Physicians

What’s Behind Today’s Primary Care Crisis? You Don’t Know the Half of It

By BOB WACHTER, MD

If you’ve ever been on a diet, you know that it really helps to keep a food log. Seeing your consumption chronicled in one place is illuminating – and often explains why those love handles aren’t melting away despite two hours on the treadmill each week.

In today’s issue of the New England Journal of Medicine, internist Rich Baron chronicles the work of his 5-person Philadelphia office practice during the 2008 calendar year. Rather than “Why am I not losing weight?”, Rich’s study aims to answer the question, “Why does my work day feel so bad?” The answer: an enormous amount of metaphorical snacking between meals.

In the NEJM study, Rich (who is a dear friend – we served together on the ABIM board for several years) found that each of the physicians in his practice conducted 18 patient visits per day (a total of 16,640 visits over the year for the practice). That’s not an unmanageable workload, you say. You’re right, but that was just the appetizer. On top of these visits, daily each physician also:

  • Made 24 telephone calls
  • Refilled 12 prescriptions (a vast underestimate of the daily refills, since a) the number reported in the study doesn’t count refills done during an office visit, and b) the study counted the act of refilling 10 meds for a single patient as one refill)
  • Wrote 17 e-mails to patients
  • Looked at 11 imaging reports, and
  • Reviewed 14 consultation reports.

A little math tells us that, beyond what happens during the 18 patient visits, the docs perform nearly 80 acts of data exchange and review each day. After Rich’s practice analyzed this workflow, they re-defined a “full-time physician” as one with 24 scheduled visit-hours per week, embedded in a 50 hour work-week. In other words, docs in Rich’s practice can expect to spend half their time on office visits with patients, and the remaining half on non-visit paper/computer/telephone work.

This wouldn’t be such a big deal if – like attorneys – primary care doctors billed out their time in six-minute aliquots, or by activity. But PCPs aren’t paid that way – the office visit is ostensibly the only billable event in the life of the practice (except when they buy and use an office ultrasound or treadmill – small wonder that so many PCPs do just that). The Catch-22 is obvious and tragic: the incentives drive PCPs to maximize office visits, while both patients and “the system” clearly benefit from these non-visit activities.

A few weeks ago, I asked Rich how he’d overhaul the payment system in light of his office’s experience. “I would favor a DRG-type payment based on age, gender and diagnosis,” he wrote me, adding that CMS has considered such a model as part of its Medical Home demonstrations, but it hasn’t gained much traction.

But payment reform won’t be enough – the NEJM study demonstrates the necessity of comprehensive practice redesign. In fact, after seeing these data, Rich’s group hired an RN whose job is “information triage” – managing the mountains of lab reports, consult notes, and phone calls.

Ultimately, the work of primary care must be greased by a superb ambulatory electronic health record (EHR). Rich told me that, while his office is far more computerized than the average practice, it is still not quite there. The ideal EHR, he writes, would

understand the ‘data aggregation’ task we face: when I refill a prescription, there are predictable pieces of clinical data I need, and there could/should/must be a way to present those ‘automatically’ upon entering into the refill work. Our EHR does a fair amount of this – it does show last refill date conveniently but not relevant lab data or problem lists (even as it does show body-mass index and body surface area). Someone wanting to do this re-design would need to follow one of us around for a while to figure out what we actually do.

Without question, creating a higher “value” – better quality at lower cost – healthcare system will depend on having adequate primary care capacity. (So too will caring for tens of millions of newly insured patients under health reform.) Unfortunately, the trends point in the opposite direction: the primary care infrastructure is collapsing and very few trainees are choosing careers as primary care docs (can you blame them?). Creating the primary care workforce and capacity we need will require a deep understanding of today’s practice environment, which makes Rich’s study essential reading for those concerned about the future of American healthcare.

Robert Wachter, MD, is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.

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22 replies »

  1. All you doctors who are refilling medicines by email for 30 times without seeing the patient better call your medical boards and tell them the need to issue you your new license without any documentation for the next 30 times. I expect they will want to talk to you either way. Better check their website for their position statement on prescribing requirements and seeing the patient. Even better, tell your defense attorney you will testify by email.

  2. “…I fear that the changes to move delivery to a more reliable and value oriented arrangement…”
    Are we still talking about Walmart here, or about health care and medicine? I’m starting to get very confused…..

