In this first of a two-part look of the role of acute visits in primary care, we’ll discuss why offering this access is so important and will help determine the future of primary care. In the next blog, we’ll discuss what practice administrators and clinicians can do to effectively prepare for same day patients.

Here’s a question for you. What business would survive yielding up its most valuable and profitable product to a competitor? Not sure if your answer is different than mine, but I’m going to go with “none” or at least none I’ve ever heard about. Of course, there may be an exception, but I’m pretty sure primary care medicine isn’t it.

Getting back into the conversation

Before considering the benefits inherent in increased acute care access, let’s take a look at what’s generating part of the problem:

A short while back, I came across an online message from Aetna Health Insurance targeted primarily to its policy holders but also to the public in general. The information focused on the benefits, including convenience and out-of-pocket cost savings, of accessing retail walk-in clinics or urgent care centers instead of emergency rooms for non-life or limb-threatening conditions.

Based on average claim costs, Aetna made a strong financial case for using the clinics and centers through a straight comparison of the same non-emergent treatments. What was clear as I read the information was that primary care practices weren’t even in the urgent care equation, despite the fact that most of the conditions shown could be appropriately resolved on the primary care level.  Not being part of the conversation is an omission we should be addressing for a number of reasons that benefit patients and practitioners alike.

The most valuable visit of the day

In our practice, acute presentations were the most profitable segment of the day, providing the highest level of reimbursement per minute. In most cases they were also the quickest and among the most satisfying.  What we found was that the episodic care – specifically two acute visits a day – paved the way for employing a full-time MA or LPN which in turn, enabled us to see several more patients.

I want to emphasize that two same day visits more per day was all that was necessary to pay for one additional full-time employee. This extra staff member, trained with true exam room skills, not only helped provide our patients with the timely access they needed, but also helped restore my own work-life balance to a healthier and far more satisfactory level. With this addition, I could see 5-6 more patients per day while working fewer hours. Intentionally working to capture all the same day visits within a panel can transform this aspect of a comprehensivist’s practice from a loss leader to a profit center.

While the majority of unscheduled visits are still reimbursed on a FFS basis, the continuing movement toward newer value-based payment models should continue to position acute treatment as a significant factor in improving the continuum of care and the bottom line.

The visit that helps strengthen the provider-patient relationship and significantly raises population health

Historical and contemporary medical literature are replete with articles, monographs and chapters on the role of the therapeutic relationship as the foundation for trust and open communication. And there’s a strong connection between this special relationship and treating acute care patients.

What we found was that the well-documented benefits of a strong provider-patient relationship as a major determinant in patient and staff satisfaction and compliance were enhanced even more by our commitment to bringing urgents in as quickly as possible. These encounters offer an excellent opportunity to grow the trust and overall level of engagement that, in turn, positively impact other visits for the same patient, including both preventive care and chronic condition management. Simply put, treating a sore throat on a Saturday morning is a significant part of a continuing relationship that can add substantially to the patient’s long term health.

In fact, my own experience leads me to believe that the most effective management of chronic diseases takes place when reliable access, including same-day access by the same provider, is consistent across the continuum.  On a very personal level, that same experience has convinced me that timely access can save the lives of patients who won’t go to the ER because they want to be seen by their own familiar and trusted doctor.

Access is key but it’s a sore throat, not a Starbucks moment

Timely access is at the absolute center of effectively meeting acute needs in the primary care setting. By “timely access” I mean access when the patient needs it provided by someone he or she knows and trusts. Sustaining that level of access requires a considerable amount of focus, and you may have to sacrifice catching up on your patient’s recent life story since unlimited time with one individual precludes access for another.

But looking at it from the patient’s perspective, even a short visit with a familiar provider is a highly desirable and valued experience. It’s also an experience we have to view as a necessity rather than a luxury. If people can’t get timely care from their regular provider they will go somewhere else for it, with the understanding that health may not be possible if it’s not on time. And in the process they will sacrifice money, trust, comfort and even a degree of competency for convenience, access and reassurance.

