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aton499lIn the movie “I Robot,” there are these robots. The robots perform many tasks necessary for the survival of the society. They took care of old people. They took care of sick people. They probably filled out paperwork to get folks those “Rascal” scooters. The robots, as the story unfolded, often felt under appreciated.  In fact, it turns out they felt themselves to be superior to humans in many ways.  It wasn’t until the robots were completely incorporated into the fabric of society, indispensable, as it were, that the humans figured out that they had a plan.

We just had the meeting of the Family Medicine department chairs. Harold Miller, our keynote speaker, challenged us to go to our Deans. He pointed out that us saying to the Dean that “Family Physicians are the solutions to America’s health care problem so we need more resources to teach them” is not going to get us a lot of traction in these challenging times. This is likely to be true even if we say it really loudly or like we are really sincere. He suggested that what we need to do is walk into the Dean’s office and ask “How may I be of service?”

The following is a list service that should be provided by Departments of Family Medicine under the changing payment model. As we perform these services, we potentially become indispensable to  the Academic Health Center:

Directly Impact the AMC/Hospital Bottom Line:

  • Reducing readmissions to avoid hospital penalties
  • Reducing/controlling post-acute care costs (Episode payment and Medicare Spending Per Beneficiary (MSPB) will create accountability for total costs)
  • Reducing low-paying/uncompensated admissions (e.g., chronic disease admissions, Medicaid/uncompensated admissions)
  • Attracting and managing a large base of primary care patients (What can FM do to improve the patient experience of care, connect the medical center to a network of community PCPs, etc.)

Coordinate Primary and Specialty Care

  • Making the most effective use of specialists (e.g., reducing overuse of specialists for minor conditions/patients inappropriate for procedures, increasing use of specialists for effective diagnosis and appropriate procedures)
  • Managing care for complex patients (e.g., coordinating roles of multiple specialists, effectively managing in-home care, dealing effectively with end-of-life care)

Reduce Costs Through Improved Primary Care

  • Improving screening and preventive care to avoid high-cost conditions/treatment
  • Reducing unnecessary and duplicative testing
  • Improving maternity care outcomes for Medicaid patients and coordinating maternal and primary care (e.g., better pre-pregnancy care, better prenatal care, and better continuity of smoking cessation, etc. after pregnancy)
  • Reducing medical and non-medical costs for employed patients (e.g., reducing time away from work for commercially insured patients)

Adapt Family Medicine and other primary care efforts to PCMH, ACO, and Other Value-Based Payment

  • Organizing team-based primary care
  • Providing patient-centered, non-visit based care

I spent the last several days engaged in a discussion over immigration policy enforcement in Alabama. I had worked to get the national meeting of the Association of Departments of Family Medicine to schedule their 2013 meeting in Mobile. Upon announcing Mobile as a site, the group was immediately made aware of the passage, enactment, and subsequent enforcement of HB 56. Living and working in downtown Mobile, I had always thought of us as described by the Downtown Mobile Alliance:

Mobile is the most cosmopolitan city in the state of Alabama, home to several international corporations that have enjoyed wonderful relationships with the city and its citizens. The Downtown Mobile Alliance actively seeks to create an atmosphere where diverse cultural, ethnic and demographic groups are welcome and encouraged to enjoy our 300 years of hospitality.

Instead, I had to admit that the reality is:

H.B. 56 requires schools to check and report the immigration status of their students. It instructs police to demand proof of immigration status from anyone they suspect of being in the country illegally (if stopped for another reason), even on a routine traffic stop or roadblock. It also invalidates any contract knowingly entered into with an illegal alien, including routine agreements such as a rent contract, and makes it a felony for an unauthorized immigrant to enter into a contract with a government entity.

 In addition, there were some really hateful provisions written in but enjoined as non-enforceable at this time (but liable to be enforced in the future):

It is a crime to harbor or transport unauthorized immigrants; unauthorized immigrants cannot enroll in or attend public universities; it is  a crime for unauthorized immigrants to apply for, solicit, or perform work; it requires that schools check and report on the legal status of their students and their students’ parents; and lastly, it is a crime to be without status in the United States.

In short, if you “look illegal” in Alabama, the police will have the right (if this law is upheld) to detain you until you can prove you belong in America. This concerned ALL of our Latino members, who felt they could not be assured safe passage.

These are not idle concerns. The most recent issue of Mother Jones magazine details some of the consequences of the law, including:

As of this writing, under the new guidelines of the law, Tuscaloosa police have arrested 141 people for driving without proper identification: 97 blacks, 34 Latinos, and 10 whites. Twenty-eight people were handed over to ICE, though officials could not confirm how many, if any, have been deported

Among the arrested was a German executive from Merecedes Benz, so I guess it isn’t all about brown people. The organization elected to move the meeting from Alabama, at a significant loss to the organization and to the city. This prompted a reader of the local coverage to post the following comment about undocumented workers:

Don’t tell me that they pay taxes, I know, they pay taxes on purchases but not on income. So, as you say, and I am a Christian, whatever you do to the least of these, you also do unto me. That knife cuts both ways.

