What will health care teams mean for patients?

Have you heard that soon most primary care in the U.S. will be delivered by teams?

Yep. Team-based care is one of the characteristics of the patient-centered medical home, a way of organizing the care of patients that allows primary care clinicians to see more patients in a day while at the same time delivering better care. This move toward team-based care started long before health care reform and was embedded deeply into the Affordable Care Act through its support for patient-centered medical homes and accountable care organizations. It has been endorsed by the professional organizations of our primary care clinicians. There is a lot of activity directed toward making this the way most of us receive our regular health care.

What does this mean for us?

It’s not clear. The growing literature on team care focuses mostly on the skills that primary care clinicians, professionals and office staff must learn and the changes they must make to deliver care as a team: how they should be trained, how the work-flow is organized, how the group is led, how to build cohesiveness and trust within teams, how team members should communicate, etc.

How team care will affect us directly is sparsely described, but when it is, it is common to find promises that teams will coordinate our care among different settings (different specialists and hospitals, for example), that teams will pay more attention to helping us learning how to care for ourselves, and that we will have greater access to team members who can answer questions and help us solve minor problems. In a few papers, reference is made to “patients and families being members of the team.”

Recently, I was asked to make some remarks about team care at a conference. Now, I have heard from a number of people over the years about their experience of being cared for by an oncology or cardiology team during cancer treatment or after a heart attack, for example, and they thought it was great being able to call the nurse, for example, and get quick, useful help. But I hadn’t heard anything about people’s experience with primary care teams.

So I asked 10 people (regular ones, not health care experts) I encountered over the course of a couple weeks what they thought about the idea that “your regular health care would be delivered and coordinated by a team of people – your doctor and nurse and maybe a pharmacist and social worker and others, not just your doctor” meant for them. (Tiny sample, not representative, I know).

Their comments clustered around three themes:

1. People were concerned that a team would make getting care less personal. “Team care doesn’t sound good. I just want my doctor to take care of me. I think this team care thing would get in the way of that.”

“What, now they want me to know all these other doctors and nurses and aides and other professionals and to figure out that I have to call this one for this question and that one for that question? It’s bad enough as it is. Sounds like the management consultants are running the show.”

2 People were puzzled about what difference being cared for by a team would make. “I’m a member of Kaiser Mid-Atlantic so I suppose I’m treated by a team. You’d think they would look at me as a whole person but I still go off to see the foot doctor and the hand doctor and the heart doctor and the only thing they share is my electronic health record.”

“You know, they might have team care already for all I know. No one wears a name tag or tells me who they are or what their job is. I just shuffle around wherever they tell me.”

3. I asked them whether they thought they and their spouse or someone else they chose should be members of the team. “I don’t think I should be a member of the team, but I should have the final say about my care.”

“Are you kidding? I don’t know what they know and all those different specialists and nurses talking about my problem? Nah. They have to organize it for me.”

I too am puzzled about what team care means for us. When – and why – as a patient, do I need team care and what do I need to know about it?

Here are a few questions I – and many of my fellow patients – would like answers to:

First and foremost: Will I do better if my care is delivered by a team? Will my chance of having a better outcome improve? This is what I value. This is the bottom line.

And then, will my experience of my care be better – safer, more effective – if delivered by a team? For example:

  • Will I have less contact with my trusted physician or will team care enhance our relationship?
  • Will team care afford me greater opportunities to understand my health problems and discuss my choices about treatment?
  • Will team care mean there are more “rules” for me to follow to get help from my doctor? More gatekeepers?
  • Will team care make it easier for me to get answers to my questions/prescription refills/appointments?
  • Will my team coordinate my care so I don’t have to?

I don’t know the answer to these questions, but I can see that team care has the potential to affect positively or negatively both the outcomes of our care and our experience of it.

If shifting to team care means that our care will improve, why not tell us how. Explain (again and again) what we should expect from our team and help us understand how to take full advantage of the change. This is one way for teams to hold themselves accountable for their promises: tell us your goals and then ask us if you’re meeting them.

And should we consider ourselves members of the team? Try asking for our preference.

Jessie Gruman is the founder and president, Center for Advancing Health. She is the author of Aftershock: What to Do When You or Someone you Love is Diagnosed with a Devastating Diagnosis. She blogs regularly on the Prepared Patient blog.

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  • Ron Smith

    As a solo Pediatrician with two full time and one part time Pediatric nurse practitioners. Though they always schedule new patients to see me the first time, if possible, I always have stressed that our office is a team. I am always discussing the patients with my mid-level colleagues and often introduce them to patients with more complicated or rarer diagnosis. But the team approach does not stop there. I have key nurses and staff in the nurse triage position, the insurance verification and referral position, and a novel architecture for nursing in the back office. All of us are part of the ‘team.’ Even the best practitioners will get a lousy feedback when patients have poor experiences with the office staff. We strive for a complete satisfaction experience; the patients, the staff, and the practitioners. I give much credit to my practice manager. She is not an office manager, but has total control. I think that is the reason that month by month we consistently have high numbers of new patients.

    Good medicine must be equalled by good experiences.

    • Adolfo E. Teran

      Dear Ron, you are running a baseball team in your office. They get paid so somebody have to see more patients in order to paid for those salaries . Some offices double or triple book their schedule appointments in my area. My patients don’t want to repeat their stories and issues with different providers.
      Maybe what you describe works for you,your practice and your patients in your local area.

