Will any of these solutions save primary care?

Researchers at the American Academy of Family Physicians’ Robert Graham Center have estimated that the U.S. will require 52,000 additional primary care physicians by 2025 due to the effects of population growth, aging, and insurance expansion. Since it takes at least eleven years of post-secondary education to train a family physician, even a renewed surge of student interest in primary care careers is unlikely to meet this anticipated need.

Another recent Graham Center study concluded that expanding the scope of practice of nurse practitioners and physician assistants would still result in an overall shortage of primary care clinicians.

This month’s issue of Health Affairs contains several proposals to expand the capacity of the existing primary care workforce. Scott Shipman and Christine Sinsky review effective strategies for reducing waste and improving efficiency in office practice: delegating clerical and administrative tasks, using medical assistants as work “flow managers,” establishing non-physician protocols for routine chronic care and test ordering, and moving some types of acute care visits online. If each practicing primary care clinician could free up capacity to see one more patient each working day, that would translate into 30 to 40 million additional visits per year.

Another review by Jonathan Weiner and colleagues projects increases in efficiency and reductions in future demand for office visits from expansion of health information technology and e-health applications. Based on the published literature, they estimate that even incomplete implementation of existing technologies could increase physician visit capacity by up to 21 percent.

Finally, Arthur Kellermann and colleagues propose creating the new occupation of “primary care technician,” analogous to the existing profession of emergency medical technicians (EMTs), who provide the vast majority of first-contact emergency medicine in the field. This is their job description:

What we need are primary care extenders with local ties and cultural competence of community health care workers, the procedural skills of PAs, and ready access to the knowledge of NPs and primary care physicians. They should be easy to train, inexpensive to employ, and capable of working miles apart from their supervising providers … Primary care technicians could be quickly trained to deliver basic preventive, minor illness, and stable chronic disease care to populations that currently lack access to care.

Are these proposals, taken individually or in combination, adequate solutions to the problem of too few U.S. family physicians?

Kenneth Lin is a family physician who blogs at Common Sense Family Doctor.

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  • Dr. Drake Ramoray

    None of these articles are written by practicing physicians or even people who know anything about medicine, let alone running a practice.

    If I am ever required to have “a work flow manager to guide physicians from task to task” I will retire in a heartbeat.

    I’d be interested to here about online acute care visits and primary care technicians from a malpractice perspective.

    I have a pretty good idea how I could see 20% more patients and save thousands a year in the process. Ditch my EMR.

    Who are these people and who funds their research?

    I’m still in shock. I can decide whether to laugh, cry, shake my head, or be offended.

    • NewMexicoRam

      Go ahead. Do all of the above. I’ll be laughing, crying, shaking my head as well. As far as being offended, I guess I’ve become too numb for that anymore.
      Ditching the electronic record is a great idea, so that means it won’t happen.
      I hope this is just the Dark Ages before the Renaissance in healthcare.

      • Dr. Drake Ramoray

        With regards to the EMR issue. It is my understanding that as the current penalty schedules stands the penalty caps out at 5% maximum and not till after 2017. I’m not sure if that changes with the current law in committee that there is a thread on this site about.

        So ballparking our vendor fees, extra computers, power, software, the part time person we had to hire for all the scanning (darn optho eye exam reports), and the work the IT guy does for us I estimate that each provider in our practice has to be pulling about 200k (probably a little less) in revenue a year from Medicare. Given that our practice is max 30-35% Medicare (some higher some lower depending on the provider). I can pretty safely say I didn’t make the kind of money this year that would suggest keeping our EMR makes sense. We haven’t run the absolute figures yet (our office manager is working on it) because my napkin math doesn’t include the fact that Medicare pays less than our private pay patients (just making it more likely that it makes no sense to keep our EMR).

        Add to that the fact that the Mayo Clinic can’t meet Stage 2 meaningful use metrics.

        http://www.kevinmd.com/blog/2013/04/build-patient-portal.html

        I think it’s safe to say my mostly rural practice won’t meet those metrics either. So I’m paying all the above fees for an EMR and I still will get penalized. We are still independent and the clinical research company we are contracting with doesn’t require us to have an EMR. Right now it’s looking like when our contract is up with our EMR vendor that we are going back to paper.