In the book Educating Physicians, which is being used as a template for medical school reform, the importance of physician advocacy on behalf of patients is emphasized. Examples of this advocacy included volunteering time at local school events, volunteering on local boards which further the health of the community, as well as collective action to produce better policy. The authors feel that through these collective actions the professional values and identity of the professional group is continually refined. The organizational logo of ADFM includes the statement “Vision, Voice, Leadership.” The actions of the organization in this case speak even louder.

PCPCC has a new executive director. Marcia Neilsen, has begun to move the organization from one of advocacy for policy change into one of implementation. Her credentials are as follows:

Nielsen holds a Ph.D. in health policy management from Johns Hopkins School of Public Health and a master’s degree in public health from George Washington University. Her interest in public health began with work as a Peace Corps volunteer in Thailand and matured through a position as a Senate staffer for Bob Kerrey during the health care reform debate of the 1990s. She also served as assistant director of legislation for the AFL-CIO. She was appointed by then-Kansas Governor Kathleen Sebelius as the first board chair of the Kansas Health Policy Authority, later becoming the executive director, responsible for developing a policy agenda and overseeing administration of the medical portion of state health programs including Kansas Medicaid, the State Children’s Health Insurance Program and the State Employee Health Program.

We were lucky enough to have her speak last week at the ADFM conference. Her insights into the world of care transformation were both exciting and overwhelming. Exciting because she sees the benefits of our organization:

“Primary care transformation is the foundation for larger transformation we need to see across the entire health care delivery system, and population health is at the heart of such change. This is something departments of family medicine recognized long before Affordable Care Act. They helped lay the foundation, and they are essential to the success of health care reform efforts,” she said.

Overwhelming because now we have to put our money where our mouth is.

I returned from Palm Desert California on a 6:45 am flight today after attending the Association of Departments of Family Medicine meeting this past week. To say the airport in Palm Springs is congested would be an understatement. To get the airport with plenty of time, I had the “car” arrive at 5 am. At 5 o’clock it is pretty dark and the roads are pretty empty so the driver was in a talkative mood. He was about 40 years old and reminded me of a surfer that had taken one too many waves the wrong direction. This, for some reason, was not odd in the desert. The conversation went something like this:

Driver: So, what do you do?

Me: I teach people to be doctors.

This is a common ploy of mine to avoid the “Doc, doc it hurts when I go like this” moment.

Driver: Oh, you’re here for that medical convention. Tell me, how do you train doctors?

This allowed me to discuss medical students and residency, the differences, what is teachable in lectures (medical information) and what isn’t (values such as integrity).

Driver: Sooo, you’re not a doctor?

Having just been exhorted to exhibit integrity in all I do, I confessed that I was indeed a doctor who not only taught but saw patients. This brought about the next question:

Driver: What do you think about Obamacare?

Me: I think the Affordable Care Act, though not perfect, offers the tools to allow all Americans to have access to affordable health care and includes improvements in the system to allow that to happen.

Driver: You don’t think all that government control is unAmerican?

Me: The ACA is essentially based on a plan based on a Nixon administration idea. I somehow don’t think it is unAmerican.

Driver: I just think we ought to let the market dictate how the health care system works.

Me: The problem is there are a bunch of people who have to spend health care dollars on severe illnesses or are sick due to no fault of their own. If we are going to let the market take over, we need to not let people who access the market ineffectively or make poor decisions seek out health care when their money runs out. In essence, we would have to let them die.

Driver: Yeah, that’s letting the market take over.

Uh oh, this is going  badly. It is still dark. Aren’t we at the airport yet?

Me: No, the real problem is that people need help in accessing the health care system because they don’t have the knowledge to interpret symptoms effectively. The Affordable Care Act puts primary care doctors in a position to help people interpret their problems and decide if they need to see another kind of doctor.

Here’s the turn to the airport, time for my big finish:

Me: In addition, we need to figure out a way to make doctors do the right thing for the right reason. Let me give you an example. Let’s say you could drive your cab around all day and find people who are walking and say to them, “If you say you are tired, I can give you a ride and charge someone else.” Bet you would get a lot of tired folks. We’ve got to find a way to have doctors only provide needed services to folks. The ACA has provisions for this as well.

Driver: Well, I still don’t like the idea of government healthcare.

Personally, I would prefer a single payor but I’ve yet to get my luggage.

Me: This is far from government health care. President Obama has just done a poor job of telling people about it.

Driver, pulling to a stop: Wow, man. Thanks for the didactic ride

Me (to myself): Shaka bro’