Rewarding primary care physicians for time spent with the patient

Abraham Verghese is a professor of medicine at Stanford University, and one of the most articulate physician-writers today.

He recently wrote an op-ed highlighting primary care’s plight, and focuses on the scarcity of time:

The science of medicine has never been more potent – incredible advances and great benefits realized in the treatment of individual diseases – yet the public perception of us physicians is often one of a harried individual more interested in the virtual construct of the patient in the computer than in the living, breathing patient seated on the exam table.Time is the scarcest commodity of all. Patients, particularly when it comes to their routine, day-to-day care, want a physician who has time to understand them as people first, and then as patients.

It’s been frequently discussed on this blog, with solutions ranging from paying physicians per hour to cash only practices.

There’s no easy answer, and worse, money isn’t even the root of the problem. Often left unaddressed is the burnout that primary care doctors face, practicing in unpalatable environments where the doctor-patient relationship is obstructed by bureaucracy and paperwork.

Dr. Verghese applauds expanding coverage, but acknowledges that significant payment reform needs to come next, writing, “rewarding primary care physicians for time spent with the patient and taking away the fee-for-procedure incentives. Getting to know a patient and having the time to do so is a critical step; I am convinced it prevents unnecessary tests and saves money. It’s just good practice. And it’s what patients want.”

Maggie Mahar recently had a guest piece saying that primary care doctors are being rewarded, to the tune of a 10% increase in Medicare office reimbursements.

Not only is that not nearly enough to sway the tide sinking primary care, it leaves the practice burden facing most primary care doctors completely unaddressed.

Kevin Pho is an internal medicine physician and on the Board of Contributors at USA Today. He is founder and editor of KevinMD.com, also on Facebook, Twitter, Google+, and LinkedIn.

Comments

bett l.martinez
Kevin, Congratulations! AT least I so agree with you. I just wrote a long email to a policy person yesterday, head of the federal review board on Preventive Med, advocating same thing. They actually have a mission statement to the tune of “Time, not tests”, and yet, what they are mandating seems to more more of the latter. I believe that if the annual wellness exam that insurance companies are allowing – a least here in CA – covered a 35-45 min visit/review, so doctors can meet patients in a relaxed atmosphere, and make recommendations, particularly w/respect to lifestyle changes, it would reduce costs. Many studies have shown people do respond to doctors’ suggestions better than to “education” and so-called “incentives”. I wish someone would fund a study and at least give this a try. What is your opinion? Or, what is your idea?
bett martinez, M.Ed.

stargirl65
Since I am lucky to get $75 for a complete physical there is no way I can spend 35-45 minutes on a physical. They get 15 minutes because any more time and I am losing money. If I were to do that then I would go out of business. If insurers want patients to get a physical then they need to pay us what it is worth.

jsmith
Good one: Verghese asked if anyone had ever seen a freestanding posh geriatric center (geriatrics being a notoriously underpaid field, avoided like the plague by savvy docs and med students).
http://www.BocaConciergeDoc.com Steven Reznick MD FACP
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.
KP Internist
I am paid every 2 weeks for the time I spend with my patients. It doesn’t matter how I do it. I have good days and bad days (today is a good day, by the way). Good days, I have more time to talk, e-mail and call my patients. Bad days, I have less time. Salary is the same regardless. The paycheck is routed into my bank account. This is not a new idea, by the way.

stargirl65
I think the overall concept of KP is very good. Accessibility is the problem. The closest KP to me is over an hour a way. This would be a problem for me for commuting (but not impossible). We are in a seasonal area though and it would take me 4 hours to return home on a Friday in the summer months. Also for patients to have to drive over an hour for every appointment would be difficult. I reviewed the local map and many of the centers are 30 minutes apart minimum. If you live between centers you can pick a center I guess. On an outlying area you are near none.

pcb
KP,
maybe you should spend 3 minutes with each patient and have a panel of 7000.
’cause it doesn’t matter. it’s just all time with patients.
The real questions here are:
1. what is an ideal patient panel?
2. How much time do our patients deserve?
3. How would we like to practice medicine?
4. How should we get paid?

KP Internist
1. Our panel size is adjust to a full time average of around 2200 patients (varies per medical center). If we have more patients than doctors or we have too many “over-empaneled” doctors, then we hire more PCPs.
2. Time is tough to define in our system. A 5 min phone call, a 5 second reply to e-mail a 15 minute office visit. The time we spend depends on the encounter type and the complexity of the visit.
3. My time is spent on clinical matters. Things that a doctor should have to do, is generally done by a system solution or by a non-physician extender. We have very little wasted physician time. Let’s face it, in our system, physician time is a premium. I think KP should be the model (very biased opinion).
4. I think we should all be in large medical groups and salaried with bonus for quality performance (hitting access goals, patient outcomes and patient satisfaction survey measures).

family doc
may i ask what your yearly salary is at KP?

KP Internist
Primary Care starts at around 190K in addition to VERY generous benefits. Salary can be as high as 260K with incentive payments, extra shifts taken for pay instead of vacation and bonuses given by the medical group for good fiscal years. I suspect our salaries will continue to grow, give then huge investments in Health Connect EMR. PCPs do most of the clinical work and generates over 85% of the prescriptions in our pharmacies.

