Rewarding primary care physicians for time spent with the patient

There is no substitute for spending time with your patient, listening to what they have to say, observing and using that information to guide your exam and develop a differential diagnosis problem list.. Getting to know the patient as a complete human being and having the time to do so allows one to find subtle changes and intervene at an early stage of health change reducing the number of crises. As the baby boomer population ages , and their chronic multisystem disease becomes more complex , you need the time with the individual to provide appropriate and comprehensive longitudinal care. Dr Pho’s article and the quotes by Dr. Verghese are right on the mark and explain clearly why compensation for effective time with your patient must become part of health care payment reform if we expect any young students to enter general internal medicine or family practice in the future.

rwatkins, KP Internist, J Smith

rwatkins–First on telemedicine: Under thenew legislation,
Medicare and HHS wilil be albe to roll out any successful pilot prooject Nationwide—without going through Congress. This is ia Huge Change. It means that lobbyists can no longer block needed reforms that begin as Medicare pilot projects–, even if the reforms cut into someone’s income stream.

Secondly, here is evidence that in many situations, nurse-practioners do an excellent job: (I’m quoting from a post I worte on HealthBeat in April here http://www.healthbeatblog.com/2010/04/hey-nursie-the-battle-over-letting-nurse-practitioners-provide-primary-care-.html
” Research published in BMJ suggests that NPs spend more time with patients than doctors do, and simultaneously, cut costs. A study by Avorn colleagues published in the Archives of Internal Medicine supports the thesis. See http://www.ncbi.nlm.nih.gov//pubmed/2012450
The study used a sample of 501 physicians and 298 NPs who responded to a hypothetical scenario regarding a patient with epigastic pain (acute gastritis). The doctors and nurses were able to request additional information before recommending treatment. If they took an adequate history, the provider learned that the patient had ingested aspirin, coffee, and alcohol, and was under a great deal of psychosocial stress. Compared to NPs, the physician group was more likely to prescribe a medication without seeking the relevant history. NPs, in contrast, asked more questions, obtained a complete history, and were less likely to recommend prescription medications.”

“A 2004 study by Mundinger, Kane, and colleagues is now considered the most definitive research on the quality of NP care. (http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=nursehb&part=ch43
It explored the outcomes of care in patients randomly assigned either to a physician or to a nurse practitioner for primary care after an emergency or urgent care visit. The NP practice had the same degree of independence as the physician: this made the study unique. After analyzing the services that patients used, and interviewing some 1,136 patients, the researchers determined that the health status of the NP patients and the physician patients were comparable at initial visits, 6 months, and 12 months. A follow-up study conducted two years later showed that patients confirmed continued comparable outcomes for the two groups of patients.

Jack Needleman, a health policy expert at the University of California Los Angeles School of Public Health rejects the argument that patients’ health is put in jeopardy by nurse practitioners. “There’s no evidence to support that,” Needleman told the AP. “Other studies have shown that nurse practitioners are better at listening to patients. And they make good decisions about when to refer patients to doctors for more specialized care.”

“Nurse Practitioner midwives also receive high marks. (See http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=nursehb&part=ch43) They attend 10% of all births in the U.S., 96 percent of which are in hospitals. A number of studies of low-to-moderate-risk women giving birth show that after controlling for all social and health risk factors, the risk of infant death with a nurse-midwife is as much as 19 percent lower, neonatal mortality as much as 3 percent lower, and low-birth-weight infants up to percent fewer than with physician-delivered babies.

“Other studies reveal lower rates of caesarian sections, as well as significantly fewer infant abrasions, perineal lacerations, and complications.”
(In Europe, 85% of deliveries are done by nurse-midwives.)
“Researchers point out that it is possible that mothers who choose nurse practitioners to deliver their babies are healthier, or less inclined to want caesarians. But at least one study of high-risk mothers in an inner-city hospital suggested that midwives provide equally safe care in these more difficult cases.

“Some NPs point out that they must do better. As Chicago nurse practitioner Amanda Cockrell explained to the AP: “We’re constantly having to prove ourselves.”

