In the last blog we looked at the Perfect Storm and its metaphoric counterpart, the forces that loom on the near horizon and threaten the current viability and future hope of primary care medicine. The first is the Patient Protection and Affordable Care Act usually shortened to “the ACA” and more commonly called, by opponents and supporters alike, Obamacare. The ACA hasn’t created the primary care crisis in America, but it will reveal the fractures in the current system and contribute to the pressures already directed to the PCP unless it can effectively re-engineer how we care for patients in the exam room.

We’re still in a short holding pattern on exactly what to expect, but we do know that large numbers of newly insured people, estimates range to 30 million plus, will be presenting themselves to primary care doctors. As waiting rooms fill up, many doctors will not be in a position to accept new patients.  As I discussed in The Familiar Physician: Saving Your Doctor in the Era of Obamacare, the Massachusetts experience, probably the closest model we have for comparison, doesn’t offer a lot of hope in that area.

My colleague, Paul Grundy, MD is frank about the broken payment system in America and its affect on the people it’s meant to serve. “The rewards system in health care is so convoluted that people become opportunities to make money. Somewhere in all that we lose the humanity.”

Regardless of your stand on reform (and I still find myself on both sides of specific ACA provisions) the fact is that the United States Supreme Court upheld the constitutionality of most of the reform legislation.  So if you’re waiting on the health train, that one has left the station.

Based on discussions with colleagues I am not alone in my contention that the success of reform and its role in improved health care delivery depend on a robust and expanding primary care workforce. I believe further that reform will be at its most effective if it helps strengthen the doctor-patient relationship as a powerful, quality-producing, cost effective force in medicine. In the meantime I ask people to “imagine health care without the Familiar Physician. “Every time you’re sick, you’re a stranger, enduring long waits for someone to help solve your problem … someone who may have never seen you before.”

Between 2010 and 2011, the number of insured Americans grew by just 3.6 million people, an increase of less than 1.5 percent that was easy to absorb into the existing system.  However, the instantaneous 15-percent increase in the number of insured Americans will shock a system accustomed to much slower growth. The potential for serious gridlock is clear.

So here’s what we’re left with: the ACA, which can be a positive force in improving access to coverage and, ultimately, to care, also carries within it the potential to crush the primary care system unless we make appropriate changes … and quickly.

One third of the healthcare dollar, in the United States, is spent on the last 6 months of a person’s life and that’s because our system revolves around sickness, rather than wellness. Due to the Affordable Care Act (ACA), the end result is that sickness will no longer bring in more money!

Who can argue that shifting our healthcare system from incentivizing sickness to wellness is wrong?

We’ve been spending some time explaining how Triple Aim is going to be accomplished under the ACA. Let’s refresh…

The three goals of Triple Aim are:

1. Improve quality of care

2. Improve health for populations

3. Reduce costs

Created by the ACA, an Accountable Care Organization (ACO) is a collection of healthcare providers linked together legally, financially, and clinically, who take a shared responsibility for delivering care to a 5,000 person patient population.

ACOs are paid directly from the government through the new payment system called “bundled payment.” Pretty soon we will see that if a patient becomes sick and uses more services than expected, they will more than likely come close to their “cap”, or amount allotted for that disease entity, or exceed it.

There are no limitations to the kinds of providers who can participate in ACOs – hospitals, emergency rooms, home health, hospice, nursing homes, urgent care centers, primary care, specialists, etc.; basically anyone who has a healthcare service can be in this provider organization. It will be up to each individual ACO administration as to who can be a part of their organization.

There is absolutely no patient reform in the ACA. A patient can go to any provider they choose, anytime the want and as frequently as they see fit. This is acceptable to patients, but has created a real vulnerability for the ACOs.

When a patient is signed up under an ACO, they are not obligated to seek services from only the providers within their particular organization. This is the Achilles heel of ACOs; providers are no longer only responsible for their patients that walk through their office doors, but also those that don’t. This is a huge change in healthcare provider’s thinking.

Just yesterday, nine Pioneer ACOs admitted to failure because of their inability to control a patient’s activity outside the ACO network.

By definition, ACOs are entirely responsible for the health of their assigned population of patients. To not manage the health of their population efficiently makes the ACA vulnerable and the efforts of the Triple Aim null.

It will be a combination of building the structure for these providers to work together, under an ACO, as well as aligning finances with quality, under the bundled payment system that we will experience a restructuring of our healthcare system.

We will continue our conversation about ACOs tomorrow.

Aging baby boomers and an increased number of newly insured patients are only a couple of stressors primary care physicians are being faced with today. The need to improve America’s healthcare delivery model in primary care offices is staggering. By 2015, the expected physician shortage may be close to 35,000 primary care physicians.

Many have argued the way to fix the physician shortage is to elevate the role of mid-levels to replace physicians.

The American Medical Association supports the idea of physician-led teams. It is within these teams that nurse practitioners would serve the greatest purpose. The American Academy of Family Physicians published a whitepaper that described a model where 3-4 nurse practitioners would operate on a team alongside a physician.

The way I see it, and being a primary care physician once myself, physicians spend at least 50% of their time doing non-physician work. This was a large source of my frustration because it caused me to turn away some of my patients who wanted to see me.

One of my primary care physician friends told me about how he frequently spent time cutting out forms and taping them together fora mail order prescription company. It makes me cringe to think about him doing a task, such as this, when there are plenty of patients begging for his time.