Now that we have a sense of how vital it is to provide access to patients with urgent care needs, the second part of this blog will discuss the mechanics for making it happen. To be continued…

Amidst the uncertainty of healthcare’s future under the new presidential administration, there are certain attributes of good care which hold true, regardless of what policies are in place. I’ve written about these attributes before, and we’re continuing to refine how they translate at the ground level in our work with practices and systems across the country.

Primary care is struggling to keep up with the needs of consumers, but I believe there are practical steps we can take to move us in the right direction, even if progress is slow. So in the spirit of changing seasons and how Spring symbolizes growth, here are three ways for providers to change the way they think about care delivery in 2017:

Redefine the purpose of the exam room

What many providers don’t realize is that time is essentially the product we offer. We’re equipped as physicians with education and training, but we exercise that expertise in segments of time. So it’s not accurate to think about our medical training as the service we deliver—it’s the time we spend with patients in the exam room.

But it’s also not right to operate under the assumption that the more time we spend with patients, the better the quality of care we provide. The provider/patient connection is vital, but it requires boundaries. Many providers are losing time—their most valuable resource—through burdensome ancillary work, inappropriate focus on socializing with patients and too much leeway for unreasonable patient expectations. No business can survive if it gives away unlimited product, and the same principle holds true in medicine. Unlimited time for one patient destroys access for another, and it’s this lack of appropriate, timely access for our patient panels that has marginalized the discipline of primary care.

Health achieved for every patient under our care—whether seen on a particular day or not—should always be the goal of the exam room. The quality of care for our panel is what determines its success—not the amount of time the provider spends in it.

Rethink priorities inside the exam room

It’s fair to say that time management begins with priority management. And that’s very applicable to the context of the exam room. Primary care providers must prioritize their time in order to deliver the quality of care their panels need and create or maintain patient health.

So what does this priority management look like? It means the provider is personally involved in the health of each of his/her patients and responsible for ensuring they receive the care they need. It means creating appropriate access for the entire panel and communicating with patients in a timely manner. And all of this is accomplished by facilitating a team approach to care so non-physician work is accomplished by clinical staff, freeing the provider to do what only he/she can.

Recognize the high cost of independence in the exam room

I know all too well how difficult it can be to change habits in the exam room. My practice was on the verge of failure before I was able to change its course by altering my care delivery model.

I and many other primary care providers are independent by nature and training. Medicine as a discipline has been historically and culturally organized around the individual. But our fierce independence has come at a high cost: to providers, consumers, the sustainability of practices and the discipline of primary care itself. It has impeded our ability to offer appropriate access for our panel, adapt to new challenges and mobilize a team approach to elevate our delivery process. And without recognizing how this independence inhibits good care, we’ll continue to fall short of the goal of improving health outcomes.

There’s much that could be said regarding these different areas, and I’ll be sharing more about them in the future. As we look for new and better ways to help primary care achieve its full potential—improving medical outcomes, consumer satisfaction, and financial viability along the way—primary care providers must embrace new ways of delivering their product. The health of our patients is too important for the comfort of old habits or fear of change to prevent us from doing everything we can to provide accessible, comprehensive care in the context of a long-term provider/patient relationship.

You don’t have to be a member of the infamous Corleone Mafia family to understand there’s a difference between what’s personal and what’s business:

But sometimes the lines are blurred, and distinctions are easier in theory than reality—especially within the provider/patient relationship of primary care.

This relationship can’t thrive without some measure of friendship. Where we need clarity, however, is understanding the difference between professional and personal friendship. We’ll take a look here at characteristics of a healthy provider/patient relationship, consequences of poor boundaries and how professional friendship promotes robust primary care.

The “familiar physician” at work

In my book Lost and Found: A Consumer’s Guide to Healthcare (co-authored with Dr. Paul Grundy), we discussed the impact of the “familiar physician” on patient health:

“Keep in mind that a familiar physician may be the most valuable professional relationship you’ll ever have, seeing you through many of the stages and transitions of your life… Based on a considerable body of research, you’re more likely to live longer, live healthier, and spend less for medical care when you see your familiar physician on a long-term basis. No other single entity in medicine can help you achieve those outcomes.”₁

But it’s not always easy to translate value into practice. And if you’re a provider trying to deliver accessible, relationship-based care to your panel, you’ve got your work cut out for you, particularly when navigating the murky waters of professional versus personal friendship.