      • Ron Smith

        We don’t double book patients. We contact them about missed appointments and if they repeated miss appointments we release them from the practice. If you take a look at my practice web site www (dot ) ronsmithmd (dot) com you will see testimonials in the right margin. These are real responses.

    • Tom

      I for one do not want to have to establish myself with four, five or six different “practitioners” like that. If I were happy to see a different medical provider every time I or a family member got sick, we would just use the local “Doc in a Box” or Walgreens.

      • Ron Smith

        On one hand I can see your point, but many people already do this in multi-disciplinary practices. You are likely to see a different mid-level provider at any particular time at a Doc in the Box.

        But I challenge you to consider just how closely supervised and integrated are the mid-level providers in a Doc in a Box (or even local small ERs) as compared to our office. That is saying nothing about the quality of care at a Doc in the Box. We have cohesive as a team that functions much like a team in residency. We all try to know what is going on with all the kids. We all answer email. We try to tell patients whether they need to come in or not.

        I’m always available to our mid-levels. They are well qualified for my primary practice. Our team provides not only continuity of care but care from their perspective as a mid-level, something I value highly.

        I can’t tell you how many times I’ve seen patients after a Doc in the Box visit where they got poor or even wrong advice. I think the problem lies in physician supervision. I don’t think the mid-levels have access to doctors when they have questions and so they have to wing it.

        That’s not fair to the mid-levels and it doesn’t hone their skills and make them better providers.

        • Suzi Q 38

          I am glad to hear your positive description of how to properly utilize “mid level” NP’s.
          I knew their mere existence and employment in various offices and other medical settings were NOT all bad, LOL.
          Thank you.

          • Ron Smith

            There is nothing bad about mid-levels at all! I hate turf wars and I’ve seen such division. I respect my NPs and learn from them too. We really get excited about doing a good job and working together taking care of children. I take good care of my NPs too as an employer.

          • Suzi Q 38

            Good for you, Dr. Smith.
            I am happy that there are physicians like you that are not threatened by the existence of the NP’s and PA’s.
            They can be of great service to you, and very loyal in many ways.
            Thank you for posting.

        • Guest

          “You are likely to see a different mid-level provider at any particular time at a Doc in the Box.”

          Yes, and now that will apparently be the case at real medical centres as well.

          So if you’re only going to get mediocre service, you might as well get mediocre service at a place that’s cheaper and has better hours. like Walgreens or Doc In A Box.

          “Physician supervision” means nothing if the physician the mid-levels may — or may not — call if they realise they don’t know what they don’t know, has never even met you, or maybe only once five years ago.

          If you’re going to be treated by non-physicians who you don’t know, and they’re going to be “supervised” by doctors you don’t know, may as well go Walgreens.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Team care can mean different things and can be implemented in various ways. One way is simply having practice staff organized more efficiently to support direct care delivery by the doctor. This in my opinion is a very good idea for most practices to evaluate, customize and deploy.
    The other extreme of team care is to remove the physician from direct patient care most of the time, and turn him/her into some sort of floor manager or supervisor of less qualified resources. This is a fundamental shift in primary care delivery and, again in my opinion, stands in direct contradiction to the joint principles on which this model is founded. May be a bit cheaper though, so it will most likely take hold for most patients.

    • Sandra Barton

      Margalit, as I understand (and have practiced) team-based care, the MD does NOT act as floor manager or just sitting there as supervisor of less qualified resources. The MD is actually seeing more complex, more MD-level medical issues, and is there to assist any lower-level staff with questions regarding the basic/routine/simpler medical issues that come through a medical office every day. Team-based care is a win-win for patients who get their needs met by qualified staff for their need, and for the MDs who can stay in primary care for a career rather than burning out and leaving after a few years due to the overwhelming workload.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Sandra, I guess I must be missing something. The first question in my mind is who decides if a patient gets to see and MD? I certainly hope that in a patient-centered environment, the patient makes that decision, without exception. Is that how things work?

        Second, I believe the #1 principle of a medical home is a personal physician. Not a physician back up, but a personal one that has a long term, personal relationship with the patient. I am having trouble figuring out how that #1 principle is observed under the model you describe, and particularly if physicians are asked to be “responsible for a lot more patients”. Is it possible for one doctor to be the “personal” physician for so many people that he/she may not see for years in between brief encounters?

        • Sandra Barton

          First question: in a well-run team-based practice, a skilled, experienced, kind RN who works very closely with the doctor would hear what is going on with the patient and triage or guide the patient to the appropriate team member, be it physical therapist, RN, nurse practitioner, or MD. Believe it or not, when done well, 90+% of people are very satisfied with this method of health care utilization. A smaller percentage of people are needier and do want to discuss all of their issues with MDs regardless of whether MD-level knowledge and expertise is really needed, and that’s fine.

          • azmd

            I have some questions about how “patient centered” a patient centered medical home is when patients who want to see an MD for medical care are described by the practice as “needy.”

          • Tom

            “I have some questions about how ‘patient centered’ a patient centered medical home is when patients who want to see an MD for medical care are described by the practice as ‘needy.’”

            Exactly.

          • Guest

            And “ugly.” Now she’s added “ugly.”

