Proceedings of the 25th National Conference; April 14, 2014 (First Plenary Session, Kahn)

This session immediately follows: Proceedings of the 25th National Conference: Introductory Remarks

We gratefully acknowledge the sponsorship of the Wright State University Boonshoft School of Medicine (Dayton, Ohio) for funding the transcription and editing of this section of the Proceedings of the Twenty-Fifth National Conference:

 

Norman B. Kahn, MD (Council of Medical Specialty Societies, Chicago) [Doctor Kahn is a Senior Fellow of the National Conferences on Primary Health Care Access.]

Norman B. Kahn, MD;  Council of Medical Specialty Societies, Chicago
Norman B. Kahn, MD; Council of Medical Specialty Societies, Chicago

It’s really a pleasure to be back. I was telling several people at the morning’s breakout meeting that I don’t get to come to these meetings every year, obviously we’ve had 25 meetings, I’ve only been to 10 of them.

But I’ve been to 10 of them. And it’s not just because it’s a reunion and because I enjoy seeing Bill and other folks but it’s a very good meeting. And it’s my privilege to have the opportunity to present some remarks this morning.

I only have 12 slides. I’m only going to spend some time on two of them. The rest of them are background.

KAHN SLIDE 2

The Crossroads

What I want to talk about this morning (1) if this is about training family physicians, (2) if this is about the Affordable Care Act (3) if there’s some relationship between those two issues, then we’re at this crossroads.

First of all, who am I?

The Crossroads
The Crossroads

CMSS

Right now I work for the Counsel of Medical Specialty Societies [CMSS].

CMSS is an organization of 39 medical specialty societies, virtually all of the specialties in medicine, all but one.It represents about 700,000 physicians in the United States.

Can you guess which specialty does not participate with its peers and colleagues in its national coalition? I know, having worked in many communities, that individual specialties in individual communities can be a problem,. But nationally, there is one specialty that doesn’t play ball on the team: orthopedic surgery.

KAHN SLIDE 3The Ambulatory Quality Alliance

I have some other relationships that are probably, not financial relationships, but they affect what I have to say.

As of this year I’ve moved from the reporting work group to the steering group of the Ambulatory Quality Alliance (AQA).

I sit on the committee of the National Committee on Quality Assurance, NCQA. The clinical programs committee that used to be, you know, concerned with back pain recognition, diabetes recognition.

NCQA has moved from those matters to creating the criteria for recognition of patients under medical homes, and patients under specialty practice and accountable care organizations. That’s kind of an interesting place to be.

I also sit on the National Priority Partnership (NPP), which is formed by the National Quality Forum and it’s all about working together nationally on national priorities to achieve the National Quality Strategy.

KAHN SLIDE 4A Pretest on a National Quality Strategy

Here’s a pretest, which means there’ll be a posttest at the end. Think about the answers, At the end we’ll get to talk about it. This is one of the slides I’m going to focus on.

Are we preparing residency program graduates who will contribute to the United States’ National Quality Strategy?

Will their practices be seen by their patients and peers as medical homes?

Will they consider the full basket of services their primary responsibility in their practice? That’s part of the first future of family medicine project!

Will they provide measurably provide better care? Will they measurably improve the health of population? You recognize these this is part of the National Quality Strategy.

Will they bend the cost curve? Those are the three elements of the National Quality Strategy.

Will they model a culture of performance in practice? That is the strategic priority of my organization. That’s what the National Specialties can get together on, which is quality improvement.

Can they survive and thrive in practice? We’ll come back to the National Quality Strategy.

 KAHN SLIDE 5The 2004 Future of Family Medicine Project

Ten years ago, the first Future of Family Medicine project was developed as a strategy to transform and renew the specialty to meet the needs of people and society in a changing environment. Be careful what you ask for, you might get it!

You can decide for yourselves how successful the Future of Family Medicine project was in the first 10 years. Hopefully over the next three days, I’ll have some opportunities to contribute, as I did at the breakout this morning, some of the experiences of the Future of Family Medicine project the first time around.

KAHN SLIDE 6You may not be able to see this slide but this is the Smithsonian Institution and this is a family doctor.

The reason why the future of family medicine project was created the first time; was that there was a sense that the nation’s family physician would be something that was a historic element, but not part of the future.

I’m going to ask us this morning, whether or not there’s some validity to that, or whether this is just a funny cartoon.

KAHN SLIDE 7In 2013, just last year, the National Research Council and Institute of Medicine published a report. The evidence reviewed in this report documents the US health disadvantage that spans decades and continues to trend downward.