A provider’s responsibilities to patients (i.e. what he or she is paid to deliver)—personal connection, timely access and competent medical practice—can’t exist in isolation of one another. The balance of these three areas is essential to the robust primary care system required for our society and to the quality, cost-effective care patients need. And the latter two are crucial for reaching the Triple Aim.

Tried and true

Trust helps people relax, let down their guard and feel safe. That’s the kind of environment patients need, and it’s the most basic element of a strong provider/patient relationship. It develops over time as the patient relies on the provider’s expertise to make the best decisions, and the provider expects honesty and cooperation in return. They become true partners, working together for the patient’s well-being.

Every interaction should be focused on medical intervention while getting to know the context of the patient’s life—family issues, economic situation, employment and stress factors—in order to make the best decisions possible for his or her health. That knowledge of the patient beyond EHR data is critical to the quality of care delivered.

But the provider/patient relationship is also a business transaction, which is where it differs so dramatically from a personal friendship. It must be controlled by normal business parameters in order to protect individual interests and make the practice successful. That’s why we have medical records, quality benchmarks and medical liability for the patient’s safety and why the amount of time the provider spends with patients must be limited to maintain the quality of the product (i.e. medical expertise + time).

Don’t take it personally

Another important aspect of a professional friendship is that it serves a specific purpose—something a personal friendship doesn’t always do. A patient’s purpose for a relationship with a provider is to achieve or maintain health at a reasonable expense and receive help making decisions that will lead to continued wellness in the future.

It can be difficult to keep patient health as the primary focus when a truly gratifying friendship develops. That’s why many providers struggle to keep their interaction within the confines of a professional relationship because they genuinely enjoy getting to know and caring for patients. Those relationships can even become a bit of a refuge for the provider from other stressors. But when personal dynamics take prominence in a professional friendship, they can destroy the very purpose of the relationship and lead to all kinds of bad outcomes. We’ll come back to that topic in a few moments.

Care must be honest and given in the patient’s best interests. Sometimes the most honest, caring thing a provider can do is tell a patient he or she has six months to live. That’s not an easy or enjoyable conversation, but it’s the best kind of care a provider can give to help the patient prepare for what’s to come. Without a strong commitment to act as a practitioner first and friend second, we risk losing the objectivity and candor required for those difficult conversations.

None of my business

During my years as family medicine provider, whenever I had a patient call me his or her best friend I knew that statement indicated one of two things. Either the patient was incredibly lonely and didn’t have much interaction with people beyond the brief and infrequent time with me, or the patient was possibly neurotic and inappropriately focused on what our relationship could provide. Those instances were good reminders of the need for wise interaction with patients to maintain a healthy professional friendship and avoid inappropriate reliance on me.

Disordered or disregarded boundaries can have serious consequences, whether unhealthy dependence develops or a lack of objectivity leads the provider to make faulty decisions. The first casualty is often lack of focus on the primary goal—the patient’s health.

As I’ve worked with practices around the U.S., I’ve observed many providers enter an exam room and spend 10–20 minutes socializing and only five minutes delivering medical care to a patient who’s in terrible health. The patient might appreciate the personal attention, but the interaction doesn’t facilitate better health as effectively as it could—and should.

Poor boundaries can also promote inappropriate behaviors such as control, abuse, relationships of a romantic or sexual nature, or improper prescribing of narcotics because the provider assumes undue responsibility for helping the patient cope with other areas of life.

On perhaps the most practical level, lack of appropriate time boundaries is simply destructive. The provider eventually loses his or her personal life because the workload is unmanageable, staff members get burned out, and financial viability for the practice is threatened.