            All you ugly, needy Americans don’t DESERVE real doctors in the new scheme of things, I guess. You’ll still keep putting out the same amount of money, but all you’ll get is a nurse. And you’ll be marked down as UGLY and NEEDY in your new Universal Permanent Record, aka Electronic Health Record, if you dare say “boo” about it. So there.

          • Noni

            My jaw dropped. Wow.

          • Adolfo E. Teran

            Who pay for that RN ?

          • Tom

            “a skilled, experienced, kind RN who works very closely with the doctor would hear what is going on with the patient and triage or guide the patient to the appropriate team member”

            But there is not one person in that “patient centered medical home” who will actually KNOW that patient. The so-called “primary physician” who has possibly never even met the patient does not know, none of the other random “caregivers” the patient has been shunted off to for this or that will know, the care has been so fragmented that the people doing the triage have no idea who this patient even is.

          • southerndoc1

            You pay an RN to answer the phone and schedule appointments?

          • Sarah95

            THank you so much for revealing your inner bias. People who prefer to see an MD are “needier.”

            Who knew?

          • Sandra Barton

            Sorry if I touched a nerve! Perhaps needy isn’t the correct term — if you prefer to see an MD to deliver RN or lower-level advice to you over a problem such as “knee pain for 3 days”, you are an misuser of healthcare resource, an “ugly American” of healthcare, a first-world problem indulger — but hey, we’re here to serve, so indulge yourself away!

          • Guest

            “if you prefer to see an MD to deliver RN or lower-level advice to you over a problem such as ‘knee pain for 3 days’, you are an misuser of
            healthcare resource, an ‘ugly American’ of healthcare”

            ===================================

            And yet in countries with universal health care like Australia, no one would THINK calling patients names if they dared to expect to see their own GP for medical problems rather than some miscellaneous non-physician “allied health care professional”.

            I think we have “Ugly Americans” here, but they are in the medical profession and not on the other side of the fence!!

            Seeing a doctor for one’s medical problems should not be seen as an unreasonable luxury, not in a first-world country like America!

            How dare you call patients “ugly” and “needy” for wanting their medical needs taken care of by their own doctor rather than by some “mid-level” non-physician.

          • southerndoc1

            Exactly.
            If those needy patients would just quit indulging themselves, and let us cram this Patient Centered Medical Home down their ugly throats . . .

          • LIS92

            How do you know that “knee pain for 3 days” is simple and only needs an RN?

            I have been experiencing some knee pain. I am 100% sure that an RN would get it wrong.

          • Suzi Q 38

            I have had knee pain for over a year.
            Two MS specialists, a neurologist, and MY long-time PCP of 12 years may have gotten it “wrong.”
            I harbor no resentment. Why? I was not dying.
            At 57, I had and still have knee pain. Its etiology was unknown without a battery of diagnostic tests, which are expensive and at times, considered unnecessary.

            My gut feeling (guess) was that it could be arthritis or an old soccer injury. I gleefully played soccer until I was 42, not only that, I loved to play volleyball and ski in my youth. I also liked to exercise. I told them so. “No, they said. this is a nerve thing or you may have thrown a clot.”

            Over the year I slowly got tests done, one after another to their credit. Ct scan, then ultrasound.
            A couple more months went by. I leg was still swollen. I requested an Xray and/or an MRI of the knee. My doctor declined my request.

            I went through physical therapy at $330.00 a visit. Still no change.

            I finally strongly asked for an MRI and an xray. I looked at my PCP and said: “Do you know how long this has been going on??? He was concerned that the insurance company was going to deny his request. I told him to let me handle the insurance company.

            The tests showed that I had severe osteoarthritis in my knee. No meniscus. Bone on bone whatever. I now have an appointment with an internal med rheumatologist because I want relief, but I want to avoid surgery for now.

            My point is that yes, the nurse could get it wrong, but you are wrong. The PT and patient actually got it right. The nurse could get it right.

            In my case, the doctors (not just one) got it wrong, and I do not chock this up to stupidity, I chock it up to “that is the way it is, everyone is human; they all have a different opinion.”

            Anyone can get it wrong or right.

          • LIS92

            My knee problem is not a knee problem but an SI problem. Correct the SI problems and the knee pain goes away. A medical care system that suggests someone with the experience of an RN would be able to diagnose such a problem is silly. After all the high tech imaging, it was a hands on examination by an experienced doctor that make the diagnosis.

            It is also silly that I should have to check in with that RN to get physical therapy. I have a relationship with a PT and I get the care I need because she knows me.

          • Suzi Q 38

            I am glad it worked out for you.

          • Guest

            I remember once upon a time when it was doctors who provided medical care, and nurses who provided nursing care. Imagine that!

          • Suzi Q 38

            Yes, put everyone “in their proper place.”
            Medicine is continuously evolving. Few things in life stay the same forever.

            You are not being realistic with what you want to happen vs. what is happening.

            I understand that you do not have to like it.

        • Sandra Barton

          As to your second comment, Yes, in a well-run medical home the physician would be the personal physician as you say for a group of 1500-2000 patients, and would see those folks when they needed MD expertise (which is again about half the time they contact a medical office). You need to keep in mind that the reason people in the US especially have been cultured to think that only the Md can help them or that they need to see the MD for all complaints no matter how minor, has been our fee-for-service payor system that only pays a doctor’s office if the MD (and no one else) sees the patient in an office visit. Fortunately, all of that is changing now, eventually at least.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            In a well run solo practice, physicians can and do see 2000 to 2500 patients for everything on their own right now, so I am not sure I see the savings. I could see other benefits if team members took over all the administrative burdens.
            As to fee-for-service, most of the developed world is running (much better than we do) on fee for service and small private practice, so I don’t know how fortunate we are to see this change.