  3. Maybe we don’t know the half of it. Is the other half:
    1) evidence research?
    2) safety audits and improvement programs?
    3) practice design projects?
    4) performance/operating measurement, reviews?
    In other words, where is there time to make a practice a practice let alone a better and better one…in their microsystem as well as with their peers across the care spectrum.
    The strong feelings and attitudes here are artifacts of fragmentation and isolation. Physicians by and large have worked themselves to the bone and haven’t, unfortunately, had the time (nor the training) to explore a wide world of organizational, financial, operational and–most importantly–leadership practices to change towards the good. Heck, its hard for even those who spend a career on it. In the absence of integrating ideas, people, and practices, I fear that the changes to move delivery to a more reliable and value oriented arrangement (through things like capitation, paying on performance, quality, & other accountability measures) will bring about very unproductive reactions: walk-outs, etc.

  4. “insurers should pay for the time to provide these valuable other services”
    Quick economics lesson Anonymous, insurance premium is claims cost, plus taxes, plus overhead etc. Your $5 refill fee you just wanted to pass on to your insurance company now cost you $6 in premium. Do you think maybe it wouldn’t make a little more sense to take the insurance company out of it an pay the $5 directly?

  5. A variation of the above:
    “To hear some patients talk of the way they access health care, they should be receiving care at WalMart so they can get the cheapest rates and expect the most lavish services concurrently, and make the doctors feel like they should feel blessed to be available at patients’ beck and call, be shamed if they don’t quickly fix the human conditions, and be cursed for any sins by the physician.”
    Is it me, or if I interpret what I read Anonymous to be implying above, he/she hasn’t seen the physician for 30 refills of meds? And who do you think will be sued in a heartbeat if Anonymous has a negative event while having a script filled without responsible follow up? And who’s fault is it, the patient’s, or doctor’s? If you said both, you get to see what is behind the curtain! Tell ’em what they’ve won, Don Pardo!
    It ain’t immortality!!!
    Colleagues, do you read this attitude here?! At another posting they are trying to equate WalMart practices with health care?! Is this how dumbed down Obamacare has made health care to look?!
    Hey, you write the stuff, commenters!

  6. As I understand it, primary care doctors in the UK earn more than their U.S. counterparts. They are paid a fixed amount per month for each patient on their panel. On top of that, they can earn a substantial bonus based on how they perform on 146 separate metrics. Electronic records are critical to gather and analyze the data needed to determine the bonus compensation. Finally, the system allows doctors to eliminate some patients from the list used to determine bonus compensation for a variety of reasons including non-compliance. Up to 5% of patients might be excluded.
    Primary care lends itself better to capitated payment than other parts of healthcare. The UK has shown the way on pay for performance as well. I think there is a lot we could learn from studying their approach for possible implementation in the U.S., at least once we have the necessary electronic records capability.

  7. I love the image of Warren Buffet as a non-emailing, primary care physician. Although Warren might have made a great doctor, I’ve picked another doctor who is willing to refill my maintenance medication prescription (for the 30th time in a row) via email. Charge me $5 for a refill, fine (insurers should pay for the time to provide these valuable other services.) But I’m not paying (nor should insurance), pay $80, leaving work, and waiting in an office for an hour just to fulfill a refill request.
    Doctors are in the service business, but many of them don’t know it. To hear some doctors talk about their business, it sounds like they’re holding confession and think their patients should feel blessed and thankful for the opportunity to wait in line, feel shame for their human condition, and be cured of their sins.

  8. Here is one instance of how outcome should impact someone and it could work. My wife’s dental filling came out in a year. As per the insurer they will not pay for same tooth in less than 2 years. As per them old dentisit should guarantee and refill it. The old dentist refuses to do anything with that. Now our outcome is not a predicted or modelled outcome. It’s a real outcome based on quality of work.
    The only thing I can do is to maybe rate the dentist poorly. First of all I don’t see proper website with good visibility to rate him. The one I see ask me questions which have nothing to do with outcome. It’s about staff courtesy, appointment time and all other unrelated stuff. And finally it doesn’t even leave one proper texb box for me to describe what I wanted to say.
    Unless we get active patients we will not get very far. There are some active patients though. Next, the active patients also need to be supported well. I am surprised why insurer’s don’t support active patients better.

  9. Margalit, I agree (as all who appreciate the complexity of medicine do) that our ability to pay on the basis of outcomes is limited. My 50-50 proposal couldn’t be instantiated in the next few years responsibly. But there is no reason to think with computer modelling and EHRs we couldn’t do it well enough in the future to make it more than worthwhile.
    An hourly wage has some advantages over FFS, though if the institional structure exists to pay on this basis, in many (most? nearly all?) cases it will also exist to pay a monthly wage (i.e. a salary). Part time jobs pay part time wages. But I’m all for experimenting with different models to move away from FFS. No reason it has to be one size fits all.

