Friday, May 21, 2010

Primary Care: What takes so much time? And how are we paying for it?

In a piece that has gotten a lot of attention, “What’s Keeping Us So Busy in Primary Care? A Snapshot from One Practice”(New England Journal of Medicine, Apr29,2010;362(17):1632-6), Philadelphia general internist Richard J. Baron writes about the many tasks – many of them unreimbursed – that occupy the time of the physicians in his practice. While the physicians in the practice saw an average of 18.1 patient visits per day (the one activity they were paid for), they also returned an average of 23.7 telephone calls, and 16.8 email messages. They refilled 12.1 prescriptions, reviewed 19.5 laboratory reports, 11.1 imaging reports and 13.9 consultation reports per day. They also filled out large amounts of paperwork that they do not report on because they are not captured by their electronic medical record, such as “…administrative forms (e.g., for physical examinations for work, camp, and school and Family Medical Leave Act forms), correspondence received from health plan (e.g., disease-management letters), and reports on home care and physical therapy.” That’s a lot of work that is not being paid for. This is a huge issue in providing primary care, and one that is not often appreciated by the subspecialists, medical and surgical, who are very highly reimbursed for the procedures that they do, so that the paperwork, phone calls, etc., such as they are, are well subsidized.

Dr. Baron’s report reinforces both frequent observations and studies that have been done earlier. In 2003, Yarnall, et. al., published an article that looked at the amount of time it would take a primary care physician with a typical practice of 2,500 patient to provide all of the preventive care recommended by the US Preventive Services Task Force (USPSTF) at the “A” or “B” level. In “Primary Care: Is There Enough Time for Prevention?” (Am J Public Health. 2003;93:635–641), they found that:

In all, an annual total of 1773 hours, or 7.4 hours of every working day, is required for the provision of all recommended preventive services to a practice of 2500 patients with age and sex distributions based on the US population.”

That is a staggering statistic; in itself this is a full-time occupation, and yet it does not include any time for managing the chronic diseases that people have, or the acute conditions that are bothering them! In a later piece in 2009, “Family Physicians as Team Leaders: ‘Time’ to Share the Care” (Prev Chronic Disease Apr2009;6(2):A59), Yarnall and colleagues further assess all three types of care (preventive, chronic, and acute) and determine that together they would take 21.7 hours a day! This is reassuringly less than 24, as even doctors need to sleep and eat!

The recommendations from Yarnall, et. al., and from other recent pieces assessing the changes that will need to take place in the structure of primary care, coincide with the decisions made by Dr. Baron’s group to increase the size of their team. While the internists in Philadelphia mainly added a triage nurse, a true team requires a more comprehensive approach. Proposals planning for the Patient-Centered Medical Home (PCMH) understand that “it takes a team,” not just a physician. Among the best recent review and analyses is “Transforming Primary Care: From Past Practice To The Practice Of The Future” by David Margolius and Thomas Bodenheimer (Health Affairs May 2010, 29(5): 779–784 ). Virtually all these proposals advocate developing a team of providers, including doctors, nurses, medical assistants, pharmacists, secretaries/clerks, social workers, mental health specialists, even public health professionals, to collaboratively provide the appropriate and necessary care.

This is a great idea, but hard to implement in the current fee-for-service system, a system unlikely to change given the degree to which the new health reform law is built around insurance companies. Dr. Baron’s practice was participating in a demonstration project to provide coordination in the interest of the PCMH that was funded by the state of Pennsylvania; most practices are not. As I have said before, if proceduralist could do the procedures and subspecialists manage their particular rare or advanced disease, and allow primary care doctors to manage complexity and counsel and do prevention (and mental health professionals, and social workers, and pharmacists, and therapists to all do the things they were best able to do) rather than trying to do more procedures because they would make more money, this would make – sense.

Comprehensive care for people is a big undertaking. It is much more than consulting on one problem, or doing a single procedure and follow up. It is caring for many problems, and providing the preventive care that people need, and addressing their acute complaints, and doing counseling for both psychosocial issues and decision-making issues (e.g., “should I have this surgery?” “what is the risk of this diagnostic procedure recommended by the consultant?”) It is being available to refill lost or expired prescriptions, reviewing lab and imaging results and consultant reports, and answer questions by phone or email, and review and coordinate the care being provided by consultants. It is doing all those things that people expect that their “family doctors” (in whatever specialty they are actually certified) will do. It is a very different practice than that of a subspecialist; while for the latter “the buck stops here” for treatment decisions for a particular condition, for the former “the buck stops here”, period. There is nothing in the medical realm with which they cannot, reasonably, be expected to be involved.