Medical evidence that NPs offer as good or better care threatens some physicians. “They’re really scared that we’re going to do something that will take money away from them. As long as we went out and only gave healthcare to poor people, nobody said anything,” Dee Swanson, president of the American Academy of Nurse Practitioners, told ModernHealthcare.com earlier this month. “Let’s face it: We have a crisis in primary care in this country, and it’s an area that physicians have not been interested in, or there wouldn’t be a shortage.”
FOR LINKS TO ALL Studies See My Original post here
http://www.healthbeatblog.com/2010/04/hey-nursie-the-battle-over-letting-nurse-practitioners-provide-primary-care-.html

Despite all of the convincing data about the quality of care that NPs provide, “Acceptance by health plans varies across the country,” the AANP’s Towers told Managed Care Executive. ”
But acceptance is rising.” the Josiah Macy Jr. Foundation, which funds programs designed to improve the education of health care professionals, recently recommended that regulators immediately act to remove legal and reimbursement barriers preventing nurse practitioners from providing primary care, and to empower them to lead multidisciplinary teams of primary-care providers. Dozens of health care organizations signed the report; the AMA was not among them, but the American College of Physicians was. ”

The reform legislation puts significant funding into raising salaries for nursing shcool teachers and funding education oif NPs.

These days, nurse practitioners are spending more time in school. For example, on top of four years in nursing school, Chicago NP Amanda Cockrell spent another three years in a nurse practitioner program, much of it working with patients. (That’s 7 years of training.)

By 2015, the American Association of Colleges of Nursing will require its approximately 200 members to offer a Ph.D. Johns Hopkins already has rolled out a forward-looking graduate program for nurse practitioners that focuses on evidence-based medicine.

Some docotors who responded to my post had experience working with NPs in primary care and praised them: For example: “doctors and NPs are different and better at different things. Which is why, in a better system, we should work together.
What is my NP better at? Making the worried well feel comfortable, doing routine stuff, doing routine GYN stuff. What am I better at? Diagnosis and treatment of serious medical problems, such as acute severe disease (MI, pulmonary embolism, acute abdominal pain, and yes, acute severe pelvic pain in a female) or severe or complex chronic disease. Which is why we work together, as we should.”

Other docs were outraged at the idea of NPs providing primary care.

Nevertehless, the numbers of NPs are growing: and they are being accepted in more states. “Twenty-three states now credential nurse practitioners as primary care providers, and given the legislation under consideration in states nationwide, that number is bound to grow.In 1990 there were 30,000 NPs in the U.S. Today there are 115,000 according to the American Academy of Nurse Practitioners (AANP).

80% choose primary care.

KP Internist-
Thanks for commenting.

Salaries may be different at Kaiser, but in general NPS are paid less: “They do cost less than PCPs: “In 2008, median pay for primary care doctors was $186,000 according to the American Medical Association, though some primary care docs make much less. Median income for nurse practitioners now averages $83,000 to $86,000. (See my post for sources.)” (See my post on HealthBeat for links to sources.)

Interesting to hear that you don’t use “physician extenders” at KP.
This is probably an example of how certain reforms work well in some places, not in others. Also, if you’re in California, it’s a state where acceptance of NPs is lower and the California Nurses Association tends to be proactive to the point of making people very angry.

More than a year ago, I interviewed Dr. Marc Patterson, at Mayo in Rochester, and he said: “We are starting to make better use of nurse and nurse practitioners are being integrated into the teams,” he adds. “We also have a lot of physician assistants here—and they are extraordinary people.” (I interviewed Patterson because after 9 years at Mayo, he moved ot Manhattan where he practiced at New York Presbyterian. He wanted to be in New York, and liked his collagues at NYP, but after seven years he moved back to Mayo because he “wanted to be at a placed that worked.” http://www.healthbeatblog.org/2008/10/what-makes-minn.html Mayo is, of course, a model for collaborative care.

Also, NPs do cost less tlhan PCPs. They do cost less than PCPs: “In 2008, median pay for primary care doctors was $186,000 according to the American Medical Association, though some primary care docs make much less. Median income for nurse practitioners now averages $83,000 to $86,000. (See my post for sources.)

In the future, I suspect that NPs will make more. But most woudl be very happy making, say $40,000 more than they do today. NPs are not comparing themselves to radiologists making $450,000. Money is always relative.

jsmith–For you, ,money is “the root of everything.” So you probably won’t ever be happy unless you’re near the top of the physician income ladder.
(I’ve never found money the key to job satisfaction and independence.)
It’s strange you chose primary care. You could make more money sitting in a dark room reading X-rays all night.

Sorry you had an unhappy experience at Kaiser. I know a doctor who was at Kaiser in N. Cal during that period–also a PCP. Very happy.

rwatkins-

If you read the legislation, you’ll find that “succesful pilots” are defined as pilots that improve quality while reducing costs. We now have AHRQ and other standards for quality
Still insufficent measures of good care, but a beginning.
When both patient satisfaction and physicans satisfaxtion are part of the mix, you begin to get and idea of the quality of care– if these measure sare applied to very large groups of patients in a hospital/doctor network (which is what hte legilsation does).

If you try to measure quality fo individual doctors, the patinet pool is too small and too easily skewed by non-compliant patients, seriously il patients etc..