  10. It seems a way too much for one doctor to do all the activities mentioned. I thought they had support staff to do a lot of the stuff mentioned here.
    My kid’s doctor is really good and take phone calls, after hours as well, really patient and mostly gets her diagnosis right. I feel bad that she doesn’t get paid for that another not so responsive doctor earns same monet as she does. I guess the only favor I do for her is spreading good word about her practice.
    Since it is all about cost control, it’s best handled with caramel coating of quality and outcomes, somehow paying a few higher and most other lower. Once the model is established it may not be necessary to pay most lower as better results have to lower overall cost.
    I find it a bit socialistic to pay all doctors same regardless of their competency.

  11. I completely agree with… “I’m not sure we can measure outcomes correctly, particularly in small practices with not enough patients. Second, outcomes are not entirely dependent on the doctor.” The P4P movement is severely misguided.
    The payment model in Denmark appears to be well accepted by physicians. The primary care practices are largely privately owned, and there is a fee for services regardless of whether it is email, phone or face-to-face. Physicians are additionally given a PPPM. A small bonus is available, of which I am not clear on the details. I was under the impression the bonus payment based on “performance” measures was low, and there were measures of patient satisfaction included. It is my prediction that the PCMH models that succeed in the U.S. will be very similar to this. In Denmark, there is over 90% physician satisfaction. The PCMH model in the U.S. could largely reproduce this, if (big if) physicians can adapt quickly enough.
    Physician acceptance will follow the pattern as Moore describes in Crossing the Chasm (http://en.wikipedia.org/wiki/Crossing_the_Chasm ). My concern is less that most physicians will adapt, because they will as long as it is a win for them and their patients. My concern is if the rate of physician adaptation can be rapid enough considering the demoralization and skepticism they have (and for good reason). There will always be a vocal class of laggards.
    My greater concern with the transition to value-based payment systems is that the current power elites in the healthcare system will succeed in promoting ACO models that are not founded on PCMH principles. This will fail, and I encourage physicians to oppose these vigorously.

  12. I don’t know about outcomes, jd. First of all, I’m not sure we can measure outcomes correctly, particularly in small practices with not enough patients. Second, outcomes are not entirely dependent on the doctor.
    I still think that paying largely by time increments is most equitable and it is closer to the salary model that you seem to prefer. Maintenance should be paid by health status and you could always have bonuses for quality measures, but they shouldn’t be too significant or non compliant patients will be avoided.

  13. Exhausted,
    1) I’m a PhD, not an MD. I made clear in previous posts that I work in managed care now, not on the provider side.
    2) I have never earned as much as $130K in a year.
    3) I don’t know what you mean by a “fallback.” Sure, I could do something else. As an MD you have fallbacks as well.
    4) Congratulations on instantiating Godwin’s Rule.
    5) I read Ayn Rand in high school and was a fan for a while, but was able to see the cardboard characters for what they were by about the age of 20 and moved on. The Ellsworth Toohey’s, Floyd Ferris’s and whatnot are charicatures. If those are the kinds of people you think you’re arguing against, on behalf of the Dagney’s and Hank’s, you are an idiot.
    6) I agree with you that going to a straight capitation model is a mistake. I don’t know why you think I or anyone is advocating this. A mixed capitation model, with maybe half the payment based on a flat rate for manageement and half based on outcomes, can work. Ideally, as I mentioned, we should go to a salaried model. The hyperbole you engaged in about deafening silence and rationalizations is based on nothing. No one wants what you accuse us of wanting, nor are we moving towards it.

  14. Sorry, but it is worth the risk of being banned to put the jds in their place: you are the Chamberlains of a crisis that, while is not the best analogy of the attempted sell out of Britain to the Nazis, you doctors who just want to cave to this intrusion by governmental control are pathetic! And making $130K a year for the past 5 years as a full time doctor is not wealthy, you presumptive jerk, and in fact I would hazard to guess you have your cushy fall back, so you don’t really care if you have to give up clinical care responsibilities, if you have any at all now!
    Mock those of us who are being harsh and challenging, just you wait readers, who will have to come to depend on the jds and others who sell you this rosy future of governmental controlled health care, focused solely on costs first, and care probably not even second. Go back and find my Ayn Rand quote I have given here in past postings, and realize the jds are the end of it, “and even moreso for those who do not care!”
    See what capitation does to the thinking process by doctors who succumb to it. And watch those who just believe that progress has to fully give in to costs. Yes, that has truth to it, but what will technology firms conclude once the taxation kicks in? When you watch someone who could have possibly benefitted from a breakthrough, but both your government and physician lackey said no because, well, the money has to go to someone else’s pocket. That is the truth to this legislation. And again, I am not advocating for the status quo. But, will the defenders admit to what they are advocating for? The silence is deafening once the pontifications and rationalizations have been exposed.
    We just won’t go away to let the lie be sold further.
    Deal with it!

