Family Medicine Training:
Time to Be Counterculture
*Again*
Thomas L. Stern Lecture
RAP April 3, 2006
Bob Phillips
The Robert Graham Center
Policy Studies in Family Medicine and Primary
Care
Our Discussion Today
The Toxic Environment
Evolve or Die
„
„
„
The Toxic Environment
2005 health spending
$1.9 trillion
($1,900,000,000,000)
$6,700 per person
$2000-$4600 1980-2000 (adjusted to 2000)
„
Functional division of the AAFP
Editorial Independence
Mission: To bring an evidenceevidence-based
perspective of family medicine and primary
care to policy deliberations
Purposefully place in Washington, DC
The Toxic Environment
Too much money of a good thing
Fertilizer in the Gulf & Money in Healthcare
New Models of Practice
Testing the Model—
Model—A Role for Residencies
Training to the Future—
Future—Can’t get there
without you!
Be Counterculture Again
Levee Breach – in Crisis, Opportunity
„
Just a Word about the
Robert Graham Center
NutrientNutrient-rich discharge from
Mississippi causes algae
blooms that suck the
oxygen out of the water –a
Dead Zone
The Toxic Environment
16% of the US Economy
From 2000 – 2005 healthcare devoured nearly
25% of our Economic Growth
$133 billion increase over 2004
Alan Sager, Ph.D. and Deborah Socolar, M.P.H.
1
The Toxic Environment
The Toxic Environment
Health
Education
Defense
Healthcare’s major role has become Economic Engine
It is toxic to primary care and to population health
The Toxic Environment
US Health Expenditures to 2015
16.5%
15%
20%
$2 trillion
10%
5%
0%
19
93
20
02
0
20
3
0
20
4
05
20
06
20
20
10
20
15
Year
NHE as percent of GDP
National Health Expenditure
Private funds
Public funds
better------Primary care score ranking-------worse
0
Healthcare Outcomes
Rank*
$4 trillion
20%
1
2
3
4
5
6
7
8
9
10
11
12
0
1
2
3
4
5
6
7
UK
UK
Netherlands
NTH/DK
Denmark
Sweden
SWE
SP
Spain
Australia
AUS
Finland
FIN
Canada
Belgium
GER
8
Germany
9
United
States
10
*Rank based on patient satisfaction, expenditures per person,
14 health indicators, and medications per person
Toxic to Patients
Annual Family Health Insurance Premiums Compared to Annual Household Income
(Actual 1996-2002; Projected 2003-2025)
Toxic to Patients
“Never has so much, bought so little, for so few”
$100,000
$90,000
$80,000
$70,000
$60,000
Median
Household
Income
% Uninsured
$50,000
$40,000
$30,000
Average Family
Premium
$20,000
$10,000
Health
% GDP
$19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
20
16
20
17
20
18
20
19
20
20
20
21
20
22
20
23
20
24
20
25
Percent GDP
Doesn’t buy better outcomes
$4,500
$4,000
$3,500
$3,000
$2,500
$2,000
$1,500
$1,000
$500
$0
Spending (Billions)
25%
Average Household Income
Average Family Premium
2
The Toxic Environment
Future of Family Medicine
“Unless there are changes in the broader health
care system and within the specialty, the position
of family medicine in the United States may be
untenable in a 1010-20 year time frame”
Does Family Medicine Still Matter?
Despite being just 13% of the physician
workforce, family physicians are where
most Americans turn:
„ Most named usual source of care
„ Most reliedrelied-upon by healthcare safety
net
„ Distribute like the population
Evolution and FoFM
New Model of Practice – based on a
relationshiprelationship-centered personal medical home
Hypothesis:
Even within the constraints of the current
flawed health care system,
system, there are great
opportunities for family physicians to redesign
their models of practice to better serve patients
while achieving greater economic success
Evolve or Die
We are Highly Valued, FoFM
Future of Family Medicine Project—
Project—what
we learned
„
People value what family medicine offers
even thought they don’t know what family medicine
means
even though we don’t deliver consistently
„
Subspecialists value what we do
New Model of Practice
Not achievable absent EHR and
asynchronous communication tools
A reliable basket of services, possibly
augmented
A MultiMulti-disciplinary team, configured
differently –for functions not finances
Scalable-one size unlikely to fit all
Scalable--one
3
New Model
Doctor centercenter-stage
----
Patient centercenter-stage
Barriers to access
----
Open access
Paper records
----
EHR
Care often fragmented ---Unpredictable services ----
Care is integrated
Defined, reliable
package
Individual patients
Individual and
population
----
New Model
Visits organize care
Quality is assumed
-------
Safety assumed
Doctor provides care
OneOne-onon-one visits
----------
Knowledge held close ----
Care is asynchronous
Quality measured &
improved
Safety systematic
Team provides care
Individual & Group
visits
Knowledge shared,
produced
Call for Counterculture
The New Model is
Counterculture!
