Primary Care

IN THE STATES: Creating Incentives for Primary Care Physicians in Massachusetts

Paul Testa — Wed, 14 May 2008 15:06:00 -0400

Since 2006 more than 340,00 previously uninsured residents of Massachusetts have gained health insurance. As The New York Times recently noted, the expansion in coverage stretched the state's health care resources, especially in primary care. That's why we were particularly encouraged to read Elizabeth Cooney's Boston Globe piece on how community health clinics in Massachusetts have successfully recruited much-needed primary care physicians through a loan repayment program.

Funded by a $5 million grant from the Bank of America and administered by the Massachusetts League of Community Health Centers, the program provides up $25,000 a year for three years to repay loans. In its first year the program recruited 47 clinicians—more than double what they expected. Before the incentives, these centers last year had been unable to fill about 10 percent of their primary care positions.

We've written before about the importance of community health centers in providing primary care to underserved populations. Finding the doctors to meet the demand is not always easy. According to the Globe, doctors working at such clinics earn noticeably less than they would in private practice (Salaries range between $110,000 and $130,000 a year in Massachusetts). But for a typical young doctor who comes out of training with more than than $139,000 in debt, the program helps both the doctors and the patients they serve.

Study after study has shown primary care to be crucial to improving the quality and reducing the costs of medical care. Dr. Roy M. Poses at Health Care Renewal writes frequently about the flawed way we reimburse primary care compared to more procedure-intensive specialties in this country. More broadly, the shortage of primary care doctors in Massachusetts and our country as whole speaks to the need to reform the way we pay for and deliver health care. The goal of the payment system should be keeping patients healthy, not just making specialists wealthy.

CLINICIAN INNOVATORS: The View from the Clinic.

Joanne Kenen — Fri, 02 May 2008 15:00:00 -0400

I mentioned that I attended a conference a few weeks ago of the Institute for Healthcare Improvement, where doctors thought about how to reinvent their own clinical practices. The conference was not classic CME (continuing medical education) in the sense that they were not, for instance, learning that this drug was better than that drug for diabetes, or that this device was better than that one for a failing heart. They were addressing how they organize their practices and deliver the care to make it both more efficient and higher quality. And they were encouraged to think about being a doctor—or a patient—in a way they had perhaps not thought about it for some time.

In the big hallway in the convention center (this was Texas, so the hallway was indeed big), conference organizers put up lip charts and invited docs to scrawl their responses to three key questions. People in politics and policy circles are so busy drawing up models and plans and simulations for health care reform, they sometimes forget what the docs may have to contribute. So here are some of their answers from those flip charts, a peek into the minds of caregivers who care.

I'm not listing all of them—but the topic that came up over and over and over again in various forms was communication. And in a health care system where doctors are often pressed to keep office visits short, communication can be less than optimal.

When you or a family member is a patient, what matters most to you?

Communication with attending staff. Re: care; planning for future-next hour, next day, discharge; getting information early and not after the fact.
Being "heard" and the opportunity to talk.
Getting an answer I understand.
Knowing the health care providers/support staff care about me or my loved ones.
Eye contact from care givers: touch.
Getting to participate in my own health care decisions.
Information in writing. The ability to review key points.
Be compassionate and listen to MY story.
Not feeling "judged."
Not feeling rushed!
IT systems that talk to each other.
Relate my health needs with what is personally important to me...i.e. being able to travel, staying active/healthy for my grand children, etc.
That I don't fall through the cracks when the different health care teams don't speak to each other.
Right diagnoses, one provider to direct the care, knowledge safe alternative to traditional medicine.
That someone will CARE about what happens to me.
Honesty.
Not running late!
I want to feel like I don't have to be on guard second guessing the orders, feeling like I am the only one with a sense of urgency and having to be vigilant for mistakes.

How do you renew your energy and passion for patient care?

