Highly Effective Business Approach To Reducing Healthcare Costs

“Helping employees improve their health is right for the company’s bottom line and is doing right by our employees.  Healthier employees are happier, demonstrate less absenteeism and presenteesism, and are more productive.  This is a win for everyone involved.”  Quoted from John Torinus, Jr., in The Grassroots Healthcare Revolution; he is retired CEO and current board chair of Serigraph, Inc., a mid-sized Wisconsin company with about 500 employees in the USA.

In my earlier posts in this series I have written primarily from the perspective of what primary care physicians can do to not only improve the health of their patients while reducing total costs of care yet also reclaim their right to practice in a non-frustrating environment with a limited number of patient visits per day. Torinus approaches improving health care from the perspective of a business leader faced with rising health care costs. Here I will quote and paraphrase from Torinus’ book and, since I basically agree with his recommendations, will amplify with some of my own thoughts.

He argues that company CEOs must make health care a strategic priority since it is one of the top three costs for any company. Healthcare costs can make the company noncompetitive if not managed aggressively. However, strategic priority to him also means it is essential for the company to attend in a proactive manner to the health and wellness of its employees, not just be the provider of an insurance plan.

CEOs need to think of the long term for their companies and therefore for their employees. The company and the employee together spend about $16,000 per year for a family for insurance today.  An employee who works for a company for 25-40 years represents an insurance expenditure over a lifetime career that could be as much as $400,000 to $640,000 in today’s dollars.  This drives home the point that it obviously only makes sense to have a long term view of employee health beginning with an aggressive approach to maintain wellness, actively reduce risk factors and  manage disease as it occurs.

He observes that the current health care system focuses on specialty care whereas it needs to focus on the care recipient with high quality primary care – the patient/consumer/employee.  But to be effective, the patient/consumer/employee needs to be engaged.  The current healthcare system disengages the patient – it removes responsibility because the patient is not the customer of the doctor.

In his company, expenses were rising to double digits by 2003 but with their new plan in place, it dropped to 2% or less per year.

Torinus’ “prescription” for all companies (and what his company initiated beginning in 2004) follows:  First, every company, including small companies, should self-insure with an added stop-loss catastrophic policy.  Second, employees should be offered only a consumer directed healthcare policy (CDHP), in essence a high deductible plan (often about $2500) with either an associated health savings account (HSA) or a health related account (HRA.)   The company should prefund the account with an amount (often about $1500) that the individual can use for any health care needs with the assumption that since it is now the individual’s money, he or she will spend it more wisely – employee/patient engagement.

Third, the company should insist that each provider have price transparency. Since that’s often difficult to obtain Serigraph uses various companies like Alithias Inc. to provide that for them so that they can compare one provider to another.  For example, they determine the all-inclusive (gastroenterologist, anesthesiologist and facility fee) price along with quality data of colonoscopies at the nearest five centers and then rank them. The employee or family member who needs the colonoscopy is told that, for example, the company sees it as appropriate preventive care and so will cover the cost, in this case up to $1,500.  [His book appeared before the ACA became law so colonoscopy would be covered now by the insurance component but the principle is still valid.] This is an amount that will pay for say, four of the five local centers; but if he or she selects a provider that charges more, they are on the hook for the remainder. 

Fourth, if the company is large enough, it should provide an on-site primary care clinic at no cost to the individual.  At Serigraph, the clinic includes a concierge-type physician (meaning that the physician is salaried, has a low number of patients under care and gives extensive time and energy to each employee/family member patient consistent with some of my previous posts) plus a nurse practitioner, a health coach, a dietician, and a chiropractor.  If the company is too small to justify a full-fledged clinic then the company can pay the retainer for a nearby direct primary care/membership/concierge physician who works with others such as the health coach.  Fifth, the clinic, with special attention by the health coach, gives all employees a health risk assessment annually and then works one-on-one with each employee (and family member) at no cost to maintain wellness and health including the use of behavioral change programs around diet, nutrition, exercise, stress management and smoking cessation.

Sixth, there is very intense management of chronic diseases by the clinic staff and coordination of specialist visits when needed.  Seventh, Serigraph uses what Torinus calls Centers of Value for procedures beyond those that are done by the primary care physician. These are doctors/institutions that have outstanding quality records yet a competitive price for, say, a knee replacement. Serigraph gives their employees $2,000 toward the deductible or totally covers the deductible for the surgery when they make use of these Centers of Value.  Seventh, his company gives (and he recommends others do likewise) generic drugs for free and all of the above prevention and wellness programs are supplied free of charge.  Finally, the company makes free counseling available for developing advanced directives and in the event that an individual requires end of life care, hospice is available free of charge.

I notice that his company spends considerably on extensive/comprehensive primary care including wellness maintenance, proactive prevention and chronic care management but it is rewarded in return with lower total costs and healthier workers.