Physicians can easily lose 30-45 minutes per day doing non-physician work. The real key to fixing the primary care office is to train staff to do all non-physician work. Physicians need to be able to focus on the things that they went to medical school to do. If someone else in the office can do it, then physicians shouldn’t. This is a rule of thumb that I adopted in my office and the results were astronomical.

Fixing this inefficiency should be our first focus before we begin building a team around physicians. Adding nurse practitioners to the same, old and inefficient model is not the answer. If  we are able to fix this inefficiency and expand the panel of physicians by 20-40%, we have the chance of wiping out primary care’s physician shortage almost entirely.

Between 2014 and 2016, the Congressional Budget Office is projecting 35 million individuals as being newly insured. Therefore, primary care physicians have to fix this inefficiency to avert the coming crisis.

With the impending Affordable Care Act (ACA) on the horizon, primary care physicians are just waiting for their fate – will they thrive or will they be crushed? The demand of our culture, along with the ACA, is shifting healthcare responsibilities to primary care. It’s inevitable, in order to meet the needs of our culture, primary care physicians have to see more patients. In order to do so, we are going to have to learn to become more efficient, and fast.

A poll conducted by the Robert Wood Johnson Foundation and Harvard School of Public Health reports that 3 out of 5 patients feel as though their doctor is rushing through the exam. This is one way to cut corners.

Some physicians are responding to this shift by increasing their productivity, without much thought or planning. This is reckless and will lead to dissatisfied patients.

I asked 100 physicians in D.C. if they had to cut corners in order to see more patients. Do you know that all, but 1 said they did?!

Larry Shore, a physician in San Francisco says, “When you have that pressure to see three, four, maybe five patients an hour, you can’t wait for the exposition of the patient’s story. Which is exactly what you should do. But you can’t.” Combine this reality with the fact that the number one need of a person is to be heard, the inevitable result is very poor patient satisfaction.

I will argue that cramming our schedule to see more patients will not satisfy our cultures need for quality healthcare. Patients want to be heard and they want to feel as though their doctor cares about their health.

When you choose to stop cutting corners, you will experience a sense of confidence and pride in the quality of care you are providing your patients. Furthermore, you will begin to enjoy practicing medicine again because you are meeting your patient’s needs and no longer going through the motions of providing healthcare to meet quotas. You can go to bed at night knowing that the quality of care you are providing is improving healthcare in America, as a whole.

Providing access to quality care outside of the emergency room, like primary care offices, will lead to more cost efficient treatment, unless it is a true emergency. Our culture has grown to accept emergency rooms as a safety net and source of convenience for all healthcare. Unfortunately, primary care providers have added to this problem because of their inability to see patients when they need or want to be seen. Often times, they rely on emergency rooms to evaluate their patients after hours and admit patients with significant medical illnesses.

Did you know?

• Emergency room physicians make up only 4% of all physicians in the United States

• 28% of all acute care is handled in emergency rooms

• 50% of all acute care management to Medicaid and CHIP beneficiaries are handled in emergency rooms

• 66% of all acute care treatment to the uninsured is handled in emergency rooms

It has always been understood that Medicare, Medicaid and the uninsured populations use emergency rooms far more than the privately insured population. However, a study conducted by Truven Health Analytics found that more than 70% of visits by insured individuals, to the emergency room, were for non-emergency medical issues.

The crippling cost of waste

One of my patients suffered from shortness of breath due to anxiety. There were times when I would work with her over the phone because she did not have insurance; I didn’t feel the need to bring her into the office if it was not absolutely necessary.

On an evening that I was off, she called the doctor-on-call, who sent her to the emergency room for shortness of breath. What would have been a $100 visit, ended up costing her $12,000 in the emergency room.

The inappropriate use of the emergency room has become a major source of our healthcare system’s waste. Money is being spent unnecessarily and crippling the economics of both businesses and households. It’s also lack continuity and overwhelmingly more expensive.

If anyone is to blame, it’s primary care

Patients willingly choose to go to the emergency room because it’s accessible all the time, even though, most times, they would rather see their primary care provider. The need to recreate primary care for cost control is critical if we ever expect to decrease the cost of healthcare as a whole.

Accountability empowers patients to be the decision maker for their health. It also allows their doctor to guide them toward the path of improved health outcomes. Nevertheless, in order to be held accountable for something, individuals must be engaged in an established relationship. Insurance companies frequently call patients about their health – diabetes, weight, blood pressure, A1C, etc. Their intentions are explicitly to collect information; however, patients are disturbed and upset by the telephone call.

The following are some of the patients’ reactions, “Why does the insurance company want to know this?,” “Are they trying to save money, by writing me out of their insurance?” and “Are they trying to charge me more?” Patients simply cannot understand the real purpose of the call.

You see, this is exactly why relationships are the foundation for engagement – it makes all the difference. Since the patient did not personally know the insurance person calling, there is an immediate distrust and they are hesitant to freely provide any information.

On the contrary, I have seen patients respond completely different to the same set of questions asked by someone from their doctor’s office. A call from someone they know is always received better.

When dealing with someone who is familiar and trusted, patients are transparent about their struggles and concerns; they ask questions openly and provide information that is helpful for understanding their conditions. Not only this, but they promise to make changes so they can report improved results the next time we call. Therein lies the key to accountability.

Maintaining a relationship with our patients holds them accountable for taking care of themselves. We set the tone for enabling a patient to be an active participant in their overall health. In this example, a call from our office motivates them to want to do better. Over time, they understand that we are invested in their health and they put forth the effort to invest in it as well. That’s invaluable to achieve the outcomes that we need to help our patients be healthier.