Conserve my energy by 1) recognizing my limits 2) Maintaining a life, as well as a practice, 3) Recognizing I cannot "cure all ills." Passion: time to recognize patients as people, with past and futures and value, not just decisions or management problems. Go to educational events to get perspectives different from mine.
Sharing and encouraging sharing the personal stories—we are societal creatures, let's get it all out in the open.
Engaging with the reality as experienced by the patient—identifying the gaps between the patient safety measures possible and the experience reality and resulting in to address the issue.
As a general internist, demographics are in my favor. The population is aging and we are the experts in caring for this growing population.
Art work and creative writing—as well as hiking/backpacking—total rebirth rejuvenation.
By listening.
Every time I am or my family is a patient I have either a good, bad, or mediocre experience. I want more of the good and want to improve the bad or mediocre ones.
It seems to happen too infrequently but when I can get into another's life story and connect it with mine, whether it is about joy or simply being "broken," the bond is there and I go away...thankful
I remember the words of Tom Marshall: "General Practice is the best job in the world—you get paid for talking to your friends".
I sing.

What are your thoughts about WHAT we need to reinvent about primary care and HOW we can reinvent it?

Stop seeing primary care givers as "jack-of-all-trades" and emphasize that we are in fact, masters of care management for our patients. Educate practitioners so we can be good patient care managers and educate our specialist colleagues for our value for patients and for them also.
Primary care does not need to be "re-invented." We have a good product. We practice in a toxic environment. We have to gather up the tools and create around us the structures that allow us to do our job. "Get our house in order-model the behavior-guide our colleagues."
Mash tents around the country with affordable care for all.
Remember that behavioral health is primary care—too often this is left completely out of the thought process in planning and development.
Demand payment for services rendered.
Primary care is the foundation of all health care. It is where the patient gets the most care.
Need to "re-invent" mechanism of sharing innovations that we develop with others. We have developed many systems to provide care of chronically ill patients, but aren't focused on writing/publishing or presentations. Therefore, no one knows to come to us and ask about our processes that are yielding results far better than large systems who often have staff to write/publish/speak.
I think Dr. Douglas Eby summed it up well: We cannot improve on a process if it is fundamentally flawed. We make a huge assumption that our current healthcare delivery system is the correct one. We really need to take a look at the process and determine if our starting point is correct.

QUALITY: There's No Place Like (a Medical) Home

Guy Clifton M.D. — Thu, 17 Apr 2008 16:29:00 -0400

What if we told you a program in North Carolina reduced Medicaid spending in one year by close to $244 million while improving care? The N.C. program offered primary care doctors a $3 per-patient, per-month payment to manage the patients on top of the usual fees for clinic visits. It also organized a multi-disciplinary team of medical personnel to assist the patients. The result: doctors spent more time with patients, coordinating treatment for chronic conditions and reducing hospitalizations. The overall quality of care improved.

The Patient-Centered Primary Care Collaborative (PCPCC)-a broad coalition of business leaders, policymakers, primary care physicians, and other stakeholders is looking carefully at success stories like North Carolina's to see how our whole health care system can redevelop our primary care infrastructure to control costs and improve quality in our country. After all, there's a reason it's called primary care.

Primary care matters. Just take a look at MedPAC, the WSJ's Health Blog, the NEJM or my forthcoming book, Flatlined—you'll see an airtight case for expanding primary care and changing how we pay for it and provide it. At the PCPCC's annual stakeholders meeting Wednesday, I was encouraged to see how such how changes are being translated into reality through the paradigm of "medical homes." These "homes" are the locus of patient-centered, accountable, primary care delivered in one place by one doctor or group of doctors assisted by a multi-disciplinary team. This model is being tested in both public and private sector initiatives across the country. (See the PCPCC''s recent guide for purchasers here).

This energized meeting was packed with individuals and institutions committed to seeing real change in primary care. It was only fitting then, that my colleague Len Nichols, Ph.D., gave the keynote address. Len placed the concept of the medical home within the broader framework of national health reform. He emphasized the potential for medical homes to realign the incentives of our health care system toward a model of "shared savings." Physicians would be paid for the quality—not just the quantity—of care they deliver.

