Value-based care is driving more and more physicians to seek outside support

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:

  • 68% of group practices of ten or more physicians reported they would seek external advisement on financially and clinically transforming their operations before Q2 2019
  • 89% of all surveyed physician organization decision makers on hiring a value-based care consultancy agree that they prefer an advisor with both Population Health Management and Revenue Cycle Management expertise
  • 21% of academic medical centers physician departments and clinics surveyed will have engaged a value-based consultancy by Q4 2018
  • 93% have no strategic plan activated for transforming population health management or value-based care solutions end-to-end to confront known deadlines because there are no internal experts identified
  • Less than 7% of physician organizations surveyed have begun comprehensive value-based care software vendor selection activities and are considering consultants to assist them
  • 95% of group practice and large clinic Chief Information Officers state they do not have the information technology or staff in-house needed to transform value-based care end-to-end as their physician and or executive team envisions.

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, 2019

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How many patients are most primary care physicians seeing?

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, 2019

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Independent primary care physicians are more productive than hospital-employed physicians according to study

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, 2019

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What are chronological records?

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, 2019

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What is the future of primary care?

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, 2019

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Most young patients say EHRs have improved care quality according to new survey

Healthcare quality and data security are typical concerns for primary care patients. However, the level of those concerns differs between various age groups, according to a Data Note published recently by the Kaiser Family Foundation. “Data Note: Public’s Experiences with Electronic Health Records,” published in March 2019, examines data from the January 2019 KFF Health Tracking Poll.

Overall, patients say they are experiencing increased use of electronic health records (EHRs) among their primary care physicians as well as their other health providers. As the Data Note describes, “EHRs have become ubiquitous.” Patients responding to the poll indicate that an increasing number of providers are entering medical information into a “computer-based medical record.” In fact, the number has almost doubled in the past 10 years, from 46 percent in 2009 to 88 percent in 2019.

Across all ages, a little less than half of the patients participating in the poll state their “physician’s use of an EHR has made the quality of care they receive and their interactions with their physician “better” (45 percent and 44 percent, respectively).” However, those patients ages 18-29 have a more positive view of provider EHR use, with a majority (57%) saying the quality of care they receive when their physicians use EHRs is “better” and none say that it is “worse.”

Interactions with patients are also viewed as “better” by slightly more patients in the younger age group. While the number is 44% overall, 49% of patients ages 18-29 believe their interaction with their healthcare provider is “better” when that physician uses EHRs and only 1% see it as “worse.”

As to privacy and security, only 42% of patients ages 18-29 participating in the 2019 Health Tracking Poll were “very” or “somewhat” concerned that their medical record could be accessed by an unauthorized person. That number increased to over half for participants in older age groups.

KFF has been tracking patients’ perceptions of EHRs since 2009, when the debate over healthcare reform began.

Damien Neuman
May 30, 2019

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What is patient-focused care?

Technology can help primary care physicians manage their patients’ medical data, entering information during the visit and reviewing the patient’s record after the visit. Physicians also need to focus on their patients, though, to provide quality patient-focused care. Patients want their primary care physician to engage with them during the visit, answering their questions and focusing on their needs.

What is patient-focused care? A research study published by the US National Library of Medicine National Institutes of Health states that “Patient-focused care includes four broad areas of intervention: communication with patients, partnerships, health promotion, and physical care (medications and treatments).”

The research study identifies the “three Cs” of patient-focused care, as “communication, continuity of care, and concordance (finding common ground).” Communication is critical to patient-focused care. Lack of focused, clear communication can create misunderstandings or misinterpretation. Patients who feel their physician is not taking the time to provide them with detailed information or to listen to their concerns may become discouraged.

When patients are engaged by the primary care physician, however, they become more involved in their own healthcare. They tend to follow instructions more closely and collaborate with the physician on critical decisions that impact their plan of care. The patient’s family or caregivers may also become more actively involved in the patient’s well-being.

For the physician, as the research study points out, there are benefits resulting from patient-focused care “in terms of improved outcomes for their patients, higher patient retention, and potentially a reduced risk of litigation.” In addition, patient-focused care “has been shown to improve physicians’ performance, patient satisfaction, and health outcomes without requiring additional investment in time or resources.”

Patient-focused care may also be a valuable approach for the primary care physician treating “difficult” patients. Those patients who do not understand their diagnosis or treatment plan or who simply do not want to follow the prescribed plan may become more actively involved in decisions regarding their health if their primary care physician practices patient-focused care.

Damien Neuman
May 30, 2019

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What is the importance of care quality?

In 1990, the Institute of Medicine (IOM) defined quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Quality can impact healthcare costs, the effectiveness of patient care, and the extent to which patients understand and are able to comply with a plan of care.

From the physician perspective, this means providing value-based care with the most up-to-date technology to achieve quality patient outcomes. From the patient point of view, one of the significant measures of quality care, factors include:

  • Staying Healthy. Getting help to avoid illness and remain well.
  • Getting Better. Getting help to recover from an illness or injury.
  • Living with Illness or Disability. Getting help with managing an ongoing, chronic condition or dealing with a disability that affects function.
  • Coping with the End of Life. Getting help to deal with a terminal illness.

