Of all of the challenges in transforming our healthcare system, the most fundamental is transforming the Primary Care Physician’s (PCP’s) day. If we don’t fix the PCP’s day, high-quality, efficient and reliable care will be elusive. PCP’s have to have the time, capacity and energy to do what they do best, make clinical judgments, build relationships with patients and their families, define and manage a care plan and lead a team of care providers. Primary Care is defined as “care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern (the ‘undifferentiated’ patient) not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis. Primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (e.g., office, inpatient, critical care, long-term care, home care, day care, etc.)”. Our current model of primary care delivery was developed in the mid-1800’s when acute “undifferentiated” patients and infectious diseases were the primary reasons for a visit to the doctor. The industrial age Taylor assembly line “scientific management” model of business design was popular during that time from which doctor’s offices and hospitals borrowed. The volume and nature of the patient demand fit the design. So an acute-care focused, reactive, visit-based model of care became the norm.
However, the patient demand has changed dramatically, especially over the past 30-40 years. Not only has the prevalence of chronic diseases increased dramatically but the complexity of delivery has increased due to fragmentation and new specialized technology. In addition there is increasing demand for performance on quality metrics for acute, preventive and chronic care in the quest for increased value. This new and changed patient and stakeholder demand has overwhelmed the primary care delivery system. When you consider that for a typical panel size, if a PCP endeavors to deliver on all of the quality requirements for chronic and preventive care he or she would have to spend 17 hours a day, the problem becomes clear. Adding insult to injury is that compensation has been flat for PCPs and a fraction of what many specialists make. Not only does the Fee-For-Service (FFS) system provide perverse incentives to focus on volume over value but it also does not pay for things it should such as care coordination. The fact that we have a mix of payment mechanisms from pure FFS to capitation and everything in between adds to our schizophrenic care delivery model.
A recent snapshot of a PCP’s day shows the chaotic and overwhelming nature of primary care practice. Greenhouse Internists is a community-based internal medicine practice employing five physicians in Philadelphia. They have had an electronic medical record system since 2004. In 2008, they analyzed the typical PCP day for their practice active caseload of 8440 patients between 15 and 99 years of age. They had a interesting payer mix which is fairly typical for practices living in the two worlds of FFS and capitation. Their payer mix included 7.2% of payments from Medicaid, 21.5% from Medicare (of which 14.0% were FFS and 7.5% capitated), 64.7% from commercial insurers (34.5% FFS and 30.2% capitated), and 6.5% from pay-for-performance programs. With the exclusion of copayments and fee-for-service payments received on behalf of patients in capitated plans, 35.2% of their total revenue came through capitation. In a typical day, each doctor saw 18 patients, made 24 telephone calls, sent 17 e-mail messages, and reviewed 31 laboratory and imaging reports and 14 consultation reports. In general, the telephone calls, email messages, test report reviews and consultation report are not reimbursed in a FFS model. In fact, this non-visit uncompensated care assessment and care coordination is some of the most value-added work a PCP does, especially as it relates to decreasing unnecessary cost and improving patient safety. Uncoordinated care costs America an average of $240 billion a year, according to a recently published study based on analysis of more than 9 million insured lives in five states. That population includes those who are receiving extremely fragmented care and are accessing the system in a very inefficient and uncoordinated manner. The study found the average annual cost for an extremely uncoordinated care patient was more than five times higher than other patients. Additionally, the study found that patients with the most uncoordinated care represented on average about 10 percent of the patient population, yet accounted for approximately 45 percent of drug costs, 30 percent of medical costs, and 35 percent of total health care costs annually. The uncompensated and high value care plan assessment and care coordination that PCPs provide also takes a lot of time. In one study, Faber found that the mean time spent per physician per week on uncompensated care was 112.2 minutes (range, 36 to 260 minutes), which represents an additional 6.7 minutes (range, 1.7 to 13.8) of care provided outside of office visits for every 30 minutes of time spent scheduled to see ambulatory patients. For a full-time physician scheduled to see 14 patients per day in 30-minute visits over a 5-day workweek, this would represent an extra 7.8 hours of clinical work per week.
How do we fix the PCP’s day? The most important intervention is establishing the Patient-Centered Medical Home (PCMH) as the new standard model for primary care delivery. This model recognizes the need for team-based care, use of technology, outreach, access and patient-centered care. Most importantly, the compensation model must change so that PCPs are compensated and rewarded for delivery of value-based care. Through the use of technology and process redesign, routine activities should happen automatically, in the background (e.g. A1c testing for diabetics). PCPs will need to learn to delegate, lead teams, trust “the system” and become more of a coach. Distributing and automating the work is the only way to reliably deliver high-quality care according the new demands of proven high-value chronic and preventive care. With PCPs feeling their work is valued and supported and with more time for non-urgent but important activities such as truly coordinating care and building trusted relationships with patients and their families, value in the system will increase.