        As for seeing 20% more patients. Not a chance. Working on clinical research and the previous time spent clicking boxes and charting in the EMR will be used to spend with my family.

        • southerndoc1

          We run the numbers frequently. We see no reason to switch from paper anytime in the near future.

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

            Pretty soon you’ll be able to charge extra for privacy since it won’t be a service covered by Medicare :-)
            BTW, high-tech people seem to also favor old fashioned schools for their kids where computers are banned. There is a pretty famous one in Silicon Valley (I think it’s Waldorf or something similarly posh…)

          • Kristy Sokoloski

            A school that bans computers? Wow. When I was in grade school and Junior High computers were just starting to come in to the schools. What a novel idea.

          • LeoHolmMD

            Seriously: “Doc off the grid”.

    • buzzkillerjsmith

      Precisely. These idiotic ideas are advanced by people who are not on the hamster wheel. They hang out with suits and the hypoxia in the higher floors degrades their cognition. The catered lunch result in sedation and inattention. The money for nothing is an opioid.

      Let’s return to the real world, shall we?

      1. EHRs are trash, known to be so. Gigantic time and money sucks with no improvement in patient care or cost savings. Yet these knuckleheads are waiting for the day they will transform medicine for the better. I myself am waiting for the day that the WSU Cougars (Go Cougs!) win the BCS Championship. My hope is more realistic.

      2. It’s the money, always has been, always will be. Other nimbskulls say it is the prestige–nonsense. It’s the money. I’m old enough to remember the day when dermatologists were thought of as wimps who couldn’t handle being on call-zero prestige. My how things have changed. Ka Ching!

      Unless or until the money gets straightened out, primary care is lost. And it’s not going to happen.

      3. It’s the working conditions. Quite nasty indeed, particularly since we are now the information managers and clerks for those silly, silly EHRs (see above). The geriatric revolution also takes its toll.

      4. Mainly because of the money, most of us are minions, like those one-eyed guys in Despicable Me. Eleven years of post-high school education to work for a 25 year-old ex-fratrat with the brains of a turnip and the humanity of Bernie Madoff.

      The money specialties don’t have to put up with this to the same extent. Even if they’re minions, they bring in the bucks are so are treated better.

      5. CorpMed will drop us PCPs like a bad habit as soon as possible if enough NPs and PAs can be found. Doctors are just too much of a pain to deal with. I know I am.

      I’ve said it before and I will say it again: “Young med student, if you go into primary care, you are a damn fool.”

      • rbthe4th2

        You should have a warning before reading this post. “Will cause you to splatter monitors if you are drinking”. I couldn’t get past the hypoxia moment for a while because I was laughing so hard.
        One of the best posts I’ve ever seen. Thanks for the comments.
        Randy

  • southerndoc1

    No.

    The chronically clueless Dr. Sinsky thinks the problem is primary care docs don’t see enough patients. There is not a single primary care physician in this country who wants to see more patients on regular basis, work flow manager or no work flow manager. Every one of us wants to see fewer patients and have more one-on-one face time with them. As buzzkiller described on another thread, every day we have patients who need an hour or more squeezed into a fifteen minute slot. Dr. Sinsky wants to make that a ten minute slot.

    If we have too few primary care docs, the first goal should be not to break the ones we have.

    Life is too short for crap like this.

  • PrimaryCareDoc

    Have an MA as a “work flow manager?” Who comes up with this stuff. An MA doesn’t even have a college degree. I can barely get my MA to room my patients and take vitals correctly (and I’ve worked with many MAs). This is the person who is supposed to make manage my work flow?

    • buzzkillerjsmith

      Hey, wait a minute! Is my MA moonlighting at your office?

      • PrimaryCareDoc

        I doubt it. I can barely get her to cover the hours she’s supposed to be at my office!