Given that healthcare has become a company strategic priority, then it needs to be managed and that requires data. Hence, he urges all companies to develop health-related management dashboards including both a financial dashboard (how much is the company spending) and a health dashboard (how many individuals in the company have uncontrolled blood pressure, uncontrolled asthma, uncontrolled cholesterol, have not had appropriate mammography or colonoscopy, etc. – all information collected from the clinic in an unidentified manner to protect individual privacy). 

These approaches are based on fundamental principles including individual responsibility; market place discipline – installing consumerism, steering business to the best quality and price (“do good work and you get our business”); proactive care – maintain employees’ health and wellness and give extensive care to those with chronic illnesses; and sound management – putting those who pay, i.e., the employer and the employee, in charge. 

Torinus suggests there are multiple rewards for following this basic approach (I added number 2 since he implied but did not write it.)

1)     The reward for business is a healthier work force and more affordable healthcare expenditures. 

2)     The reward for individuals is more health and wellness, less illness and fewer dollars spent. 

3)     The reward for high value providers is more business.

4)     The reward for entrepreneurs comes if they innovate with better care provided at lower cost

5)     There could be a reward for tax payers - if government (federal, state and local) were to utilize these approaches

Sound advice.  Your thoughts?

The next post will delve into company wellness programs.

Direct Primary Care – A Response To Your Comments

Over the past few months KevinMD has posted a series of articles by me on what I call the “Crisis in Primary Care.”  (BTW, I was not a PCP.) Most recently have been a few posts related to direct primary care. They have generated many comments – some pro and some con. I have greatly appreciated everyone’s interest; it makes it worth the time to write. So thanks.

My fundamental belief, contrary to some comments, is that PCPs are much more than providers of “simple” stuff. They are more correctly specialists that deal with the very complex. Comprehensive primary care includes wellness and health maintenance, prevention and risk management strategies, attending to the episodic events that occur in life, and the care of those with complex chronic illnesses including coordination of care when a specialist is needed. It also includes developing a strong relationship between doctor and patient, building trust along the way and offering true healing. This means that the PCP can competently handle the vast majority of our health needs. 

But all of this takes time and when the current practice business model forces the PCP to see 25 or more patients per day, there is just not enough time. Direct primary care (DPC) is one way to regain that time. It is not the only way. I plan to discuss some other approaches in later posts. 

 

A few themes have arisen repeatedly in comments from these posts about direct primary care. One is that there is a difference among the terms DPC, membership, retainer, and concierge.  But to me, they all mean essentially the same thing - fewer patients per doctor and therefore more time for the patient with the doctor which equates to better care.  There does seem to be a degree of concurrence that DPC and membership are terms most often used for those practices that cost less per month or year and retainer and concierge for those that cost more. (There are a very few that charge a huge fee; I discount these as giving the term “concierge” a negative connotation to many.) 

Among the most common other themes from the perspective of a patient are: DPC is too expensive, especially for those of lesser means. DPC is an added expense if you already have primary care coverage by your insurance (e.g., Medicare or company policy). The PCP “abandons” patients when converting to DPC and does it because he or she is greedy. And the question - Is the care quality really better and are costs really lowered? Some thoughts on each.

First, DPC is certainly not for everyone – patient or doctor. But it is one model and it has proven very effective for some. 

Expensive? It’s relative. The average American family spends $2237 per year for cable TV, internet and phone. A Starbucks a day adds up. A parking space per month in a downtown lot is probably more than the DPC doctor. It is about prioritizing our personal expenditures. I also posted an article using as examples three practices that have been termed “blue collar” in the popular press because the costs per month are relatively low, the service is high and with the added benefit of generic drugs at wholesale prices many patients can save handsomely. Two of them have noted that they have many uninsured patients. These practices are cheaper than urgent care clinics and much cheaper than the ER. One person commented that I cherry picked cheap Midwest practices; DPC in urban areas cost much more. That is likely true if only because rent and staff cost more. Here is a chart from Concierge Medicine Today related to costs across the USA.

Why sign up if you already have insurance that covers primary care? The question to answer for each person is whether it is worth the extra money to get more time with your PCP? A lot more time. My PCP converted about five years ago. I was ticked off that I had to pay an extra $1500 a year since I am on Medicare and primary care is mostly covered. Some of my friends decided to not convert with him. Others decided as I did to pay up. My wife’s PCP converted to a retainer approach a few years ago. Same thoughts. But it has been worth the price – to us. But probably not for everybody. Again, it is a question of your priorities.

