Monday, March 31, 2014

Causes of the Crisis in Primary Care

The Crisis in Primary Care –Part 2

Primary care physicians (PCPs) have too little time per patient which means too many referrals to specialists, too little time listening and thinking, no time to delve into the stress or emotional causes of many symptoms and substantial frustration by PCP and patient alike.

In my last post in this continuing series on primary care, I described a patient with a straight forward if unusual symptom who was bounced from specialist to specialist at great expense, with no one offering a diagnosis, with no resolution of her symptoms and with no physician ever exploring the actual underlying causes of her symptom – stress related to a long ago family issue. Why did this happen? Because the PCP had only 15 minutes, not enough time to listen and to think and from there delve into her psyche.

Why so little time? The short answer is the insurance system, attempting to manage costs through price controls. Medicare has for years set a low reimbursement rate for regular office visits to the primary care physician. Commercial insurance always follows Medicare’s lead and has done likewise. Reimbursement rates have remained fairly steady for a decade or more (Medicare has very recently begun to raise rates a bit as a result of the Affordable Care Act) but office costs have risen each year. Overhead includes not just the nurse and receptionist but also the billing and coding people, accounting and legal needs, malpractice and disability insurance, health care insurance for the staff, supplies and rent and utilities for the office. With costs rising and income steady, the PCP tries to “make it up with volume.” This means seeing more patients per day, usually about 24-25, often even more. In order to see that many, the PCP has generally stopped seeing his or her patients in the hospital or ER and has shortened the time per visit – most visits being about 10-12 minutes of actual “face time” with the patient.

This is enough time for a strep throat, a quick blood pressure medication check or possibly to diagnose and treat Lyme disease. But it is not enough time to deal with a more subtle problem like the patient described in the last post experienced. It is not time to explore family issues, personal stress or anxiety that so often lead to or accompany symptoms and sickness. This lady had a straight forward issue that primary care physicians encounter frequently and those that are experienced know well what it implies. But it still requires time – time to carefully listen to the patient’s story, time to put it into the context of the patient’s life situation, time to do an examination and then some time to think about how to proceed. And once the management decision is made, it takes time to talk to the patient, reassure her and yet explain that she should call should are any further concerns arise – and to come back soon for a further follow-up and attention to the underlying issues.

The situation is compounded when the PCP has a patient with multiple chronic illnesses who is taking multiple prescription medications. Chronic illnesses like diabetes, heart failure, chronic lung disease, kidney failure or multiple sclerosis by their nature are difficult to manage, persist for the patient’s lifetime (some cancers excepted) and are inherently expensive to treat. These patients need very close attention and often need the benefit of a team approach to care. The diabetic patient for example may need an endocrine consult at some point, a podiatrist, an ophthalmologist, a nutritionist and an exercise physiologist, to say the least. But any team needs a quarterback and this is or should be the primary care physician. But here again, care coordination by the PCP requires time, the one thing the PCP most lacks in today’s reimbursement environment. The result is fragmented chronic illness care, disjointed care and care that is much more expensive than it needs to be. From a total healthcare system perspective, this is critical because chronic illnesses consume 75 – 85% of all claims paid by insurers.

But with little time to listen and think, the action step of many PCPs, as with the patient described last time, is to send the patient to a specialist. Indeed, according to an article in the Archives of Internal Medicine, about nine percent of all visits to PCPs result in a specialist referral, far far higher than truly necessary. This is up from about five per cent a decade earlier; 41 million referrals per year then compared to 105 million in 2010. Something needs to be done. The push for accountable care organizations, medical homes, population health and a switch from fee for service to a salaried or capitated system are noble but unless the PCP is given time and enough of it, these changes – no matter their apparent utility – will prove valueless.

Meanwhile, fewer and fewer medical school graduates choose to enter primary care. They are smart and see that PCPs are very busy and very frustrated. They know that given the PCP’s average income it will take many years to pay off their high educational debt load.