            By the way, fee for service is paying for NPs and PAs visits. A bit less than an MD, but it is paying.

          • buzzkillerjsmith

            DING, DING, DING! We have a winner. The award for most insightful comment, M. The ability to separate the wheat from the chaff. Not surprising you won really.

            Most of the advanced countries do have autonomous docs in private practice and things work quite well. Why not here? Simple really.

            I would submit that this team stuff and a lot of the other doomed-to-fail innovations in the business of medicine are merely rearranging deck chairs on the Titanic. But, at least in the short term, the buzzards will feed well on the gutcart. Corporate medicine can almost taste the money to be made on the backs of doctors and their pts. The financial industry has little on CorpMed.

        • Tom

          Thank you Margalit, these are my concerns too. The term “patient-centered medical home” is sounding more and more Orwellian, the more I hear it defended. It sounds like it is centered around the practice, NOT the patient. Who is demeaningly described as “needy” if they dare to ask to see their primary care physician.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            My problem with this is that the term itself has been co-opted by this industrialized method of “team care”. If you read the original literature, a medical home was supposed to be a place where on top of having a personal physician, you also got the benefits of a supporting team for additional services. So you see your doctor, but if you need say nutritional counseling, someone will be there to provide that, or if you need a referral someone will coordinate that for you, etc. This is what the “team” was supposed to be for. Not to replace your doctor. And by the way, there are small practices out there that implement this idea beautifully. Those are the true medical homes in my opinion.

          • Tom

            That sounds like what my Mom got, when she developed congestive heart failure. She still kept seeing her normal doctor, who was affiliated with a local hospital, but there were “add-ons” to him. He was like the hub of the wheel, and she’d be directed to one spoke or another of the wheel, but everything was the one wheel, and her doctor was still at the center of it all. This new model doesn’t sound anything like that. As you imply, it sounds like they’ve co-opted a “brand name” that had a fair bit of good-will attached to it and are subverting it for a completely different, NON-patient-centered purpose.

          • southerndoc1

            The idea that only complex patients get to see the doctor and the “simple” ones are fobbed off on other members of the “team” was first pushed in the Annals of Family Medicine Task Force 6 in 2004, one of the most laughably dishonest articles ever published in a reputable journal. This concept was one of many flaming hoops they had to jump through to make the PCMH appear financially viable. Of course, everything they posited was completely wrong. But the simple/complex divide was picked up by the AAFP and TransforMED, and there’s been no stopping it since.

  • Jason Simpson

    Shifting to a team-based model will only increase costs.

    For the same episode of care, we are now paying for a physician, an NP, a PA, a social worker, a pharmacist and a copule of other ancillary people when in the past we would have paid only an MD.

    Why are we paying 5 people for the work of 1? Costs will skyrocket as everybody bills insurance for the same patient encounter.

    • Sandra Barton

      Or, Jason, another way to pay for care would be a capitation-type system, where no one gets paid any more or less for seeing or not seeing a patient, and thus the MD can concentrate on using their MD-level expertise for complex medical issues, and leave the basic/routine issues to lower-level and lower cost team members. MDs could be responsible for a lot more patients this way, thus lower costs per patient.

      • Suzi Q 38

        Good description.
        Our daughter is going to get her NP license in a year.
        I told her that not all doctors are happy about this, understandably.
        There will still be a need for her services if she is good at what she does, like it or not.
        A good NP can assist the MD in caring for those patients that have less complex conditions.
        The public is getting more and more used to this idea of care.
        Moreover, I appreciate that they can spend a bit more time with their patients.
        If their condition(s) become more complex, a visit to the MD is customary.

        • Tom

          Not all patients are, either. With all due respect to your daughter, if their long-time doctor suddenly shunts them off to some nurse they’ve never even met before, because their issues aren’t “important enough” for him to waste his time with, your daughter will not be their favorite person. She will be the person they are forced to see, against their will, because they are suddenly not worth their doctor’s time.

          • Suzi Q 38

            You make good points.
            Sometimes, though doctors are also overworked and need help in order to serve more patients.
            If the NP is licensed to assist those doctors, so be it.
            Yes, not all patients will be sanguine with this idea, but several others may be.
            Like it or not, NP’s will have their “place” in medical care.
            Doctors on this site keep talking about the FP or PCP shortage looming in the future. It has already begun. My PCP has more patients than he can handle.

            If this is the case in your practice, why not consider the services of an NP?

          • Tom

            Yes, but if it’s only because patients have no choice, don’t expect them to be happy about it.

          • Suzi Q 38

            I beg to differ. At my dermatologist’s office, at times I am offered….DARE I SAY IT….a “midlevel” PA. I will have to say that she does very well.
            If I am concerned as I heal from whatever treatment I received, I ask to make an appointment with the MD and the office staff complies.

