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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
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, 2019Read
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, 2019Read
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:
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:
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, 2019Read
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, 2019Read
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, 2019Read
Timely follow up by the primary care physician after a patient’s visit to the emergency room (ER) may be the key to reducing return ER visits as well as hospitalizations. Ideally, the provider and patient will have an established relationship, enabling the primary care physician to initiate the follow up and possibly even avoid the need for the patient’s initial ER visit. However, even if the patient finds it necessary to be seen at the ER, the follow up with the primary care physician can be a critical point in the long-term outcomes for that patient.
According to a study published by the US National Library of Medicine (National Institutes of Health), 50% of all hospital admissions are a direct result of patient ER visits. The study investigated the impact of a “rapid-access-to-primary-care program” at New York-Presbyterian / Weill Cornell Medical Center in terms of health outcomes, cost savings, and the provider’s ability to engage ER patients in continued primary care and preventive measures.
Patients who feel the need to visit the ER may not be covered by insurance or may not have an established relationship with a primary care physician. The study found that a rapid-ED-to-primary-care-access protocol “has the potential to save costs over time.” This type of timely follow up by the primary care physician “can also provide a safe and reliable ED discharge option that is also an effective mechanism for engaging patients in primary care.”
Research has established that “regular primary care is associated with a number of health benefits including increased receipt of preventative services and better chronic disease management.” When the patient follows up with a primary care physician promptly after an ER visit, the opportunity also exists for the provider to engage that patient in long-term primary care. Establishing a medical home can be critical for patients with chronic or complex conditions, in particular.
The study found that “a rapid-ED-to primary-care follow-up program can provide a safe and reliable ED discharge option that is also an effective mechanism for engaging patients in primary care. Such primary care engagement has the potential to lead to further containment in overall healthcare costs, as well as to improved patient care and health outcomes.”
A rapid-ED-to-primary-care-access program may allow EPs to avoid admitting patients to the hospital without risking ED revisits or subsequent hospitalizations. This protocol has the potential to save costs over time. A program such as this can also provide a safe and reliable ED discharge option that is also an effective mechanism for engaging patients in primary care.
Damien Neuman January 28, 2019Read
As the Centers for Medicare & Medicaid Services (CMS) continues to shift its reporting and reimbursement programs to accommodate over-burdened physicians, there continue to be challenges for the primary care physician in providing value-based care.
CMS initiatives that involve more financial risk – for potentially greater rewards – are accompanied by reporting requirements and value-based care measures that may be difficult for some independent physicians to achieve. A report published by ArborMetrix found that “Provider groups and health systems face real limitations accessing data and developing the infrastructure and engagement necessary to succeed under new paradigms.”
Tackling physician barriers to value-based care in 2019 will involve:
Taking advantage of available technology. Electronic health records (EHRs) enable the independent physician to manage patient data and to easily coordinate care for patients. Elation’s EHR solution is designed for the primary care physician to holistically evaluate the patient population with a longitudinal record that trends vitals and lab values over time. The physician can quickly identify patients who aren’t meeting goals based on custom care management protocols, Meaningful Use objectives, or specific document tags, and easily schedule a follow-up appointment to address any potential gaps in care.
Establishing partnerships with community service providers. For those patients who face their own challenges in accessing healthcare, primary care physicians can coordinate with area organizations to facilitate the delivery of value-based care. As Healthcare Informatics explains it, “Social determinants of health often prevent certain populations from accessing care in a timely and cost-effective manner. However, the shift to value-based care, coupled with a willingness of companies across industries to integrate technologies into each others’ platforms, is creating new and interesting collaborations to address some of these disparities.”
Getting involved and providing feedback on value-based care requirements. CMS typically issues draft or proposed rulings with a comment period for physician input. Take advantage of those opportunities to review those documents and submit feedback and input that could make a significant difference in the value-based care landscape.
Damien Neuman January 22, 2019Read
The earliest patient records, dating back to “antiquity,” were created for instructional and educational purposes at least 4,000 years ago. Written case history reports were found to have been developed for didactic purposes by medieval physicians. The forerunner of modern medical records, researchers have discovered, “first appeared in Paris and Berlin by the early 19th century.” It was not until the 20th century that “a clinical medical record useful for direct patient care in hospital and ambulatory settings” was developed and used regularly.
By the early 20th century, healthcare providers were charting patient visit notes and medical history to be used in the treatment of those patients. According to an article published by Rasmussen College, “Documentation became wildly popular and was used throughout the nation after healthcare providers realized that they were better able to treat patients with complete and accurate medical history. Health records were soon recognized as being critical to the safety and quality of the patient experience.”
Patient charting was standardized by the American College of Surgeons (ACOS), which established the American Association of Record Librarians. Today the association is known as the American Health Information Management Association (AHIMA). Paper patient charts were handwritten and kept in files on specially designed shelves until the mid to late 20th century, when new technology was being developed.
Throughout the late 20th century, patient charting began to be moved into electronic systems. The electronic health record (EHR) was originally developed for hospitals and universities, but by the 1980s, more focused efforts were made to increase the use of EHR among medical practices. While manual patient charting and filing was vulnerable to errors, the Centers for Medicare & Medicaid Services (CMS) recognized that the EHR “can improve patient care by:
• Reducing the incidence of medical error by improving the accuracy and clarity of medical records.
• Making the health information available, reducing duplication of tests, reducing delays in treatment, and patients well informed to take better decisions.
• Reducing medical error by improving the accuracy and clarity of medical records.”
Patient charting has advanced significantly in the past 4,000 years. In the 21st century, patient data can be accessed and shared seamlessly among providers caring for the patient, through EHRs. The primary care physician now has the ability to coordinate care electronically and accurately, ensuring the highest quality outcomes.
Damien Neuman January 9, 2019Read
Preventive screenings occurred at a higher rate under value-based care than with physicians in a fee-for-service arrangement, according to the latest report published by Humana, a healthcare payer. The Value-Based Care Report published annually for the past five years, examines the physicians within the Humana system and their impact on patients. Chronic condition management also improved with the value-based care model.
The report cites the example of breast cancer screenings, in which “patients affiliated with physicians in value-based care agreements had a higher frequency rate of breast cancer screenings (78 percent) compared to patients affiliated with physicians in fee-for-service (69 percent) and fee-for-service plus bonus agreements (69 percent).”
An increase in preventive screenings was also found among patients in value-based care for osteoporosis management, rheumatoid arthritis management, blood pressure control management, statin medication adherence, high blood pressure medication adherence, and adult BMI assessment. 83% of patients showed improved adherence to statin medication in value-based care, as contrasted with 79% of patients in the fee-for-service model. Medication reviews for older adult patients were reported at 96% in value-based care and 88% in fee-for-service care.
Humana reported that their physicians practicing in “value-based agreements had more favorable results than physicians in fee-for-service agreements in all HEDIS (Healthcare Effective Data and Information Set) Star measures.” Further, the report states, “Focusing on prevention and the whole health of their panel population allows physicians and their care teams to work more strategically to improve the care of their patients, thus keeping them home and out of the hospital and emergency room.”
Emergency room visits and hospital admissions were also significantly lower in the value-based care models than with fee-for-service physician practices. Proper and timely preventive care has been shown to have a significant impact on hospital stays as well. Overall, the report states, “physicians who practice value-based care are achieving higher rates of patient engagement in preventive screenings, medication adherence and management of chronic conditions as measured by HEDIS.”
Damien Neuman December 14, 2018Read