PCPs are looking for ways out of their dilemma. Many are retiring early. Others are closing their practices and beginning to work for the local hospital. But the hospital wants the physicians to earn their keep. That means high productivity. So it is still 24 – 25 patients per day, albeit without the administrative hassles of a private practice.

It is clear that the resolution will not come from commercial insurers, not from the government insurances (Medicare, Medicaid), nor will it come from the Affordable Care Act. It will likely be in the actions and decisions of the primary care physician himself or herself to change the paradigm to allow and encourage better quality of care with lessened frustrations for doctor and patient alike.

For starters, many PCPs need to look carefully at their practice patterns and determine if they can adjust their own workload by maximizing the talents of their team of nurses, nurse practitioners and others and with better use of technologies. This requires a change in thinking about how to organize the practice and who does what and when.

Beyond that, some PCPs have decided to no longer accept insurance. Instead they expect the patient to buy care directly. And since they no longer have the expense of coding, billing and collection (one estimate of this is $58 per patient visit!) they can charge a quite reasonable amount. This can take the form of a set fee for any visit, a sliding scale depending on the type of visit and its length, or of a set amount for all care for the year, a retainer-based (concierge) approach. In each of these models and others the patient replaces the insurer as the actual customer of the physician and as such has a more appropriate professional-client relationship. The patient also becomes a purchaser of services directly and thus begins to ask questions, to challenge and in general to bring down the costs of care while receiving a higher level of quality along with greater satisfaction and less frustration for both doctor and patient.

These are but a few of the approaches being taken by PCPs today in an effort to overcome the current non-sustainable business model so that they can not only give better quality of care but reduce their sense of frustration and increase their patients’ satisfaction.

In the posts to follow I will review what primary care is all about; the characteristics of a good primary care physician and a true healer; who does primary care and why and why not; the critical role of the PCP in managing chronic illnesses; the need to listen and think – both requiring time; the use of teams in the primary care doctor’s office; the importance of care coordination, wellness promotion and disease prevention; the current non-sustainable business model; what approaches are being taken to overcome the current business model; and finally how primary care can once again take its rightful place as the backbone of the American healthcare system offering superior quality, outstanding service and greatly reduced overall costs.

The next post in this series will address the critical shortage of primary care physicians.

Monday, March 24, 2014

The Meaning And Depth of the Primary Care Crisis

The Crisis in Primary Care – Part 1 of a Series

The primary care physician (PCP) should be the backbone of the American healthcare system. But primary care is in crisis – a very serious crisis. The first statement is my considered opinion and I will attempt to convince you of its truth. The second sentence is a simple fact.

Accounting for only 5% of all health care expenses, the PCP can largely control the “if and when” of the other 95% and hence can be the one to best affect quality of care and the totality of costs. This crisis limits the effectiveness of the primary care physician such that care quality is nowhere near what it could be or should be and the costs of care have skyrocketed.

This crisis is the most pressing and frankly most urgent issue in health care delivery today. Healthcare delivery must be restructured – now - so that everyone but especially older adults with multiple chronic illnesses can obtain quality, compassionate, cost effective care. And this means having a committed primary care doctor who has the time along with the knowledge and experience to deliver the care needed.

This is the first of a series on the crisis in primary care that will appear over the coming weeks and months.

To be effective, the PCP needs, of course, to be well educated, well trained and up to date. This is necessary but not sufficient. He or she can be more effective with an appropriate team approach that puts the patient in the center of the equation – the patient centered medical home concept. He or she also needs to be a deep listener and needs to think extensively. Listening and thinking require time and for those patients with one or more chronic illness, the PCP needs to quarterback all of the other providers involved with the patient’s care. This also takes time. Time is the element that has been lost in the past decade or more for the PCP. Without the time to listen, the full picture of a person and their illness does not emerge. Without time to think, the diagnostic process suffers immensely. Without time to listen, the PCP is no longer a healer but rather a well-paid care giver. Without time to think, the PCP is quick to send the patient off to a specialist. Without time, the opportunity for outstanding preventive care is diminished. And without time to coordinate all of the specialists and other providers that are required for someone with a serious chronic illness, the care becomes disjointed, quality suffers and expenses rise.