            I am still happy.
            It depends on what my situation is.
            If I have controlled asthma, I may be fine with seeing the PA or NP for an RX refill of albuterol.
            If the MD places me on Diovan and I am doing fine for a year, I may see an NP for a follow-up visit if I have no troublesome or annoying symptoms.

            It depends. Of course, I would like to see the doctor from time to time. Optimally as many times as he/she is available. I am just not opposed to seeing the NP once in awhile.
            If I am really impressed with h/her, I may agree to see h/her more often.

            I am well aware of the difference between an NP, PA, and MD. I am just saying that yes, mistakes can be made, but errors happen with MD’s as well.

            To say that this group of professionals have little place in medicine is a bit irrational and somewhat paranoid.

            Be confident that you are the primary choice for the patient’s office visits.

          • Adolfo E. Teran

            Dear Suzi , if you are happy then that is the end of the conversation . I love grilled salmon, do u think every must love it? Or do you think vanilla ice cream is everybody’s favorite? Or everybody must eat their steak well done? Or everybody must own a pick up truck?
            We are different across my town or country. You are saying mid levels are here to stay, I think you right. I think the consumer will determine if that is going to happen. I think it is waste of my time trying to guesstimate the future. If my patients are happy with our care they will stay.

          • Suzi Q 38

            You are so right.
            I like your creative writing skills.
            Hence my point:
            there will be a “place” for NP’s.
            Anyone’s patients will stay if they are happy with their care MD, NP, PA, or a combination thereof.

          • Adolfo E. Teran

            Dear Suzi, I’m not against NPs. I’m married to one, she is the PCP of our pediatric population in our clinic. We are working in the same place, she grabs me to see her patients that need my attention. She discuss her patients with me whenever she needs it.
            She is pediatric NP and won’t never see my 60-70s year old patients. My patients see me only and she see hers.we work as a small team. I don’t think it is appropriate for the patients to see different providers. There is no continuity of care and patients have a perception of poor care. Regarding the comments about obamacare, I did not read the 3000 pages of legal nonsense. Obamacare is promoting the dead of the small solo Practitioner . He wants the ACO which is in IMHO a HMO, is monopoly. When u create a monopoly you need the supervisors and managers and lawyers that would never work for free, not even answer the phone without sending u a bill. Also obamacare was created by a lawyer,therefore there is no tort reform. Defensive medicine is expensive all the time. Also obamacare did not address the system abuse by the people who live in this country. I have seen so many people abusing Florida Medicaid . People claiming to be poor and they are not really poor. People that live together as a couple but never get marry because legally don’t live together, because if they do they won’t qualify for food stamps and Medicaid .
            IMHO it doesn’t matter who occupies the White House if they don’t fix the complex situation where in the obamacare won’t improve anything.

          • Suzi Q 38

            You make some good points. Thanks for responding.

          • LeoHolmMD

            There is no physician or provider shortage. There is a disparity or maldistribution problem with medical care period. NPs will be subjected to the same problems MDs face who try to provide care in rural and primary care environments. As long as those conditions exist, the “shortage” will continue.

          • Suzi Q 38

            Yes, I wonder how my daughter will fare in Southern California. This area a saturated with doctors. I am not sure about the PCP, though.
            there are certainly plenty of specialists and first tier hospitals to choose from.
            I am sure that she will find a job that “fits” her skills. As it is, her first tier hospital pays 50% of her tuition. In exchange, she has to work for them for a couple of years.She is a very smart young lady, (of course I say that, I am her mother, LOL), and she is not jaded yet.

            I would take her care when she has completed her education over a jaded MD that is bored and complacent any day.
            It all depends on what kind of MD you are.

            A good one, or one that is so jaded that h/she doesn’t care anymore?

          • Henry E. Adams

            Leo,

            Looks like your own associations disagree with you: https://www.aamc.org/download/100598/data/

          • Henry E. Adams

            Suzi Q,

            Right on. The thing is no one seems to get the demographics of this:

            (1) the world’s population, now that we’re 7.4 BILLION humans on this planet, is growing much faster than when we were 4 BILLION. In fact, 100 times faster than (2) the pace at which we’re producing physicians, NPs, PAs, or RNs. (3) 80% of those people coming on board live under the poverty line. (4) The worldwide epidemic of chronic diseases – heart, lung, diabetes and cancer – over the next 10 years will chalk up HALF A BILLION deaths. (5) People with chronic diseases are dying 100 per minute. Chronic diseases claim 60+% of all deaths; acute infectious diseases – those caused by viruses, bacteria, parasites, fungi like TB, HIV, some cancers – cause 40% and dropping.

            For every 10 patients a doctor some where sees today, 144,000 will be waiting tomorrow morning in the global waiting room.

            Implication? Old-style health care has been overwhelmed, and it’s dead. Either as patients we self-manage the conditions of our diseases occurrence or the system being erected will make you a full-time patient who is disabled, unemployed, probably medically bankrupt, with no more personal life, and will likely kill you prematurely.

            The positive note: chronic diseases are preventable. We learned bad habits and got used to making bad choices. We can learn good habits and get used to making good choices. Do not wait for Big Daddy government to take you by the hand and care for you.

          • Suzi Q 38

            Thanks for the information, Henry.
            I know that NP’s are not doctors, but they can help others in their own way.

          • Suzi Q 38

            I agree, but not all patients are unhappy about it.
            Some are just fine.

