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The concept of value is not one that can be measured precisely. Value may mean different things to different people, depending on their situation and perspective. A conversation with two physicians conducted by AAFP recently helps clarify what high-value care means to providers and their patients.
The conversation with Kyle Leggott, M.D., a family physician doing a fellowship in health politics and policy at the University of Colorado, and Allison Edwards, M.D., a direct primary care practice owner in Kansas City, Kan., was conducted in response to a study published in the American Journal of Managed Care (AJMC) that “found that getting rid of cost-sharing for primary care actually saves money and reduces utilization.” An editorial followed the article, in which the writer asserted that unlimited, unrestricted access to primary care would lead to increased unnecessary care.
Dr. Leggott and Dr. Edwards pointed out that the value of care stems from the relationship that the physician and patient are able to establish as well as the decisions made collaboratively by provider and patient rather than by third-party entities. Dr. Leggott commented that “A patient’s access to a family physician shouldn’t increase costs if the patient and physician are working together to spend health care dollars appropriately.”
Dr. Edwards further explained that “high-value” care may be seen differently by different people. She gave an example of a patient who was prescribed a very expensive medication that he was not able to take as an outpatient because of the cost. The prescription was seen as high value based on its evidence-based success in treating a certain condition and reducing readmission; however, to the patient who could not afford the drug, the prescription was essentially worthless.
Understanding the cost of treatment and prescriptions is critical for the provider and the patient, to determine what truly will be high-value care for that particular patient. The physician who knows the patient well enough to recognize what is feasible and reasonable for that patient will be more successful in providing that high-value care. As Dr. Edwards emphasizes, “The discussion about value-based care is incredibly nuanced because it requires that we be rigid with our definition of value, and in reality, life doesn’t play out that way.”
Damien Neuman November 18, 2019Read
The Federally Qualified Health Center (FQHC) is focused on providing primary care to patients in underserved areas that may not have insurance or the ability to pay their medical bills. The Centers receive funding from the Health Resources & Services Administration (HRSA), an agency of the Department of Health and Human Services (DHHS), that is the “primary federal agency for improving health care to people who are geographically isolated, economically or medically vulnerable.”
FQHCs are also known as Community Health Centers and can be found in every state in the US as well as in the US territories. In fact, there are “nearly 1,400 health center organizations with more than 11,000 locations in urban, suburban and rural communities across the country.” FQHCs must meet a stringent set of requirements to be able to meet the needs of the underserved in their communities and receive funding from the HRSA.
Specifically, FQHC services include:
Damien Neuman November 1, 2019Read
When a patient sees multiple providers, particularly for a chronic or complex condition, that patient’s care needs to be coordinated to ensure the delivery of safe and effective treatment. The patient who has a medical home has just that kind of healthcare coordination, with the primary care physician monitoring the patient’s health status and collaborating with other providers throughout the various stages of that patient’s life.
The patient-centered medical home (PCMH) is focused on the continuing care of the patient, rather than simply treating one condition for a limited period of time. In a PCMH, the primary care physician is able to engage the patient, to ask pointed questions, and to observe changes or signs that may need further exploration by a specialty provider or diagnostic lab.
As described by the Patient-Centered Primary Care Collaborative (PCPCC), “The medical home is best described as a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. The Agency for Healthcare Research and Quality (AHRQ) describes the PCMH “as a way to improve health care in America by transforming how primary care is organized and delivered.”
The PCPCC adds that the PCMH is “a philosophy of health care delivery that encourages providers and care teams to meet patients where they are, from the most simple to the most complex conditions. It is a place where patients are treated with respect, dignity, and compassion, and enable strong and trusting relationships with providers and staff…. a model for achieving primary care excellence so that care is received in the right place, at the right time, and in the manner that best suits a patient’s needs.”
A PCMH is focused on the patient, with the primary care physician developing a close relationship with that patient. The provider collaborates with other healthcare providers and may work with the patient’s family as well, to cultivate a true understanding of all the factors affecting the patient’s health. The AHRQ also recognizes the role of health IT, including electronic health records (EHRs), “in successfully operationalizing and implementing the medical home.”
Damien Neuman October 17, 2019Read
The number of hospital-employed physicians continues to rise, but the trend may be slowing as significant numbers of employed doctors are switching to independent practices. Many physicians are either launching their own practices or joining with other independent providers in a move away from employed positions. Although employment offers security and stability, independence provides autonomy, flexibility, and an opportunity to offer more affordable care to patients.
The number of hospital-owned physician practices has increased in recent years, but the numbers are still low in the southern and western geographic regions of the US. According to a Physicians Advocacy Institute/Avalere analysis, 28% of physician practices were owned by hospitals in the South and West as of January 2018. In the southeast, especially in North Carolina and Georgia, the healthcare environment is heavily focused on fee-for-service models, which makes it more conducive to the success of independent practices.