A patient story may help elicit the meaning and the depth of the problem.

Monica is 68, married, retired, on Medicare and in generally good health. She has a PCP who she sees intermittently. She began to have a strange sensation in her right chest described as a sort of shooting sensation, almost electrical or vibrational in nature that stretches from high up in her right mid chest down as a narrow line over her rib cage and just onto the abdomen. It seems to be immediately under the skin. It starts intermittently and ends at no set time. There is nothing she has found to make it start nor stop. She visited her PCP and offered this description, adding that she was concerned that maybe it was her heart. The doctor asked additional questions and did an exam and an electrocardiogram. All were normal save the description of the sensation.

The PCP was now about out of time for that 15 minute visit. Here was a fork in the road, two paths to choose between. Given that Monica was concerned about her heart, the PCP chose the path to send her to a cardiologist for further evaluation. The cardiologist found nothing abnormal but nevertheless suggested a stress test and an echocardiogram. Both were normal. The cardiologist suggested since the sensation crossed over to the upper abdomen, maybe it would be a good idea to see a gastroenterologist. The GI doctor found nothing. Nevertheless he ordered a CT scan of the abdomen. All was normal except that in her uterus there was a small cystic structure. The radiologist read it as a probably benign cyst but – feeling the need to be cautious –recommended Monica visit a gynecologist. The gynecologist also said it looked benign but just to be on the safe side, she could remove it. Monica would be out of the hospital the same day and feeling fine in a day or so! The cyst was just that, a benign cyst. Monica still had the strange sensation in her chest and no one had found an answer for her.  But given that it seemed to run in a line with an electrical sort of feeling the gynecologist suggested that maybe it was a nerve issue. So she visited a neurologist who of course found nothing, commenting that nerves run around the chest, not up and down.

Monica illustrates the problem so common today in primary care. The PCP did not truly listen to the patient. And he did not stop and think the issue out carefully. He had no time because there was a waiting room full of patients and he needed to see about 24 to 25 each day. So instead, he took the easier path and referred the patient to a cardiologist since this seemed at least logical given that the strange sensation was in the chest and the patient was personally concerned about heart disease. Had he followed the other side of the fork in the road and had listened long enough and then thought about it he would instead have concluded that the patient was hypersensitive to minor – albeit real – sensations. He would have offered reassurance that it did not represent a life concerning ailment. He would have said that it was real but of no concern. He might have offered a few weeks of a low dose anti-anxiety medication, offered further reassurance and told her to return in two weeks for a follow-up. At the follow-up he would have explored the issues producing anxiety or stress in her life – financial, marital, a disruptive child, an overbearing in-law. Had he done so he would have soon discovered that Monica was deeply concerned and feeing guilt about a family issue. What Monica really needed was assistance to overcome her sense of guilt and shame – not months of specialist hopping. Anxiety and stress are often components associated with a physical symptom and these can only be addressed with more time to carefully listen and then time to respond with suggestions.

But this was not the way it was to be for Monica. She was shipped from doctor to doctor, test to test, even an operation yet with no one really listening enough to figure out her problem. All each specialist could do was say it wasn’t in their “organ system” and left her with a sense of floundering and without a sense of closure from any physician. Each one said it wasn’t in their sphere – not the heart, not the stomach, not the nerves, etc. And the “surgery went fine.” But she still had the unpleasant sensation. So it resulted in far less than adequate medical care and obviously cost a king’s ransom. Neither was necessary. But that is what all too often happens today. And, I assure you, Monica’s saga is not uncommon.

Monica’s experience is all too common and results largely from the PCP’s lack of time – time to listen and time to think. The result is less than adequate care, certainly not humane care, not healing care and very high costs.

In the next post, I will address the causes of this crisis in primary care.

Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).