  15. Randall, if MDs Hell and Exhausted are any indication, your worries that the physician community is not ready to switch from a volume-based to a value-based system are well-founded. It will take 20 or so years before all the dinosaurs go.
    To read these wealthy people with deeply ingrained senses of entitlement, about which they are oblivious, complain about how unfair their reimbursement is and about the sense of entitlement that their patients (customers) have is, frankly, disgusting. I have to restrain myself from getting into nasty fights with them every time they gush forth with their narrow self-interest couched as wisdom.
    Even someone pretty far to the right, like Nate, sees the problem with complaints about reimbursement that serve no purpose other than putting more money in the pocket of the wealthiest occupations in the nation outside of Wall Street. Not that Bob W is nearly as bad as our two upper income malcontents.
    We can pay you more if you manage to use that money to do a better job at keeping other costs down while improving the quality of care and the health of populations (at the very least, doing no worse). There is no good reason (economic or moral) to pay a dime more for primary care otherwise.
    Doctor complaints about payment so often amount to a case of the top 5% looking at how the top 0.5% live and feeling like they’ve been cheated. And their strategies to get more necessarily take mostly from the other 95% earning less than them.
    The majority of us take a salary with bonus payments and raises based on performance. It seems to work quite well when it is tried in medicine. If integrated systems are too hard to pull off in the near future, then some combination of per capita and outcomes based payment will have to do. The sooner we can get to a system like this, the better. We are going there. The writing is on the wall. I wonder how much longer our malcontent MDs rail against it.

  16. Care has to be built on meaningful relationships. When we have the tools to deliver real care coordination at the point of care the only logical place to have that coordination function is in the hands of the person doing comprehensive care, and again, this is stronger and more powerful in a relationship of trust. In order to be meaningful this relationship has to support the longitudinal and comprehensive care of patients. But in all of this, there needs to be accountability and it need to be done down at the coal face of the doctor patient relationship in the face of a caring relationship. Comprehensive, continuous, patient centered personal and holistic primary care which is based on strong relationships between patients and their physician — this is foundational to good health. Practice and payment reform are the prescriptions for achieving it. PCMH and ACO are the emerging mechanisms for reform. No matter how well-intended, if the current power elites (hospital systems, payer derived networks, etc.) remain in control, the emerging ACO projects will simply fail. PCMH/ACO must be the same thing… the view from the top down, is the same. from the bottom up. If we try and make them two different items, we fail.
    I encourage physicians to get more involved, and only support initiatives that best serve their patients.
    Perhaps there might soon be opportunities for physicians to chose to play a role other than the victim? The system is about to change from volume-based to value-based, and I have concerns that the physician community is not going to be there to respond appropriately.

  17. To Dr Kakutani:
    Uh, yeah, I do look at things from a patient’s point of view, because I have been a patient, and practice what I preach as a doctor, and that is DON’T WAIT UNTIL THE LAST MINUTE FOR REFILLS, make sure when you are in the office you come in with a list of issues and concerns and make sure the doctor is privy to it at the beginning of the visit, and realize that paperwork is not our immediate agenda, and god knows I do not work for any lawyer or court, so when legal documentation is at hand, BE PREEMPTIVE AND PRESENT IT IN A TIMELY FASHION, and if the attorney screws up and forgets to pursue it until the last minute, then let the attorney pay someone for the urgent paperwork.
    It is that simple, the MD As Hell docs like him and me are not being insensitive, we are setting limits. Frankly, to be challenging him, all you are doing is aiding and abetting this quick fix mentality and instant gratification bs too many patients now expect, not request.
    It is time doctors take into account we are under-appreciated, and this health care reform debacle will just enhance the demise to light speed. And I am not just disappointed, but disgusted to read colleagues agreeing with inappropriate mind sets created by non-providers. You took a Hippocratic Oath, not a priestly one, and there is a difference! Step back and reappraise, please!