BladeDoc
Until the patient is the customer this is all pi$$ing in the wind. The third party payer system doesn’t care about anything but the sheer number of patients that you can shoehorn through your practice without making so many angry (or providing poor enough care) that a huge number complain to their company or senator (private insurance/medicare respectively).
Just look at the term Kevin used in the title “Rewarding primary care physicians” like tossing a kibble to your puppy. Rewards are something given for a special act — you would never talk about “Rewarding plumbers for stopping the leak” or “Rewarding your lawn guy for doing your lawn.” You, the customer PAYS the tradesman what you believe they are worth. Once you put a TPP in the system you have no way of proving your worth to the customer (the TPP) and no incentive for the customer to value anything but your mere existence.
KP Internist
I see about 20 patients a day. I respond to about 20 e-mails and make about 10 phone calls. Pay is same regardless how much time I spend per day. I get paid to manage a panel and not per unit of work executed. I don’t bill. We focus on the panel size and that is what determines how busy I am. The relationship between PCPs and specialists is very good. We all work for the same group and have shared interests the group’s performance. Our roles are very defined and there is not much by way of turf wars.

family doc
sorry man, i just spoke to a soutern ca fam med doc and was told starting salary was 158,000/yr. and they are seeing alot more than 20 patients a day. ALOT MORE. try 25-30 pts/day. plus many emails/day. plus admin work such as sortaing thru labs and calling patients. i just dont believe you cause i am talking to doctors who work for kaiser who tell me different information to my face than what you are anonymously able to put online. somehow what you are saying doesnt add up.

http://www.davisliumd.blogspot.com Davis Liu, MD
KP Internist is correct. Your friend is correct. KP Northern California operates differently than KP Southern California and hence the difference and yet accurate stories by both individuals. Learn more at – http://physiciancareers.kp.org/ncal/index.htm. To be clear, I work in KP Northern California.
–
Davis Liu, MD

http://www.healthbeatblog.org maggiemahar
Kevin–
I agree that when it comes to attracing PCPs, working conditions are at least as important–if not more important–as pay.
Being a solo practioner–or working in a small primary care practice–is very tough. These days, overhead in most cities and suburbs is high, as is the cost of labor. More nad more docs are relalizing that they need electronic medical records. If you want to pay the rent and keep the lights on, you have to work long hours, seeing many patient, without enough time to talk to them.
Under reform, things will get somewhat easier. Medicare will begin paying for telemedicine, which means that a doctsor or a nurse can fill prescriptoins via phone or e-mail. Doctors who provide a medical home will also receive bonuses for talking to patients about chronic care management. In general “thinking medicine”–talking and listening–will be rewarded.
But hte economic reality is that, in most places the very small practice is no longer viable. Overhead is just too high.
Reserach suggests that doctors practicing in large multi-specialty practices (or accountable care organizations) are happier. They have more support. They don’t have to run a business. They have a fixed salary. And, if it’s a good
mutli-specialty practice they are valued for outcomes, not volume. (Medicare will be moving away from paying fee-for-service and toward paying more for better outcomes, which should help.)
At the end of the day, primary care is still a difficult specialty.
Primary care docs see many older patients–some find those patients difficult. Others enjoy them. Primary care isn’t for everyone–and raising pay by 20% wouldn’t make the difference.
Finally, under the refomr legislation we’ll be training many more nurse practioners adn physicains’ sassistants (because reform raises pay for nurses who teach and provides generous loan forgiveness and scholarships for nursing students.)
Many of these NPs and PAs will wind up working with primary care docs in newly expanded community clinics (we’re doubling capacity) . Again, this isn’t a job for everyone, but very satisfying for some.
In NYC we have some excellent communityi clinics run by Dr. Neal Calman–a long-time primary care doc who has treated the poor in NYC for many years. .They are well-run. This is a work environment that many would like..

r watkins
“Research suggests that doctors practicing in large multi-specialty practices (or accountable care organizations) are happier”
Interesting comments, but seems like you’re missing the big point.
What does it matter what type practice primary care docs are happier in if NO ONE is going into the field?
It seems like people are willing to argue themselves into knots trying to say that it’s not about money. Unfortunately, it is, and even if every PCP signs up with a big clinic, there won’t be anywhere near as many as we need.
“Medicare will begin paying for telemedicine, which means that a doctsor or a nurse can fill prescriptoins via phone or e-mail. Doctors who provide a medical home will also receive bonuses for talking to patients about chronic care management. In general “thinking medicine”–talking and listening–will be rewarded.”
Is this across the board, or are these just a few of the several hundred demonstration projects included in the ACA?
KP Internist
I agree with most of your points, except one. I actually don’t think that NPs or PAs work as well in primary care clinics as in subspecialty clinics. In a othopedic practice or a dermatology practice, the easy work that would get done by them are focused into a anatomical area or organ system. So having more of them would generally save money because it improves access. In a primary care setting, we are generally asked to integrate many pieces of information, manage multiple conditions and it is generally harder to keep patients focused on one complaint. Also, they don’t tend to save money. We don’t hire physician extenders in my primary care department anymore. We found that they generate more consults to specialist for things that most Physician PCPs can handle and they also tend to order more testing (MRI for 2 weeks of non-specific back pain, for example). They also tend to carry much smaller panels due to patients switching out of them when they find out they are not doctors. I think that if NPs or PAs are used in a primary care setting, it should be as single chronic conditions manager or is a very limited visit description such as a participation physicals. Also, their salaries are not much less than that of a physician PCP.