Between September 2018 and March 2019, two separate groups of physicians based in North Carolina and employed by large health systems, Atrium Health and Novant Health, left their employers to form or join independent practices. Ninety physicians resigned their employment with Atrium Health and another 42 left Novant.
Dr. Dale Owen, formerly employed by Atrium Health, left that system along with a number of other providers to form Tryon Medical Partners in Charlotte, for which Dr. Owen is now CEO. Dr. Owen states that the high level of fee-for-service medicine “could be one reason the Charlotte region has seen an exodus of hospital-employed doctors as they step out onto a stable platform where an independent group can launch a practice without taking on additional risk.” Charlotte, North Carolina, is actually one of the highest-cost places in the country in regard to receiving healthcare.
Owen adds that “The epicenter of change you are going to see from an independent physician standpoint is Charlotte. Fee-for-service allows groups to solidify themselves and pave the way for others to come out. You can start up a practice while standing on fee-for-service and morph rapidly into value-based medicine.”
Dr. Ehab Sharawy, who left Novant to join Holston Medical Group, says that being independent doesn’t necessarily mean being anti-hospital. Rather, independent practices are able to be more patient-centric, as they are not tied up in corporate regulations or decision-making processes. Providers in independent practices also experience lower burnout rates, attributable to their autonomy and flexibility in providing quality care for their patients.
Damien Neuman September 20, 2019Read
For the past ten years, ECRI Institute has compiled a list of Top 10 Patient Safety Concerns “to support organizations in their efforts to proactively identify and respond to threats to patient safety.” The list does not necessarily include issues that occur frequently or that are considered the most severe. Rather, the annual list “identifies concerns that might be high priorities for other reasons, such as new risks, existing concerns that are changing because of new technology or care delivery models, and persistent issues that need focused attention or pose new opportunities for intervention.”
The top patient safety concerns in 2019, according to the ERCI Institute, are:
Damien Neuman August 28, 2019Read
Most independent physicians are not prepared for the transition to value-based care payments, according to a survey of almost 900 physicians conducted in 2018. Black Book Market Research LLC conducted the value-based care study in Q1/Q2 2018, focusing on “measuring the increased demand for advisors to help medical providers and practices make the move to value based care by easing their administrative burden across payers and supporting the launch and management of their own health plans.”
Significant findings from the survey included insight into ways that the “new era of how providers get paid is going to impact the entire organization and most physician organizations aren’t remotely prepared for it according to 88% of surveyed practice managers.” Other findings from the survey involving 877 physicians, as described in Black Book’s news release, included:
Doug Brown, Founder of Black Book Research, commented that “Consultative approaches that emphasize physician engagement, culture change, actionable data and analytics are producing some very prepared and motivated physician organizations as they move from volume to value.”
Damien Neuman August 1, 2019Read
The number typically used when discussing the standard panel size for a primary care physician is 2500. However, according to various research studies, that number seems unrealistic and unreasonable. An article published in the Journal of the American Board of Family Medicine (JABFM) states that “a family physician would need 21.7 hours per work day to deliver recommended care to a panel of 2500 patients.”
The panel size of 2500 is “anecdotal,” rather than based on factual research. In fact, according to the JABFM article, a research study conducted in 2005 arrived at a figure of 2300 for the typical patient panel size for primary care physicians. More recent studies have found “current panel sizes ranging from 1200 to 1900 patients per physician.”
As the JABFM article points out, smaller patient panel sizes enable the primary care physician to focus more on each patient, giving each patient more time and attention, and enabling the primary care physician to more effectively coordinate care, particularly for those patients with chronic or complex conditions. The article notes that primary care physicians “who provide continuity of care to an appropriately sized panel of established patients are better equipped to address the individual needs of their patients; they also have more time available to coordinate care with subspecialists, improve communication with their patients, provide behavior change counseling, evaluate quality, and monitor patient outcomes.”
The 2018 Survey of AMERICA’S PHYSICIANS Practice Patterns & Perspectives – the Physicians Foundation, a research study involving 8,774 physicians, found that those physicians responding to the survey “see an average of 20.2 patients per day, down from 20.6 in 2016, but up from 19.5 in 2014 and 20.1 in 2012.” The survey involved both employed physicians as well as independent physicians running their own practices.
Even though many primary care physicians responding to the survey indicated they were at or above capacity, 20% of all physicians indicated they could see more patients, with the number reaching 25% for independent physicians. Interesting to note that the survey results showed employed physicians seeing 11.8% fewer patients than independent practice owners. The average number of patients per day for an independent practice owner was 22.8 and the average number for all primary care physicians participating in the study was 19.7.
