Building Better Metrics: Invest in “Good” Primary Care and Get What You Pay For

flying cadeuciiIn 1978, the Institute of Medicine published A Manpower Policy for Primary Health Care: Report of a Study (IOM, 1978) where they defined primary care as “integrated, accessible services by clinicians accountable for addressing a majority of heath care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” The four main features of “good” primary care based on this definition are: 1. First-contact access for new medical issues, 2. Long-term and patient (not disease)-focused care, 3. Comprehensive in scope for most medical issues, and 4. Care coordination when specialty referral is required.  These metrics ring as true today as they did many years ago.

Estimates suggest that a primary care physician would spend 21.7 hours per day to provide all recommended acute, chronic, and preventive care for a panel of 2,500 patients.  An average workday of 8 hours extrapolates to an ideal panel of 909 patients; let us make it an even 1000 to simplify.  A primary care physician could easily meet acute, chronic, and preventative needs of 1000 patients, thereby improving access.  Our panels are much larger due to the shortage of available primary care physicians and poor reimbursement which keeps us enslaved.  Pay us what we are worth and then utilize this “first-access” metric to judge our “quality.”

Hippocrates said “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” Primary care physicians excel at knowing their patients. Continuity of care and long-standing treatment of families within the larger context of the community is our raison d’etre. Numerous studies have confirmed accessible, comprehensive, and integrated primary care is associated with better clinical outcomes and lower costs.  Track how long our patients have been with us as yet another reimbursable measure.

The significance of enduring patient relationships at small practices cannot be overemphasized; our practice has had more than 3 dozen families for 46 years, which is older than one of the physicians (me) at my two-physician practice.  The Commonwealth Fund in 2014 found an inverse relationship between practice size and preventable hospital admission rates, precisely because we know our patients better. Practices with one or two physicians had preventable hospital admission rates that were 33% lower than practices with 10-19 physicians, and practices with 3-9 physicians had a reduction of 27% comparatively.  CMS plans to bonus large practices with more than 100 physicians because they believe “bigger is better.”  What on earth do you think their preventable hospital admission rates will be?  Likely more than twice the rate when compared to small, but mighty solo or two-physician practices.

A third worthwhile metric would be evaluating whether primary care physicians are able to provide comprehensive care to meet the majority of medical needs.  A study by the Robert Graham Center evaluated 3,652 physicians and 555,165 Medicare patients and found that patients of physicians who provided a wider range of services experienced fewer hospitalizations and incurred lower health care costs.  Costs were reduced by 10-15% and patients were 35% less likely to be admitted to the hospital when physicians could provide comprehensive care.  Dr. Kevin Grumback, who wrote a commentary accompanying the study, said “This probably trumps any other innovation in terms of reducing Medicare costs.”  Increasing health care costs have far outpaced economic growth for many reasons; relying on specialists to meet a wider scope of health needs has undoubtedly contributed to increasing expenditures.  As a pediatrician, Obamacare plans refused to reimburse me for cauterizing an umbilical granuloma because the procedure was considered too specialized.  Any mammal with opposable thumbs can treat an umbilical granuloma. What is the purpose of this narrow-minded short-sightedness?
Studies have demonstrated preventive services are delivered more efficiently and cost-effectively by primary care physicians.    Primary care physicians order fewer tests than specialists and help protect their patients from inappropriate and unnecessary care resulting in significant reductions in health care expenditures. Even when costs are calculated for treating common conditions, such as pneumonia, specialty care is more expensive compared to primary care and patient outcomes are no different.  Metrics should reward us for utilizing the full breadth of our skillset.

Finally, primary care physicians should coordinate care when specialty referral is required.  This is one of the largest drivers of redundant evaluations and testing.  Records without critical interoperability, specialists are starting fresh with each new patient and often repeat testing unknowingly due to inept communication.  Physician to physician conversation is paramount; primary care physicians need sufficient reimbursement for the work and time involved.  This would allow for a more focused, efficient evaluation by the specialist and reduce spending.

If primary care physicians were paid what they are essentially worth, there would be more of us to go around and health expenditures would decrease substantially.  The physician workforce in the United States is currently 80% specialty, 20% primary care.  Over a 40-year medical career, the income gap is 3.5 million, on average, between a primary care physician and a specialist.  Increasing by one primary care physician per 10,000 people, decreases mortality by 5.3% thereby avoiding 127,617 deaths per year in the U.S.  Payment methods must better reflect the value of services provided by primary care physicians especially in small practice settings. Reimbursement for conversation and less for testing and procedures results in the right kind of care.

Building better metrics is about incentivizing delivery of superior quality health care.  Small practices are the first point of access for many underserved populations.  Increasing the number of primary care physicians compared to specialists would control escalating costs, but our income must reflect our work.  The physician-patient relationship is a tremendous therapeutic force.  Business entities must recognize that power of relationships built over decades in small practice settings and harness it.  We are clearly worth our weight in gold; isn’t it time for those in power to recognize our value?

Niran al-Agba, MD is a physician in Washington State.

