Fundamental
F
d
t l Transformation
T
f
ti off the
th
PCP Workday
y
Lawrence P. Casalino MD, Ph.D.
Livingston Farrand Associate Professor of Public Health
Chief, Division of Outcomes and Effectiveness Research
Weill Cornell Medical College
Academy Health Annual Research Meeting
June 28, 2010
1
Key points
• we reward bad physicians and exploit good
physicians
• unless the PCP workday is fundamentally
transformed:
– the patient-centered medical home will not succeed
– primary care will not be a viable career
• fundamental transformation will require:
– changes in payment methods
– cultural changes
g
– changes in medical education/training
2
“Bad” physicians
• see patients as rapidly as possible - as many
as 40 per day
• order tests rather than take a good history
• refer
f any patient
i likely
lik l to require
i time
i to a
specialist
• spendd very li
little
l time
i on the
h phone
h
with
ih
patients, specialists, nurses . . .
• do
d not create or cooperate with
i h organized
i d
processes to improve quality
3
Good physicians
• see 20-25 patients per day
• spend the time needed with patients
g
treatment, and care
for diagnosis,
• only refer patients when specialist care
is necessary
• spend a lot of time on the phone and,
perhaps on ee-mail
perhaps,
mail
4
Consequences
• Bad physicians earn a lot of money
and
d may even eat dinner
di
with
i h their
h i
children
• Good physicians earn much less and
arrive home when their children are
asleep
• Is this the kind of choice we want
physicians to make - every day?
5
Typical
T
i l practicing
ti i physicians’
h i i ’ response
to the Patient-Centered Medical Home
“That’s a nice idea, but how am I
supposed to find the time to do all the
extra work it would require?”
q
6
Fortunately:
• most current visits with primary care
physicians need not occur in person
• this is a hypothesis, but not just mine
(Tom Bodenheimer, Joe Scherger . . .)
7
When is
Wh
i an in-person
i
visit
i it necessary??
When any of the following apply:
•
•
•
•
•
new patient
communication
i i barrier
b i
complex problem must be addressed
emotional problem must be addressed
something physical must be done
diagnostically (e.g. cardiac auscultation or
therapeutically (e.g. inject a joint)
• patient wants an in-person visit
8
When iis an iin-person visit
Wh
i it usually
ll
not necessary?
y Examples:
p
• upper respiratory symptoms
• low back pain and many other
p
common musculoskeletal problems
• urinary tract infections
• routine follow
follow-up
up of chronic problems
(e.g. hypertension, diabetes)
• currently,
l these
h
are all
ll very common
reasons for in-person visits
9
Transforming the PCP Workday
• see 8-10 patients daily face to face
– long
l
visits
i it when
h helpful
h l f l
• e-mail and phone communication with
– patients
i
andd ffamilies
ili
– other health care workers
• coordinate
di t care
• work with practice staff to systematically
i
improve
the
th health
h lth off the
th practice’s
ti ’
population of patients
10
Likely effects:
• contact with many more patients per day
• saves patient time as well as physician time
• better diagnosis,
g
, patient
p
self-management,
g
,
and coordination of care
• less chaos
chaos, fewer interruptions,
interruptions better quality
of work day
• makes it possible to implement the PCMH
11
If thi
this model
d l is
i so great,
t why
h isn’t
i ’t it
common?
• payment is usually made only for inperson visits
• culture: the idea simply isn
isn’tt on
patients’ or physicians’ radar screen
• training: the individual physician vs.
the organized process idea of quality
12
The conceptt is
Th
i nott found,
f
d even
where it might
g be expected
p
• PCMH and Chronic Care Model
concepts imply the model proposed
here
• Yet, review of 26 recent PCMH or
CCM articles: not a single one
suggested that PCPs see many fewer
patients per day
13
Training/Culture
• “individual physician view of quality”:
– quality is what I do for any patient who
pp
to show upp in front of me, while
happens
he/she is in front of me
• “organized
organized process view of quality”:
quality :
– quality is also what my organization does
f our entire
for
ti population
l ti off patient,
ti t
during and between visits
14
“Here is Edward Bear,coming
downstairs now, bump, bump, bump,
on the back of his head, behind
Ch i
Christopher
h Robin.
bi It is,
i as far
f as
he knows, the only way of coming
d
downstairs,
t i but
b t sometimes
ti
he
h feels
f l
that there really is another way, if only
h could
he
ld stop
t bumping
b
i for
f a momentt
and think of it”
A.A. Milne 1926
Illustration E.H.Shepard
E H Shepard 192614
15
Relevant recent articles
Baron, Richard M. “What’s Keeping Us Busy in
Primary Care?”
Care? NEJM 2010; 362(1):1632-36
362(1):1632 36.
Casalino, Lawrence P. “A Martian Prescription for
Primary Care.” Health Affairs 2010; 29(5):785-90.
Margolius, David and Thomas Bodenheimer.
“Transforming Primary Care from Past Practice to
the Practice of the Future.
Future ” Health Affairs 2010;
29(5):779-84.
Reid,, Robert J et. al. “The Groupp Health Medical
Home at Year 2 . . .” Health Affairs 2010;
29(5):835-43.
16