(This is the fourth in a series of excerpts from Terry’s new book, Physician-Led Healthcare Reform: a New Approach to Medicare for All, published by the American Association for Physician Leadership.)
Many other countries’ healthcare systems outperform ours for one simple reason: They place a much greater emphasis on primary care, which occupies the central place in their systems. “The evidence is that where you have more primary care physicians, where you coordinate care, and where you pay to keep people healthy, you get better outcomes at lower cost,” says David Nash, MD, founding dean of the College of Population Health, part of Thomas Jefferson University in Philadelphia.
The evidence that Nash mentions includes studies by Barbara Starfield and her colleagues at Johns Hopkins University. In a 2005 Health Affairs paper, they showed that a higher ratio of primary care physicians to the population is associated with a lower mortality rate from all causes and from heart disease and cancer; in contrast, having more specialists in a particular area does not decrease the overall mortality rate or deaths from cancer and heart disease.
Another study of Medicare data found that states where a higher percentage of physicians were PCPs had higher quality care and lower cost per beneficiary. This factor alone accounted for nearly half of the variation in Medicare spending from one state to another. A separate study found that in the areas of the country that had the most primary care providers, the average Medicare cost per beneficiary was a third lower than in areas with the least PCPs.
One reason for this is that primary care doctors provide comprehensive, continuous care, including preventive and routine chronic care. Chronic illnesses drive 90% of health costs, and some studies show that intensive primary care can reduce ER visits and hospital admissions and improve the health of chronically ill people.
Meaningful Use was a vision for EMRs that in many ways turned out to be a joke. Consider my list of Meaningful U’s for medical providers instead.
When electronic medical records became mandatory, Federal monies were showered over the companies that make them by way of inexperienced, ill-prepared practices rushing to pick their system before the looming deadline for the subsidies.
The Fed tried to impose some minimum standards for what EMRs should be able to do and for what practices needed to use them for.
The collection of requirements was called Meaningful Use, and by many of us nicknamed “Meaningless Use”. Well-meaning bureaucrats with little understanding of medical practice wildly overestimated what software vendors, many of them startups, could deliver to such a well established sector as healthcare.
For example, the Fed thought these startups could produce or incorporate high quality patient information that we could generate via the EMR, when we have all built our own repositories over many years of practice from Harvard, the Mayo Clinic and the like or purchased expensive subscriptions like Uptodate for. As I have described before, I would print the hokey EMR handouts for the Meaningful Use credit and throw them in the trash and give my patients the real stuff from Uptodate, for example.
I’d like to introduce an alternative set of standards, borrowing the hackneyed phrase, with a twist. MEANINGFUL U’S for medical providers:
He cancelled his followup appointment because he was feeling fine. He didn’t see the point in wasting a Saturday to come to my clinic when he had lawns to mow and chores to do.
Less than two weeks before that he was sitting on the exam table in my office, again and again nodding off, waking up surprised every time his wife prodded him. The stack of printouts from the emergency room illustrated all the normal testing they had done.
He had experienced a brief episode of numbness in the left side of his face and felt tired with just a slight headache. When I saw him the headache was a bit more severe in the back of his head and down the right side of his neck. But his neck wasn’t stiff.
His blood sugar was 87, normal for most people, but this man had a history of diabetes although his blood sugars had steadily improved over the past year. I told him to stop all his diabetic medications although I don’t think he took notice. His wife said she would make sure he stopped them.
The Smithsonian National Museum of Natural History has reported its biggest number of visitors in more than 2 ½ years. There’s a string of new Broadway musicals that are well-attended every night. It’s safe to shop in malls, eat out in restaurants and go to movie theaters again.
Of course, this has all been made possible by an effective vaccine against COVID-19 that was widely administered in the fall of 2021. Vaccinated citizens of the world are now confident that it’s safe to go out in public, albeit with appropriate precautions.