  18. Here are my problems with this article:
    “Our staff included four medical assistants, five front-desk staff, one business manager, one billing manager, one health educator (hired midyear), and two full-time clerical staff. Our staffing ratio was approximately 3.5 full-time support staff per full-time physician.”
    The biggest expense in any practice is payroll. The amount of non billable staff in this clinic seems excessive.
    The other problem I have is that the article has no details on actual revenue and net revenue. So are these docs saying that their revenue is too low, or are they just describing the office workflow?
    If the former, I would suggest employing two NPs and cutting down on front office and other clerical staff. A lot has been said about economies of scale if docs practice together instead of in solo practices. Looking at this practice, if they were to split into 4 solo offices, the ratio would be about 1:4. That’s too much.
    I am not surprised that docs do more than just visits, and it is interesting that none of the items listed are mindless paperwork. Everything seems to be clinical work.
    The FFS the way it is set up now, does provide higher reimbursement for complexity, but I think it would be much cleaner if visits were based on time spent only, and an additional layer of payment would be added for maintenance, based on DRG. So a 15 minutes visit will have two components, a flat per minute rate and a DRG rate. One of the reasons docs are rushed, is that time spent is not a significant component of the payment (most of the time).

  19. If I still owned a PPO my first question would be what are you asking for? Even as a payor and designer of plans I still have no idea what PCPs want?
    18 visits a day in a 24 hour subset in a 50 hour week works out to 16 minutes per patient for the exam. Are you saying you want to stretch that to 20 minutes and do more preventive care without losing revenue? That comes out to 14.4 visits a day. Or are you ok with 18 visits but just feel you need to make another $15 per visit because you don’t feel fairly compensated when your at the country club with your specialists friends?
    The ramifications of either answer are obvious. In most cases I don’t have any sympathy for your financial situation, your still doing better then me, my clients, and their employees. Now if you’re claiming you could deliver a better product and reduce cost if we paid you for 18 visits when you only do 14.4 that would be an entirely different conversation.
    Plan sponsors are intelligent people for the most part who one way or another manages to keep their businesses running. If you come to them and say I can save you 5% off your healthcare cost with a 25% increase to my reimbursements that would get people’s interest. If the Average exam is reimbursed at $60 and we wanted to keep compensation the same we would need to pay $75. While as a percentage it is high, in the $3000+ PEPM average annual cost perspective that is nothing.
    Before I agree to pay you 25% more how do I know your going to spend that extra 4 minutes with patients and do the work to lower total cost? So far I haven’t seen PCPs stepping up willing to be held accountable.
    DRG does nothing for me, I don’t see how it does anything at the PCP level to improve care, in fact by improving health you would actually be reducing you revenue. I want to pay for service or results, not for just being there. FFS with expanded reimbursement for email and other services, with access to said emails, I’m not paying $10 for you to ask how my members date was last night, or capitation. Ideally I would like laws changed so PCPs and other low dollar low risk specialties can accept capitation outside an HMO license.
    Most employers want stability and predictability. If we are paying $40 PMPM for primary care that accomplishes both those goals. It also removes us from the PPO BS game, my plans can pay $40 PMPM for the PCP of the members choosing, the doctor and the member can sit down and settle on how much the doctor is going to charge monthly, if he is a great doc and thinks his time is worth $55 a month and the member is willing to pay the $15 difference who am I to get in the way of that? If the member knowing $40 PMPM of his benefit money is going to that doc and he doesn’t feel the 3 hour waits and 5 minute visits are worth it then he can choose a new one.

  20. MD as Hell–Do you ever think about these issues from a patient’s point of view? Is it reasonable to ask people with stable problems who have been seen in the last 1-2 years to take 2 hours out of their day just to get a refill? Is it reasonable to expect people to come 3 or 4 times for follow up when phone calls or email could accomplish the same thing? Do you ever read about other high performance healthcare systems where primary care is not only relevant but saving the system money? Start with Denmark, you may learn something.

  21. Warren Buffett does not use email and neither should a doc.
    No refills without a visit. That is exactly why there are prescription drug laws and why the doc has a license. Medical boards require face to face encounters and proper documentation.
    Adding overhead in place of adding productivity is stupid, as will the EHR boat achor we all get to but and make it play like a Stradivarius.
    But the real reason primary care is dead is because it is irrelevant. The primary care doc or whatever has no standing in court to defend an action. You must bring in “expert” witnesses to defend not sending the patient to a specialist.
    Primary care and all of healthcare is not worth the money spent because it is not the patient’s money; it is not valuable to them. They certainly would not buy it with their own money.
    But there is no shortage of appetite for either free cheese or free healthcare.

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