What’s Behind Today’s Primary Care Crisis: You Don’t Know the Half of It

If you’ve ever been on a diet, you know that it really helps to keep a
food log. Seeing your consumption chronicled in one place is
illuminating – and often explains why those love handles aren’t melting
away despite two hours on the treadmill each week.

In today’s
issue of the New England Journal of Medicine, internist Rich
Baron Rich Baronchronicles
the work of his 5-person Philadelphia office practice during the 2008
calendar year. Rather than “Why am I not losing weight?”, Rich’s study
aims to answer the question, “Why does my work day feel so bad?” The
answer: an enormous amount of metaphorical snacking between meals.

In
the NEJM study, Rich (who is a dear friend – we served together on the
ABIM board for several years) found that each of the physicians in his
practice conducted 18 patient visits per day (a total of 16,640 visits
over the year for the practice). That’s not an unmanageable workload,
you say. You’re right, but that was just the appetizer. On top of these
visits, daily each physician also:

  • Made 24 telephone calls
  • Refilled
    12 prescriptions (a vast underestimate of the daily refills, since a)
    the number reported in the study doesn’t count refills done during an
    office visit, and b) the study counted the act of refilling 10 meds for a
    single patient as one refill)
  • Wrote 17 e-mails to patients
  • Looked
    at 11 imaging reports, and
  • Reviewed 14 consultation reports.

A
little math tells us that, beyond what happens during the 18 patient
visits, the docs perform nearly 80 acts of data exchange and review each
day. After Rich’s practice analyzed this workflow, they re-defined a
“full-time physician” as one with 24 scheduled visit-hours per week,
embedded in a 50 hour work-week. In other words, docs in Rich’s practice
can expect to spend half their time on office visits with patients, and
the remaining half on non-visit paper/computer/telephone work.

This
wouldn’t be such a big deal if – like attorneys – primary care doctors
billed out their time in six-minute aliquots, or by activity. But PCPs
aren’t paid that way – the office visit is ostensibly the only billable
event in the life of the practice (except when they buy and use an
office ultrasound or treadmill – small wonder that so many PCPs do just
that). The Catch-22 is obvious and tragic: the incentives drive PCPs to
maximize office visits, while both patients and “the system” clearly
benefit from these non-visit activities.

A few weeks ago, I asked
Rich how he’d overhaul the payment system in light of his office’s experience. “I would favor a DRG-type
payment based on age, gender and diagnosis,” he wrote me, adding that
CMS has considered such a model as part of its Medical Home
demonstrations, but it hasn’t gained much traction.

But payment
reform won’t be enough – the NEJM study demonstrates the necessity of
comprehensive practice redesign. In fact, after seeing these data,
Rich’s group hired an RN whose job is “information triage” – managing
the mountains of lab reports, consult notes, and phone calls.

Ultimately,
the work of primary care must be greased by a superb ambulatory
electronic health record (EHR). Rich told me that, while his office is far more
computerized
than the average
practice
, it is still not quite there. The ideal EHR, he writes,
would

understand the ‘data aggregation’ task we
face: when I refill a prescription, there are predictable pieces of
clinical data I need, and there could/should/must be a way to present
those ‘automatically’ upon entering into the refill work. Our EHR does a
fair amount of this – it does show last refill date conveniently but
not relevant lab data or problem lists (even as it does show body-mass
index and body surface area). Someone wanting to do this re-design would
need to follow one of us around for a while to figure out what we
actually do.

Without question, creating a higher
“value” – better quality at lower cost – healthcare system will depend
on having adequate primary care capacity. (So too will caring for tens
of millions of newly insured patients under health reform.)
Unfortunately, the trends point in the opposite direction: the primary
care infrastructure is collapsing
and very few
trainees are choosing
careers as primary care docs (can you blame
them?). Creating the primary care workforce and capacity we need will
require a deep understanding of today’s practice environment, which
makes Rich’s study essential reading for those concerned about the
future of American healthcare.