What about abandonment? It is another of those questions where the answer depends on your perspective. A group practice I know planned to convert and announced it to their patients. Soon articles appeared in the local paper about “greedy” doctors and patients who would be left without a doctor. But everyone who wanted to find a new PCP did so quickly – often with help of their former PCP who guided them to an appropriate doctor. Of course, in say a rural community where there is just one provider, it would be a different story. An analogy given me by Dr Josh Umbehr might be useful. Consider a 60 watt bulb. Try to push more voltage through it and it will burn out and there is no longer any light at all. Run it as it is supposed to be and it will last a long time. If the doctor is burned out and gets sick or just quits, that is not abandonment. It is actually worse. 

And the greedy doctor issue? When a PCP with a busy practice converts, they often end up with a much lower income, at least at first. Read some of Dr Rob Lamperts posts about what happened to his income including a one about his application for health insurance and for Medicaid. Later their income may rise and sometimes it will be more than before. From that same Concierge Medicine Today article – 73% of concierge or DPC physicians earn less than $200,000 per year. But it is really not about more money; it is about more time for each patient.

Quality up and total costs down? I wrote about this in my last post; here is a summary. It is hard to find other than anecdotal data with individual practices or even group practices. MDVIP [which is not a DPC practice since it still takes insurance in addition to a retainer] is a practice model that lowers the number of patients to doctor to about 500:1. Among the about 700 affiliated doctors there are about 215,000 patient members, enough to do some observational studies. They have found that quality measures like blood pressure control, diabetes control, immunization percentage, screening for cancer, etc. are substantially better than a comparable group of individuals not in their network. Similarly, there is a very substantial reduction in total medical care costs of $2551 per capita as a result of fewer referrals to specialists, fewer prescriptions, fewer hospitalization and fewer trips to the ER. As to satisfaction, perhaps the most important marker is that few individuals leave the practice. 

Similarly, Iora Health, Qliance and AbsoluteCARE, organizations that like DPC practices lower the number of patients per provider, can demonstrate better outcomes with lower total costs. Here again the cost reduction is from fewer specialist visits, fewer hospitalizations and fewer ER visits among other parameters. Qliance, for example, has noted 35% fewer hospitalizations, 65% fewer emergency department visits, 66% fewer specialist visits, and 82% fewer surgeries than simi­lar populations. (And before you tell me, I know that this reduction in costs may not directly accrue to the patient although it could convert into a substantial dollar savings for those with a high deductible policy. My point however is that fewer patients means better care which in turn means lower total costs.) 

What about doctors? Is DPC for every PCP? I doubt it. When a practice is converted a lot fewer patients convert with it than might be expected – maybe 15-20%. Income will probably go down, at least initially. Some patients will feel the doctor is being greedy as noted above. There can be legal issues; the insurance commissioner may say it is essentially an insurance policy for primary care; a doctor is not an insurance company. Some sound advice would be important before embarking.  Doctors are a cautious bunch; this is a big change. My bet is that, until patients actually start demanding more time and agreeing that this is a sensible approach, the total numbers of PCPs who convert will be modest.

Next time will be a different topic; what employers are doing to assure better care yet lower company costs. In many cases it too amounts to getting the PCP more time.

Saving Relationship Medicine with Direct Primary Care

The fundamental problem in health care delivery today is a highly dysfunctional payment system that leads to higher costs, lesser quality and reduced satisfaction. It also means less time between doctor and patient with the loss of “relationship medicine.” The core problem? Price controls and regulations that reduce the trust and core interactions between doctor and patient. The patient is no one’s customer and visit times are all too short. I have argued in the Washington Times as an Op-Ed that paying the doctor directly is better for all concerned.

I believe that some of the best attempts to improve this dysfunctional delivery system have been accomplished by primary care physicians themselves.   They have essentially said “I won’t take it any longer; this is not good for my patients or for me.” They have also said that it is time to “stop tinkering” and make a fundamental change. They have opted for a new, better system – direct primary care - rather than wait for others to fix it for them.

The concept with direct primary care is to reduce the number of patients in a PCPs practice so that each patient gets added time as needed. Often this means removing the insurance system as the payer from primary care and always it means a payment model that compensates the PCP directly by the patient. Direct primary care takes many forms. There are two principle payment systems. One is for the patient to pay the doctor directly for each visit, usually at a rate far below what would have been charged in the insurance model since the overheads of billing and coding have been eliminated. Many such PCPs post a defined price list – transparency. This is sometimes called direct pay or “pay at the door,” not unlike the way it was until a few decades ago before insurance morphed from being only for major medical or catastrophic issues to being essentially prepaid medical care.

The second model is for the patient to purchase a package of care for the year paid by the month or annually. This basic model comes with many variations and may be called membership, retainer or concierge. Despite the various names, they all have certain characteristics in common but there are many variations in how the practice functions.