Consider a patient who tells a subspecialist, say their cardiologist, about their knee pain. The cardiologist says “I don’t do knees,” and sends them back to their primary care doctor, or refers them to an orthopedist. On their next visit the patient says “I saw the orthopedist you sent me to,” and the cardiologist, reasonably, says “I don’t do knees. Do whatever s/he told you.”

Now consider the patient presenting with the same knee pain to their primary care doctor. Maybe that doctor has a good idea of what the problem is and how to treat it, but to be sure refers the patient to the orthopedist. On the return visit, the patient now wants to talk with “their” doctor about what the orthopedist said, what s/he recommended, what the primary care doctor thinks about that, and needs help making a decision. So, while for the subspecialist (cardiologist, in this example) a referral disposes of potential work, for the primary care physician, it will usually, while reassuring the doctor that the right care is being done, actually increase the amount of work.

Most primary care practices discover, as did Dr. Baron’s, that it is inefficient to have physicians doing virtually any of the work that could be done by a lower-paid staff member; this could be a nurse (which his practice did not employ initially) or a medical assistant. Subspecialists have always known this, employing nurses, physician’s assistants, and others (including medical “fellows”) to augment their productivity; for example, a surgeon can be in the operating room while a physician’s assistant sees patients in the office. But it takes money to pay such staff.

As long as the only reimbursement is for actual patient visits, and that reimbursement is spectacularly lower for primary care doctors than for subspecialists, and particularly proceduralists, the financial viability of such practices will be low, and the attractiveness to highly indebted medical students comparably low. This calls for a restructuring of the entire payment system, into one that encourages collaboration and the most appropriate management. A capitated payment system is very desirable because then patients can be “seen” in the most appropriate way based on the perception of patient and physician – phone, email, office, hospital, home – but only if that reimbursement is high enough to make the development and implementation of patient centered systems worthwhile.


AbbaJeff said...

There is great power in backing up our impressions (that primary care physicians are involved in endless uncompensated tasks) with data. The next step might include examining the importance of various activities on the health and health outcomes of individuals, families, and communities, and changing the payment system to parallel "what really matters"
Jeff Borkan

Josh Freeman said...

That is obviously what we need, and it would seem to be a massive undertaking.
Do you have some ideas for design of such a study?

Stephen M. Rose said...

There are two problems that are bundled: the fee-for-service payment mechanism and the market-based privatization of care. As you note, the latter stimulates and sustains the former.
Capitation, in the absence of total universal, comprehensive coverage for all medical/psychosocial conditions, moves us forward in the direction you describe. But this assumes a risk-adjusted captitation rate that is not anchored in profit. How we get there is another problem, one requiring an initial commitment to universal coverage.
The other issue raised is how to deliver primary care, even with capitation and universal coverage. This gets to the need for patient-centered medical homes that are designed to acknowledge the overwhelming majority of patient contacts are chronic illness based. This requires a paradigm shift from an acute care model. Chronic illness care necessitates a best practices medical intervention paired with self-management of care by the patient participating in the chronic care team as an authentic partner (not a complying object).
Authentic partnership is built through empowering relational connections to patients, relationships that must be initiated and sustained by team members who do not need medical knowledge or training. This becomes particularly important for people whose backgrounds include extensive childhood and adult exposure to deprivation and/or family/interpersonal violence as the impact of their experience has blocked their capacity to "self" manage. These are the patients most likely to suffer multimorbidity and have the fewest material and social networ resources to respond to an invitation to be part of their care team. The care model cannot simply deliver information about medication compliance, diet, exercise, smoking cessation, etc. It requires a health-based, rather than a medical definition of need. This further extends the discussion to the pre-conditions, material and psychosocial, for active participation in the production of one's health.
Stephen M. Rose, Ph.D.

Stephen M. Rose said...

There are two bundled issues that require separation: the fee-for-service payment mechanism and its structural base in a privatized, profit-based medical/insurance industry. One response requires a shift to a capitation finance mechanism; the other requires a fully controlled public option. Without public control, the prospects for an approriate risk-adjusted capitation rate are minimal.

The second vital issue in your entry involves the need for coming to terms with the preponderance of chronic illness care seen in primary care settings (estimated at 75% by the CDC). Shifting to a chronic care model requires construction of interdisciplinary teams that include the patient as an authentic partner. Authenticity as an equal participant in the production of optimal health, and optimal use of everyone's human capability, cannot occur within a medicalized paradigm, a reality based in the belief that chronic illness care must rely upon the integration of medical best practices with self-management of care. Self-management, in turn, requires the "self" to be seen as a contextual human being - a person with a specific life experience. People exposed to brutal material deprivation and family violence, for example, cannot be expected to adhere to instructions about their goals, diets, smoking, or exercise habits. They must be engaged as valid subjects in their own lives, subjects who, to cite Freire, must know and act. This involves relationship building, trust, and time - none of which require medical training or physician leadership.

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