Thursday, October 24, 2019

Expecting everything from primary care: reasonable?

In 2003, Kimberly Yarnall and colleagues from Duke University published an article in the American Journal of Public Health documenting that it would take 7.4 hours a day, essentially an entire workday, for a primary care physician to perform all the preventive services recommended by the US Preventive Services Task Force (USPSTF) on a typical population of 2500 patients.[i]  Six years later, they wrote a follow-up article in which they added the time it would take to also deliver care for the acute and chronic conditions that patients actually came to their doctor for, and it came to 21.7 hours of a 24-hour day![ii] One year after that, in What’s Keeping Us So Busy in Primary Care? A Snapshot from One Practice, Richard Baron wrote about a day in his practice, where, in addition to seeing 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, and 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.”[iii]

When I wrote about this, in Primary Care: What takes so much time? And how are we paying for it? (May 21, 2010), I discussed the incredible burden that this placed on primary care physicians, and how unrealistic it was to expect this of them. I addressed an article by David Margolius and Thomas Bodenheimer, Transforming Primary Care: From Past Practice To The Practice Of The Future,[iv] in which they envision the effective and efficient provision of primary care by well-designed teams. I also expressed some skepticism about how likely this would be to happen. So, now it is another 9+ years since the Baron article, and how far have we come? Not, as it turns out, all that far. The impetus in medicine, from health systems, payers, and primary care physicians’ own specialty colleagues, is for more and more work to be expected from primary care providers, both in terms of direct patient care (acute, chronic and preventive) and the kind of paperwork and form-filling-out described by Baron. This comes, unsurprisingly, with little additional financial reimbursement to the doctors or practice (or financial support from health systems for the kind of expanded teams envisioned by Margolius and Bodenheimer), and certainly without more hours in the day!

Why? For one thing, it’s easier. If you don’t know where something fits in the always-getting-more-complex-and-confusing health system, assign it to primary care providers. This is particularly attractive if you are a specialist and it’s something you don’t want to do. And, if you are a health system manager, if it is something that is poorly reimbursed. Think about it. The surgical subspecialist, for example, wants to operate on people. S/he wants, perhaps, to consult with patients about their particular problem, and maybe even their concerns about it, but mostly wants to operate, and to generate the income that comes from operating and not to fill their time up with additional paperwork, or blood pressure checks, or FMLA requests. When they do follow-up they mainly want to follow up the narrowly-defined surgical problem; if there are other complications that are acute, there are consultants for that; if there are longer-term issues that will need to be dealt with, there are primary care providers for that.

Similarly, the health system makes money from procedures being done, and wants their proceduralists, say this subspecialty surgeon, to generate the surgical procedures that make them money, not “waste their time” on more poorly reimbursed medical activities -- or certainly paperwork. When such work can be done by others – nurse practitioners or physician’s assistants, or scribes or nurses, or anyone who gets paid less, then it is financially efficient to fund those positions. In her New York Times article “The Business of Health Care Depends on Exploiting Doctors and Nurses” (June 8, 2019), Danielle Ofri, a physician at Bellevue Hospital in New York, makes a truly important point: that health care professionals actually care about their patients, and want to do the right thing, and will work hard even when that requires more hours than they have or are being paid for. In this sense, it is the health systems (individually) and the health system (writ large) that is profiting. But it is also true that the degree of exploitation (and payment) is not the same for all health professionals; it is not the same for nurses and doctors, and it is not the same for primary care doctors and many subspecialists.

Primary care physicians may inadvertently encourage this. As Ofri describes, they want to be professional and responsible, to know about everything that is going on with their patients. They want to be the physician for the patient, not the disease, to coordinate and manage all the care, to interpret for their patients what other doctors are telling them, especially when the messages that the patients are getting are mixed or unclear. This is what makes them good doctors. However, it is also what makes them really good candidates for being the “buck-stops-here” venue, the “take care of everything no one else can or wants to”, especially if these tasks, from the larger health system point of view, are not reimbursed or poorly reimbursed in themselves but are required by payers (private and government insurers) to be done in order for the system to get reimbursed for the high-ticket items (such as surgery) that they provide.