  • Kristy Sokoloski

    And if one goes with having Primary Care be such where it is paid directly such as a monthly fee then there would be even less patients for the doctor to see. The reason? Because the patient can’t afford to pay monthly fee to see their doctor. Direct pay is what dentists already do now and they wonder why most people don’t go to them for regular care? It’s because most people can’t afford to go to the dentist. And then some practices and clinics are taking Care Credit, but the people have to qualify to get it just like when one applies for a credit card and if one does not have a good credit history then they can’t get the card. So they are left without care. I have a friend that does not have access to healthcare at all as far as through an insurance plan and they are doing self pay and even the frequency that she needs to go to see her doctors is very small because they don’t have the money to afford to have her see her doctors more often.
    When looking at the plan choices for next year when it comes to health insurance one of the plans I looked at said that the cost to the Primary Care Physician was 15%. There was no set copay like with the kind of insurance I have now. And when I saw that I am like “yikes, I don’t know how they think people can afford to pay that 15% to the doctor.”

  • JR

    Getting insurance won’t automatically mean people start going to the doctor. I know I’ve avoided going to the doctor because I couldn’t afford the co-pay when I had insurance. I have a friend waiting to go until they can afford their co-pay, and they have insurance. I have another friend with insurance who hasn’t been to the doctor in 10 years – they won’t go unless they have an emergency. (I’m trying to convince them to go to at least get their Tdap updated).

    There are a lot of reasons people don’t go: Lack of money, previous negative experiences, etc. People without insurance who want to go to the doctor just go to the ER. When they get insurance, those people will hopefully switch to primary care, thus easing the ER congestion – but I don’t think those who aren’t going now will start going.

    • Kristy Sokoloski

      I agree with this. I had mentioned to a friend one time that even with the healthcare law that just because they have the insurance that doesn’t necessarily mean that they will see the doctor. She’s like “oh they will go”. Ok, they might for a time but then after a while go right back to normal as far as the way they have always done things.

  • southerndoc1

    The title is misleading. These thought leaders have no interest in “saving” primary care: they’re just coming up with ways to squeeze the last possible drops of productivity out of us before we retire. F*** them.

  • Guest

    “We also (as a society, I mean) compound this by fostering a sense that healthcare is a “right”, however vague that is.”

    This is very true. I was honestly shocked when the hospital called me for my $250 copay before giving birth. Even I, someone in healthcare, felt like going to the hospital and having a baby was “above” money, and it seemed odd to have to deal with that. I can only imagine how patients with no clue about how profit hungry health care is feel about being asked to deal with cost while ill.

    • NPPCP

      Feels weird defending hospitals but, it costs them money to deliver a baby and their payment is nowhere near what folks think it is. Believe it or not they Need that 250 to help make it worth their while financially.

  • Kristy Sokoloski

    I also agree with this, but to get a new IPhone the person may do that once a year, or maybe every 2 years. So the price for that IPhone as far as to buy it is only one time for a certain time depending on how hard they work their phone. The amount to pay each month for the bill for that phone depending on their finances is sometimes cheaper than the cost of seeing the doctor. No, I am not saying that this is ok to be more concerned about whether the IPhone, IPad and such work the way that they should because it’s not. One’s health is more important than an IPhone or an IPad.
    As for fostering a sense that healthcare is a “right” I do agree with this that it is a right, but let me ask you a question that may have been brought up before in other threads somewhere else on this blog. Why shouldn’t healthcare be a “right”? The reason that I ask this is because in order for someone to be able to work, pay their bills they have to have their health. If not, you are going to have even more people getting disability benefits than you already do. Currently (unless the number has changed in the last several months to a year) there are 14 million people getting disability benefits from the government. A good number of those people not only can’t hold a job because of health problems but if it wasn’t for the disability benefits’ program would not have access to their doctors to keep an eye on their chronic conditions.
    How are people supposed to be able to get to their doctor for “annual physicals” and “wellness” visits if they don’t have the money necessary to be able to pay for the gas to fill their cars (if they have one) in order to get to those visits, or for those that are chronically ill to have follow-up sick visits?

    • NPPCP

      For a routine office visit and all of the annual “fixins” it’s just not that expensive. There is no excuse to have a cell phone and not want to pay for a health care visit.