However, U.S. residents who have health problems are facing a new challenge. Five years ago, in 2017, the median wait time of new patients for doctor appointments was six days. In 2022, the wait time is six months or more.
The reason for this is no mystery. While life has started to return to what we think of as the new normal, the U.S. healthcare system has taken an enormous financial hit, and primary care practices have been especially affected. Many primary care physicians have closed their practices and have retired or gone on to other careers. Consequently, the shortage of primary care has been exacerbated, and access to doctors has plummeted. Urgent care centers, retail clinics and telehealth have not filled this gap.
Because of the long waiting times for primary care appointments, many more people now seek care in emergency departments (EDs). The waiting rooms of these EDs are overcrowded with people who have all types of complaints, including chronic and routine problems as well as emergencies. And this is not just a common sight in inner-city areas, as it once was; it’s now the same pretty much everywhere.
Healthcare today, in the broadest sense, is not a benevolent giant that wraps its powerful arms around the sick and vulnerable. It is a world of opposing forces such as Government public health ambitions and more or less unfettered market ambitions by hospitals and downright profiteering by some of the middlemen who stand between doctors and patients, such as insurers, Pharmacy Benefits Managers, EMR vendors and other technology companies.
Within healthcare there is also a growing, more or less money-focused sector of paramedicine, promoting “alternative” belief systems, some of which may be right on and showing the future direction for us all and some of which are pure quackery.
I stand by my conviction that physicians must embrace the role of guide for their patients. If we see ourselves only as instruments or tools in the service of the Government, the insurance companies or our healthcare organizations, patients are likely to mistrust our motives when we make diagnoses or recommend treatments.
Today, primary care is considered the bee’s knees of value-based care delivery. Instead of being viewed as the punter of the football team, the primary care physician (PCP) has become the quarterback of the patient’s care team, calling plays for both clinical and social services. The entire concept of the accountable care organization (ACO) or patient-centered medical home (PCMH) crumbles without financially- and clinically-aligned PCPs. This sea change has resulted in rapid employment or alignment to health systems, as well as a surge in venture capital being invested into the primary care space.
Before we get too far in the weeds, let’s first begin with the definition of primary care. The American Academy of Family Physicians (AAFP) defines a primary care physician as a specialist typically trained in Family Medicine, Internal Medicine, or Pediatrics. Some women do use their OB/GYN as their PCP, but these specialists are not traditionally considered PCPs. Now if you’ve gone to your local PCP and noticed that your care provider is not wearing a white coat with the “MD” or “DO” credentials, you are either receiving treatment from a hipster physician, nurse practitioner (NP), or physician assistant (PA). Two of the three professionals are trained in family medicine and can provide primary care services under the responsibility of an associated PCP. At least one of the three has a beard.
The crazy thing is, despite the industries heightened focus on the importance of PCPs, we’re still expecting a shortage of primary care providers. In April 2019, the Association of American Medical Colleges (AAMC) released a report estimating a shortage of between 21,100 and 55,200 PCPs by 2032. Given we just passed 2020, this not that far off. The primary reason for the shortage is the growing and aging population. Thanks mom and dad. Digging into the numbers will really knock your socks off, with the U.S. Census estimating that individuals over the age of 65 will increase 48% over that same time period. Like a double-edged sword, the issue is not just on the patient demand side though. One-third of all currently active doctors will be older than 65 in the next decade and could begin to retire. Many of these individuals are independent PCPs who have resisted employment by large health systems.
The Primary Cares Initiative provides new value-based payment models aiming to enhance the delivery of primary care to promote efficiency and quality while decreasing healthcare costs. In the second part of this two-part series, we explore how eConsults directly support this new initiative across several key metrics.