How often you go places and talk to people who say “Damn it, we have the best health system in the world”. Only a couple of hands. Well, this is very telling, because 20 years ago, everybody would have raised their hands. That was the perception. It’s not the perception anymore.

Most people recognize we don’t have the best health system in the world. That’s the good news. Almost all trend lines indicate that in the absence of corrective action the US healthcare, the health disadvantage relative to other high-income countries will continue to worsen as it has for years. That is a pretty sobering conclusion from the Institute of Medicine.

Now all of the specialties in my organization, all 39 of them are organized for the same purpose, to protect and advocate for their own members. Family medicine is only slightly different; in fact, it may not be much different.

So you might ask, why do they even bother to get together at the national level? That is a question that I’ve been helping them ask. I’ve been their mirror for the last six years.

Because it is an obvious question to answer. One that I learned early in my tenure working with all the specialties;

I interview the CEOs of each of my specialties every winter. I do one on one interviews with most of the CEOs of all the specialty societies. I get about two-thirds of them annually.

The first year I asked them a question and got a very interesting answer. I asked them: “What is most challenging about your job as the CEO of a national specialty society?” I didn’t expect the answer.

The answer turned out to be the same for family medicine or cardiology or neurosurgery. My dues paying front-line members want me to protect their pecuniary and fiduciary interests at all costs. But once they are elected by their people and rise up through the ranks and find themselves sitting on the board of directors of a national organization, they find themselves challenged to solve national problems.

KAHN SLIDE 8The National Quality Strategy has evolved in just the last few years. It was developed by Doctor Donald Berwick and the Institute of Healthcare Improvement before he went to the Centers for Medicaid and Medicare Services (CMS). He brought it there and it’s now the National Quality Strategy. It has been adopted nationally.

Its aims are: 1) Better care, improving the overall quality of care. 2) Healthy people in healthy communities improving the health of US populations, incorporating both individual care and population health management, and 3) affordable care; reducing the cost. This is the National Quality Strategy.

So at my level I can get my organizations around this. We adopted the National Quality Strategy last year, unanimously. Now you might ask, so what? What are you doing about it?

Disruptive Innovation?

Well, let’s ask ourselves: “Are we preparing graduates in family medicine who will address the National Quality Strategy?” This is our goal as a nation. So, what can we do that no one else can do in family medicine; except maybe be the disruptive innovator?

Here we have January, a year ago, January 2013; from the Congressional Research Service; the Affordable Care Act may effect both the demand for physician services, as well as the volume of physician services available; We’re short, We talked about that in our morning breakout.

“And”, the Congressional Research Service report continues “therefore may influence determination of the appropriate size of the physician population.”

KAHN SLIDE 9The Affordable Care Act contains a number of provisions aimed at increasing access to insurance coverage which could in turn; increase the demand for physician services, particularly what kind of physicians? Primary care physicians, absolutely, but this also came out a month later from the Kaiser Health News.

David A. Bayer, former CEO of the American Association of Nurse Practitioners, says “That despite doubts from some doctor groups, nurse practitioners are honing their craft in patient care and research to position themselves [to provide] the healthcare for this new influx of patients, and they are doing so without sacrificing the quality of care.” [This quote is from Clayton Christiansen’s Disruptive Innovation.]

We’ve been 10 years since the first Future of Family Medicine, and as Doctor Clasen pointed out this morning, the match was up a little bit. Ok. Well when you numbers are up just a little bit trying to solve a huge problem, then some other disruptive innovator is going to step in to solve this problem.

What happens at retail clinics? Eight years ago we had this deal that we struck with the retail clinics that they would just provide limited services, and now the retail clinics are announcing that this is the new market, that this is where people are going to go for convenient care. Wal-Mart’s going to have whole healthcare delivery system. Disruptive innovators!

KAHN SLIDE 10So, what are the environmental perceptions of family medicine? This is really the reason I think I was invited. I work with all the specialties, except one. I’ve phrased several questions that ask what is family medicine from the prospective of the environment;. (There are statements hidden in these questions.)

The questions are: Is family medicine the foundation of the US healthcare delivery system? Is it perceived as the foundation? Do we perceive it as the foundation? Do we recognize what other countries do?

In this country, is family medicine perceived as the foundation of the US healthcare delivery system? I hate to tell you, but the answer is no. Sorry, I guess you don’t have anything really dangerous to throw at me, just those little Hershey Kisses®, that Doctor Fredrick passed out, right?

