Physicians

An Open Letter to Primary Care Physicians

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Dear Doctor,

The future is in your hands.

You have the opportunity to make primary care better.

More efficient.
More accessible.
And more affordable.

We know you and other primary care doctors have more responsibilities than ever. But you also have great influence, along with the ability and opportunity to change this country’s health care system for the better.

Primary care is essential to the quality of health care, and we need you now more than ever.

Maneuvering the Minefield

According to research firm Harris Interactive, “the practice of medicine is … a minefield. … Physicians today are very defensive – they feel under assault on all fronts.’’* Harris questions, “how much fight the docs have left in them. Some are still fired up … while others have already been beaten down.’’

Those who feel frustration, anger and burnout say they are squeezed by administrators, regulators, insurance companies and more. They worry about the possibility of a lawsuit that could destroy your career.

The question is: What can be done about it? Some of you may choose to remain in the status quo. Some of you have chosen to retire early or otherwise leave the field of medicine entirely. Yet some of you have said enough is enough and found specific solutions that mark a pathway forward. You sought – and found – specific solutions that mark a pathway forward.

If you’ve rejected the status quo and joined your fellows in search of innovations from other practices that you have applied at home, congratulations. You’re a physician leader who’s doing great things for your patients, your colleagues and yourself. You are undoubtedly more satisfied in your work than before, and you are quite likely providing better care.

To those of you who aren’t sure of how to proceed, there is a way out. But you have to act.

First, take a look around at what some of the most highly functioning primary care organizations are doing. Whether your goal is to address access, flow, safety, staffing or other issues, know that these are issues that others have tackled successfully. The solutions to what ails your practice are out there.

To identify and adapt those solutions requires you to actively engage in the Learning Coalition, defined in The Doctor Crisis as “an organic gathering of people, organizations and activities that exist within the fabric of health care today … a dynamic coming together of physicians and other caregivers along with health plans, policymakers and patients with the core mission of turning the best work anywhere into the standard everywhere.”

Seek Out Examples

What does it mean to be an active participant in the Learning Coalition? It means getting outside your own walls and finding solutions in other places that you can apply at home. It means seeking out others who have done excellent work in primary care improvement. It means taking the time to understand what is out there and what might work best in your setting.

There are numerous examples of the power of the Learning Coalition throughout the country. Drs. Chris Sinsky and Tom Bodenheimer and their colleagues authored the Joy in Practice report, which identified 23 high-functioning primary care practices.** Sinsky et al are blunt in their assessment that “the current practice model in primary care is unsustainable.”

They recommend simple solutions that work. One example is proactively planned care with pre-visit planning and pre-visit laboratory tests. One primary care site Sinsky visited was not doing pre-visit planning. She told the team about the work being done at some other clinics and the team subsequently implemented pre-visit labs. “It decreased the number of phone calls for lab results 89 percent, decreased the number of letters sent out with lab results by 85 percent and decreased visits by 61 percent.’’

Dr. Bodenheimer, professor of medicine at the University of California-San Francisco, has conducted a good deal of work in this area and, as we noted in a recent blog post, he suggests that there are essentially two types of adult primary care practices: “bright spots” and “dark shadows.”

He defines the bright spots as having many of his 10 Building Blocks of Primary Care***:

  • Engaged leadership, Creating a Practice-wide Vision With Concrete Goals and Objectives
  • Data Driven Improvement Using Computer-based Technology
  • Empanelment
  • Team-based Care
  • The Patient-Team Partnership
  • Population Management
  • Continuity of Care
  • Prompt Access to Care
  • Comprehensiveness and Care Coordination
  • Template of the Future

How many of these building blocks are present in your practice? If your answer is “too few,” what can you/will you do about it? How do you shift from being in the shadows to becoming a bright spot?

The Learning Coalition is the answer. If you have the courage to stand up and lead, you will quickly find that identifying great practices from which to learn isn’t that difficult. Don Berwick, MD, former head of the Centers for Medicare and Medicaid Services (CMS) for the United States, puts it this way: “It’s not hard to describe the health care system we want; it’s not even hard to find it. … Among the gems and the jewels throughout our country… lie answers; not theoretical ones, real ones where we can go and visit these organizations and see how good they are.”