The Primary Cares Initiative aims to enhance the delivery of primary care through value-based payment models. In Part One of this two-part series, we broke down the five payment models offered through this initiative, including two performance-based models (Primary Care First) and three risk-sharing plans (Direct Contracting). Alongside previous programs such as Patient-Centered Medical Home (PCMH), the Comprehensive Primary Care (CPC+) program, and the Medicare Advantage Value-based Insurance Design (VBID), the Primary Cares Initiative represents the most recent push for enhancing primary care within health care systems.
as programs such as these continue to emphasize primary care providers as a
locus of optimal care, the question becomes: how can primary care providers (PCPs)
best work within initiatives such as these to enhance care delivery efficiency
and effectiveness, and what kinds of services and technologies can support this?
Swedish Healthcare seemed competent but a bit uninspired and rigid to me but my medical school class trip to the Soviet Union showed me a healthcare system and a culture I could never have fully imagined in a country that had the brain power and resources to have already landed space probes on Mars and Venus by the time my classmates and I arrived in Moscow in the cold winter of 1977.
The first time we sat down for breakfast at two big tables in the restaurant of the big Россия hotel near the Red Square, our two male waiters asked if we wanted coffee or tea and people started stating their preferences. The waiters shook their heads and put their hands up in the air. No, they couldn’t split the beverage order, they explained. We had to all decide on one beverage with no substitutions.
The restaurant obviously had both coffee and tea, and as far as I know, they cost about the same. The only thing standing between the tea drinkers and their favorite morning beverage (the coffe crowd won the popular vote) was convention and attitude. I don’t know if this was a policy set by the hotel management or a complete lack of service-mindedness by he staff, but my classmates and I felt as if we, the customers, did not matter.
In April 2019, the Centers for Medicare & Medicaid Services (CMS) announced the Primary Cares Initiative, which is expected to reduce administrative burdens and improve patient care while decreasing health care costs. Learn more about the Primary Cares Initiative and its proposed value-based payment models in part one of this two-part blog series.
While the health care landscape has never been static,
rarely has it seen such radical changes as it has within recent decades. The
population of the United States continues to age, and the prevalence of chronic
conditions such as obesity, diabetes, heart disease, and anxiety or depression contribute
to a substantially increased demand for care. These factors are pushing a shift
from a provider-centric model toward more efficient outcome-based models that
put the patient at the center and heavily rely on primary care as the steward
of patient care.
Primary care is a vital resource in dealing with the many factors altering the health care landscape. A 2019 study published in JAMA Internal Medicine found that for every 10 additional primary care physicians (PCPs) per 100,000 people, patients saw a 51.5-day increased life expectancy.
To promote further adoption of primary care-based models, the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) recently announced a set of payment models meant to further transform primary care through value-based options under the new Primary Cares Initiative. This voluntary initiative will test financial risk and payment arrangements for primary care physicians (PCPs) based on performance and efficiency, including five new payment models under two paths: Primary Care First (PCF) and Direct Contracting (DC). These models, slated to hit 20 states in 2020, seek to address the many difficulties in paying for, and incentivizing, valuable primary care within current payment models.
In learning my third EMR, I am again a little disappointed. I am again, still, finding it hard to document and retrieve the thread of my patient’s life and disease story. I think many EMRs were created for episodic, rather than continued medical care.
One thing that can make working with an EMR difficult is finding the chronologyin office visits (seen for sore throat and started on an antibiotic), phone calls (starting to feel itchy, is it an allergic reaction?) and outside reports (emergency room visit for anaphylactic reaction).
I have never understood the logic of storing phone calls in a separate portion of the EMR, the way some systems do. In one of my systems, calls were listed separately by date without “headlines” like “?allergic reaction” in the case above.
In my new system, which I’m still learning, they seem to be stored in a bigger bucket for all kinds of “tasks” (refills, phone calls, orders and referrals made during office visits etc.)
Both these systems seem to give me the option of creating, in a more or less cumbersome way, “non-billable encounters” to document things like phone calls and ER visits, in chronological order, in the same part of the record as the office notes. That may be what IT people disparagingly call “workarounds”, but listen, I need the right information at the right time (and in a place that makes sense to me) to make safe medical decisions.