Data from the Memphis Project 1989 -2004 Which

Data from the Memphis Project, 1989 -2004 Which Procedures (Services) Add Value? In the Average Group of 5 Physicians, Which Diagnostic and Therapeutic Procedures Make Sense? Wm. Mac. Millan Rodney, M. D. , FAAFP, FACEP Advanced Family Medicine Specialists Editor, Procedural Skills and Office Technology Bulletin Web site: www. psot. com

BACKGROUND EXPERIENCE AND DATA Wm. Mac. Millan Rodney, M. D. n n n n Medical Technologist ASCP 1971 Rural emergency medicine 1977 -1987 Residency Director 1979 -1984 Vice Chair, Interim Chair 1984 -1989 Chair Family Medicine 1989 -1998; 2000 -2004 Designed and Implemented Rural Demonstration Projects and Fellowships in California, Tennessee, Arkansas International projects-Venezuela 1993, Uruguay 1995, Kenya, Ecuador, Guatemala, Honduras Private Practice-Medicos para la Familia; Meharry/Vanderbilt Faculty 1999 -present

Transfer of Technology Projects n n n n n Simple Lab in the Office[pre CLIA 1988] ECG-CXR in the Office Minor Surgery in the Office Flexible Sigmoidoscopy 1979 -established ENT Endoscopy 1984 -established Colonoscopy/EGD 1986 -contested in the hospitals Colposcopy/LEEP 1984 - established OB-Gyn Ultrasound 1984 - established, but FP-ob? Others n “The little good I have done is that which cost me the greatest trouble…. . ”—William Hunter 1718 -1783

Impact of Procedurally Enriched Genera The Ability to Perform Procedures and O Hospital Services a. Access for patients b. Quality ( failure to diagnose) c. Patient satisfaction d. Physician satisfaction multiple studies Larimore e. System cost Greenfield NEJM f. Revenue to practice depends on who is running the budget

Impact of the Educational Environment-A Bibliography LIMITED GENERALIST STUDIES n PART I: n n Rodney WM, Beaber RJ: Maximizing patient care services to improve funding in a family medicine residency. J Med Ed 1984; 59: 567 -572. Rodney WM, Hahn RG, Deutchman M. Advanced procedures in family medicine: The cutting edge or the lunatic fringe? J Fam Pract 2004; 53: 209 -212. PART II: Rodney WM, et al. Enhancing the family medicine curriculum in deliveries and emergency medicine as a way of developing a rural teaching site. Family Med 1998; 30(10): 712 -719. Tribute to UTMG business model n PART III: Rodney WM, Hahn RG. The impact of the limited generalist (no procedures, no hospital) on the viability of Family Medicine. J Am Board Fam Pract, May-June 2002; 15: 191 -200 GLOBAL IMPLICATIONS Dresang LT, Rodney WM, Leeman L, Dees J, Koch, P, Palencio M. ALSO in Ecuador: Teaching the Teachers. J Am Board Fam Practice. 2004; 17(4): 276 -282. http: //www. jabfp. org/cgi/content/full/17/4/276 n

Multimillion$Megatrends for Medical Care in the 21 st Century Ten percent of the information makes ninety percent of the difference n Twice the service could be provided at less than half of the cost. n USA healthcare bill approaching $2 TRILLION The assumption of endless abundance for healthcare funding is irrational. n Eighty percent of the planet is uninsured. This is a niche market which remains untapped. n

Medicos para la Familia Project n n n Established 1999 during when Community Medicine and Primary Care became unlikely career choices for US medical students. Was designed to provide data on health care services in underserved communities apart from the academic hospital. Evolved into a hybrid specialty. Retained hospital privileges for physicians with an emphasis on prenatal care and delivery of babies. Became self sustaining through reimbursable services without external support. Utilizes data from the Transfer of Technology Project 1979 -present. See website for “Procedural Skills and Office Technology” www. psot. com

The Antidote to Limited Generalism FAMILY MEDICINE- r er-ob: e The Most Logical Solution Twice the service at less than half the cost. n Sustainable for uninsured patients. n A critical mass of 4 procedurally enriched family physicians can form the foundation of a health care system in a rural community or a developing country. n Form follows finance: It’s not just about the money. It’s about financing the health of our community. n

