THCB

Categories

Tag: primary care

I Wish My Doctor Knew …

• 3

By NIRAN AL-AGBA, MD

flying cadeuciiRecently the New York Times published an article What Kids Wish Their Teachers Knew. As a pediatrician, I have spent a good part of my lifetime fighting for the health and welfare of our young people. They are the future. We owe our children a safe, caring, stable childhood whenever possible. Outside of a supportive family, a long-term family physician or pediatrician can be an important role model for impressionable youngsters.

For confidentiality reasons I have altered identifying details, but will give you some of the great things heard over the years and a few tragic ones as well.

I Wish My Doctor Knew… there is not enough food at home. Many years ago, I was seeing twins for a yearly checkup and giving them shots when one, older by 4 minutes, blurted out there was not enough foods to eat at night when she was hungriest. I contacted the school counselor to ensure both children were offered free breakfast and lunch at school. They were added to the program sending home a backpack full of food every weekend. At Thanksgiving, this family received one of the donated dinner baskets with turkey, mashed potatoes, and all the trimmings. The children grew better and crossed percentiles in the positive direction; their grades improved as an added bonus.

Continue reading…

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

• 11

By NIRAN Al-AGBA, MD

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.”

Continue reading…

A Comprehensive Strategy For Primary Care Payment Reform in Medicine

• 16

By MOSTASHARI,  KOCHER and McCLELLAN

farzad_mostashariStrengthening primary care has been a core goal of health care payment reform over the past several years. Primary care physicians are the cornerstone of the health care delivery, directing billions of dollars of follow-on care. With better support, the models presume, primary care doctors could guide their patients toward a better health, direct them to the right care when needed, and in so doing, bring down unnecessary medical costs. Moreover, especially if coupled with payment reforms that can support better coordination with specialist practices, these reforms can provide an alternative to health system employment and health care consolidation, thus buoying competition in local markets.

The most recent effort toward this goal lies at the heart of the recently announced Comprehensive Primary Care Plus (CPC+) program. This program doubles down on the kinds of “medical home” payment and delivery reforms that were the hallmarks of previous Medicare initiatives, most notably the Comprehensive Primary Care Initiative, which in its first two years showed significant improvements in some dimensions of quality – but so far has generally failed to show reductions in overall costs significant enough to offset the per-member per-month (PMPM) payments to primary care practices to support their reforms. While some medical home payment reforms have shown both savings and outcome improvements, overall results have been mixed particularly in Medicare, with the result that the CMS actuaries have not yet “certified” any such medical home model as leading to overall spending reductions.

Continue reading…

Patient-Centered Service

• 13

By ROB LAMBERTS, MD

flying cadeuciiAmerican healthcare has a customer service problem.  No, customer service in the US is terrible when it comes to healthcare.  No, the customer service in the US healthcare system is horrendous.  No, healthcare has the worst customer service of any industry in the US.

There.  That seems about right.

What makes me utter such a bold statement?  Experience.  I regularly hear the following from people when they come to my practice:

  • “You are the first doctor who has listened to me.”
  • “This office makes me feel comfortable.”
  • “I didn’t have to wait!”
  • “Where’s all the paperwork?”
  • “Your office staff is so helpful. They really care about my needs.”
  • “This is the first time I’ve been happy to come to the doctor.”
  • “It’s amazing to have a doctor who cares about how much things cost.”
  • “You explain things to me.”
  • “You actually return my calls.”

Continue reading…

Competing With Urgent Care

• 11

By MARC-DAVID MUNK, MD

Screen Shot 2015-01-02 at 8.08.19 AMAbout seven years ago, the California Healthcare Roundtable and HealthAffairs sat down to prepare a white paper on the emerging “phenomenon” of urgent care centers, and what it might mean for primary care. At the time the group couldn’t agree that urgent care was a “disruptive” innovation, but it seemed clear to all participants that it represented a threat to primary care: The rise of UC, the group noted, would lead to 1) less preventive care and 2) concentrate acuity in primary care clinics. They wrote: “[Urgent care] means fewer patients per day, a higher intensity environment for providers, and potentially lower reimbursement.”

In particular, the group couldn’t understand if patients were choosing to leave primary care because they didn’t value having a PCP, or if they were settling for the inherent limitations of UC because cost and convenience outweighed its disadvantages.

 Seventy-five percent  [of UC customers] are women ages 28 to 42 and their children. Some hypothesize that this consumer group thinks of its health care relationships differently than do people of the baby boomer generation and older. The younger cohort often has no “medical home,” while baby boomers and older people tend to view the primary care physician as the center of their medical care. Discussants concurred that what the data do not reveal, however, is whether the medical “homelessness” of this younger group and its high relative use of retail clinics reflect how these consumers want to receive their care or is instead merely their experience (or is a function of the fact that they have fewer chronic conditions and thus need less care and care coordination).

Since the roundtable in 2007, there has been a flood of urgent care centers with ongoing rapid growth. The American Academy of Urgent Care estimates that there are around 9300 UCs nationally. Across the country, clinics are sprouting like flowers, sometimes fueled by private equity investors, but often by hospitals and health systems who are reflexively installing UCs in repurposed strip malls, sometimes without a clear strategy other than “keeping market share” in an otherwise low margin business.

The reasons for growth, according to the American Academy of Urgent Care? Primarily extended hours (as compared to primary care) and better wait times and lower prices than the ED.

