Primary care is more than just office visits

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 a recent issue of the New England Journal of Medicine, internist Rich Baron Rich Baron chronicles 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.

Bob Wachter is chair, American Board of Internal Medicine and professor of medicine, University of California, San Francisco. He coined the term “hospitalist” and is one of the nation’s leading experts in health care quality and patient safety. He is author of Understanding Patient Safety, Second Edition, and blogs at Wachter’s World, where this post originally appeared.

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  • Erica

    You might consider checking out the Swiss model when it comes to billing. Physicians actually DO bill like lawyers. Most of the time my EOBs (I pay first and then submit to keep MY administrative costs lower from the insurance company I chose) show five minute increments. The first time I saw it I thought it was NUTS! Then I realized that they also bill for phone and e-mail. Again I’m a regular customer 3.5 years later so I might get some grace on certain things, but standard is to bill for everything they do! And the insurance companies pay for it! Until I meet my very high deductible each year I am judicious about what I make an appointment to deal with vs what I might e-mail about. I know “ME” and know the difference between when something needs eye balls vs can wait for an answer over e-mail. The next person might not be the same. As an American overseas I think the US could learn a lot from the Swiss health insurance model. That said, I still think the US has probably the top trained healthcare workers in the world.

    Now I wonder when the insurance companies are going to start allowing me to subtract for time spent in the waiting room!?

  • gerridoc

    Richard Baron’s article masterfully delineated the amount of time that primary care physicians spend “behind the scenes” involving patient care. Unfortunately, our health care system is built upon rewarding physicians for procedures or office visits (the latter to a lesser degree). It is my hope that a wider audience will read this article in the New England Journal and begin to discuss how to reform medical care. i am not sure that the “medical home” concept is the ultimate answer, but it is certainly a step in the right direction.

  • KP Internist

    Great post. I wonder why we would want to push for any type of billing system for primary care. Why don’t we have all primary care become capitated or supported by a larger entity. PCPs could be “employed” by the a large group practice (Permanente), government (VA), hospital (safety net public hospitals) or payors. This is because what we do in primary care isn’t easy to produce a billable unit of work. So, to have a payment system that pays based on bills submitted is ripe for abuse and require us to do billing work to get the bills paid. This is a gross waste of time. Also, primary care requires capital investment in infrastructure and removal of the usual barriers that prevents sharing of information to be efficient. This can only be done by large entities that would stand to benefit from our increased efficiency. The only way that primary care will survive is to completely change the way we get paid (more pay would be nice also).