Damien Neuman July 24, 2019Read
Engagement and connection appear to be prominent factors in the productivity and success of independent primary care physicians. A recent study of 1,029 physicians, as reported by Becker’s Hospital Review, found that primary care physicians who own their practice tend to be more engaged and more productive than those employed by a healthcare organization or hospital.
In the study, primary care physicians’ responses to questions were combined with data on productivity, such as work relative value units (wRVUs) that physicians generate. The research study found that in terms of productivity, PCPs who owned part or all of their practices generated 26.9 wRVUs per day on average, as compared to employed physicians who generated 23.1 wRVUs per day.
Physician work RVUs “account for the time, technical skill and effort, mental effort and judgment, and stress to provide a service.” Research data that was used to develop the RVU formula originally came from a Harvard University study in the late 1980s. The RVU measurements have since been refined and, in fact, the Centers for Medicare & Medicaid Services (CMS) is required to review and update (when appropriate) RVUs every five years.
The researchers also found that 37.5 percent of primary care physicians (PCPs) who owned part or all of their practices were more engaged in their practice, compared to 26.3 percent of those PCPs who worked for another organization. Engagement with patients and internally has been shown to contribute to the PCP’s effectiveness in terms of positive patient outcomes.
Independent physicians may be more productive and more engaged because of their vested interest in their practice ownership. Not only do they have a financial stake in the practice as the owner or partner, they are also able to develop strong relationships with patients and have a deeper involvement in their patients’ healthcare outcomes.
Damien Neuman July 8, 2019Read
As its name suggests, a chronological record is quite simply the events, encounters, and diagnoses for a specific patient, listed as they occurred. The chronological record is based on when things happened, not when the relevant notes were input. On a paper chart, chronological records can become a challenge, requiring the provider to sort through separate pieces of paper to organize the information appropriately within the file. In an electronic health record (EHR), however, the primary care physician has the ability to view information about a patient as it occurred with that patient.
The chronological record lets the primary care physician quickly see what has happened since the last visit. Specialty provider visit notes, laboratory results, and notes put in by the provider after the visit are listed. Items requiring action are filtered to the top of the chart, incoming reports are clearly organized, and the patient’s pharmacy data is downloaded for a clear view of an up-to-date medications list.
Access to the patient’s chronological record enables the primary care physician to see the whole picture, rather than just notes from the previous primary care visit. Anything that happened in between visits, such as diagnostic tests and specialty provider visits, can be viewed so the provider understands exactly what the patient needs during the current visit and beyond.
Chronological records within the EHR facilitate the primary care physician’s treatment of the patient, giving the provider the “ability to generate a complete record of a clinical patient encounter – as well as supporting other care-related activities directly or indirectly via interface – including evidence-based decision support, quality management, and outcomes reporting.”
Coordinating care is made easier and more effective with chronological records. The primary care physician does not have to search through faxed paperwork or rely on handwritten (sometimes unreadable) notes from a lab or specialty provider to understand the holistic picture of the patient’s treatment plan. Coordinated care enables the primary care physician to provide higher quality care, based on the complete patient profile.
Damien Neuman June 21, 2019Read
Primary care has progressed from the days of the family doctor who did everything to the primary care physician (PCP) as medical home for the patient, coordinating care with other physicians and medical providers. Where does primary care go from here?
Many experts believe that primary care will continue to increase in importance, even while the number of PCPs may be decreasing. The Association of American Medical Colleges (AAMC) commissioned a study recently on the impending physician shortages. The study found that for PCPs, “the estimated shortage will be between 8,700 and 43,100 physicians by 2030.”
The shortage occurs as the need for primary care grows among an aging population. As patients become eligible for Medicare, additional requirements around providing value-based care and reporting regulations imposed by the Centers for Medicare & Medicaid Services (CMS) will affect the future of primary care.
On the positive side, innovation will improve the effectiveness and the efficiency of primary care. The use of electronic health records (EHRs) will enable PCPs to better coordinate care, track their patient’s medical history, and plan for an improved healthcare plan for that patient. Implementing EHRs will become a requirement for those PCPs participating in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program (QPP).
Value-based care will increase in importance for PCPs. Medicare reimbursement will depend on the PCP’s ability to provide quality healthcare. Many private insurers, as well, are moving toward a value-based reimbursement system, and away from the fee-per-visit model. Rather than track the number of patient visits, the PCP will be called upon to track and document medical progress for the patient.
A growing number of PCPs are opting out of the traditional insurance reimbursement model completely, instead forming direct primary care (DPC) practices. In the DPC model, patients pay a monthly membership fee that covers basic primary care services. The DPC physician is able to spend more time with each patient, see fewer patients per day, and realize greater rewards in terms of financial stability and healthcare outcomes.
Damien Neuman May 30, 2019Read