7 Responses to “What’s Behind Today’s Primary Care Crisis: You Don’t Know the Half of It”

  1. Bob Wachter April 28, 2010 at 11:32 pm #

    As I guessed, the Rich’s article struck a nerve — here’s the coverage in the New York Times

    and in the Washington Post

    and by Reuters

    and in USA Today.

  2. menoalittle April 29, 2010 at 5:06 am #

    Bob,

    You provided insightful coverage of this topic. Most doctors are working harder for less amidst onerous conditions placed upon them by denials of treatment, hospitalization, and diagnostics, and the need to justify such for the bean counters. These were not mentioned. It is worse for the PCPs who truly care about their patients.

    Over the past decade, the less PCPs and all doctors are paid for the increasing amount of requisite work, the greater the rate of health care inflation.

    On the role of HIT in the practice, the likelihood of their wishes being fulfilled in the foreseeable future is remote: “Someone wanting to do this re-design would need to follow one of us around for a while to figure out what we actually do.” This has been an integral component of the failure of HIT to deliver in the US and other countries. What goes in to any order, for a medication and its dose and dosing adjustments, for example, is far more complex than a weight and body surface area.

    I doubt IT designers will ever figure out what doctors do without doing what doctors do because the workflow is complex and changes with each individual patient. Even if they did, the current platforms may be too antiquated to work as desired and the HIT equipment costs will bankrupt most practices, unless they are in servitude to a hospital. Absorbing the HHS penalty appears the economic strategy of choice to avoid being saddled by high costs of obsolete equipment.

    Best regards,

    Menoalittle

  3. bev M.D. April 29, 2010 at 10:44 pm #

    I have been complaining for awhile that an adequate HIT system for Dr’s offices does not really exist. (And I’m a pathologist, for crying out loud – these are just my observations as a patient!). Dr. Baron should be connected to Dr. David Kibbe and Dr.John Halamka to perhaps gain some “official” input into how these things should be redesigned. Platforms are changing so the potential is there – but in terms of clinical utility the vendors,so far, just are not getting it.

  4. Randy Roy April 30, 2010 at 4:29 am #

    It was also covered on WSJ health blog. Most primary doctors will go bankrupt with 18 patients /day, where did that number come from, most see 22-30 patients. So this article is actually not reflective of most practices. How can we have come to this pitiful state that we treat our front line doctors this way, shameful, undignified. I think because of this poor respect despite being the most important role is what is driving the med students away. How can ACP and AMA watch this happen over past 2 decades and now the viable solution seems that nurse practioners and PAs will take over this field.

  5. Erik May 3, 2010 at 8:28 pm #

    Unless the payment model changes, eventually all primary care will either be retainer practices or simply care that misses things not because of the doctor’s lack but skill but because of lack of time to aggregate the data.

  6. AD May 5, 2010 at 12:54 pm #

    Dr Baron’s study was lacking in a single detail, the financial productivity of he practice and the overhead costs. A back of the envelope calculation would allow any physician who is currently in an Internal Medicine practice similar to that portrayed to conclude that the physicians receive little no compensation for their efforts after paying for the sophisticated support systems (health educator, EHR) that most similar practices lack.
    As a practIcing Internist I so not consider the wok load especially onerous but consider it inadequate to financially support the overhead.
    internal Medicine has always demanded hard work,this factor is not the cause of it’s decline compensation not commensurate with effort is the real reason.
    Perhaps Dr Baron can provide this detail to the readers of this blog

  7. Tex Bryant May 13, 2010 at 8:32 pm #

    It is indeed difficult for primary care physicians to prosper without long hours of work. I see that Dr. Baron uses e-prescribe in his EHR. I hope that he is also getting the incentive from CMS for doing so. Other ways to improve income while improving patient qualilty are targeting pay-for-performance rewards using a registry. There are many other ways to transform the PCP practice to improve care while improving income.

Leave a Reply