So, when we add these elements together, the pathway forward emerges:

  1. Step forward as a leader
  2. Identify problem areas within your practice
  3. Find practices that have done a nice job of solving those problems
  4. Learn from others
  5. Apply what seems like the best fit to your practice

Take comfort in the fact that whatever your most challenging issues are, there are practices out there doing it better than you are. Go out and learn from them. And if it doesn’t work entirely as expected the first time, go back, make adjustments and try again!

If your goal is to improve your practice, then what’s the meta-goal? We think Arnie Milstein, MD, at Stanford University describes it well. “We need to shrink that gap between top performers and all the rest by a lot,” he says. “Think about a race in the Olympics: the last sprinter in the 100-yard dash doesn’t finish two or three seconds after the leader, he or she finishes two- to three-tenths of a second after the leader. All Olympic sprinters are excellent. That’s what we need in medicine — everyone crossing the finish line on the heels of the winner.’’

Gary Kaplan, MD, spoke to a gathering of his Virginia Mason team soon after he became CEO 14 years ago. He looked at where Virginia Mason was at the time, and he looked into the future. Then he bluntly told his team: “We change or we die.”

What will you choose?

* Kaiser Permanente internal study, “US Physicians and the Language of Health Care Reform: Preliminary Findings from Qualitative Research and the SHP Physician Study,” November 2012.

** “In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices,” Annals of Family Medicine, May/June 2013.

*** Bodenheimer, et al, “The 10 Building Blocks of High Performing Primary Care,” Annals of Family Medicine, March/April 2014. 

Jack Cochran, MD, FACS, (@JackHCochran) is executive director of The Permanente Federation, headquartered in Oakland, California.
Charles C. Kenney is a former reporter and editor at the Boston Globe and author of several books on healthcare in the United States.

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Krystyna Szewczyk Szczech MDMandyDr. JohnLeslie Kernisan, MD MPHallan Recent comment authors
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Krystyna Szewczyk Szczech MD
Guest
Krystyna Szewczyk Szczech MD

Hello!
I am looking to make my practice more accessible and better. I would like to perform Dexa Scans and ultrasounds for tendons . It is almost impossible to find out if the services will be covered by major medical and Medicare, if performed in the office setting. Do I need to have Radiologist or only technician?, or I can do the tests after certain training?.
If anyone can help, I will really appreciate

Mandy
Guest
Mandy

Hello, readers of thehealthcareblog.com! I’m a research assistant from the Department of Psychiatry and Neurology at the University of California, San Francisco (UCSF). At the moment, we are researching how we can reduce suicide rates in primary care settings. If you are a physician, nurse practitioner, or a physician’s assistant in the United States, it’ll be great if you can help us fill out this 5-10 min survey! We already have about 120 responses for this study, but we’re hoping to get more participants for a more extensive study. Here is the link! http://www.surveygizmo.com/s3/1607736/PCP-Perceptions-in-Clinical-Care

Dr. John
Guest
Dr. John

Neither author is a primary care doctor. Enough said on that.

Dr. Bodenheimer’s list is interesting. But a lot of family docs, including me, don’t get enough sleep so will probably not be going down it.

We can’t solve the problems in primary care. Only the country can, by paying us a lot more money for a lot less work. This is not the direction thing are heading. Medical students have noticed.

Pretty words are pointless. I see no realistic plan in this article.

LeoHolmMD
Guest
LeoHolmMD

From the AAFP article: “Physicians in small practices have no negotiating leverage with health insurers, so insurers typically pay them much lower rates for their services than they pay physicians who practice in larger groups or are employed by hospitals,” wrote the authors. A fine example of how negotiating on the basis of “quality” is a completely empty farce. Insurers surrender patient values to be churned in large systems, ignoring the true value already blatantly obvious in the system of Primary Care. Why are we being discounted when we are already reducing medical costs and utilization? It’s time Primary Care… Read more »

allan
Guest
allan

You got it, but there is too much money and power concentrated in large systems. Not only that, but government likes to deal with a few large entities making both even more powerful.

The winners are the leaders of those systems along with their political supporters that rake off profits not from treating patients but from denying care while taking a percentage off of those that are doing the work.