The. NEGATIVE impact of the limited generalist model (no procedures, no hospital) on the viability of Family Medicine J Am Board Fam Pract, May-June 2002; 15: 191 -200 Wm. Mac. Millan Rodney, M. D. Department of Family Medicine Meharry/Vanderbilt Alliance Nashville, Tennessee Ricardo G. Hahn, M. D. Department of Family Medicine University of Southern California

The Limited Generalist Data Part IV Suggests Some Directions for the Future of Family Medic 2006 -2016 n n n Understand that for each MD in a well managed office, the limited generalist model of family medicine loses at least $35, 000 per year in procedural collections and $60, 000 per year in Ob collections. MINIMUM Incentivize productivity. Physicians should receive $300 extra for each delivery and $700 for each Cesarean. The OB component sustained many other previously undescribed procedural services such as ultrasounds, circ, etc Insist on fiscal accountability. Despite an unfavorable case mix in Part IV of this study, collections increased to 59% of charges. In the same state, University A obtained 32% and University B obtained 45%. Family Medicine needs to expect an equal share of revenue opportunities and better practice management.

The Limited Generalist Data Part IV Suggests Some Directions for the Future of Family Medic 2006 -2016 n n n Define limits in accordance with community needs. Construct a business plan. Geriatric services were fewer in the 2004 bilingual practice, because demand caused the practice to focus on families with children. This practice is full. Develop open access to provide acute ortho, acute OB-Gyn care, and minor surgery services. This recaptures part of the heritage of service, and gives physicians a competitive advantage in overdoctored markets. Recolonize emergency medicine. Consider ER shifts at $50 -150 per hour to build volume and skills.

Data from the Memphis Project, 1989 -2004 Which Procedures (Services) Add Value? In the Average Group of 5 Physicians, Which Diagnostic and Therapeutic Procedures Make Sense? Wm. Mac. Millan Rodney, M. D. , FAAFP Advanced Family Medicine Specialists Editor, Procedural Skills and Office Technology Bulletin Web site: www. psot. com

Multimillion$Megatrends for Medical Care in the 21 st Century Ten percent of the information makes ninety percent of the difference n Twice the service could be provided at less than half of the cost. n USA healthcare bill approaching $2 TRILLION The assumption of endless abundance for healthcare funding is irrational. n Eighty percent of the planet is uninsured. This is a niche market which remains untapped. n

The Low Cost High Yield Basics n n Skin Surgery-Acute Injuries-Chest Pain-Cough-Dyspnea -Dyspepsia[ECG, CXR, EGD, etc. ] Women’s Health Care n n Prenatal Care, Family Planning Ultrasound Diagnosis Delivery Services Cancer Prevention n n Endometrial Biopsy Colonoscopy-Biopsy Paps Smear-Colposcopy Others

Rational Groups of Services -Urgent Care[Open Access] Enablers Complaint Musculoskeletal Injuries Lacerations/Lipomas URI/Asthma/Pneumonia Pregnancy/Pelvic Pain Abdominal Pain Tools Plain Film Radiography Parenteral sedation/analgesia Skin Surgery Pulse Oximetry-CXR Ultrasound; less HCG Ultrasound, CBC, UA, HCG, GI Endoscopy

Groups of Diagnostic and Therapeutic Services (Procedures) Skin Surgery Package Cost Biopsy Laceration Repair Ellman Surgitron Avg charge $150 -$350 $1200 Benefits (Local Anesthetic, Scalpels, Pickups) Sutures $ 800 Avg time 15 -30 min Chest/Ortho X-Ray Package X-ray unit with Developer Staff training 8 days Digital Conversion[2005] $30 k; room $15 k Avg charge $50 -300 $50, 000 no chemicals, films Cardiology Services ECG ETT Holter Echo $6 k Charge $ 60 $12 k Charge $200 --no cost if you’re already doing OB ultrasound