Balancing act

Lack of appropriate time boundaries is detrimental for patients as well. We’ve become so out of balance as an industry that we’ve emphasized the quality of medical education without making the changes needed to facilitate patient access. Providers in the U.S. have some of the best education in the world, and yet our inattention to time has severely limited access for the patients who need our care. Unlimited time for one patient destroys access for another.

No matter how much trust exists between the provider and patient or how talented the provider is, the relationship fails the patient if timely access isn’t available when it’s needed. And more seriously, unavailable or delayed care can be detrimental to his or her health.

Primary care has become a quagmire because of its struggle to offer personal care within the context of poor business parameters. If we don’t understand the differences between professional and personal friendship, we won’t have the capacity to meet the needs of our patient panels and build financially sustainable practices. That’s why it’s so critical for us to get it right.

Business is business

Our care for patients should always be focused on strategies to improve their health in the context of appropriate boundaries. We can’t be great providers without creating an environment in which patients feel known and safe. That level of relational investment drew me to primary care, and the pleasure of caring for patients over time and helping them experience the best quality of life possible is what made me stay.

But like Michael Corleone in The Godfather, we have to remember that despite our personal involvement with patients, the revitalization of primary care through strong professional friendships must be strictly business.

₁ Lost and Found: A Consumer’s Guide to Healthcare by Peter B. Anderson, MD and Paul H. Grundy, MD with Tom Emswiller and Bud Ramey

There’s one thing we can all agree on when it comes to healthcare: it’s expensive for everyone involved.

UnitedHealth Group’s decision to exit the ACA insurance exchanges next year in most of the 34 states where it offers plans signals a need for continued evolution of payment reform. After suffering financial losses (and a projected $650 million in 2016), the largest U.S. health insurer’s withdrawal indicates growing concern regarding the sustainability of the marketplaces.

Something’s gotta give

It’s evident our healthcare system is desperately broken when you consider a large portion of our population can’t afford the cost of healthcare. The exchanges have helped pay for the cost of insurance premiums with tax subsidies from the government, but they have also attracted a sicker population that uses healthcare services more than the average consumer. That means the payer—an insurer like UnitedHealth—stands to make less or even lose money on the exchanges in comparison to the return available outside of the exchanges. So it’s not surprising that an insurer would choose the free market payer system.

With other payers (including Anthem and Aetna) struggling on the exchanges, it’s easy to imagine that in the future there could be fewer and fewer left in the arena to offer a product (i.e. insurance coverage) to consumers taking advantage of tax subsidies. Either costs for insurance will continue to increase so insurers offering individual plans on the exchanges can be profitable, or the government will have to provide more Medicaid/Medicare access to those who can’t afford insurance. If current conditions persist, there’s a real possibility that eventually no payers will offer coverage on the exchanges.

In the market for a better solution

The wrong conclusion to make here is that a single payer is the answer to the problem. A one-payer system won’t give us the access and care quality required to reach the Triple Aim. If the government ever institutes a single-payer system, this payment structure will be mandated to control costs. Free market principles driving competition in the primary care sector are essential for excellent primary care delivery, and a single-payer system would remove most of this competition.

My goal isn’t to debate the value of a single-payer system, but to instead advocate for why robust primary care offers us the only truly viable way forward to achieving the Triple Aim. What payers—the government included—should be doing is incentivizing and rewarding health.

Incentivizing health

Achieving the Triple Aim isn’t as simple as figuring out who’s going to foot the bill. The solution is to create a healthier population, thereby bringing down the overall costs of care. This can only be accomplished by a robust primary care system coupled with payment reform to address the damage done by the fee-for-service model. This payment model promoted sickness rather than health and encouraged both patients and providers away from primary care.

Robust primary care can be boiled down to three characteristics:

• Relationship-based care with a strong provider/patient relationship, leading to increased patient engagement and better, more cost-effective healthcare decisions

• Timely, convenient access to relationship-based care so patients can receive appropriate chronic disease management and aren’t relegated to urgent care from unfamiliar providers

• Excellent quality of care

These attributes will enable us to provide the care our population needs while also driving the costs of care down, thus accomplishing the Triple Aim. We won’t get there by throwing more money at the problem—we’ve already (unsuccessfully) tried that with three trillion dollars. It’s becoming clear we can’t remedy the situation by paying more bills. We must create better health for our society. To do that, we need a strong primary care system with a payment system that incentivizes health and not sickness.