We know how to do that
“Primary care education must be
revitalized, with an emphasis on new
delivery models and training in sites that
deliver excellent primary care”
--The
--The Future of Primary Care
Showstack,
Showstack, Rothman, Hassmiller Eds,
Eds, 2004
Call for Counterculture
New Model and Residencies
Keystone III: the role of family medicine in a
changing healthcare environment, 2001
“We should model and provide training in
aspects of improved systems of primary
care (list many FFM New Model
elements)”
'learning lab'
what works and what doesn't when it comes
to implementing change in different
practice environments
Will include residency programs
More to come about other opportunities for
residencies!
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Why You
Matter
Why You
Matter
Footprint of the
University of Florida
residency program
in Jacksonville
Footprint of the
Mercer residency
program
Personal Medical Home
Training for the New Model
Information Systems
Access to Care
„
Patient-centered care
TransforMED
Access to Information
- Website
- Lab results online
- Lab results phone
- Nurse line
TeamTeam-based care, continuous QI, practice information
management and mastery, population & community
health, reliably delivering a basket of services,
research in practice, using decisiondecision-support tools
while delivering care
Redesigned Offices
- Optimized patient flow
- Facility redesign
- Idealized offices (options)
- Group visit space
- Optimized space use
- Multiple venue
app’t scheduling
- Open Access Scheduling
- Access to all
- Call coverage
- E-visits (encrypted)
Model
of care
Quality and Safety
- Best practices
- PEP
- Patient feedback
- Outcomes analysis
Whole person orientation
The New Model needs revolutionary change, but
sustaining it will take evolution
Evolution requires training to change so the next
generation of family physicians will expect to
practice this way
New competencies
- CHiT compliant
- Clinical guidelines
- Chronic Disease Mgmt
- Interoperability
- Affordability
Practice Management
- Change Management
- Software
- Optimized billing
- Disciplined financial mgmt
- Coding
Team Approach
- Multidisciplinary team
- NP/PA
- Collaborative relationships
- Hospital care
- Maternity care
Complete Practice
- Ancillary services
- Procedures
- Disease prevention
- Wellness promotion
- Acute/chronic disease mgmt
- Integration of care
Continuous relationship with a
family physician
Residencies and the
Counterculture New Model
Training for The New Model
Have to overcome “curriculosclerosis
“curriculosclerosis””
(hardening of the categories)
Training sites will be:
„
„
and “curricululm
“curricululm ossification”
(an often epidemic casting of the
curriculum in concrete)
—Keystone III quoting Stephen Abramson
„
„
„
Laboratories and producers of innovation
Attract venture capital and partner with
technology corporations
Connected to the NIH Research Roadmap
Discoverers of the epidemiology of personal
and community disorders
Be able to demonstrate value to health and
economy
5
Crisis = Opportunity
How is family medicine training like
New Orleans?
In Crisis, Opportunity
„
„
„
„
„
Crisis = Opportunity
Levee’s insufficient
Poor engineering & eroded buffers
Hurricane’s are predictably unpredictable
We know we’re not prepared
We care for lots of vulnerable shoreline….
and people
Crisis = Opportunity
And, like New Orleans, our particular crisis
is an opportunity for:
“a new design for delivering health care in
this country”
Michael Leavitt
US Secretary of Health and
Human Services
February 21, 2006
Crisis = Opportunity
Crisis = Opportunity
Some economists suggest:
„
„
„
healthcare spending is good and could go to
oneone-third of GDP
growth in healthcare spending too important
for the economy to disrupt
The Market and “consumer“consumer-driven” choices
will offer corrections
Other economist think those economists
are nuts
Employers and payers are crying “uncle”
„
„
Starbucks spends more on employee health
coverage than on materials to brew coffee
GM and Ford have negative net worth due to
retiree health liability
What else are we prepared to cut?
„
Personal finances, Food Stamps, Education?
Michael E. Chernew, Richard A. Hirth, and David M. Cutler, “Increased
Spending on Health Care: How Much Can the United States Afford?”
Health Affairs, Vol. 22, No. 4 (July – August 2003), pp. 15-25.
6
Crisis = Opportunity
Crisis = Opportunity
better------Primary care score ranking------- w orse
2005 GAO report confirms that Medicare trust fund has
IOU’s in excess of $280 billion BEFORE Medicare Part D
Healthcare Outcomes
Rank*
0
1
2
3
4
5
6
7
8
9
10
11
12
0
1
2
Netherlands
NTH/DK
Denmark
SP
Spain
3
4
5
6
UK
UK
Finland
FIN
Sweden
SW E
CAN
Australia
AUS
Canada
Belgium
BEL
7
8
GER
Germany
9
United
States
10
Get Ready to be
Counterculture, Again
Thanks!
The Robert Graham Center: Policy Studies
in Family Medicine and Primary Care
Lisa Klein
Jackie McGee
Jessica McCann
Martey Dodoo
Andrew Bazemore Bob Phillips
Stephen Petterson
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