Transforming Family Medicine Education for the New Model Practice

1
Transforming Family Medicine Education for the
New Model Practice
Program Directors Workshop 12 June 2007 Overland
Park, Kansas

• Richard G. Roberts, MD, JD, FAAFP, FCLM
• Professor of Family Medicine
• University of Wisconsin School of Medicine
  Public Health
• 777 South Mills Street, Madison, WI 53715
• TEL [phone] FAX [phone]
• Email richard.roberts_at_fammed.wisc.edu

2
The United States has the best healthcare system
in the world.
1. TRUE 2. FALSE
3
Which of the following best describes your views
on the future of family medicine.

• Wildly enthusiastic
• Cautiously optimistic
• Uncertain
• Worried
• Its doomed

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U.S. Healthcare System

• 1,300 payers1
• 4,919 hospitals2
• 764,000 physicians3
• 3,119,000 nurses4
• 302,000,000 people5

1http//www.ahip.org/ 2http//www.aha.org/aha/rese
arch-and-trends/health-and-hospital-trends/2006.ht
ml 3http//bhpr.hrsa.gov/healthworkforce/reports/b
ehindrnprojections/2.htm 4Dionne M, Moore J,
Armstrong D, and Martiniano R. The United States
Health Workforce Profile. Rensselaer, NY Center
for Health Workforce Studies, School of Public
Health, SUNY Albany. October 2006.
http//chws.albany.edu. 5http//www.census.gov/
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U.S. Healthcare Coverage

• 118 M (40) ERISA
• 74 M (25) HMO
• 45 M (15) public
• 45 M (15) uninsured
• 15 M ( 5) indemnity

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U.S. Healthcare System 2007

• National Health Expenditures (NHE)1
• 16.2 of GDP (Switzerland 11) largest sector
• 2,262 billion
• 7,498 NHE per capita
• 1 in 4 without any or enough insurance2
• 2000 World Health Report3 ranked 37th

1httpcontent.healthaffairs.org/cgi/content/abstra
ct/hlthaff.26.2.w242v1 2http//www.census.gov/prod
/2006pubs/p60-231.pdf 3http//www.who.int/whr/2000
/en/whr00_en.pdf
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1966 Three reports focus on frustrationswith
the U.S. healthcare system.

• Millis Commission The graduate education of
  physicians
• report of the Citizens Commission on Graduate
  Medical Education.
• Willard Committee Meeting the challenge of
  family practice
• report of the American Medical Association. Ad
  Hoc Committee on Education for Family Practice.
• Folsom Commission Health is a community affair
  
• report of the National Commission on Community
  Health Services.

All three reports call for a new medical
specialty of family practice to meet peoples
perceived needs in a fragmented heath care system.
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Total Physicians and FP/GP per 100,000 Population

Total physicians
FP/GP
Colwill JW, Cultice J. www.cogme.gov/00_8726.pdf
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Family Physicians

• Doctors of first resort
• Continuous comprehensive care
• Responsible for total health needs
• 75 of complaints are self-limited
• Time as diagnostic therapeutic tool

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Family Medicine Metrics
1969 2006 20th specialty ABFP ABFM Ge
neral Practitioners 58,000 15,000 Family
Physicians 0 75,000 FM
Residencies (started 1970) 0
475 Departments or divisions 0
113 Clerkships 0 106
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Family Medicine Firsts

• CME requirement
• Ambulatory training
• Board recertification
• Quality?
• Electronic health record?
• Patient-centered?

12
Access
13
Current Primary Care HPSAs
Current Primary Care HPSAs
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Primary Care HPSAs without FP/GPs
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Physicians per 100,000
Colwill JW, Cultice J. www.cogme.gov/00_8726.pdf

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Healthcare services
U.S., 2004
Physician office visits 910,857,000 Emergency
dept visits 110,216,000 Hospital outpatient dept
visits 84,994,000 Hospital admissions
36,927,000
Source National Ambulatory Medical Care Survey,
2004 http//www.cdc.gov/nchs/data/hus/hus06.pdf
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U.S. Physician Office Visits 20021
499 Million
391 Million
56
44
214 Million
160 Million
125 Million
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18
14
1 Excludes anesthesiology, pathology, forensic
pathology, radiology, therapeutic radiology, and
diagnostic radiology. Source US Department of
Health and Human Services, Public Health
Services, Centers for Disease Control and
Prevention, National Center for Health
Statistics, 2002 National Ambulatory Care Survey.
http//www.cdc.gov/nchs/data/ad/ad346.pdf
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U.S. Physician Office Visits 20041
452 Million
459 Million
50
50
205 Million
147 Million
101 Million
23
16
11
1Excludes anesthesiology, pathology radiology.
Source http//www.cdc.gov/nchs/data/hus/hus06.pd
f
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Outcomes
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Mortality Outcomes

• Primary care physicians 1 per 10,000 (20) more
  primary care physicians decreases mortality by 40
  per 100,000 (5 fewer deaths).
• Family Physicians 1 per 10,000 (33) more
  family physicians results decreases mortality by
  70 per 100,000 (9 fewer deaths).
• Specialists 1 per 10,000 (8) more specialists
  increases mortality by 16 per 100,000 (2 more
  deaths).