      • Kristy Sokoloski

        For the most part I agree with you. Now, let’s take out of the picture those that don’t have a cellphone because they can’t afford it. What about the people who make amount of money that allows them to pay bills such mortgage and electricity as well as food but yet still can’t pay for a healthcare visit?
        The reason I ask this is because there are some people like some of my friends that can’t even afford to get to the doctor at all. One of them is trying to get disability benefits so that she can get going to the doctor more regularly but she has been denied. Yes, she is appealing.
        It is true that not everyone’s priorities are in the right place when it comes to a lot of things. But unfortunately whether one can afford a cellphone or not (and some can’t even do that so some may make use of the free cellphone services provided by the government) we can’t make someone pay for a healthcare visit if they can’t afford it.

  • Martha55

    None of my poor friends have iphones….

    I once overheard an conversation of my co-workers discussing their tax return. One of them was really excited to get a $250 refund.

    I have an iphone. Among other things, I use it to improve my health. While I can afford to go to see my primary care doctor, I often feel the money spent is not worth it. I am told something I already know or I am shuffled off to a specialist I should have seen in the first place. I’d rather have the iphone.

  • lord acton

    There is a better way. I got off the gerbil wheel 3 years ago, am doing direct primary care, just me and my nurse, no insurance, no EMR, no front staff, no back staff. It has been awesome from day one, albeit hairy financially the first year. Be not afraid!

  • Kristy Sokoloski

    I have friends that are also struggling to be able to get their own food, keep a roof over their head, and get their own clothing as well. One of my friends is the one I mentioned that is trying to get disability benefits.
    I agree with your question though about how and when did all of this happen. Especially in light of the fact that there are still a lot of people that not only can’t find a job but some of them truly can’t work so to even meet the basic needs as well makes it a struggle which in turn makes it even more of a struggle for them to be able to get to the doctor for routine visits.
    Now for those that don’t think that these kind of visits are important which goes back to what you said about those that can buy their own food, house, clothing, entertainment which also goes back to what the other poster mentioned to me about there being no excuse to not try to get in for regular visits with a doctor then yes something is definitely wrong. Their priorities are in the wrong place. The question then becomes how does one go about trying to convince those people where to set their priorities need to lie? And to be able to get to the doctor regularly even if it’s for a problem visit only.
    Another thing that I don’t know if it is something ever discussed in all the issues with regard to Primary Care is those that choose not to go to the doctor at all because of either personal or cultural beliefs. How do you go about educating them to know that it’s ok to go and get help?

    • Mike

      You can’t change culture by government fiat. You can’t legislate the populace into doing those things which tend to make people healthy, wealthy and wise, against their wishes. You change the culture by changing the culture. Make it so that avoiding routine check-ups is as socially unacceptable as smoking, I don’t know.

      That said, I don’t know that it’s such a big problem that some people don’t go in for annual screenings and check-ups and all that. If you’re generally healthy, if you don’t have any chronic conditions that require active medical management, it may well be best to stay away from doctors if you can. At the very least, it should be a legitimate option.

  • Rachel Phillips

    I feel really bad for physicians and nurses who have become the pawns of the government pushing immature EHR systems and the patients who are put at risk. Who thought that paying millions for documentation would improve care or decrease cost?

    Our healthcare industry needs to refine its processes and connectivity before we develop/utilize massive documentation systems. We also needs to refine its delivery and pricing models (besides relabeling a historically unsuccessful model like an HMO as an ACO and pretend that the word ACCOUNTABLE means this model will create accountability).

    I think a good way to offer incentive for primary care physicians is to offer them monetary bonuses based on quality and to give them more respect. I think the insurer should pay for them to have a utilization/disease manager in their offices whose responsibility it is to f/u frequently on the patient’s status at home, paying them for appropriate telephonic interventions e.g. increasing their BP meds if hypertensive, decreasing metformin if their blood sugars are too low).
    Physicians don’t have time to spend on managing their patients care between office visits or taking the responsibility to treat over the phone without any kind of reimbursement.

    We are going to have to develop some radical and EFFECTIVE models of care in order to turn this system around.

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