All of these models offer a reduced patient to doctor ratio: instead of the typical 2500-3000+ patient panels, the PCP may adjust the number of patients to a low of 300 when the panel is very ill or to a high of about 800 for a panel that has mostly low risk patients. Some accept insurance and also charge the retainer; others just charge the monthly or annual fee.

With a reduced patient panel size, the PCP commits to offering same or next day appointments lasting as long as necessary, a comprehensive annual examination, email communications, and an invitation to contact the PCP on his or her personal cell phone 24/7. Some make house calls and nursing home visits for no extra charge; others add a modest fee. Some see their patients in the ER and some follow their patients in the hospital.

There may be an arrangement to obtain laboratory testing, imaging and procedures at highly discounted rates from selected vendors. Some practices offer a limited number of laboratory tests at no charge. Some PCPs are supplying medications at no or wholesale costs. For the patient on multiple prescription medications, the savings on drugs can more than offset the monthly/annual subscription cost of direct primary care.

Many only work with specialists who are willing to discount their fees for those of their patients who pay cash and have high deductible plans or no insurance at all.

Often regarded as highly expensive and only for the “elite,” the rich, or the “one percent,” in fact membership/retainer/concierge practices can be of quite reasonable cost and very appropriate for those with no or limited insurance and for those with modest incomes – “blue collar” concierge medicine.

Fees range from about $500 to $2000 or more per person per year. [I will ignore those doctors who charge a very high fee for “exclusive” services.] By some degree of common usage those on the lower price end often refer to their practices as direct primary care or membership whereas those at the higher end often refer to their practices as retainer or concierge. To the extent that there is any real difference, it is probably in the number of patients in the panel or seen per day, the extent of the annual evaluation and added values such as following one’s patients in the hospital and in the ER.

For those who have high deductible insurance policies from work or from the exchanges, connecting with a direct primary care physician can offer a significant savings. The individual and the physician now have a direct professional business relationship. The person begins to take a much more active role in the entire care process. And the doctor can allot meaningful time for patient interaction – a return to “relationship medicine.”

With little to hope that government or insurers will improve the lot of primary care physicians, direct primary care is a rational manner for PCPs to change the paradigm and return to relationship medicine. It means better medical care, less frustration and more satisfaction for doctor and patient alike and an encouragement to medical students to consider primary care as a career option. It also means that total medical care costs go down. A triple win.

Next post – more on the costs of direct primary care

Solving the Crisis in Healthcare Requires Solving the Crisis in Primary Care

There is a crisis in the provision of primary care in the United States. If you are a patient, a primary care doctor, an insurer, an employer or a policy maker, this crisis is exceptionally important to you. The crisis means that Americans do not get the level or quality of healthcare that they deserve and need. This crisis is the major reason that healthcare in total is so expensive and why costs keep rising. This crisis needs to be fixed and fixed as quickly as possible. Fortunately, a solution exists that is within reach. It will be a disruptive and transformative change so it will not come easily to a profession that is “conservative” by nature. My new book Fixing The Primary Care Crisis, addresses all of these issues in easy to read language.

Contrary to what many assume, PCPs are much more than providers of “simple” stuff. They are more correctly specialists that deal with the very complex. Comprehensive primary care includes wellness and health maintenance, prevention and risk management strategies, attending to the episodic events that occur in life, and especially the care of those with complex chronic illnesses including coordination of care when a specialist is needed. It also includes developing a strong relationship between doctor and patient, building trust along the way and offering true healing. This means that the PCP can competently handle the vast majority of our health needs. To appreciate this is to begin to understand why the current system just does not and cannot work and why it needs to change.

The fundamental problem is that primary care doctors (PCPs) care for too many patients with too many short visits per day, and as a result do not have the time they need to provide high level care. They need time to listen, time to think, time to give quality preventive care and time to offer care of complex chronic illnesses and to coordinate care for those actually do need a specialist referral. They also need to be able to build a trusting relationship with the patient and to offer true healing, something that also takes time. In other words, they need time to practice their profession, something they currently are unable to do fully or effectively.

This crisis has led to a culture of highly frustrated doctors who feel they are on a never ending treadmill, and are leaving private practice or retiring early. It means that patients are equally frustrated at the long waits, short visits, high costs and no sense of being listened to, of not receiving empathy, of not being actually cared for. The crisis means that there are currently not enough primary care doctors, and it will only get worse because students in medical school see the impact of this crisis and choose not to enter primary care as a result.  It’s a downward spiral that needs to be reversed.