Groups of Diagnostic and Therapeutic Services (Procedures) GI Endoscopy Group Cost Benefits Flexible sigmoidoscopy Hospital privileges Patient satisfaction Colonoscopy Scheduling ½ d/week MD satisfaction Polypectomy Equipment--$10 -$60 k Revenue > office visits EGD Charges > $6 k/day - 8 patients) Sanford Brown FPM April 2006 -give up on thehospital and the fight for privileges Cancer Prevention in Office Package Colposcopy WA Video path with Avg charge $150 -$450 printer/$20 k[$7 k-2006] Cryomedics used $2 k Flexible Sigmoidoscopy $6 k; Biopsy tools $1 k Cryosurgery $4 k Avg time 15 -20 min Endometrial Biopsy (7

Hospital and Procedural Services Oppor Costs, Overhead, and Charges “In all analyses, deducting costs of equipment, opportunity cost for lost visits, malpractice, and training costs, these services provided additional revenue for physicians’ time spent in these activities. Even when equipment is purchased totally in year one, there is a net positive impact on the practice. ”J Am Board Fam Pract. 2002 Something more than generic primary care is needed for community centered medical care. This is also true for developing countries.

Basic Assumptions from the Literature-opportunity costs 1. 2. 3. 4. 5. 6. 7. Average work year of one FP = 6, 500 office visits. Average MD work year = 47 weeks (5 weeks vacation/CME) Average # visits per day = 28. Average day > 85% established patients. Average office visit charge 1997= $60; 2004 = $70. Net collections (worst case scenario) =. 40 x charges. Net collections (best case scenario) =. 80 x charges.

Total Charges and Two Reimbursement Scenarios for a UT-Memphis Teaching Practice 12 Consecutive Months 1997 Yearly Averages Service Unit Charge ($) OFFICE Visits (n=30, 422) 60 HOSPITAL ACTIVITY Med/Surg/Peds(n=510)[ LOS 5 d] 423 Deliveries (n=252) 2300 Newborns (n=252) 198 HOSPITAL SUBTOTALS Totals without Procedures Can’t peel this onion without shedding a few teaars Total Charges ($) Net Collections ($) 40% 80%_ 1, 815, 720 726, 288 1, 452, 576 215, 730 579, 600 49, 896 845, 226 86, 292 231, 840 19, 958 338, 090 172, 584 463, 680 39, 917 676, 181 2, 660, 946 1, 064, 378 2, 128, 757

Revenue Projections by Specific Service Group 1997; Office visits 30, 422; Deliveries 252; Limited Generalist Project: Part III Medicaid 40% Allowed Total Net $ Add X-ray, ECG[408], Skin Surgery Add Flex Sigs[n=73] Add GI Endoscopy[n=215] Add Colposcopy [n=123] Add Pregnancy (US = 533, NST) Revenue Gained 72. 1 6. 2 69. 8 19. 6 81. 9 80% Allowed Total Net $ 155. 5 11. 7 167. 5 38. 1 162. 9 $249, 600/year $535, 700/year Charges for procedural services 1997 were approximately $622, 500 This was the last year that the department had control over its billing. [IBM[

Average Annual Procedural Revenue 1997 Office Visits = 30, 422 per year Clinical Volume One Yr X-rays 1323 ECG 408 Skin Surgery 265 EGD 104 Colon 129 Flex Sigs 73 Colposcopy 161 Ultrasound 525 NST/AFI 95 Subtotals Avg Charge $ 82 51 243 838 947 200 296 320 376 Tenn. Care Allowed 28 23 97 281 315 85 122 130 144 Net $/Yr 27. 9 9. 4 25. 7 29. 2 40. 6 6. 2 19. 6 68. 3 13. 7 $249. 8 k 80% Allowed 66 40 194 671 757 160 197 256 300 Net $/Yr 87. 3 16. 6 51. 5 69. 7 97. 7 11. 7 38. 1 134. 4 28. 6 $535. 6 k Standard Limited Access Model+Nursing Home; LGSIL= Colpo; University rules were a negative; Educational revenue was priceless