As the private-equity fueled urgent care bubble expands, here’s my prediction on how this all plays out: Don’t bet the farm on UCs being the final answer to the consumer’s search for value. For all of UC’s utility, it’s also possible that urgent care may just get out- maneuvered by the next generation of primary care.

Continue reading…

A Doctor is a Doctor is a Doctor, Right?

• 5

HANS DUVEFELT, MD

flying cadeuciiI am a foreign born, foreign trained doctor, serving many patients from an ethnic minority, whose native language I never mastered.

So, perhaps I am in a position to reflect a little on the modern notion that healthcare is a standardized service, which can be equally well provided by anyone, from anywhere, with any kind of medical degree and postgraduate training.

1) Doctors are People

No matter what outsiders may want to think, medicine is a pretty personal business and the personalities of patients and doctors matter, possibly more in the long term relationships of Primary Care than in orthopedics or brain surgery. Before physicians came to be viewed as interchangeable provider-employees of large corporations, small groups of like-minded physicians used to form medical groups with shared values and treatment styles. The physicians personified the spirit of their voluntary associations. Some group practices I dealt with in those days were busy, informal and low-tech, while others exuded personal restraint, procedural precision and technical sophistication. Patients gravitated toward practices and doctors they resonated with.

Continue reading…

Primary Care Physicians Need To Be More Like Financial Advisors

• 18

By TOM VALENTI

Screen Shot 2014-11-05 at 9.10.30 AM

Man looks into the Abyss, and there’s nothin’ staring back at him. At that moment, man finds his character, and that’s what keeps him out of the Abyss. – Lou Mannheim (Hal Holbrook) in the movie “Wall Street”

We hear reform ideas all the time: primary care physicians need to work at the top of license, physicians need to work in teams, healthcare must deliver top-notch customer service, the focus needs to be on creating strong physician/patient relationships, and physicians need to be paid for delivering value.

The question then becomes: how does the healthcare industry implement such ideas?

I believe it would be smart to apply the lessons from other industries.

Specifically, the financial services industry.Continue reading…

Solving the Primary Care Shortage

• 6

By RICHARD GUNDERMAN, MD

GundermanOne of the top students at one of the nation’s largest medical schools, Ishan Gohil has made an unusual – and to many of his colleagues – inexplicable decision.  Instead of seeking to train in one of medicine’s most highly specialized and competitive fields, he says, “I elected to pursue a career in family medicine.”  Many view his choice of primary care as ill-advised, largely because family medicine is one of the least competitive fields and ranks at the bottom for income of all medical specialties.

Until his third year, Gohil had planned to pursue orthopedic surgery, which is considerably more difficult to get into than family medicine.  In 2014, the average score on Step 1 of the US Medical Licensing Exam for students entering family medicine was 218, while for orthopedic surgery it was 245 (the overall average is 230).  Average annual salary levels diverge even more widely, at $122,000 for family physicians and $488,000 for orthopedic surgeons.Continue reading…

Innovation, Primary Care Style

• 7

DAVID HARLOW

Andrew Morris Singer PCP

On a recent evening at Harvard Medical School, the Primary Care Innovation Challenge and Pitch-Off ,sponsored by WellPoint’s American Resident Project, brought together six finalists, primary care luminaries and trainees, and a host of hangers-on and camp followers for a couple of hours of demos and discussions. The tenor of the evening, which was in many ways a pep rally for primary care – not that there’s anything wrong with that — was best captured by the rhetorical question posed by Asaf Bitton to the primary care practitioners and trainees in the hall, “Are you going to be a playwright or a critic?”

The hoots and hollers in response made clear that these are not your grandfather’s primary care docs. The call to action was echoed by many of the speakers, notably community organizer turned primary care physician Andrew Morris Singer and Dennis Dimitri, both advocating for, well, advocating for primary care.  Bitton’s opening also included the exhortation that proved to be predictive of the winner of the top honors from among the six pitches: Innovation in primary care is not about the technology; it needs to enable better human care.

Continue reading…

Waiting For Payment Reform?

• 40

By CHARLES KENNEY and JACK COCHRAN,  MD

Jack CochranThe Health Care Blog recently featured our Open Letter to Primary Care Physicians,generating quite a bit of reaction. A commenter made the point that “we cannot expect” primary care physicians “to act differently until and unless they get paid differently.” [Emphasis added]

The comment refers to a doctor in solo practice and notes that “the first step is changing how you are paid, in one way or another. And there are many ways that work better than the current code-driven fee-for-service model.”

Does waiting for payment reform make sense? Or should primary care practices act now to change the way they practice in anticipation of payment shifts?

Moving Toward Value-based Care

Some physicians groups seem somewhat frozen – unsure exactly where health care payment is headed and thus waiting until there is a clearer signal.

But it seems to us that the payment reform signal grows louder and clearer and support for that contention comes in a recent research report* from McKesson, the international consultancy:

We can now say with certainty that healthcare delivery is moving in one direction: towards value-based care.

This is care that is paid for based on results – on measurable quality – as opposed to the traditional fee-for-service approach that pays for volume. McKesson notes that

The affordability crisis is causing unprecedented changes in the healthcare landscape, the most significant of which is the transition from the current volume-based model [fee-for-service] to myriad models based on measures of value.

To remain relevant and competitive, payers, hospitals, health systems, and clinicians must respond now to integrate value-based models into their existing systems.

Continue reading…