The Future of Family Practice, Quality Improvement

The current information is from a lecture given on September 8, 2007 by Kent Bottles, M.D. He is the Vice President and Chief of Iowa Health System and a well known futurist. Dr. Bottles was asked to speak to the MOA board. An MAOFP representative was invited to attend.

Family Practice is undergoing change. Patients, insurance companies and governmental agencies are pushing for proof of high quality, safe, cost-effective care. Insurance companies are collaborating to obtain quality improvements. Reimbursement levels will be tied to reduction of variation in delivery of care, documentation of quality, and future use of internet technology. The focus will be on chronic illness management, population and community health management .

Ignoring the quality initiative can affect the physician in more ways than just reimbursement. The court system has begun to look at failure to adopt and implement clinical protocols as possible negligence. In January, 2007 a Texas appellate court ruled that a lawsuit could proceed based on hospital failure to implement protocol, stating that hospitals have a duty to pursue quality.

On August 5, 2007 the New York Times noted that cutting payment to the physicians would not solve the cost crisis in medicine because physician salaries comprised only 20% of the total national health care spending. Half of this percentage was for practice expenses, leaving only 10% attributed to physician pay.

In the future, physicians must expect constant review and publicity about their ability to deliver quality, as well as safe and cost-effective health care. Reimbursement will be tied to these issues, striving for a reduction of the variation in care delivery.

Medical practice will place more emphasis on chronic illness management, with the evolving Medical Home concept. Physician offices will build care giving teams to allow more patient support and interaction. This will be reimbursed.

More importantly, medicine is expected to evolve into understanding the wisdom of using protocols. These protocols are based upon expert consensus of organizations expected to keep current on changing environments.

Difficult conversations are of three types. In a “what happened” conversation the assumption is that someone was at fault and that no further information is needed. In the “feelings” conversation one party’s feelings are assumed to be irrelevant and the other party wishes to avoid talking about these feeling. In the “identity” conversation the goal is to protect the competent or incompetent image that the speaker is trying to portray. To defuse the difficulty of the conversation, the “what happened” speaker needs to explore the story from the other’s standpoint and assume that both parties have contributed to the result through the combination of their actions. To defuse the difficulty of “identity” conversations, assume that there may be a lot psychologically at stake for both speakers .

Transparency involves making all decisions in public, with all information available for review. The problem with transparency is that there is confusion about charges, administered prices, negotiated prices, and discounts.

Good networks require members with diverse environments, and that these members spread ideas and information to connect different parts of society. Members do not have to be leaders. These networks share a collective pool of knowledge and insight.

After we move to a different understanding of these concepts, we are ready to move into the future. We can then measure, learn from and eliminate variation arising from professionals.