rwatkins
Good point.
Similarly, docs in fee-for-service situations like to hire PAs/NPs because, seeing a rapid stream of “uncomplicated” patients and ordering more tests, they generate higher charges per hour than MDs. Docs have a bad habit of “wasting” time they won’t be paid for dealing with complicated patients with multi-system disease (sarcasm).
Ms. Mahar seems to have great faith in the ability of PAs and NPs to improve our health care; I wonder what evidence she has to support her beliefs.
http://www.davisliumd.blogspot.com Davis Liu, MD
Completely agree with KP Internist’s assessment.
Would add, however, that the integrated Kaiser model is not the only one that will allow primary care doctors to thrive (and it isn’t the Patient Centered Medical Home as noted in this post – http://www.kevinmd.com/blog/2010/08/americans-doctors-physicians-leaving-primary-care.html)
–
Davis Liu, MD

http://www.healthbeatblog.org maggiemahar
Just read KP Internist comments.
This is exactly the kind of situation I’m talking about.
He sounds pretty happy with his job.

jsmith
But not as happy as the dermatologist or radiologist. This is r watkins’s point, which is the key one. America doesn’t have to make family docs happy, because we are already trapped. It has to induce medical students to go into the field and that’s not happening. Sure Kaiser is treating its docs well now, but I worked there from 1989 to 1995 and was treated like a serf. And what happens if all or most of the new fam med jobs are in large multispecialty groups? Will they continue to treat their docs so well? To think so would be naive in the extreme.
Going through 11 years of post-high school education and racking up 160k in debt to put yourself at the economic mercy of Kaiser, and at 100k less per year than you could make in a different specialty, a specialty in which you had more independence? That makes no sense to most med students, and I don’t blame them. And of course it is the money at root, because money is directly translatable into job satisfaction and independence. Med students know this, even if you try to tell them different.

http://www.healthbeatblog.org maggiemahar
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
Thanks for the reply, and all the references.
I would still say, though, that it is all about the money.
Lousy working conditions are often cited as turning med students away from primary care. I would say that low pay for E&M codes forces primary care docs to see too many patients which increases the hassle factor (that all specialties are victim to to some degree) beyond the breaking point for many. Increase pay for office visits significantly, so that the doc can both see fewer patients AND increase take home pay, and you’ll have a much more attractive proposition for med students.
I would particularly point out that adding the administrative burdens of the PCMH to the responsibilities of the primary care doc WILL NOT encourage more students to enter the field. Does anything think that undergrads go through the rigors of pre-med and med school in order to spend their careers supervising “health care teams,” and sitting in front of computers dealing with patient registries?
Primary care docs thrive on direct, face-to-face patient care, and any health care model that devalues this will only speed up the death of IM and FP.
Back to telemedicine: so it seems like, docs still won’t get paid unless the pilot projects are deemed “successful” (defined as: saved money? patient satisfaction? or whatever?) and the administration in office at the time decides to extend it to providers in general. Still sounds like VERY weak tea in terms of supporting primary care.
rwatkins
‘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.’
Let me add that this comment is “ad hominem” and inappropriate. jsmith chose to enter and has stayed in a low paying field of medicine, so it most obviously isn’t all about the money for him. It’s very clear that he is addressing why med students are not going into primary care.

http://www.healthbeatblog.org maggiemahar
rwatkins.
Jsmith said “Of course it is the money at root, because money is directly translatable into job satisfaction and independence.”
I wasn’t attacking jsmith.He indicated that, from his point of view, money equals job satisfaction and independence.
http://www.healthbeatblog.org maggiemahar
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..

rwatkins
Again, thanks for the replies.
I’m interested by what seems to be your reluctance to give any support to the continued existence of small primary care practices. Aren’t most of the health care systems in Western Europe that achieve better results at lower costs than we do based on a strong foundation of small primary care practices?
I’ve worked in a large, integrated group, and in a small private practice, and would unquestioningly choose the later in terms of job satisfaction, quality of patient care, and financial reward.

KP Internist
We use quite a bit of physician extender in the specialty clinics and surgery services. It is just a matter of compared to hiring another KP PCP, it doesn’t make much sense for our system. An orthopedist costs quite a bit more than an internist. So, a physician extender for them would be a cost savings. But, a NP fuctioning as a PCP doesn’t work in our system. There is a greater use of testing and subspecialty consultations either due to own perceived uncertainty in diagnostic abilities or patient demands due to lack of trust in the NP’s ability. It doesn’t matter. It is just how it. Also, they work at a reduce schedule and carry smaller panels.

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