The crisis began a few decades ago when insurers, beginning with Medicare, held reimbursement rates low (cost control through price fixing). At the same time, doctors’ office costs were rising. In order to meet basic overhead expenses while maintaining their incomes, PCPs began to see more and more patients per day. The average PCP’s income in 1970 was slightly more than today (in inflated dollars) but the PCP was seeing only one half the number of patients as today. Now, with about 25 or more patients per day, a visit is often only 15 to 20 minutes: actual “face time” with the doctor is just 8-12 minutes. If you’ve been a patient recently, I’m sure you’ve experienced this. While this amount of time is long enough for a simple problem, it is much too short for someone with a complex issue, or someone with multiple chronic diseases and taking multiple prescriptions. And it is not nearly long enough for an elderly person with impaired vision, hearing or cognition. There is no time for compassion, to build trust or to be a healer. Since there is too little time, the tendency is to send a patient off for tests or to a specialist when a bit more time with their history would provide the answer. There is not enough time to discuss lifestyle changes, meaning it is easier to just write a prescription and hope for the best. It is these steps that are the major cause of higher and higher medical care costs in the United States: unnecessary referrals, unnecessary tests, unnecessary X-rays and unnecessary prescriptions. And with it has come the loss of the close and trusting doctor-patient relationship and the lack of true healing.

When PCPs do have time, they can develop a trusting relationship and then give superb preventive care. This type of care will reduce serious chronic illnesses in the future, the diseases that today account for 75-85% of all medical costs. When they do have time, PCPs can treat the vast majority of issues brought to them by their patients without the need for specialist referrals or excessive testing. When PCPs do have time, they can coordinate the care of those patients that truly do need to be referred, ensuring high levels of quality at a reasonable cost. When PCPs do have the time, they can appreciate the underlying stress and anxieties that propel so many illnesses and trips to the doctor. When PCPs do have time, they can give truly proactive preventive care – population health - by reaching out now rather than waiting for the patient to arrive with a problem.

To address this crisis, both patients and PCPs will need to take charge and change the paradigm of primary care. Government will not do it. Insurers will be slow at best to do it although there are some examples to the contrary that we’ll explore in this book. A few enlightened employers are beginning step up as we shall also explore. But if there is to be real change—change that works—it will take PCPs and patients to force the issue. Patients need to demand the time they deserve. PCPs need to be able to give them the necessary time. This means fewer patients per PCP. Patients will need to migrate toward doctors that have 800 or less patients (compared to today’s standard of 2500 or more) and can therefore give them more time as needed.  The actual number per doctor should depend on the demographics of the doctor’s patient panel (the doctor’s patient load)—for example, a panel of mostly older individuals with chronic illnesses means fewer patients. Fewer patients means more time for each patient and much better access to the PCP. We’ll take a look at what some innovative physicians, insurers, and employers are doing—separately—to transform primary care and bring it back to being “relationship medicine” with a heavy emphasis on health and wellness and the care of complex chronic illnesses in addition to typical episodic primary care: true comprehensive primary care. One of many innovations is to not accept insurance and charge a reasonable amount per visit according to a posted price list. Another is using some form of “direct primary care” (DPC).  DPC comes in many variations and is known as membership, retainer or concierge medicine, but in essence it means charging a flat rate by the month or year for all primary care services, reducing the number of patients under care to about 500 and offering same or next day appointments for as long as necessary and access to the PCP via his or her cell phone twenty four hours per day and via email. It means comprehensive primary care not just episodic care: attention to health and wellness, reduction of risk factors, preventive actions, intense management of chronic illness and coordination of specialist care when needed and a return to relationship medicine with trust and healing. The latter is essential if we want to move from a reactive to proactive approach to healthcare. That means much improved care quality and satisfaction, and lessened frustrations for patients and doctors alike. Often it means generic medications at wholesale prices and laboratory and radiology at deeply discounted rates. Despite a widespread belief to the contrary, DPC is not just for the elite, the rich or the 1%. In fact, it can be quite reasonable – “blue collar” –  and, when DPC is combined with a high deductible health insurance policy (which is much less expensive than typical policies,) the savings for patients are substantial and the total costs of all care decline quite dramatically.

Among other options is capitation, as in some Medicare Advantage plans, but where the payment to the PCP is sufficient per patient that he or she can afford to have a reasonable total number of patients. Another is for insurers to create incentives for reducing patient numbers. Yet another is for employers to create their own primary care clinics with a low employee to physician ratio or to offer a payment into a health savings account (HSA) to purchase the membership in a direct primary care practice. One additional example is to place extensive primary care resources for the management of the “sickest of the sick,” often the socioeconomically disadvantaged with insurance via Medicaid – a team of PCP, nurse practitioner, nutritionist, mental health therapist, etc. We will explore each of these and other options.      

In all of the examples cited in the last two paragraphs where the PCP to patient ratio is reduced to a manageable level, the care quality goes up and the total costs of care come down very substantially. Throughout Fixing The Primary Care Crisis, we’ll look at the details of how that can be.

