Creating team based care: are non-physician providers more effectively used in primary or subspecialty care?

The shortage of primary care physicians in the US, which I have often discussed (most recently in “When is the doctor not needed? And who should take their place?”, January 5, 2013), has become a national theme. The Robert Graham Center of the American Academy of Family Physicians (AAFP) has done much of the work in documenting this shortage, such as in the article “Projecting US Primary Care Physician Workforce Need” by Petteson, et al., discussed in my post “Health reform, ACA, and Primary Care: Is there still a conundrum?”, December 24, 2012. Essentially the problem is we have too few primary care doctors for the current population, the demand for them will continue to grow, and the rate of production (medical students entering primary care specialties) is below that even needed to replace those who retire. The growth in demand is a result of (in order of impact): population growth, aging of the population, and a more-or-less-one-time blip from increasing coverage under ACA (although for the latter, the people with a need for care were already there; it is just that with having insurance they will be able to seek it more easily).

 In a recent issue of Health Affairs, Green and colleagues argue that “Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication “.^[1] This is not a new concept; it is a central component of what is known as the “Patient Centered Medical Home”. The article suggests that many functions now carried out by physicians can be done by others, ranging from nurse practitioners and physician’s assistants, to nurses, to others on the health care “team”. It also suggests that many problems that now require face-to-face communication (trips to the doctor’s office) could be done by phone or “virtually”, such as by structured email or web-based visits. Thomas Bodenheimer and his colleagues in San Francisco have done much of the work in this area, most recently published in Annals of Family Medicine “Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation”.[2]

Green, et al., use computer simulation models to estimate the “panel size” (number of patients that can be cared for per doctor) by the employment of such techniques; they add calculations for “pooling” of physicians, that is, sharing of patients among a group of doctors. This allows greater efficiency by “smoothing out the bumps” that may occur when one physicians has more or fewer patients coming in for same-day care or not showing up for their appointments by allocating them among the group. Using these statistical models they estimate that the ability of patients to access care (get in to be seen) would be dramatically increased by the implementation of such policies.

The work done by both the Green and Bodenheimer groups is convincing, and provides a model for more efficient primary care practice that would help to address the problems our country faces from having too few primary care doctors. Indeed, these approaches utilize the “crisis” as a way to actually improve both access to and quality of patient care. There are, however, challenges to implementation of this model. One is payment; while health systems in many parts of the nation have demonstrated that it is possible to restructure their practices to achieve these advantages, this is most effective in settings in which the provider is also the insurer (notably Kaiser). In those parts of the country where this model of care is less prevalent, where most payment to medical providers is “fee for service” for face-to-face visits to doctors, there is not only no incentive to change, there is a large negative financial incentive since any non-face-to-face care is, essentially given out free.

A second challenge is that such models only work where there is a large enough concentration of patients and providers to achieve the benefits of scale; as with most such analyses, it leaves out the needs of rural populations. Some large systems, such as Geisinger in Pennsylvania, have been successful in creating such efficiencies in their clinics in rural areas, but Geisinger is atypical; there are not many like it. In addition, it is a financially integrated system (like Kaiser) – that is, it is also the payer -- and it works in a relatively-densely populated rural area of northeastern Pennsylvania, not like the vast empty frontier counties of the West.

It is interesting to me that so much of this emphasis on efficiencies, and particularly the use of professionals other than physicians to provide care, has been on primary care. This, I am sure, is due in part to the need for primary care in all settings, while much specialty care can be centralized in larger cities. It is also because there is not a shortage of many non-primary-care specialists for the needs of the population (although there are for some, such as general surgery, especially in non-urban areas). The reason usually given for this non-shortage is largely that these specialists make so much more money than primary care doctors, so medical students are attracted to them. To the extent that some specialties also have more regular work hours and a limited scope of work, it may also increase their attractiveness.

The limited scope of work (although not, necessarily, less difficult work, especially when considering surgical interventions) also makes them, in many ways, more appropriate fields to use non-physician professionals than primary care. This is the reverse of the usual assumptions that sub-specialists are seeing difficult problems, while primary care providers see mostly colds and blood pressure checks. In fact, primary care is complex, as it sees both undifferentiated patients and those with multiple chronic diseases. Most specialty care is more routine, seeing a much more limited set of diagnoses with a more limited set of interventions; for the typical subspecialist, less than a half dozen diagnoses may account for 80% of visits, while for a family doctor the top 20 are probably 30%. Thus, the breadth of knowledge and skills in making complex decisions and appropriately prioritizing problems, require a level of sophistication and training not taught or developed in most other health professionals (family nurse practitioners are one other provider group where there is at least an effort to have this breadth of training). It is, then unsurprising that most of the tasks suggested for nurses and others to increase the efficiency of primary care practices have limited scope: maintaining disease registries, calling for recommended preventive care, screening a small set of diagnoses.

This type of narrow, in-depth scope of work is much more characteristic of subspecialty care, and it is one of the reasons why expanded-scope nurses and physician’s assistants have found so much use in these practices. They follow people with congestive heart failure for cardiologists or diabetes for endocrinologists, they manage chemotherapy recipients for oncologists, they use algorithms to care for people in intensive care units, they do pre- and post-operative care for orthopedists and other surgeons. And they do not go outside of the set of diagnoses and treatment options with which they are familiar; following the model of the physicians with whom they work, when a patient’s problem is not in their narrow area, it is referred.

The targeted but limited expertise of such nurse specialists have explains why they function so well clinically in subspecialties. What explains why it works financially is that the doctors (or hospitals, or health systems) that employ them are reimbursed at subspecialist physician rates (already very high) for work that is done by others; thus they can afford to pay such “physician extenders” relatively well compared to folks working in primary care. Reimbursement for “teams” follows the model of reimbursement for physicians: care for a limited set of diagnoses in a detailed way, especially when it involves procedures, is paid much better than management of complex sets of interactive diagnoses.

Unfortunately, the problem with such practice is challenging because the same person often has multiple conditions, and interventions that help one may make another worse. While efforts to build teams, and have each professional work at the “top of their license”, is important, so is payment. As long as primary care is reimbursed at lower rates it will continue to face challenges in recruitment of physicians, nurses, and other team members. 

We need to develop and implement great strategies for team-based care. We also need to dramatically decrease the ratio of income for subspecialists and their subspecialist teams relative to those working in primary care.

---

[1] Green LV, Savin S, Lu Y, “Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication”, Health Affairs, 32, no.1 (2013):11-19

doi: 10.1377/hlthaff.2012.1086

[2] Altschuler J, Margolius D, Bodenheimer T, Grumbach K, “Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation” , September/October 2012 vol. 10 no. 5396-400 doi:10.1370/afm.1400

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.
.