          • Guest

            If a patient decides that they’d prefer to see various nurses rather than their doctor, that’s fine. But if they’re told they CANNOT see their doctor anymore, that all they get is this nurse (or that nurse, or the other nurse, like it or not, I think a lot of them AREN’T going to like it.

          • Cyndee Malowitz

            I’m an NP with over 11,500 patients on my roster. I turn patients away simply because I don’t have time to treat anything more than minor emergencies. I guess you would be shocked to know that patients want ME to be their primary care provider, rather than their physician.

            Last year I referred more than 300 patients to primary care providers. No more – a family practice physician is going to start working out of my clinic next month and taking care of primary care issues. Still, all those patients wanted ME, a nurse practitioner, as their PCP. I wish I could clone myself.

            You guys need to get over yourselves. I can think of 11,500+ patients who prefer a NP over a physician.

          • Guest

            You’re missing the point. What if you worked at a patient care medical home with a bunch of ancillary providers with less education and training than yourself. Your patient requests to see YOU but some middle man or woman tells them “your problem can be better handled by Nurse X and Physical Therapist Y.

            THIS is the point, not that patients specifically want to see a PHYSICIAN over a NURSE. It’s that they want to see their primary care provider and not be told by someone else that they cannot.

            Yeesh, you are so busy being defensive that you didn’t even realize no one was attacking you!

          • Cyndee Malowitz

            I counted over 5 posts by people slamming NPs…as usual.

            Something else, most nurses are not NPs. Quit trying to confuse the public. I certainly never diagnosed or treated illnesses when I was a “nurse.” I did what the doctor ordered. As a nurse practitioner I can legally diagnose and prescribe medication.

            Furthermore, a patient should be able to see whomever they want to see. The only time I’ve seen this as a problem is when physicians hire NPs/PAs and have them do all the work.

      • Tom

        “,,,and leave the basic/routine issues to lower-level and lower cost team members.”

        Again, how do you KNOW which of a patient’s complaints are so “basic/routine” that they must not be allowed to waste a real doctor’s time?

        And is it worth sacrificing a patient’s continuity of care? Is it worth forgoing any semblance of a trust-based relationship between patient and doctor?

        • Suzi Q 38

          You are so right about this.
          On the other hand, two of my specialists missed routine symptoms that they passed off as diabetes rather than spinal stenosis in my C-spine.
          It can happen to any busy and jaded doctor, who is too tired or bored to listen to obvious pleadings from an educated and concerned patient.

          It happens.

    • Adolfo E. Teran

      I agree with you Mr. Simpson . I strongly believe that having more suits walking around and drinking coffee won’t help the patient. I’m a solo Practiioner , and I don’t think that the members of care team will come to work for free in my office. I witnessed such waste of resources in organizations where they have 20 millions supervisors of the. Supervisors doing and creating policies to justify their salaries and existences.
      When you have the so call team your overhead sky rocked then you just jumped in a treadmill model of medicine. My patients want to see me not a revolving door or assistants and providers. They come to see me because I’m personable and approachable and take time to listen to them. They super tired of impersonal care, waiting for weeks to have an appointment with a different and new face every time.The have waited hours for the provider that spend 5 minutes and don’t listen to them and don’t address their issues.im small and solo and tried to reduce my overhead so I can be there for them.Adolfo E. Teran,MD

      • Tom

        Exactly! And what might seem like a “small, trivial problem” to the receptionist or whoever is doing the culling of who is allowed to see a real doctor and who only gets to see a nurse, probably doesn’t know that particular patient well enough to be able to make such a judgment call.

        People are so much more than the sum of their self-reported complaints at any given time. My wife never complains about ANYTHING, for instance, so when she mentions to her doctor that she’s had “a little bit of discomfort” when walking up and down the stairs, or has suddenly started getting “a little headache now and then”, he knows her, so he knows that this is something which needs looking into.

        I do not like this new model of health care one bit. It’s one thing to take your car in to a different service person every time it needs care, or to call a different repairman in to fix your oven than the one who fixed your TV, but humans cannot be treated like this.

        I don’t even treat my dog this way! He has seen the same vet every single year, for thirteen years so far. I would not accept it if the vet suddenly said this dog was only going to be allowed to see a veterinary assistant, and probably a different one each time.

        • Guest

          We always see the same vet (and a real vet, not some semi-skilled assistant) every time. It was she who picked up that changes in our elderly Jack Russell’s personality might be due to Addison’s and tested him, and that was indeed the problem. Someone who didn’t know Spike’s normal personality for the past 11 years wouldn’t have picked up on that, I think.

          If everyone paid their doctors personally, and just had insurance to cover Major Surgeries and Cancer and Such, the way they do for pets, we would probably have a MUCH better healthcare system. Instead the insurance companies and government get more of a say than the actual patient does, because THEY’RE the ones paying the bills. So they can tell you you’re not allowed to see a real doctor anymore, because of course nurses and such are cheaper. What a mess.

      • Suzi Q 38

        That is so good. I am sure that your patients appreciate your availability and the way that you run your practice.
        You have the control because you have your own practice.
        Not every clinic and hospital is run like your practice is.
        In a “perfect world” (your own practice) you can decide what happens. Good for you.

        I still say that I “saw this coming” more than 5 years ago.
        The NP’s are here to stay. They will be utilized in all sorts of provider situations. You don’t have to like it. It will exist regardless.