Total Charges and Two Reimbursement Scenarios for a UT-Memphis Teaching Practice 12 Consecutive Months 1997 Yearly Averages Service Unit Charge ($) OFFICE Visits (n=30, 422) HOSPITAL ACTIVITY Med/Surg/Peds(n=510)[ LOS Deliveries (n=252) Newborns (n=252) HOSPITAL SUBTOTALS Totals without Procedures 60 5 d] 423 2300 198 Total Charges ($) Net Collections ($) 40% 80%_ 1, 815, 720 726, 288 1, 452, 576 215, 730 579, 600 49, 896 845, 226 86, 292 231, 840 19, 958 338, 090 172, 584 463, 680 39, 917 676, 181 2, 660, 946 1, 064, 378 2, 128, 757 $250 k $536 k

Real Revenue by Specific Services 2004 Medicos para la Familia-Memphis visits = 30, 048; Deliveries = 349 Annual Volume $ collected X-ray, ECG Skin Surgery Flex Sigs 817/219 645 5 34, 720 75, 765 486 GI Endoscopy Colposcopy/LEEP Pregnancy Ancillaries(US, NST) 41 33 754/312 9, 512 3, 552 115, 736 Avg delivery collect $ 1487* Avg newborn care collects $71 Undelivered prenatal care visits 349 259* 3893 $239, 771/year 518, 844 22, 387 55, 963 $ 597, 194 /year Open Access Model without nursing home; LGSIL = rpt Paps

Office Visits- Revenue Models n n Limited Generalist-urban; University administration $25 collected per visit Limited Generalist Medicos urban private group $55 collected per visit In 2004, Procedures and deliveries added about $27. 85 per visit for these medical practices with 85 -90% medicaid and uninsured patients. n $83 per visit Federal cost based reimbursement rates of CHC/FQHC $95 -105 per visit

Real Revenue 2004 -Medicos n n n Deliveries Office Procedures Limited Generalist Medicos n n n Office charges-No Ins: New-$70; est $60; child $40 Total visits 30, 048 Collected Approximately $ 1. 63 million Revenue per office visit $ 55 Net Collections n $ 597, 194 $ 239, 771 $2, 484, 417 Enhanced Generalist Revenue/OV $ 83

Lessons from the Medicos para la Familia Project n n Form follows finance Communities can address primary care needs without subsidy IF: n n Diagnostic and therapeutic procedures are bundled into the job descriptions of the physicians. Hospital services at the CAH level are included in the business plan. This means average risk deliveries. This business plan provides twice the services at half the cost. It is one possible solution for communities with uninsured and medicaid patients.

Procedural Skills in Family Medicine: An Opportunity for Excellence or Too Much Trouble? Wm. Mac. Millan Rodney, M. D. , FAAFP, FACEP Adjunct Professor of Family Medicine Meharry/Vanderbilt Medicos para la Familia Memphis and Nashville Website: www. psot. com

Lessons from the Medicos para la Familia-Private Practice n n n In all states and developing countries, surgical and procedural services increase quality of care and lower costs to community while funding the mission. Expanding your scope of practice is the best way to actually meet the entire family and understand the community. Mothers prefer receiving their healthcare in the same place as their children. Uninsured patients benefit from improved access at a lower cost. Without involvement with women’s health care at the point of delivery, many offices have fewer than 5% children’s visits. These are the most lucrative of the medicaid services in Tennessee. Generic medications address 95 % of needs Others

Total Charges and Two Reimbursement Scenarios for a University Teaching Practice 12 Consecutive Months 1997 Yearly Averages Service Unit Charge ($) Office Visits (n=30, 422) 60 HOSPITAL CHARGES Med/Surg/Peds(n=510)[ LOS 5 d] 423 Deliveries (n=252) 2300 Newborns (n=252) 198 Totals without Procedures Add Total Charges ($) Net Collections ($) 40% 80%_ 1, 815, 720 726, 288 1, 452, 576 215, 730 579, 600 49, 896 86, 292 231, 840 19, 958 172, 584 463, 680 39, 917 2, 660, 946 1, 064, 378 2, 128, 757 $250 k $536 k University policies are a major part of the problem Office overhead 80 % with billing outside the department Each MD = should see 6000 visits/year [24 daily x 50 weeks] but…… Office = 12, 000 square feet; 34 staff $25 k/year each+benefits