Fixing The Primary Care Crisis explains the crisis and its origins. It details what outstanding primary care can be for patients and society as a whole. It explains how and why illness has changed from the acute infectious diseases of the past (e.g., typhoid, pneumonia) to complex chronic illnesses (e.g., heart failure, diabetes with complications, kidney and lung disease) of today and why chronic illnesses now constitute 75-85% of all healthcare costs. It reviews how healthcare insurance went from covering unexpected expensive medical care (“major medical” and the catastrophic) to now include primary care; how employers have adjusted their assistance by expecting employees to pay a larger and larger portion of premium plus co-pays and deductibles. It then delves into some of the approaches referenced above that are being taken to return primary care to true relationship-based medicine.

Finally the book ends with a chapter that gives explicit recommendations to patients, doctors, insurers, employers and academic medical center leaders to effectively transform primary care to achieve the outcome of the very best care in a cost effective manner that improves quality yet reduces the total costs of care.

Together, this crisis can be solved with much better care, much improved satisfaction, much less frustration by patient and doctor alike, much less total money spent and with many more students selecting to become primary care physicians thus resolving the PCP shortage. It will be a win for everyone. But the change will only occur if and when patients become educated and then advocate for the new paradigm.  Fixing The Primary Care Crisis provides the information needed to make that transformation happen.

A Humble Opinion

Book Review - Readers of my posts know that I am a strong advocate for primary care and especially a primary care physician (PCP) that provides each patient with sufficient time. Time for the PCP to listen, to think, to treat and to prevent. This allows the patient and doctor to reclaim relationship medicine, a standard tenet of care in the past but now largely lost in our financially driven medical care system.

Dr Jordan Grumet is a primary care physician in Ohio who tries to assure his patients of a strong relationship, one in which they can build trust. Recently he has reduced his practice to about 600 patients and become “concierge.” Now he has more time for his patients and even some time for his family. For years he has written a blog entitled “In My Humble Opinion” in which he records his thoughts of events in his practice, in his home life and in his wide ranging mind. His posts are thoughtful, thought provoking, engaging, emotional and educational. Recently he published book curated from his posts and arranged into meaningful sections such as “The Grateful Death” or “In Sickness or in Sorrow.”

Dr Grumet’s book is a must read for anyone who cares – cares about their health, cares what they or their family receive from medical professionals, cares about what the doctor or nurse offers to  their patients. I have read Dr Grumet’s blog intermittently for the past few years. Always it leaves me with the sense that here is a real human being doing what he does best – caring for patients, one at a time and in the process trying to care for himself and his family. His book title - “I Am Your Doctor” - implies not a fact but a responsibility that he accepts when you come to him. The cover picture is equally powerful – a hand holding another’s, a clear and compelling symbol that this is a physician who wants to have a real relationship with you, his patient. Relationship medicine has largely been lost to today’s business and economic imperatives but doctors like Grumet are trying their best to retain it in their everyday practice. Dr Grumet brings us back to the true calling of what it is to be a physician and in his humble manner but compelling writing style reminds us that physicians are human with of the frailties and foibles as everyone else – the longings, the joys and the sorrows. But especially they want to be there with you as you experience those joys and sorrows, those exhilarations and frustrations that come with life, living and eventually dying. Here are two excerpts:

“Two weeks from now I will tell a man he is going to die. He will sit calmly in my exam room as he shifts his weight from side to side. Although his hair has grayed and his body has weakened, his face will sparkle with youth and vibrancy. He’ll stare deeply into my eyes and I'll detect a hint of mirth. "We're all dying, my friend." He will draw in a deep breath and put his hand on my shoulder. "The trick is learning how to live!" 

“It's not exactly Dr. Jekyll and Mr. Hyde, but everybody knows my level of patience varies from time to time. So I was surprised to find myself happily telling the emergency room that I would assess the patient shortly. The kids were horsing around on the playground, and I knew I would have to call my wife and ask her to come home. It would be my second 45-minute trip to the hospital on an otherwise busy Saturday afternoon. For some reason today, I was able to sublimate the automatic annoyance and return without emotional drama. I slowed down, calmly listened to the patient and reassuringly put a plan into place. Driving home, I felt both relieved and saddened by the joy that overcame me. Why didn't my life's work make me feel this way all the time? I guess it starts with one simple fact. I blame myself for every heart attack, stroke or new diagnosis of advanced cancer. As disturbing as that sounds, how could I not?”

 

Read this book and you will want him to be your doctor. Or at least you will want to find a primary care physician like him who practices real relationship medicine the way he does and who assures you that you will have his or her  undivided attention

Why Do I Only Get 10 Minutes With My Doctor?

