Transcript Established Technology Tends to Persist in the Face of New

Medicos—Eliminating Barriers to Family Planning:
Hysteroscopic Tubal Occlusion without Anesthesia
Wm. MacMillan Rodney MD, FAAFP, FACEP
Professor and Chair, Medicos para la Familia
Memphis, Nashville, and International
Editor, American Journal of Clinical Medicine
American Board of Family Medicine Obstetrics
WONCA 2010; Cancun, Mexico; Presenting
The Family Medicine Obstetrics Curriculum and Data
Medicos: A New Training Model Successfully
Expanding Health Care Services at a Lower Cost.
Eliminating Barriers to Family Planning: Hysteroscopic
Tubal Occlusion without Anesthesia
Transfer of Technology Projects
A Mission Hospital Simulation in Tennessee-Medicos
Minor Surgery, Urgent Care, and some ER
skills were reengineered for the FP office
Diagnostic services: ECG, Xrays, ultrasound,
and lab tests reengineered for the FP office
Cancer Prevention and Early Diagnosis--Lab
Colposcopy 1984, Electrosurgery and cryosurgery
came with this procedure. Hysteroscopy 1995, 2009
GI Colonoscopy/ EGD/ENT endoscopy 1981 onward
Family Medicine Obstetrics with immediate
access OB-Gyn Ultrasound 1999.
Medicos para la Familia Project
Was established as a training center in 1999. By this time
University-based Family Medicine had not maintained its
heritage in comprehensive care, and was an unlikely
career choice for medical students here and abroad.
Medicos utilized data from the Transfer of Technology
Project 1979-present. See website for “Procedural Skills
and Office Technology” www.psot.com
Retained hospital privileges for physicians with an
emphasis on prenatal care and delivery of babies.
Medicos provides data on health care services apart form
the selection bias of university hospitals. Medicos is built
upon family medicine to create training more consistent
with community needs.
Became self sustaining through reimbursable services
without charitable support.
Colpo, Cryo, Ultrasound Services
Medicos para la Familia-Memphis
Family Planning Options—
Psychosocial Considerations
Condoms, abstinence—Better than nothing
Birth Control Pills—requires compliance
IUD’s[Mirena cost in USA over $350]
Nuva Ring[rare], Norplant extinct
Diaphragm [rare]
Tubal Ligations—need OR time
Fallopian Tube Occlusion by Hysteroscopic
insertion of 4cm microinserts
Medicos Office Equipment 2009
Hysteroscope Cost $12 000+
Tubal Occlusion Without
Anesthesia
Microinserts $700 each
Requires 6 week preop with
DepoProvera 150 mg IM
Medicos--iphone photos
intraoperative for record
The protocol for Hysteroscopic
Sterilization by Essure
Remember your heritage as a family physician.
Hysteroscopic sterilization requires multiple visits
following the sequence of counseling, consent,
DepoProvera, Essure, DepoProvera, HSG, and the
possible need for additional procedures.
Psychosocial barriers may preclude the operation. The
process of informed consent is complex in the USA.
Mental illness and mental disabilities are more common
than we thought in Tennessee. Even if they signed a
paper, be prepared ……….
Be aware of costs to the patient, and plan for
followup.
Hysterosalpingogram[HSG] for
Conclusive Proof in USA
Schedule for 3 months
postop; Patient must use
alternate method
pending confirmation.
Other countries use
pelvic xray and or
ultrasound as proof.
HSG cost in USA varies
$400-1500.
Area of Ongoing
Research
The First 50 Cases Medicos over
12 months
Total tubal occlusions attempted
50
Could not place[gave IUD]
1
Initially malpositioned but successfully replaced 2
Returned for any kind of followup
Returned pregnant[never followed up]
Received HSG[1 still patent at 3 m]
Paid something[5 pending]
Denied payment for incorrect admin
Total payments
Total Cost Devices+Equipment
26
1
22
42
3
$62,806
$84,643
Medicos Obtains postop and 3m
pelvic radiographs--$30 each
Postop confirmation with
Ultrasound $100; Ecuador $15
Unexpected Lessons
Physicians who fail to identify psychosocial
problems will live to wish they had spent
more time with the patient.