These categories were developed based on Foundation for Accountability (FACCT) research, which studied the patient side of the IOM framework for quality.

The Centers for Medicare & Medicaid Services (CMS) identifies six goals within its Quality Strategy, which help outline the importance of care quality for its patients:

  • Goal 1: Make care safer by reducing harm caused in the delivery of care.
  • Goal 2: Strengthen person and family engagement as partners in their care.
  • Goal 3: Promote effective communication and coordination of care.
  • Goal 4: Promote effective prevention and treatment of chronic disease.
  • Goal 5: Work with communities to promote best practices of healthy living.
  • Goal 6: Make care affordable.

Care quality contributes not only to the short-term health of the primary care physician’s patients, but also to the provider’s ability to effectively coordinate care for those patients who need to see multiple physicians. The quality of care provided to primary care patients can impact them long-term, as well, strengthening potential social determinants of care quality, reducing costs, and improving outcomes as the care becomes more efficient and more effective.

Damien Neuman
March 27, 2019

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AAFP report shows the state of the family physician

Income is increasing for family physicians but burnout may be as well, according to a report published by the  American Academy of Family Physicians (AAFP). The report points out that family medicine was not officially recognized as a medical specialty in the US until 1969. Over the past 50 years, family physicians have made significant progress in certain areas but are still faced with a number of challenges.

Data gathered by AAFP shows that “the income gap between primary care and non-primary-care physicians has decreased from 44.6 percent in 2011 to 41 percent in 2015.” The report indicates that family physicians’ income is increasing slowly but steadily and the amount of time they spend in direct, face-to-face patient care is down slightly.

DISTRIBUTION OF FAMILY PHYSICIANS BY ANNUAL INCOME

The AAFP report emphasizes that “First-contact, person-focused, comprehensive, coordinated care – the hallmark of family medicine – is becoming even more important as the health system transitions to value-based payment.” Farzad Mostashari, MD, former National Coordinator for Health IT and now chief executive officer of Aledade states that “small, physician-owned practices have a lower average cost per patient, fewer preventable hospital admissions and lower readmission rates than hospital-owned practices.”

Patients value the time spent with their family physician, particularly those in independent practices. However, AAFP found that provider burnout rates are increasing, noting that “an alarming 63 percent of family physicians meet the criteria for burnout, compared with 54.4 percent of all physicians. When asked how they feel about the current state of the medical profession, 50.5 percent of primary care physicians report positive feelings.”

AVERAGE HOURS SPENT PER WEEK IN PRACTICE

Though a physician shortage still exists, more medical students are choosing to enter family medicine. The number of students matched with family medicine steadily increased from 2006 to 2016, the latest data available. The AAFP report notes that “continued recognition of the value of primary care, and continued increases in income, will play a vital role in family medicine’s ability to grow and to attract more medical students.”

Ripley Hollister, MD, FAAFP, a Colorado Springs, Colo., family physician and board member of the Physicians Foundation, noted in the report that “with time, as family physicians adjust, frustrations will lessen and satisfaction will rise. Family physicians have a long history of adapting to change, and the new generation of physicians appears to have more optimism.” Mostashari suggested that family physicians “will need to ingrain it into their culture and continually refocus on why they are doing the work – for patients.

Damien Neuman
February 19, 2019

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The patient experience of the future

Not surprisingly, primary care patients want to be seen and treated as human beings rather than just another patient with a medical record number. They desire a relationship with the physician and consistent treatment, whether being seen in person or communicating with the practice before and after the visit. The “patient experience of the future” should revolve around the primary care physician truly getting to know the patient and to provide resources to make healthcare more convenient for that patient according to a recent survey conducted by West’s Engagement Center Solutions.

The survey found that patients’ top priorities and physicians’ priorities do not always align. Although providers indicate they are working on many aspects of the healthcare experience that are important for patient satisfaction, patients place higher priority on certain areas. For example, 49% of the patients responding to the survey indicated that efforts to communicate out-of-pocket costs for services were “essential to improving patient satisfaction.” Providers ranked this topic almost last in their priority list.

The patient experience of the future should also include convenience for the patient, in scheduling appointments and in communicating with primary care physicians. 41% of the patients responding to the survey indicated that making it easy to schedule appointments would improve their satisfaction with their healthcare provider. Appointment reminders sent out via a patient portal can also help encourage patients to keep their appointments.

As to the visit experience, 50% of patients participating in the survey said that shorter wait times in the physician’s office would improve satisfaction. The patient experience of the future might include electronic notifications when the provider is running behind or when the patient might experience a long wait time.

During the visit, the patient experience of the future should include adequate time for the patient to ask questions and clarify diagnoses and care instructions. Currently, according to the survey results, “One quarter (27%) of patients do not have a strong sense that their providers care about them as individuals, and nearly one in five patients (19%) are not positive that their providers are focused on improving their health.”

Damien Neuman
February 6, 2019

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