Good question. You call for an appointment and are told it will be about 20 days. You arrive on time only to sit in the apt named waiting room for 40 minutes. Finally you get to see your primary care doctor (PCP). You begin to explain why you came in but are interrupted within about 23 seconds even though it would have only taken you about 6 more seconds to finish your “opening statement.” The doctor asks a few questions, does a brief exam, gives you a prescription, suggests you see the specialist and off you go, all within 8-12 minutes. At the exit desk you are told you owe a $30 co-pay. “Visa or MasterCard please.” And in no time at all you are out the door.

No time for delving deeply into your issues. No time to build trust. No time for compassion. No time for actual healing.

Why so quick? It is all in the numbers. At the risk of being boring, here they are. They might surprise you.

According to the New York Times a PCP earns on average $150,000 per year. A survey from Medscape pegs it at $170-180,000. That is about what a newly minted law student gets if he or she can land a job at a prestigious large firm or a just graduated MBA gets if hired by a big consulting company. But how does our PCP actually earn that money?

If the PCP has a private practice, in order to earn $150,000, he or she needs to bring in about $350,000 to also cover office expenses. Given what insurers like BlueCross, Aetna, United Health Care, Medicare and Medicaid pay per visit, the doctor needs to see about 25 patients per day. That is $30 to the PCP’s pocket for each visit. No wonder the visit is so short.

Said a different way, the PCP has to see 15 patients to cover expenses. Any patients over 15 and the income goes to him or her. So the PCP works for others until about 2pm.

It was not always this way. A PCP today earns about what a PCP earned (in today’s dollars)   few decades back but, in order to earn it, must see almost twice as many patients per day.

The typical PCP takes 24 phone calls per day, 17 emails, processes 12 prescription refills (above those handled during visits, ) and reviews 20 laboratory reports, 11 X-ray reports and 14 specialist consult reports. These are all done outside of the visit and obviously take substantial time. This work is clinically relevant but then there is about an hour a day – least – of time spent of dealing with insurers. And a recent report suggests that the PCP spends an nearly an extra 1 hour per day with the electronic health record (EHR.)

Look at the numbers a different way. A PCP who worked for a well-known HMO in California earned $140,000 and was assigned a panel of 2200 patients, a large percentage quite ill. That is $64 for each patient for the entire year. That is probably less than you spend taking your car for a twice yearly oil change and checkup. If each patient came in three times per year then each visit was worth $21. This PCP found herself highly stressed, unable to keep up to the level she thought appropriate and went home exhausted only to ignore her family and “crawl into bed realizing  it would start all over again tomorrow.”

On the east coast, a highly regarded PCP told me that “I thought I was going to die, literally, if I kept this up. I could not give the type of care and attention that I felt was best for my patients, I could not be compassionate. All the things I treasured doing as a doctor had vanished.”

The answer is straight forward. Pay the PCP more. Not more in total (although that might also be appropriate) but more per visit and have the PCP take care of substantially fewer patients.

There are many ways to approach this. Increase the fee for service payment in return for more attention to, at least, those with chronic illnesses who need close care coordination. At least one example of this with a Blue Cross program has worked well in the fee for service setting. In a capitated system, an insurer could assign fewer patients but pay the same total amount to the PCP. Maybe 1000 patients instead of 2200 for that $140,000. Or if the population in the pool is high risk with either mostly elderly people or those with multiple chronic illnesses as in a Medicare Advantage program, set the capitation rate so that it works with just 300-500 patients. There are good examples of this being highly effective as well.

Yes, in each of these examples the amount of money going toward primary care per capita is increased but the total costs of care comes way down. It comes down because high quality primary care takes care of most issues, offers better preventive care and coordinates the care of those with chronic illnesses. This means less referrals to specialists, less unnecessary testing and prescriptions and fewer trips to the ER or the hospital.

For PCPs in private practice, they can switch to retainer or membership models where the patient pays directly (direct primary care) by the visit or on a monthly or annual basis for all primary care in a setting where the PCP only has 500-700 patients, offers same day appointments, access to his or her cell phone 24/7, and perhaps reduced cost laboratory testing and even generic medications. Many of these practices are quite affordable - “blue collar.” And the savings on drugs can often offset the membership fee.

Insurers should consider paying the retainer for those who buy a high deductible insurance policy since quality primary care substantially reduces the total costs of care. And at a minimum, they should allow the retainer/membership fee to go against the deductible.  Employers could either buy the retainer or place an equal sum in an HSA for the employee who takes out a high deductible policy through the company. Alternatively, the company might initiate its own in house primary care clinic designed so that the employed/contracted PCP has only a reasonable number of employees to care for. In any of these models, the use of health coaches can further improve wellness, maintain health and assist with illness care.

The result: More time with the doctor. More time for the PCP to listen, more time to think, more time to diagnose and treat, more time to coordinate care for those with chronic illnesses and more time for better preventive medicine. So better care, better health, less frustrations, more satisfaction and much reduced total costs of care. Now you will no longer be wondering why the doctor allots you so little time.