        I think it is sad that there is so much animosity towards their professional existence.
        They have a right to practice medicine in the limited way that their license allows.

        • Guest

          “They have a right to practice medicine in the limited way that their license allows”
          .
          .
          .
          …and unless America’s poor hapless patients have the money to go concierge, they’ll be stuck with a variety of nurses and other “physician extenders” practicing medicine on them rather than the one primary physician they’re used to.

          So everyone gets what they want except the patient. I, too, have trouble seeing why this is then called PATIENT-centered medical care.

      • buzzkillerjsmith

        Waling around and drinking coffee. You described my dream job. But I guess I’m stuck with this diagnosis and treatment stuff.

      • Cyndee Malowitz

        Dr Teran – you seem like an excellent physician. I wish there were more like you! Just today a patient told me he wanted me to be his primary care provider. He has gone to the same clinic for over 4 years and has never even met the physician. He saw her NPs every single time.

        Even worse, I know of several patients who have seen a NP or PA every single MONTH for YEARS instead of the pain management specialist. And physicians wonder why the general public thinks all they care about is money.

        • Adolfo E. Teran

          Thanks Cyndee, I just country boy from a third world country .

    • LeoHolmMD

      There is no doubt that the PCMH raises costs. It makes you wonder why there is so much top down pressure to implement them.

    • Henry E. Adams

      Right on Jason,
      And the Bible is there, ICD-10, right next to the billing specialist that every member of the Team will have, breaking out every tiny piece of service they can bill you for. I worked with anesthesiologists in an Outpatient Pain Clinic and here’s how the billing for a typical epidural works out:
      - the doctor’s fees
      - the fluoroscopy (shows your spine on a screen)
      - the radiology tech
      - the pain nurse that stood by the doc and the gurney
      - the room where the fluoroscopy is (that’s separate)
      - the analgesia injection
      - the lidocaine local before the injection
      - and, of course, the royally expensive MRI

      You’ll also have to spend 2-3 hours arguing with the billing office that you only had 1 MRI not the 3 MRI they want to bill you for which they are certain you had.

  • southerndoc1

    What “team-based care” should be: a well-run office, as Dr. Smith describes

    What “team-based care actually is: assembly-line medicine run for the profit of BigCorpMed, with the doctor reduced to a supervisory/administrative role, and in which patients are not allowed to see a physician if they are labeled as “simple”

    Take-home message: avoid any practice which claims to deliver team-based care in the setting of a patient-centered medical home

    • Sandra Barton

      That’s a bit narrow, southerndoc1. The truth is that the only reason an MD is needed for simple issues is for billing purposes. MDs should be used for MD-level complex issues and leave the basic/simple stuff to RNs, NPs, PTs, and other common-sense team members who can handle half of all questions that come into a doctor’s office each day.

      • Guest

        But who decides what is “basic/simple stuff”? If no one practitioner in the office actually KNOWS the patient, if all they’re getting is fragmented care, how can a receptionist or whatever make the decision that THIS patient, with THIS particular complaint, is not fit to be seen by a real doctor, but only needs a low-level practitioner?

    • LIS92

      It’s amazing how accurate your description fits the care I got from a “patient-centered medical home”

    • Adolfo E. Teran

      I agree 100% with your comment.

      • Tom

        Me too. And I know a lot of people who feel the same way.

    • Noni

      Concierge seems the way for those who want adequate primary care in the future. Everyone else will be stuck with this model which sounds like a disaster to me.

      • lissmth

        I already pay privately, have a private medical record and no insurance company is involved with it. I have a high-deductible policy strictly for insurance.

  • Sandra Barton

    I’m a primary care doc? Team-based care means that not everything that people call into a doctor’s office needs to be seen or dealt with by an MD. In fact about half of all “doctor appt” requests do not actually need MD expertise to resolve the problem to everyone’s satisfaction. Knee pain for 3 days? An RN plus a physical therapist can handle that. Sore throat/cough/cold/earache? An RN or a nurse practitioner can handle that. Allergies acting up? A good RN can handle it with input from the MD but no actual MD appt needed. For patients, what team-based care means is that you need to realize that not all of your medical needs need an Md-level of expertise to resolve. For Primary care MDs, it means that they can get all of their actual MD level work done in roughly business hours (rather than hours and hours of their own time) and thus can stay in the job for a long time rather than burning out and leaving. Anyone know any primary care MDs who have left their jobs? This is why. Team-based care is the answer to keeping primary care docs in the jobs. Sorry about weird punctuation here that I can’t change including the ? In the first sentence above!)

    • LIS92

      My problem seemed simple and I suffered for 18 months seeing the nurse practitioner. My only contact with my PCP was during a physical where she decided I needed Prozac because I was frustrated with my symptoms. I referred myself to a specialist.

      Although my PCP could provide continuing care, I stick with the specialists because he never assumes my issues are simple nor does he pass me around the office.

      • Adolfo E. Teran

        You have no pcp, it is sad but it is the true

    • azmd

      Not all medical problems need to be addressed by an MD, but then you don’t really have an MD, you have a medical practice you go to for various medical issues, some of which may be dealt with by an MD. You also do not have a personal relationship with a physician, which seems like something that a large percentage of patients would like to have.

