of Transformative Change: "Most current practice models are designed to enhance physician workflow. The PCMH should be designed to enhance the patient experience. This shift requires a transformation, not an incremental change. … The work is daunting and exhausting and occurring in practices that already felt as if they were running as fast as they could. This type of transformative change, if done too fast, can damage practices and often result in staff burnout, turnover, and financial distress. … Do not be surprised if the situation seems worse after the first 6 months to a year; the experience of benefits often takes at least 2 years."  

In a one-horse practice, “the patient experience” is right in your mug all day long. If you miss it, you’re too dense to profit from the PCMH experience anyway. In a big group practice, if you can hold your breath for two years you might be OK, except that all of the TransforMED practices were heavily subsidized financially; so while you’re holding your breath, you’d better be applying for Robert Wood Johnson Foundation grants. And get ready to suffer the consequences of staff burnout and turnover.

EMR Idolatry: "The hodgepodge of information technology marketed to primary care practices resembles more a pile of jigsaw pieces than components of an integrated and interoperable system. … For example, it is possible and sometimes preferable to implement e-prescribing, local hospital system connections, evidence at the point of care, disease registries, and interactive patient Web portals without an EMR. … New Web-based technologies, electronic clinical information systems, and telecommunications are finally nearing accessibility and utility for both health systems and primary care practices. … Future PCMH recognition and certification processes should focus more on patient-centered attributes and the proven, valuable key features of primary care than on the disease management and information technology features of the PCMH." 

Challenges to the politically expedient push for EMRs are now rolling in from all directions. If you already have one, keep and improve it; if you’re starting practice, research and buy one. If you’re well established, an EMR is not going to make you more money, and will cost you a fortune in purchase, maintenance and lost productivity. 

Productivity and Efficiency: "We should be wary of industrial-like schemes and excessive use of the language of productivity and efficiency. Primary care, like healthy food, works best at a local and personal level."

There are two metaphors for productivity: the factory and the farm. To a good family physician, you cannot view your patients as widgets rolling off an assembly line; they are crops to be nurtured. You can’t hurry the growth of a plant, but you can nurture it more productively. That’s the metaphor this blog is about. On the other hand, the PCMH is more like an industrial operation than anything else; and a bad one, to boot. TransforMED proves it. Now it’s time to move on to greener pastures.

Posted at 10:13AM Jun 11, 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]

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]