Perry
Guest
Perry

I think we need to remember that whatever happens with healthcare, and with all the sweeping changes that are occurring, there are many different types of primary care personalities and practices that can have value for patients and for the nation’s healthcare in general. One size does not fit all.

Charles Kenney
Guest
Charles Kenney

Perry thanks for the link to the AAFP post, Extremely interesting stuff. Money quote:

“Specifically, the authors of “Small Primary Care Physician Practices have Low Rates of Preventable Hospital Admissions” found that practices with one to two physicians had 33 percent fewer preventable hospital admissions compared with practices with 10 to 19 physicians; practices with three to nine physicians had 27 percent fewer admissions.”

This is must read I think especially related to the question of what is it small practices have that produces such results.

Rob would be vy good to hear from you on this.

Leslie Kernisan, MD MPH
Guest

Very interesting post and thread. Re the HA article on small practices, my guess would be that how long a patient has been in the practice is a very important factor, and that this is a big driver of “people knowing each other better in small practices”. Most small practices that I know are well-established and have been staffed by the same docs for 10+ years. (Nowadays, docs don’t go setting up small practices unless they are direct-pay, like mine.) And many of the patients have been there for years. This means they have a good relationship with their PCP,… Read more »

Perry
Guest
Perry
allan.
Guest
allan.

Excellent, Perry!

“But could it be that these small practices have something large practices don’t? That’s the big question, according to Ryan.”

Yes! Small practices know they will be awakened at night and on the weekend if things aren’t handled before 5:00PM especially on Friday.

Charles Kenney
Guest
Charles Kenney

Great link — must read.

LeoHolmMD
Guest
LeoHolmMD

Thank you. Knowing your patients and stability are unheralded as the quality that patients are really looking for. It is unbelievable to see so many forces working against a model that has been successful for so long.

Jack Cochran, MD
Guest

Thank you all for joining in this very important and complex conversation and honoring these tough messages. We are getting deep into reality for many and the content and passion of these responses are critical. Yes, the patient’s role, behavior, and responsibility will always be a source of complexity. Yes, the role, behavior, and responsibility of the hospitals and specialists will always be a source of complexity. Sinsky and Bodenheimer are early adopters of the linkage of professional career satisfaction to patient centered excellence of care delivery. While they don’t have all the answers they have helped “start the conversation.”… Read more »

LeoHolmMD
Guest
LeoHolmMD

“Do you wait to change the way you deliver care until the manner in which you are paid changes? Or do you make a bet that quality care — the triple aim — will be rewarded/paid for in the future?” How many times should we get burned in one career with carrots that vaporize as soon as you reach them? There are plenty of physicians practicing value based care right now. They are known as “underutilizers” and they are being acquired by larger systems who can operate Primary Care at a loss. As Peter1 suggests, your job is going to… Read more »

Ron
Guest
Ron

Scott – calling the ACA (which is the law) the “Government Health Care Bill” is so 2013 of you…

Ron

@BobbyGvegas
Guest

“AHIPcare”

JEB
Guest
JEB

I can think of no other industry that exists today where a valued and (becoming) rare service is so poorly compensated. As PCP’s we are told time and again how critical we are to a well-functioning medical system, yet our salaries are not reflected by these comments. As soon as the powers-that-be stop with the lip service, put their money where their mouth is and financially recognize that primary care docs are the bedrock of medicine in this country and compensate us at the same rate as specialists, NOTHING will change. And no–creating more primary care training programs is NOT… Read more »

Peter1
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Peter1

“put their money where their mouth is and financially recognize that primary care docs are the bedrock of medicine in this country and compensate us at the same rate as specialists” JEB, better start with your own profession – they’re screwing you. http://www.washingtonpost.com/business/economy/how-a-secretive-panel-uses-data-that-distorts-doctors-pay/2013/07/20/ee134e3a-eda8-11e2-9008-61e94a7ea20d_story.html Frankly I don’t want to pay PCPs the same as specialists, I want to take pay from specialists and give it to PCPs. The “same pay” argument just keeps your colleagues mollified, it does not help us with costs or better care. Rob has a good alternative, for those who can afford the club membership. Most complaining… Read more »

@BobbyGvegas
Guest

“I’d like to see PCPs paid salary with benefits and pension, then they could concentrate on patients – all patients”
__

Mayo model. But, just TRY to get an appointment.