We get what we pay for in health care, and right now we're not paying primary care doctors to act as stewards of their patient's health. In fact, the typical Medicare patient has multiple specialists and even more than one primary care doctor most of whom do not know what the others are doing. Yet, in many areas of the country, primary care doctors are taking no new Medicare patients because they are paid so poorly and their role in managing care is so devalued. The result is poorly coordinated medical care of variable and often mediocre quality. The doctors who are trapped in this bad system do not like it any more than the patients. It is a case of good people working in a bad system, and it can't be changed fast enough.

Experiences like the state of North Carolina have shown that investing in primary care can improve quality AND reduce costs. Coalitions like the PCPCC are trying to determine the details of how primary care doctors should be paid and supported in managing patients. The task ahead is to create a sustainable model so that primary care becomes the backbone of U.S. medical care. It will be like the old days when most people had a trusted doctor to guide them through the medical system, to manage their chronic conditions without hospitalization where possible, and to provide preventive care so that they did not develop illnesses. I believe that this dream is on the way to becoming a reality.

QUALITY: Taking Care of the Boomers

Joanne Kenen — Mon, 14 Apr 2008 17:47:00 -0400

More bad news for those of us who plan on getting old some day. The Institute of Medicine just released Retooling for an Aging America: Building the Health Care Workforce which reminds us there are not going to be enough doctors and nurses to deal with the geriatric needs of the 78 million baby boomers who start reaching age 65 in 2011. The authors said Medicare, Medicaid, and other health plans should pay higher rates to encourage more docs to learn about geriatrics. It also recommended training for family members and other aides who do a lot of the heavy lifting (literally and metaphorically) for the elderly. In many parts of the country, it noted, dog groomers and manicurists are required to get more training than the people who take care of our seniors.

"We face an impending crisis as the growing number of older patients, who are living longer with more complex health needs, increasingly outpaces the number of health care providers with the knowledge and skills to care for them capably," said committee chair John Rowe, professor of health policy and management, Mailman School of Public Health, Columbia University, New York City.

This isn't the first report to remind us that geriatricians are underpaid relative to other specialties. A geriatrician earned $163,000 on average in 2005 compared with $175,000 for a general internist—even though the geriatrican has extra years of training. (Neither of them earn as much as many specialists.) Registered nurses who work in nursing homes or other long-term care facilities typically work more hours but earn less than nurses in other settings. Remember that the Boomers can be expected to age (and die) differently than earlier generations. They will live longer and many will live healthier, but they will also have multiple chronic diseases. Today, the report said, the typical 75-year-old has three chronic conditions and takes at least four prescription drugs. Someone has to coordinate their care.

The IOM recommended that ALL health care providers get some training in geriatrics as virtually all of them (OK, not the pediatricians) will treat at least some elderly people. The report considered too whether we need to rethink some of the roles and responsibilities of providers. Maybe we should allow a certified nursing assistant to administer some medications, freeing the R.N. to manage the more complicated needs of a chronically-ill elderly patient.

The report said Medicare needs to improve what it pays, and change its focus from short-term, acute crises to managing chronic and age-related conditions. Lawmakers are beginning to get that message. Last week, it was reported that Senate Finance Committee Chairman Max Baucus (D-MT) wants to beef up Medicare payments for primary care in the doctors' pay package he's working on. Whether the specialists go for that remains to be seen.

QUALITY: Physicians Healing Thyselves (or at Least Their Offices)

Joanne Kenen — Thu, 03 Apr 2008 20:45:00 -0400

Tired of waiting for Washington to fix health care, doctors across America are doing it themselves. I just attended a conference in Dallas where hundreds of physicians exchanged ideas on how to improve the quality of care they deliver, make their clinics more efficient—and rediscover the joy of practicing medicine. In future posts, we'll touch base with some really smart and dedicated people we met there and highlight specific innovations that got our attention—new ways of reaching hard-to-serve populations, managing chronic diseases like diabetes, involving patients in their own care, new twists on "shared visits."

