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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BenBarry CarolAnonymousVikram Cjd Recent comment authors
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MD as HELL
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MD as HELL

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.

Margalit Gur-Arie
Guest

“…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…..

Ben
Guest
Ben

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,… Read more »

Nate
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Nate

“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?

ExhaustedMD
Guest
ExhaustedMD

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?… Read more »

Barry Carol
Guest
Barry Carol

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… Read more »

Anonymous
Guest
Anonymous

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.… Read more »

Vikram C
Guest
Vikram C

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… Read more »

jd
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jd

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).… Read more »

Vikram C
Guest
Vikram C

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… Read more »

Randall Oates, M.D.
Guest

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… Read more »

Margalit Gur-Arie
Guest

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.

jd
Guest
jd

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… Read more »

ExhaustedMD
Guest
ExhaustedMD

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… Read more »

jd
Guest
jd

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… Read more »