Real Revenue 2004 -Medicos n n Net Collections approximately Deliveries Office Procedures Limited Generalist Medicos n n $2. 5 million $597, 194 $ 239, 771 Office charges New-$70; est $60; child $40 Total visits 30, 048 Collected Approximately $ 1. 63 million Revenue per office visit $ 55

Real Revenue by Specific Services 2004 Medicos para la Familia-Memphis visits = 30, 048; Deliveries = 349 Annual Volume X-ray, ECG Skin Surgery Flex Sigs GI Endoscopy Colposcopy/LEEP Pregnancy Ancillaries(US, NST) Avg delivery collect $ 1487* Avg newborn care collects $71 Undelivered prenatal care visits $ collected 817/219 645 5 41 33 754/312 34, 720 75, 765 486 9, 512 3, 552 115, 736 349 259* 3893 $239, 771/year 518, 844 22, 387 55, 963 $ 597, 194 /year Open Access Model without nursing home; LGSIL = rpt Paps; Educational revenue priceless

The NEGATIVE impact of the limited generalist model (no procedures, no hospital) on the viability of Family Medicine J Am Board Fam Pract, May-June 2002; 15: 191 -200 Wm. Mac. Millan Rodney, M. D. Department of Family Medicine Meharry/Vanderbilt Alliance Nashville, Tennessee Ricardo G. Hahn, M. D. Department of Family Medicine University of Southern California

The Limited Generalist Data Part IV Suggested Some Directions for the Future of Family Medic 2006 -2016 n n n Understand that for each MD, the limited generalist model of family medicine loses at least $35, 000 per year in procedural collections and $60, 000 per year in Ob collections. MINIMUM Incentivize productivity. Physicians should receive $300 extra for each delivery and $700 for each Cesarean. The OB component sustained many other previously undescribed procedural services such as ultrasounds, circ, etc Insist on fiscal accountability. Despite an unfavorable case mix in Part IV of this study, gross collections increased to 59%. In the same state , University A obtained 32% and University B obtained 45%. Family Medicine needs to expect an equal share of revenue opportunities and better practice management.

The Limited Generalist Data Part IV Suggested Some Directions for the Future of Family Medic 2006 -2016 n n Define limits in accordance with community needs. Construct a business plan. Geriatric services were fewer in the 2004 bilingual practice, because demand caused the practice to focus on families with children. This practice is full. Develop open access to provide acute ortho, acute OBGyn care, and minor surgery services. This recaptures part of the heritage, and gives the physician a competitive advantage in overdoctored markets. Recolonize Emergency Medicine[shifts $50 -150/hour] and outsource your imaging Sell generic medicines at $20 a bottle for your uninsured patients.

Develop and Maintain Procedural Services in Community Medicine by realizing that: Teachers of physicians should be able to perform or manage most of the procedures discussed here. n Training for rural medicine been lost in the forest of generic primary care. It was not an accident. Form follows finance. n If publicly funded programs will not train the next generation, market forces will develop a private system of training. NPI is an example. n

Develop and Maintain Procedural Services in Community Medicine by realizing that: n n Generic primary care is procedurally destitute and unattractive to over 70% of young physicians. The students have spoken[repeatedly]. Learned helplessness is perceived as a problem. Most of the planet will be best served by a return to Family Medicine-er-ob as the foundation for a rational health care system. Procedural training and competence must be rewarded. These data demonstrate that financial rewards exist, and demonstrate that academic leaders need to address the negative impact of the limited generalist.

Data from the Memphis Project, 1989 -2009 Which Procedures (Services) Add Value? In the Average Group of 5 Physicians, Which Diagnostic and Therapeutic Procedures Make Sense? Wm. Mac. Millan Rodney, M. D. , FAAFP, FACEP Advanced Family Medicine Specialists Editor, Procedural Skills and Office Technology Bulletin Web site: www. psot. com