But here's our basic takeaway on how the 9^th annual summit on Redesigning the Clinical Office Practice, run by the Institute of Healthcare Improvement, could contribute to the high quality, cost-efficient and caring health system we envision for the future: as we noted when we posted on former Gov. John Kitzhaber's keynote on Monday, IHI and its CEO Dr. Donald Berwick (pictured) get a ton of (well-deserved) attention but mostly for what they are doing in the inpatient world, fighting hospital-acquired infection, developing rapid response teams and the like. (Yes, for any health policy newbies among our readers, IHI is the make-doctors-wash-their-hands-and-send- their-ties-to- the-cleaners-now-and-then" group.) Maybe figuring out how to apply "queuing" theories that work in supermarket checkouts and LEAN business practices to outpatient primary care isn't as sexy to the headline writers but it's just as important. Reducing wait times— waiting time to get the appointment and then all the time we sit around in waiting and exam rooms—isn't just a matter of convenience. It's about reducing waste, freeing up time and resources so people get the care they need, when they need it.

There was lots of talk about electronic medical records (one session was called "Going Digital Without Going Bankrupt") but a lot more talk about patients. How to streamline office practices so instead of having three nurses answering the phones you can have two on the phones and the third working one-on-one with a chronically ill patient, keeping them out of the hospital. How to create a "medical home," where a patient's care is truly coordinated by a primary care team that knows the patient instead of fragmented care by a half- dozen specialists flung across various clinics and hospitals, none of whom knows what the other is doing. Dr. Carole Redding-Flamm, executive medical director of Blue Cross Blue Shield Association, described Patient-Centered Medical Homes that are up and running in several states, rural and urban. The insurers, in some cases, are paying the doctors extra for successfully managing the care. An extra benefit, doctors report, is higher rates of patient satisfaction.

One high risk time for patients is transitions, for instance from the hospital to home health care. It sounds like a no-brainer to say that sick, frail people at high risk of finding themselves back in the hospital within a month need more than an occasional visit from a home health aide. But in reality, that's sometimes all they get. Consultant Ann Hess described a pilot program between Mt. Sinai Hospital in New York and the Visiting Nurse Service of New York. She showed how getting a nurse practitioner to a home-care patient soon after leaving a hospital reduced the rehospitalization risk. But that required tools for assessing the risk so that the nurse practitioner (who costs more than a less skilled home health aide) goes where she is really needed. It also requires getting the patient to see a doctor after a high-risk hospitalization within seven to 14 days (which often does not happen - that's where the smart business practices and reduced waiting time makes a big difference to the quality of care).

The "reinventing clinical practice" concept is an exciting one to anyone who has spent years in Washington (where all too often policymakers reinvent stalemate). One thing we'd like to see happen in this blog is for policymakers to hear about clinicians who are creating change, and for clinicians to understand how policymakers are beginning to understand some of the linkages between cost, quality and coverage. If you know any "clinician innovators" with good stories to tell, please post a comment and let us know.

QUALITY: Let Them Eat Botox

Joanne Kenen — Thu, 27 Mar 2008 16:09:00 -0400

We may not be able to tamp down diabetes in America but at least our skin will be flawless.

For a variety of reasons —including money —lots of young doctors choose fields like dermatology and plastic surgery instead of internal medicine, geriatrics and pediatrics. As we tackle national health reform, we need to make sure we put primary care back on center stage.

Two influential physicians, Joel S. Levine, chairman of the Board of Regents, American College of Physicians and Christine K. Cassel, president and CEO, American Board of Internal Medicine, chimed in about the "upside down" health care system and distorted incentives in a letter to the editor of the New York Times today. They were responding to the recent story, "For Top Medical Students, Appearance Offers an Attractive Field."

"The fact that so many medical students are choosing lucrative specialties like dermatology over internal medicine should be a clarion call that our health care system needs an overhaul," they wrote, noting that primary care docs can't hope for the $2,000-an-hour fees that a physician can reap on a cosmetic procedure.

Levine and Cassel called for a system that makes it attractive for young doctors to go into specialties that focus on caring for the whole patient. "More than ever, Americans need access to qualified primary care physicians to manage multiple chronic conditions as baby boomers gray and disease rates for obesity, diabetes and hypertension increase."