Peter1
Guest
Peter1

Sure Bobby, I’m guessing it’s the exception not the norm in that area? Try getting an appointment with Rob as well, especially when he maxes out on needed patients. Here in Chapel Hill NC my wife is having a terrible time getting an independent PCP as well – no salary here. Of course there seems no problem with hospital based PCPs from the Duke and UNC systems which are popping up clinics everywhere. They charade as PCPs but are really feeding the hospitals with referrals and the usual expensive lab and imaging tests. I think we could get more (smart)… Read more »

Perry
Guest
Perry

” They charade as PCPs but are really feeding the hospitals with referrals and the usual expensive lab and imaging tests.”

This is a very important point. By the time many PCPs attempt to adapt to the changing times, they will find it easier to go the “corporate route”, which does nothing to decrease costs.

“I think we could get more (smart) poor and inner city kids to become PCPs if we recruited and paid for their education, then made them spend 10 years in their neighborhood area as pay back”

An excellent idea.

Granpappy Yokum
Guest
Granpappy Yokum

“I think we could get more (smart) poor and inner city kids to become PCPs if we recruited and paid for their education, then made them spend 10 years in their neighborhood area as pay back.”

If they’re smart enough to go to med school, it’ll take them about 30 seconds to realize that a 300k education scholarship is wiped out in two-three years by the pay discrepancy between PCPs and specialists.

Charles Kenney
Guest
Charles Kenney

JEB I completely agree but how do we get there?

JEB
Guest
JEB

Charles I have been saying for some time to my colleagues that the sure sign of a true paradigm shift in health care will be when you begin to see the income gap between specialists and PCPs begin to narrow considerably, ie., specialist income is being transferred to PCPs. Until this happens, there will be only cost shifting but no actual “health” care vs “sick” care taking place and our broken, backwards system will continue. And how to get there? It starts with reconfiguring the group who advises Medicare on what should be charged for certain procedures/treatments. Right now, that… Read more »

@BobbyGvegas
Guest

“What the system has done is forced physicians to behave in ways that they don’t want to behave,” he says. “No medical student goes to become a doctor to become a businessperson, but the system is so dysfunctional today that it has created this business mentality among doctors.” Jauhar says the system needs to be fixed to accommodate the needs of more ordinary patients. “The system is wonderful if you have a rare disease or if you require very high-tech care, but if you’re a run-of-the-mill patient who has a chronic disease that needs to be managed by multiple doctors,… Read more »

LeoHolmMD
Guest
LeoHolmMD

That is your path forward?
Step up, like yourself and network?
All this cloud talk is going to get us nowhere.
JF is right. Help get the economics straight, or get back on the hamster wheel and help us out.

@BobbyGvegas
Guest

I keep waiting for JF to not get it right. Still waiting. As far as HC “economics,” they continue to look like Gould’s “Drunkard’s Walk.”

Joe Flower
Guest

For many responders, this post (like many) is just one more Rorschach blot test. They see what they are primed to see. Some take it as another opportunity to rail against Obamacare (which the post does not mention). Others take it as another opportunity to rail about the requirements of the official definition of the patient centered medical home (which the post does not directly mention or recommend). Yes, it is an idealistic call to action. But its central point — that primary care physicians are critical to any better future for healthcare, and that to make that difference they… Read more »

allan.
Guest
allan.

” that primary care physicians are critical to any better future for healthcare”

They are and if they want to advance the cause of Medicine and their patients they have to recognize that most of the stuff mentioned has little evidence and little to do with the practice of medicine except for the generalizations made. The specifics we are all too frequently hearing are promotions or advertisements and should be looked at as such.

Charles Kenney
Guest
Charles Kenney

Joe you make the critical point about payment. You write: “We cannot expect them to act differently until and unless they get paid differently.” In a way I think this gets to the heart of the matter: Do you wait to change the way you deliver care until the manner in which you are paid changes? Or do you make a bet that quality care — the triple aim — will be rewarded/paid for in the future? I do not suggest that this is an easy choice but if you look at the survey results from McKesson (I noted them… Read more »

John Irvine
Guest

How truthy of you …