This is not irrational. It makes sense for people to do the work that only they can do, to, in the jargon, “work at the top of their license". But this requires changes in reimbursement. In particular, the concept that a single episode of treatment (e.g., surgery) is worth a lot more than the ongoing continuous lifelong management of a person’s health needs to be re-examined. But for this to work, adequate resources – especially human, like enough primary care doctors so that they don’t have the 2500 patients each, and enough support nurses and assistants and clerks and scribes to address the workload – have to be available.

Some primary care providers have moved into “direct primary care”, where, for a fee beyond insurance reimbursement, they provide (presumably) all the primary care needs of smaller group of patients. It has its pluses, but without adequate numbers of providers and without a national health insurance system covering everyone, it leaves too many people out; it becomes another “market niche” for those who can afford it, and this is not what health care should be.

I have heard it said that there are 3 entities that are always identified as likely places when something additional is suggested to be added to health care: primary care, nursing education, and black churches. Nursing education because, you know, nurses should know how to do that (whatever that is today). Black churches, you know, because they are important institutions in the community, with credibility, so if they urge people to healthier behaviors it may work better than when outside health professionals do. Could be a good idea. Maybe the nursing schools or black churches could hire people who could use the jobs to do this work.

But, as in primary care, rarely are these “good ideas” backed up with money, with sufficient funding to make it happen, to employ people, to support them. That money, of course, needs to go to for health systems, subspecialists, insurance companies, and mega-corporations.

Time for a change.

[i] Yarnall KSH, Pollak KI, Østbye T, Krause KM, Michener JL, Primary Care: Is There Enough Time for Prevention?

MD Am J Public Health. 2003 April; 93(4): 635–641.PMCID: PMC1447803. PMID: 12660210

[ii] Yarnall KSH, Østbye T, Krause KM, Pollak KI, Gradison M, Michener JL, Family Physicians as Team Leaders: ‘Time’ to Share the Care, Prev Chronic Disease Apr2009;6(2):A59),

[iii] Baron R, 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

[iv] Margolius D, Bodenheimer T, Transforming Primary Care: From Past Practice To The Practice Of The Future, Health Affairs May 2010, 29(5): 779–784.

Monday, October 14, 2019

Global Health at Home: Caring for Migrant Families on their U.S. Arrival

The American Academy of Family Physicians (AAFP) sponsors an annual Global Health Summit. This year’s conference, in Albuquerque, NM, was the largest so far. The conference started primarily as a venue for family physicians who volunteer their time abroad, providing health care and teaching in generally less developed countries. These were for both long (a year or more) or short trips, often sponsored by religious organizations. They also can include work done through government (eg, Peace Corps) or non-governmental but non-religious organizations (eg, Partners in Health, Doctors without Borders, Doctors for Global Health), but the religious root of much of this work is still apparent in the use of the term “mission trip” for most short-term such activities, especially involving medical students or residents. Overall, most such organizations, including those largely or partially sponsored by churches or religiously-affiliated organizations, no longer make religious proselytizing or efforts to “convert the natives” a significant part of these trips, and focus instead on health care and health system development (although there are certainly exceptions). Many of the leaders in this field are also involved in development of health systems in countries across the globe and in international health organizations and efforts including WONCA (the World Organization of Family Doctors), the World Health Organization (WHO) and its sub-groups such as the Pan-American Health Organization (PAHO), and The Network-Towards Unity for Health.

While such international work remains the mainstay of global health activity, there is also increasing interest in addressing needs in the US. To some degree, this reflects a long-standing discussion regarding the degree to which many doctors and students are more interested in going abroad on such trips than providing care to the needy at home. Of course, this need not be a contradiction, and many of the most active physicians in global health also spend the bulk of their time in the US working with underserved communities. But there are also those, including many students, who are attracted to such trips for other reasons. These include “medical tourism” – using the trip as an excuse for an exotic vacation, particularly if the place they are going is near beaches or mountains. They also include what might be called “medical opportunism”, where students go because they will get to do things to people on these trips that would be forbidden for them to do in the US, especially procedures. On the positive side, they can, provided the physicians or students are open to it and do not just talk to each other and can go beyond the “we are here to help you” mentality, allow learning and increase intercultural understanding, as well as increase knowledge of conditions that are more prevalent in the developing world. In addition, some of these conditions, as a result of the climate crisis and other factors, are moving north into our own country, so we see Chikungunya and dengue and other formerly tropical diseases. The key distinction is in how these trips are approached; they should be of benefit to you, but are not, ultimately, about you, but about collaboration with people, and health care providers, in other countries.