      The only way to have a personal physician with whom you have a meaningful relationship is for that physician to see you for all issues, trivial or not, in order to have as rich an understanding as possible of who you are as a person and a patient.

      The patient who comes in for a seemingly trivial complaint but is very stoic may have a very serious condition which could go undiagnosed if an NP who does not really know the patient takes the complaint at face value.

      Likewise, the patient who is more anxious and comes in with a more serious-sounding complaint could end up undergoing an expensive battery of unnecessary tests if the provider does not know that that patient has a tendency to overreport symptoms.

      I suppose the practice could avoid the latter situation by automatically assuming that every presenting complaint is due to the most benign diagnosis in that particular differential, but then you aren’t really delivering good care.

      To me, the “team approach” that would deliver the best care would be the one in which the hands-on patient contact is always carried out by the doctor, but all possible administrative and documentation tasks are completed by support staff. That’s the model in which I currently work, and for the most part we see it working well and our patients receiving excellent care.

      • Tom

        Very good comment, azmd, I agree completely with your thoughts there.

      • Steven Reznick

        Well said and I agree.

    • Henry E. Adams

      You’re right, the day of the Money Tree is over. The game now is cost-containment. I’ve worked with primary care docs and they’re leaving primary care because, as they say, “it’s slave labor” plus PCPs are the lowest docs of them all. New med school grads are going into the specialties but they’re apparently not aware yet that the trend is that all medical care will be provided by primary care docs, whether the care need is in their area of practice or not. Chronic diseases – like diabetes, heart and lung disease and cancer – are a real dilemma. Technically they’re preventable because they’re “chronic diseases of lifestyle” but primary care docs have no demonstrable competence in lifestyle, attitude or habit modification. So the treatment will be… meds and more meds and no one willing or responsible for their interactions. Time to pack the bags and go live in the mountains raising your own food, breathing oxygen, and learning how to do Self-Management, the only no-fee healthcare.

      • Guest

        Actually, you make some great points. Perhaps health care becoming horrible will force more people to practice good health maintenance.

  • Tom

    If you aren’t going to be allowed to see the same doctor every time, or even ANY doctor every time, why bother with a real medical practice anyway? If I wanted medical care from random providers I have no say in choosing, and where no-one actually knows me and I’d have to repeat my whole story to a new provider every time, I’d just go to a Doc-in-the-Box or those new Walgreens thingies they’re setting up.

    If I want anonymous care from random midlevels, I don’t need a proper doctor’s office for that. And really, it’s insulting to call such a thing “Patient-Centered Medical Care”, when it is nothing of the sort.

    • Sarah95

      I agree. I already hate talking to some nurse I don’t know who relays my information inaccurately and who calls me at home to market on behalf of her hospital employer. It’s already clear I’m nothing but a cash cow.

      I resent having to explain personal concerns to strangers making appointments or taking my blood pressure. If I’m going to have to put up with that I’ll go to Walgreens where I can get right in. Considering I’m seeing an NP now, there’s really no difference.

      It’s clear that “allowing a doctor to see more patients” is merely a euphemism for “making more profit for the doctor’s employer.” I feel sorry for doctors who entered their profession as independent small business people but who are now merely employee widgets in the “nonprofit” hospital that’s taken over our area.

      I watched my own doctor (who I’m now longer allowed to see because I’m shunted off to “allied health care professionals”) struggle to maintain his independence. The need for EMR was the death knell for his small business. The “nonprofit” hospital has taken the catchy name of his practice and franchised it as if it were a lemonade stand, with three identically named practices in three small towns.

      I’ll be happy to go to Walgreens just to get out of this system.

  • Doctor K Says

    Unfortunately teams,in the end, will not make any decision but influential people on the team.

  • buzzkillerjsmith

    It is quite enjoyable and diverting for us to share the pros and cons of various types of practice organization.

    But don’t you all get it? Don’t you get it? Margalit gets it. What we as doctors want and what you all as pts want simply does not matter. We are the factors of production and you are the profit centers. Other people are in charge here.

  • Sandra Barton

    So may I sum up? Sounds like the way we have traditionally done things in Primary Care in the US is fantastic — never mind that it is such an incredible burnout that literally no one is becoming a Primary Care doc any longer — and the notion of changing our status quo to something more sustainable is intolerable to most of us.

    • Guest

      Why do you consider that the only “sustainable” way forward is to ban patients from seeing real doctors? In what country which offers better healthcare than America are patients not allowed to have primary care physicians? Switzerland, Singapore, Australia, New Zealand… are patients called “ugly” and “needy” for wanting something so simple as a PCP/GP they get to see every time they come in, without a receptionist triaging the bulk of them down to a variety of lower level “providers”?

      What do you even mean by “sustainable”?

  • Ed

    The team consists solely of myself (patient) and my physician. I choose who and to what degree a provider participates in my healthcare.

    • lissmth

      If you’re in a medical home, you won’t be choosing. You’ll be told.

      • Ed

        A typical patronizing
        and paternalistic attitude by a medical “professional”! ALL
        patients, even those in a medical home, have the
        ethical and legal right to choose who and to what degree a provider (physician,
        PA, NP, nurse, medical assistant, student, or chaperon) participates in their
        healthcare! You can’t so much as touch them without their consent.

        • lissmth

          Ed, you need to study “medical homes” and “accountable care organizations.” To help you along, study capitated HMOs and what failures they were.