11 replies »

  1. You are right. Money talks. CMS and their narrow focus on large corporations and hospitals will result in increased mortality rates. Maybe when infant mortality falls low enough to be on par with the most underdeveloped nations in Africa, people will finally stand up and do something about all this.

  2. Niran, I don’t know about CMS, but our legislators know all about the old school approach. When they are on the campaign trail they talk about it with fondness, but the old school approach diminshes the value of the large corporations such as insurers, hospitals and pharmaceutical companies. Legislators don’t make deals with those having the old school approach because there is little donation money available and there is always an election around the corner.

  3. Dr. Holm- thank you for your comments. I completely agree. We rural docs provide solid, comprehensive care to our patients. Until reading about #unicornjess and her untimely death with conditions we treat frequently, I didn’t realize how much our patients benefit from our old school approach. It’s too bad CMS believes they have all the answers. They could learn a lot from one day in our bustling clinics.

  4. Very concise and powerful post. Thank you. CMS continues to believe it will dream up a better idea of what already exists right under their noses. Find success and reward it. Seems simple. Rural independent primary care has had, and always will have the answers. Time to stop destroying it.

  5. Thank you for your comment. I like that quote… you might see it again in another article I am writing about the importance of CARING RELATIONSHIPS in medical care. Thank you for reading.

  6. The Sir William Osler version of the quote, attributed above to Hippocrates, seems better to me. Both are a reminder of our profession’s illustrious forerunners: deep connections to caring relationships. To be precise, a CARING RELATIONSHIP can be defined as a variably asymmetric interaction between two persons, over time, who share a BENEFICENT intent to enhance each other’s AUTONOMY by communicating with warmth, non-critical acceptance, honesty and empathy. Empathy represents the ultimate attribute of all human capabilities.
    Paul Nelson, M.D.

  7. Agreed MommyDoc, both of these guys were instrumental in starting all this mess, perpetuated it even though it was obviously failing, then got out and now use their past positions of power to get special favors on regulatory activity for their companies. That is VERY dirty in my book, yet somehow accepted. i HIGHLY doubt their mission is anything buy genuine in them making money on the backs of hard working MDs. Obviously, I am less forgiving of them. May have been the biggest mistake of all to have ONC leaders that NEVER participated in the programs that they were burdening other MDs with…that is criminal in my book. HITECH MU PQRS now MACRA MOC ICD10 this relentless pursuit to burden MDs with these massive regulatory hurdles and burdens has damaged the profession more than anyone realizes at this point. We will look back at this decade as a very dark period, no matter how ONC and CMS tries to spin it.

  8. It is a damn shame. My only problem with these two guys in the article you linked is they set us up for this mess and now as venture capitalists, they are going to profit from its failure. I do hope their mission is more genuine this time. Thank you for reading.

  9. Thank you for the compliment on MommyDoc 🙂 I agree with everything you said. Data is NOT care. Period. We know the communities we are a part of and we know the people. It is so very important that some of our small practices survive and we are not penalized out of existence. It is indeed the little things that make “great” primary or specialty care what it is. I will keep writing, hoping that someone in the government or insurance industry pays attention to the kind of care we provide. I know without a doubt, the care you and I are describing would turn the entire health care industry around for the better. Thank you for reading and commenting.

  10. As an orthopaedic surgeon, I get to see all types of “primary care”. The patients that are well care for are obvious, first of all, they know their primary care MDs name. What do I mean by that? Not a day goes by that I hear my doctor is at the Cleveland Clinic. No name, just a huge factory facility. Or I have never seen my new one, my old one I had for a few months left and now I have a new doctor, not sure their name. Or they are shuffled among many primary care providers, no quarterback. It boggles my mind that CMS feels that value is found in mega-group, factory medicine. As you stated, there is no data to support it. But what they DO get out of monster practices is DATA. Those practices can afford to hire people to data entry all kinds of meaningless stuff that CMS thinks will somehow save a buck. When my partner and I left academic practice and started our own practice 15 years ago, we decided NOT to jump around to many locations, NOT to go to many hospitals. Just be available at one location, and one hospital. Our patients know where we are and we are here all the time. We know our referring primary care MDs. We know the community. We know the culture. We feel that is the foundation of building a great practice. We also custom built our own EHR so we can follow what WE feel are important measures, and appropriate workflow. Even small things, like if a patient’s family calls that a patient of ours has passed, we just don’t click a “deceased” box, the system forces the MA to leave the MD a message about this so we can contact the family as needed. We want to know. Its all the tiny small things that make small practices the real valuable quality medical care in the US, whether they are primary or specialty offices. We should not be marginalized nor penalized out of existence. I do believe that primary care MDs should be paid much better for their work, but not at the detriment of paying anyone else less. It should be from the tremendous savings that would occur if everyone that makes a nickel of my practice including insurance companies, American Board of Ortho and all other medical societies, hospitals, big pharma, Health IT companies, registries where I have to report PQRS/MACRA, for me to do more onerous unnecessary work like all the unnecessary preauth, bill denials/complications, clawbacks, RAC audits, complicated regulatory action that makes cottage industries…the expense is in that. Not in how I care for my patients. I do love your posts MommyDoc. Keep them coming!