One increasing area of interest that tends to bridge this US/international divide involves the care of migrants coming to the US, an issue that has becoming increasingly front and center over the last few years. While the care is done in the US, the people are coming from other countries; in the case of our southern border primarily Central America and Mexico, but people come from all over the world. Several presentations at the Global Health Summit addressed different aspects of “Border Health”, each of which is important and each of which creates the need for linkages with other aspects of the health system. One is the care of people who permanently live along the US/Mexico border. The border, of course, is artificial, and many families live on both sides including Native Americans, such as the Tohono O’odham of Arizona, whose reservation crosses the border. This is a special case of care for the poor and underserved. Another is the care of people who are migrant workers, who may “live” in the border area for much of the year, but move to other regions of the US to follow the harvest. This creates the need for linkages with migrant health providers across the country. A third is the care of just-arrived migrant families who present at our southern border and may spend just a few days in our border communities before moving on to other parts of the US where they have sponsors. This creates the need for communication with appropriate health facilities in those areas, both for general health care and “warm hand offs” for individuals with particular needs. Such needs include those with ongoing chronic diseases often made worse by the journey, acute but severe issues such as injuries (including traumatic amputation by trains) and acute renal failure from dehydration crossing the desert, pregnancies (especially those that are high risk), and newborn but small or premature infants, etc.

“Global Health at Home: Caring for Migrant Families on their U.S. Arrival” was the title of a presentation by three Tucsonans who volunteer at the Casa Alitas migrant shelter, Anna Landau, MD MPH, Patricia J. Kelly, PhD MPH FNP, and myself. Originally accepted as a seminar, it was “upgraded” to a plenary presentation when the originally scheduled Ostegaard Speaker, Michael Kidd of Australia, was unable to attend due to family issues. While it was an honor to be selected, it was also gratifying to note the level of interest among the participants, from those doing similar work in cities on the border such as San Diego, El Paso, and Yuma, AZ, to those across the US who see these people as patients in their home communities, from big US cities to small towns in SW Georgia.

I have attached the slides in 'Links to Documents', found on the right side of the blog screen. It is important to recognize that medical care, which given the fact that guests are usually present for only 1-3 days, follows a public health model of dealing with acute needs and screening for infectious disease, is only a small part of the Casa Alitas operation. Hundreds of volunteers – and all are volunteers -- work on food preparation and service, contacting sponsors and arranging transportation, collecting and sorting and distributing clothing, doing laundry, driving guests to the bus station, and the multiple other needs that migrants have. I would also like to quote some parts of an email sent out by the Reverend Delle McCormick, a long-time leader in working with migrants in Tucson, after the recent move of Casa Alitas, which she has given general permission to share widely:

Every day is a triumph of small steps toward smoothly operating, warmly encouraging, just and loving spaces for our guests and volunteers. We have fallen for this new place and time. With each move we get more nimble, creative, and courageous in what we do together. Love shines here….Despite new draconian immigration policies at the border, we still have received 2484 men, women, and children at our new Casa Alitas Welcome Center shelter, making a total of 17,418 since October of 2018 when we stepped up our efforts to provide shelter for families seeking asylum.

Our volunteers still provide extra touches to encourage the human dignity and rights of every person who passes through our door. We hear and hold the most harrowing of stories: from 80+ year-old Sra. T. who stayed with us for a month because we couldn’t locate her sponsor, to the young man who had his toes burned off because he couldn’t pay for his release from kidnappers, to the woman who was shot in the head by her husband, to the daughter whose 68 year-old mother, who is blind, was detained, to the teenager kidnapped and prostituted and beaten by the local gang,  to the many, many others, each of whom has harrowing stories that drove them to leave everything behind to seek asylum.

If anyone is interested in learning more about the work in Tucson at Casa Alitas, in coming to volunteer, or in donating, more information is available at the website Donations can be made directly to CCS at  Support Migrant Aid - Tucson and through its GoFundMe page

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