UnitedHealth Group probably won’t be the last insurer to struggle and opt out of the Health Insurance Marketplace—more of that seems inevitable. The likely reaction from consumers will be a cry for more financial assistance. But the government’s real effort should be aimed toward helping to develop a flourishing primary care system throughout the U.S. that can truly serve and improve the health of our citizens.

I remember being part of a group of young physicians in 1982 that was told by a consultant, “You’ve got to be pretty bad to screw up this business opportunity. It’s just too easy to make money because people want your product. Basically anyone can survive in business as a doctor.”

It sounded good, but we received virtually no training for how to run our practices and make them successful from an administrative standpoint.

In my last post, I talked about the great divide between clinical providers and system administrators. These two entities—clinical medicine and healthcare administration—both want to deliver care to patients. But there’s constant friction between their goals and approach.

We’ve all contributed to the problem, and most of us have put little effort into finding common ground. With healthcare (and primary care in particular) at a unique juncture in our nation’s economic, political and social landscape, it’s impossible to ignore the chasm any longer. A good starting point for providers is to recognize our faulty understanding of good business practices and examine what needs to change.

It’s a matter of time

Doctors in the 60s, 70s and 80s didn’t really have to worry about being efficient to survive. When I was told in the early 80s that barring miserable failure in medicine I’d have no trouble achieving financial success, all of the industry’s emphasis was placed on good clinical performance. The assumption was that everything else would simply work itself out.

This belief fostered poor habits and a dysfunctional business model in primary care that set us up for failure. For example, time consciousness in the exam room was considered a lack of patient focus. In other words, if you weren’t providing unlimited attention to your patients, you weren’t giving them a good product (healthcare). This and other poor habits have persisted for decades, and now we’re experiencing the consequences.

As I’ve worked with practices and systems across the US over the last five years, I’ve observed hundreds of primary care providers at work. Very seldom have I seen one who’s able to limit his or her time for the sake of maintaining a viable business model that offers the convenient, same-day access patients need.

One internist told me last year, “If a patient needs me to stay in the exam room for an hour, I’ll stay in the room for an hour.”

At first blush, this commitment sounds admirable. But when style is considered more valuable than efficiency, it ultimately leads to underperformance. Unlimited time for one patient destroys access for another. Patients who can’t be seen by a primary care provider end up at the ER or an urgent care center and generate significant expense, due to unnecessary testing and an emergency level of care for what should have been a routine visit.

The root of this problem is the belief that time boundaries in the exam room aren’t important. This single issue is probably the number one reason primary care doesn’t have the impact it should—and could—have on our healthcare system. That lack of time-consciousness has helped create our current poor access to primary care, which has led to excessive costs across the healthcare industry.

Think about this issue in contrast to notoriously time-conscious lawyers. Lawyers know their business can’t survive without billing clients for any work performed on their behalf. While that approach can certainly be exploited, the principle holds true: viability is threatened by giving away your product without boundaries on time.

Make a move

The point of this critique isn’t to cause offense, but to call attention to poor habits. If you’re like me, I wasn’t aware of my dysfunction in the exam room until I was forced to re-examine my entire delivery model. And while not all the blame rests with providers, we have to acknowledge how we’ve contributed to the problem by not viewing our work with a business-oriented perspective.

The ACA reflects how healthcare is coming to grips with the fact that we can’t spend whatever we want on patient care if the economy is going to survive. Providers must begin to think in the same terms in order for costs to come down. We can’t bridge the gap without protecting critical elements of good clinical care and sustainable business. Both are needed for healthcare to thrive.

Don’t miss the third and final post of this series, where we’ll take a look at how providers and administrators can better work as a team to build self-sustaining businesses with convenient access.