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.

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[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.

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

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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.
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