On a related point, Paul Levy, in his Running a Hospital blog fresh from a visit to Tuscany, described their per capita annual health care spending (1400 Euros) versus ours ($7000). Levy didn't convert Euros to dollars partly, he said, because "having a glass or two of Chianti while discussing the topic makes one care less about getting the numbers exactly right." Levy noted several difference between Tuscany and the U.S. including that they eat healthier and walk more -- and their health system covers people from cradle to grave. They also pay doctors less, but Italy has no shortage of doctors. One difference: U.S. doctors can end up with $300,000 in debts by the time they finish college, med school and residency. In Italy, medical education is free.

PAYMENT: When the Uninsured Become Insured, Who Will Care For Them?

Joanne Kenen — Wed, 26 Mar 2008 16:51:00 -0400

Dr. Benjamin Brewer, in his Wall Street Journal column (subscription, or read a summary in the Wall Street Journal health blog) wonders: who will take care of the 47 million uninsured in a system that already undervalues family medicine and primary care?

We would suggest that the uninsured are getting care – not enough care, too- late care, expensive emergency room care instead of more appropriate and cost-effective primary care. But Dr. Brewer’s central point is correct. Our system gives short shrift to primary care and is chockfull of incentives for fragmented specialization. In the health care system we envision for the future, primary care doctors (internists, family doctors, pediatricians, geriatricians, perhaps for some women OB/GYNs) would play an elevated role in coordinating patient care. And they would be paid for doing it well.

In the short run, though, there’s no doubt that Brewer is right in pointing out that the system undervalues primary care, both in money and status compared with specialists. The demand for family physicians is expected to surge by 2020, when the nation will need 140,000 family physicians, according to the American Academy of Family Physician's 2006 Physician Workforce Report. That's a 40% increase over the 100,000 family doctors at work in 2006, as Dr. Brewer notes.

But students aren’t flocking to primary care, which can have worse hours, less status and lower incomes than specialties. “Low payments to primary care doctors are discouraging those of us in practice and are dissuading new doctors from entering the field,” Brewer writes. For instance, only 65 more U.S. medical students chose family medicine for their residency this year than last year for a total of 1,172. (See a chart on the primary care trends here.) Compared with the bleak decline of the last 10 years, a two percent increase in family practice residents is cause for celebration among family doctors.

One last word -- we were disheartened that Dr. Brewer and several of the readers who commented on his column equate “universal insurance” with a single-payer government-run Medicare system. They aren’t synonyms. There are many ways to cover all Americans, and nearly all of the plans on the table in Washington these days use a mix of public sector and private market options. The presidential candidates are not advocating plunking an additional 47 million people in Medicare. Len Nichols, director of New America’s Health Policy Program, in a detailed post yesterday explained why simply expanding the 40-year old Medicare program is not the silver bullet for the complicated cost, quality and coverage challenges facing our system.

QUALITY: Missed and Delayed Diagnoses

Joanne Kenen — Tue, 18 Mar 2008 22:10:00 -0400

Apologies for the irony of blogging about a two-year old journal article titled "MIssed and Delayed Diagnoses" but Paul Levy on his "Running a Hospital" blog recently brought it to our attention. The study adds to the mounting evidence that the way our $2 trillion system tilts toward highly paid specialists versus primary care doctors may be hazardous to our health.

Levy points out the 2006 Annals of Internal Medicine study ("Missed and Delayed Diagnoses in the Ambulatory Setting: A Study of Closed Malpractice Claims" by Dr. Tejal K. Gandhi, et al.) about diagnostic errors that harmed patients—or contributed to their deaths. Common errors included not ordering the right tests or not interpreting tests correctly, not providing follow-up, or not doing a thorough enough physical exam. Sounds shocking until you remember that primary care physicians have 20 minutes or so with a patient.

Levy writes, "The first line of defense in proper patient care is the primary care system, yet this portion of health care delivery is systematically undercompensated and undervalued in the medical payment spectrum. We have relegated primary care doctors to a triage function, requiring them to see a large number of patients in a short period of time. It should come as no surprise that the kinds of errors mentioned in this article happen when a PCP (primary care physician) is expected to spend about 20 minutes with each patient."

Politicians on both the left and right have begun to talk about changing the way we pay doctors. Let's hope whatever new system they come up with takes into account the essential role of PCPs—those people who in a simpler era of health care we simply called our "family doctor."