Patient centered care and the family physician’s brain

Paul Grundy is IBM’s Director of Healthcare, Technology and Strategic Initiatives for IBM’s Global Well Being Services and Health Benefits.

He has led the development of the Patient-Centered Primary Care Collaborative, which is leading the way to create a more efficient and responsive healthcare system. Before I go any further, let me be very clear by saying that his work is hugely important and I agree with 90% of what this organization is doing.

I heard him speak recently at the annual meeting of the North American Primary Care Research Group, which is the largest and most influential organization for primary care research. Others sitting at my table said they’d heard him before and that his presentation that day was typical of others they’d heard.

One oddity of his talk was that he showed a model of the Patient Centered Medical Home (PCMH) full of the usual boxes and arrows. It included phrases such as care coordination, electronic medical records, and disease management (I’m going off of memory here. I can’t find the slide online), but didn’t mention family physicians or primary care physicians.

After his talk I went to the mike and asked something like, “What is being done to reform the evaluation and management (E/M) billing system (the Medicare rules most insurers follow that determines how much documentation doctors must do to justify a charge) so that I can take care of 5 issues at one visit and be paid for dealing with all of them?” He gave a very political non-answer that went something like, “This isn’t the appropriate time to ask for something like that.” I was puzzled and wondered what about his background would cause my question to not connect better with him.

According to his bio (reading between the lines), the only time in his professional career he directly cared for patients was 1979-85 when he was a medical officer and flight surgeon in the Air Force. When the E/M system was mandated in 1995-7, he was the Medical Director for a non-profit medical system. I’m sure he’s financially savvy, but it doesn’t appear that he’s ever had to earn a living as a primary care physician off the current rules, which haven’t changed since 1997.

Because IBM is a tech company and because America is a technophilic society, it makes perfect sense that gadgets such as electronic medical records (EMRs) would appeal to Dr. Grundy and others. However, the evidence that primary care provides better health at a lower cost than multi-ologist care predates all the new gizmos. All the American studies listed in the Starfield analyses didn’t rely on EMRs to achieve their results. Quad Graphics, a large printing company in Wisconsin,  has 18 years of data showing its commitment to primary care has resulted in 30% lower costs than other large employers in its region over the entire time span.

The research on the effectiveness of EMRs is spotty at best. They don’t consistently improve quality, safety, or prevention. About the only care delivery factor they have been consistently shown to improve is they make handwriting errors on prescriptions go away.

I was dismayed that the inherent patient-centeredness of my question didn’t resonate. My question wasn’t just about my needs. When I talk to non-medical people they have the same frustration about their doctors’ visits. We live in a Wal-Mart culture not a go-to-the-market-every-day culture. Americans want to save  up a list of needs then go to the market and have them all met in one visit. There are studies documenting that Americans make fewer visits to primary care physicians than other countries. In Britain, the general rule is the consultation only lasts 10 minutes. If more issues need to be addressed, the patient is expected to make another visit. Most Americans would rather not make another trip.

The E/M rules are way too complicated, but in a nutshell, after I address two issues with my patient the rest of the visit I’m giving away my services. If you’ve ever visited a primary care physician for your migraines and high blood pressure, then was annoyed that he insisted you make another appointment to talk about a rash that just appeared, now you know why he did that. If he addressed the rash on the first day he was paid nothing; if he addressed the rash on a different day he was paid the full fee.

There are lots of other ways the national bigotry against family medicine, as reflected in the E/M rules, disincentivizes family physicians from taking complete care of their patients. I’ll cover more of that in a future post.

I have nothing against many of the other features the PCMH supporters push. I accept that colleagues such as diabetic educators and nurse case managers are an important part of a highly functioning healthcare team. Their work should be paid for as well.

What Dr. Grundy doesn’t seem to understand is that the most important component of any patient-centered solution to our healthcare system is a family physician’s brain. (Sorry general internists and pediatricians. The evidence for better outcomes at a lower cost is much stronger for family physicians/European GPs than your fields.) Family physicians bring to the patient encounter a unique set of skills and approaches to patient care that lead to efficient patient-centered care. An EMR by itself doesn’t add much. I want to be the comprehensive convenient family physician for my patients and I’d like to provide lots of services in one visit. My friends and neighbors tell me that’s what they want too.

Therefore it is much less important that reformers push electronic gadgets on my practice. It is much more important that I be paid for the work I do, which means blowing up the current E/M system.

I guess this means I’m not an IBMer.

Richard Young is a physician who blogs at American Health Scare.

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