To avoid financial loss , government and
insurance regulations must be understood
and followed perfectly in the USA.
Physicians must be involved in health care
economics and the financial stewardship of
their charges and collections.
Chance favors the prepared mind.
Fluid Management is
Necessary..No fluid was draining
Family Medicine Obstetrics-Questions for Future Study
In our experience many women
have previously undetected Gyn
and psychosocial issues which
may affect this procedure.
Here is a preop ultrasound
demonstrating a small amount of
free fluid in the cul de sac.
Most of the original research
ignored or excluded pre-existing
comorbidities such as pelvic pain,
PID, ovarian cysts, etc.
Psychosocial barriers and/or
subclinical mental disabilities
prevent HSG followup in over
50% of cases.
Financing the Mission Through
Expansion of Services
Medicos where 10 percent of the information
creates 90% of the difference.
References vital to financing the mission[see
www.psot.com]
– Rodney WM, Hahn RG. Enhancing the family medicine curriculum
in maternity care (OB) and emergency medicine to establish a rural
teaching practice. Fam Med Dec 1998; 30:712-719.
– Rodney WM, Hahn RG. The impact of the limited generalist (no OB,
no procedures, no hospital) model on primary care training and
practice. J Am Board Fam Pract 2002; May-June 15:191-200.
– Rodney WM, Martinez CM, Chiu KW, Garcia RL, Carson G. Prenatal patients
not delivered: Unplanned events, uncounted services , and risks.[Delivery
volumes at one office in Memphis] Am J Clin Medicine Spring 2009; 6[2]:
31-36.
Untabulated Indirect Revenue
Office visits for Family
Planning prior to Essure
Medroxyprogesterone
injections
Pregnancy tests
Well woman visit-Paps
Pelvic ultrasound
Pelvic Xrays
Other health care
credibility as a home
N=100
Approx $600
N=100 Approx $1000
N=100 Approx $70
N=50
Approx $800
N=10
Approx $ 950
N=10
Approx $300
Priceless opportunity to
defragment care
The First 50 Cases Medicos over
12 months
Total tubal occlusions attempted
50
Could not place[gave IUD]
1
Initially malpositioned but successfully replaced 2
Returned for any kind of followup
Returned pregnant[never followed up]
Received HSG[1 still patent at 3 m]
Paid something
Denied payment for incorrect admin
Total payments
Total Cost Devices+Equipment
26
1
22
42
3
$62,806
$84,643
Transfer of Technology Projects
A Mission Hospital Simulation in Tennessee-Medicos
Minor Surgery, Urgent Care, and some ER
skills were reengineered for the office
Diagnostic services: ECG, Xrays, ultrasound,
and lab tests reengineered for the office
Cancer Prevention and Early Diagnosis
Colposcopy 1984, Electrosurgery and cryosurgery
came with this procedure. Hysteroscopy 1995, 2009
GI Colonoscopy/ EGD/ENT endoscopy 1981 onward
Family Medicine Obstetrics with immediate
access OB-Gyn Ultrasound 1999.
Medicos para la Familia
Un Modelo para Medicina Familiar
En las montanas de informacion, hay una
colina de conocimiento. En la colina de
conocimiento hay granos de sabiduria.
En el USA 2010, los financieros son duenos de
los hospitales y los hospitales son duenos de
las residencias y entrenemiento.
A los orgullosos le sigue la destruccion. A las
altanerias el fracaso. --Proverbios
www.psot.com [email protected]
Medicos—The Defining Dozen
Finance your personal and
professional needs
Build a team -sustain staff ,
equipment, computers-emr
Primary Care-outpatient
Med Peds, Paps, Family
Planning, Dispense meds
Emergency Care ACLS,
PALS, NRP, ALSO, CALS
– Open Access 7d/week
Hospital Privileges
Prenatal and Obstetrics
– 24/7, 365
Office x-rays
Office Ortho, Fractures
Office lab
Waived[strep, preg, UA,
glucose, HgbA1c
CBC=CLIA
Office ultrasound
Office surgery
Trauma, lacerationS
Biopsies, aesthetics
Gyn, colpo, hysteroscopy
IV sedation/analgesia
The Transfer of Technology
will continue