Is family medicine anachronistic and inadequate role in a system the US is leaving behind? Think about that. Are we anachronism? Meaning we’re out of time; we’re from the past. An inadequate role, there aren’t enough of us, maybe we don’t do teams right, we’re not trained well and a system that the US is leaving behind. It’s changing its system. So we’re not perceived as the foundation.

We might be perceived as anachronistic and inadequate. Are we facilitating successfully addressing the National Quality Strategy? Do our graduates know their role in addressing the National Quality Strategy?

Why should they be? Because the nation is focused on those three things. Funding from CMS will be based on those three things. Physician payment will be linked to quality, and will be linked to the National Quality Strategy. Decisions on workforce will be linked to the National Quality Strategy.

Are we just precursors to advanced practice nurses? Are we perceived as a threat to the incomes of the dominant specialists?

Here’s a story: In 2008 when I took over my job, in the spring, I’d only been on board a few months, we ran a meeting and I was responsible for educational programing at our meeting.

I figured you know all of the specialists better understand that the patient centered medical home is coming. I’m not going to promote it. I’m not in a position in my organization to promote it, but they better understand that it’s coming. So I had a speaker on the patient centered medical home, Doctor Perry Pugno was there.

After the speech a neurosurgeon went to the floor mic, and he said, this patient-centered medical home business is just a scam on the part of primary care to take money out of our pockets. That guy is now a good friend of mine. I’ve courted him over the years. But I was actually thrilled that he had the courage to say it in front of everybody else, because we are perceived as a threat to the income of the dominant specialists.

Are we the first choice of patients for their care? With apologies to my breakout group this morning, during the 2004 Future of Family Medicine project, at the first opportunity we did focus groups around the nation. We went to rural Minnesota and we said what do you think of your family physician? Oh I love him. Is your family physician practice in quality? Absolutely. How do you know? We didn’t ask that, cause they wouldn’t know. Do, you know, do you appreciate your…yes, yes, yes. If you had the opportunity would you go to a specialist? Yes. What?

The answer was I go to my family physician. I have a good relationship, I trust him. I like him. But I wish I had access to this specialist just like my friends in the big city.

Are we the first choice of payers for the care of populations? Well, maybe. This is getting a little closer.

Are we patient-centered medical homes, ten years after we reinvented them from the pediatricians? You know there’s quite a growth in patient-centered medical homes across the country. Maybe we’re getting there finally. It’s taken awhile.

Are we gatekeepers to patient center specialty practices? I picked that word deliberately of course. In my environment that’s a swear word. In this environment, we should be gatekeepers to specialties, to patient-centered specialty practices. That’s the way it’s designed. And then add your perception here.

I’ve spent a little time on this slide, the only other slide I’m going to spend time on is the last one, I guess I was invited because I have a different environmental perception and I just need to share it with you.

KAHN SLIDE 11So,this cartoon caption reads “Let me think, you’ve stumped me son. Most folks only want to know how to go the other way.”

Are we pointed in the right direction? Are we going in the right direction? Do we have confidence we’re getting to where we need to go?

So here’s the posttest. I hope, Bill, that this will generate some discussion; so I’m just going to go through the questions again and then I’m going to turn it over to Doctor Pugno.

KAHN SLIDE 12How are we preparing graduates who will . . . ? Recall that the pretest was are we preparing graduates that will . . .? This is how are we preparing graduates who will contribute to meeting the US’ National Quality Strategy?

Because if we’re not; we’re not going to be relevant. How are we preparing graduates who will be seen by their patients and peers as medical homes? I mean that’s our niche. I mean if we don’t do that a disruptive innovator’s going to do that; Wal-Mart.

Consider the full basket of services their practice responsibility. If I limit my practice I’m a limited specialist, I’m not a patient-centered medical home. Yes, I may not deliver babies in my practice, but my practice will make sure that you get your baby delivered.

Do we measurably provide better care? Better care is the first aspect of the National Quality Strategy. Do we measurably improve the health of the population of patients under our care? That’s our responsibility. Even though our electronic health record may not have a registry function, this is the second aspect of the National Quality Strategy. If we don’t do this, we’re not relevant. And third, are we bending the cost curve? Do we model a culture of performance in practice?

Those of you that are familiar with the improving performance practice project an RWJ funded project run by the ABMS Research and Education Foundation on behalf of the specialties. We asked ABMS to run it for us. These people are measuring their quality of care all the time. This is a culture, not just a one off. And are they surviving and thriving in practice? Well those folks are. But they’re the innovators; they’re the tip of the curve.

Thank you!

Perry, it’s all yours. You’ll make them feel better, won’t you?

This session is followed by: Proceedings of the 25th National Conference – First Plenary Session, Part 2 (Pugno)

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