Why Is There A Critical Shortage of Primary Care Physicians?

Primary care physicians (PCPs) are becoming extinct.  It’s true. Not many medical students choose primary care as their career path. Older PCPs are retiring early. Many others are closing their practices or seeking employment at the local hospital. And there has always been a shortage of primary care physicians in rural and urban poor areas. Today only 30% of all physicians practice primary care (compared to about 70% in most other developed countries and about 70% in the United States fifty years ago) and this percentage is shrinking at a steady rate.  

This my third post in this continuing series  

Estimates in the Annals of Family Medicine indicate that America, which today has about 210,000 primary care physicians in active practice, will need an additional 52,000 PCPs by 2025. Good luck. This is based on growth of the population (requiring 33,000 added PCPs), the aging of the population (10,000) and the added number of individuals that will have health insurance as a result of the Affordable Care Act (8000). The number needed almost undoubtedly is substantially higher. And if you accept my premise to be detailed in a later post that a primary care physician (or nurse practitioner or physician assistant) should be caring for only about 500-1000 individuals rather than the current typical 2,500+, then the need is truly much, much greater.  

About 25,000 new graduates enter medical practice each year. This represents an increase of about 3% per year while the general population has been growing about 1% per year. Today there are about 29 physicians for every 10,000 population although they are not necessarily distributed evenly across all population areas or groups.

With these numbers one could argue that there is no shortage of doctors. Indeed with the opening of new medical schools and many others increasing class sizes, there should be another 3000 added to the graduating class each year rising to 5000 by the end of the decade. But most graduates enter specialty care rather than primary care training driving the ratio of PCPs to specialists of 30%-70% ever wider. Adding further to the specialist roles (except those with known shortages like general surgery) will only add to health care costs rather than increase quality.

There is good data to support the notion that a primary care-based delivery system increases quality of care and decreases costs compared to our current specialist-based delivery system.

Critical to how many PCPs are trained are two key factors. One is how many trainee (residency) slots are available to train primary care physicians. Medicare pays hospitals to train medical school graduates during their residency. Currently, Medicare pays teaching hospitals $9.5 billion each year to subsidize the training of the next generation of physicians with residency programs that range from three to seven or even more years after medical school graduation. Medicare has kept these “slots” it will cover flat since 1997 and has given no indication of raising this as of yet. But even more importantly are the absolute numbers of PCP vs. specialist slots available. There are simply many many more specialist slots available. Medical centers want to train specialists. They represent assistance to the faculty or staff physicians and they bring an aura of quality to the hospital. No good professor and chief of, say, neurosurgery at an academic hospital would not want to have his or her own training program. It is a matter of pride. Absent a training program, the best will not chose to work for that medical center and will choose to practice elsewhere. This is a serious conundrum for the medical center that needs the specialty program to drive more revenue. And Medicare has been willing to pay for these specialty training programs over the years while not increasing funding for primary care training.

There is a recent study covering 2006-2008 residency training and Medicare payments. Lin, commenting on the article on KevinMD, noted by separating out those 20 hospitals that trained the most and the 20 that trained the least PCPs, respectively, among all teaching hospitals in the USA, “the top primary care producing sites graduated 1,658 primary care graduates out of a total of 4,044 graduates of their hospitals (41%) and received $292.1 million in total Medicare graduate medical education (GME) payments. The bottom 20 graduated 684 primary care graduates out of a total of 10,937 graduates from their hospitals (6.3%) and received $842.4 million.”  In other words, the hospitals that got the most money trained a larger proportion of specialists; perfectly logical if that is where the money is. But this makes little sense in an era of serious primary care physician shortages that will certainly worsen in coming years.

The other problem is that primary care is not seen as a desirable career path today. There are multiple reasons. Primary care physicians earn about one half of what a specialist earns. Specialists are generally seen to have a higher level of prestige in the community – “I was sent to Dr Jones, the surgeon.” Most medical school graduates have large debt loads so earning more means paying it off sooner. And with a large debt, it is harder and scarier to take out a loan to start a practice that brings in fewer dollars. But the primary reason is that medical students realize that PCPs are in a non-sustainable business model, one in which they must see far too many patients per day, accept unpleasant burdens with insurers, be on call many hours and yet not be able to offer  what they know would be better care. They see it as a no win situation and so avoid primary care even if that might otherwise be their preference.

Less prestige, high debt loads and a knowledge that PCPs work in a non-sustainable business model forcing them to see an excessive number of patients per day in order to meet overhead and still garner an income about one half that of the specialist is, combined, enough to discourage medical school graduates from selecting primary care as a career.

The next post in this series will focus on the PCP’s need for time – to listen, to think, to prevent, to treat, to coordinate.