Shi. J Am Board Fam Pract 200316412-22.
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Indonesia Infant Mortality
1996-1997 1997-1998 1998-1999 1999-2000
Primary care
10.3 9.6 8.5 8.2
Hospital
4.1 4.1 4.6 5.3
Infant Mortality
70 improvement in 14 worsening in all
provinces 1990-1996 22 of 28 provinces
constant Indonesian rupiah per capita, in
billions
Simms et al. Lancet 20033611382-5.
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Cost Quality
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Personal physician primary care vs specialist

• 33 lower cost of care
• 19 less likely to die

Frank et al. J Fam Pract 199847105-9
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Increasing physicians 1 per 10,000 population

• Specialists
• Decrease 9 states in quality
• Increase costs 526/beneficiary
• Primary care
• Increase 10 states in quality
• Decrease costs 684/beneficiary

Baicker et al. Health Affairs 2004W4184-197
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Satisfaction

• Satisfaction more closely linked
• to measures of rapport and patient
• centeredness for patients of FP
• physicians than for patients of
• internists.

Paashe-Orlow M, Roter D. J Am Board Fam Pract.
200316485-93.
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Why do people worse with specialists?

• Outside area of expertise
• CAP, AMI, CHF, UGI bleed1
• Late stage diagnosis of breast2
• or colorectal3 cancer
• Excessive utilization4
• Handoff or communication errors5

• Weingarten et al. Arch Int Med 2002162527-532.
• Ferrante et a. J Am Board Fam Pract
  200013408-414.
• Rotezheim et al. J Fam Pract 199948850-858.
• Greenfield et al. JAMA 19923671024-1030.
• Skinner et al. Health Affairs 200625w34-w37.

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Pyramid of Care
Information taken from White KL, et al. N Engl J
Med 1961265885-92 and
Green LR, et al. N Engl J Med 20013442021-25.
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How good is the evidence?

• Design Review of all original clinical research
  in 3 major general clinical journal or
  high-impact specialty journals from 1990-2003
  that were cited more than 1000 times.
• Results Of 49 highly cited studies, 45 claimed
  that the intervention was effective.
• 7 (16) contradicted by subsequent studies
• 7 (16) found effects stronger than those of
  subsequent studies
• 20 (44) were replicated
• 11 (24) remained largely unchallenged

Source Ioannidis JPA. JAMA 2005294218-228.
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People do better with primary care.

• Starfield B, Shi L, Grover A, Macinko J.
• The Effects of Specialist Supply on Populations
• Health Assessing the Evidence.
• http//content.healthaffairs.org/cgi/content/full/
  hlthaff.w5.97/DC1

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Why do people do better with primary care?
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Personal Health
CommunityHealth
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Personal
Professional
HEALTHCARE
Population
Public
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5-Star Doctor

• Care provider
• Decision-maker
• Communicator
• Community leader
• Manager

Dr. Charles Boelen, WHO. http//www.who.int/hrh/
en/HRDJ_1_1_02.pdf
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If primary care is so good,then why do things
feel so bad?
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US Healthcare System

• Power
• Prestige
• Profits
• Publicity

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Future of Primary Care Initiatives

• American Academy of Pediatricians Future of
  Pediatric Education (FOPE), 2000
• Future of Family Medicine Project, 2002-2003
• Society of General Internal Medicine
• Future of General Internal Medicine, 2003
• American College of Physicians The Impending
  Collapse of Primary Care Medicine and Its
  Implications for the State of the Nations Health
  Care, January 2006
• SOAR International Colloquium,
• September 2006

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New Model of Family Medicine

• Advanced/open access scheduling
• Online appointments
• Electronic health record
• Group visits
• E-visits
• Chronic disease management

• Web-based information
• Team approach
• Clinical practice guideline software
• Outcomes analysis
• Alternative payment models

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Disseminating the New Model TransforMED

• Established in 2005 by AAFP
• Two national demonstration projects
• Practice redesign
• P4 preparing personal physicians (to be
  effective in new models of) practice

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Patient-centered care

• Communication
• Continuity
• Concordance

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Continuity
for patients for clinicians All DFM
Clinics 55.0 55.6 Residency
Clinics 41.9 51.0 Community
Clinics 65.9 70.6 BV-Faculty 62.9 48.3 BV-
Residents 48.7 24.5
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SOAR Toronto, Oct 2006

• Australia - MJA 2006185125-127
  www.racgp.org.au
• Canada Primary care renewal www.cfpc.ca
• Netherlands MJA 200317926-29
  http//nhg.artsennet.nl
• New Zealand 2005 RNZCGP Membership Survey,
  2006 www.rnzcgp.org.nz
• United Kingdom The Future of General Practice,
  RCGP, 2004 www.rcgp.org.uk
• United States Future of Family Medicine
  www.futurefamilymed.org

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Strategies

• Convenient (convenient access)
• networks
• open access
• Continuous (effective access)
• electronic communications
• electronic records
• Comprehensive (scope)
• basket of services
• Competent
• safety
• standards
• accreditation

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Two Key Concepts

• Practice redesign
• Disruptive innovation

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Practice Redesign

• Rapid cycle design
• Waste
• Flow
• Convenient access

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Disruptive Innovation

• Internet email
• Information as commodity
• Simpler technology
• Smarter users

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Its the
RELATIONSHIP,
Stupid!
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(No Transcript)
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The Future
of
Family Medicine
51
The Future
is
Family Medicine