How should we pay for primary care?

20 Oct
2009

I have written about this subject often. The current system of “fee for service” does not fit good primary care delivery. At a recent ACP committee meeting, I talked with several experience primary care internists. They continue to love seeing patients, and continue to hate the last 1-2 hours of the day when they sit doing paper work and answering telephone calls. They are encouraged to see patients too quickly, decreasing patient satisfaction and physician satisfaction.

If we were starting from scratch and wanted to encourage great primary care, how would we design a payment system. First, we want to maximize the time physicians spend interacting with patients. We are trained to care for patients and most internists (and family physicians) love spending time with patients. Second, we would use a variety of communication methods including telephone calls and emails (perhaps including text messages). These communication alternatives can save time when used properly. Third, we would optimize the number of patients for whom each physician cares. No one can do an adequate job trying to care for too many patients. We all understand that occasionally we have a very busy day and have to see a few too many patients or stay an extra couple of hours. However, we could develop a desired panel size, and that size would likely be significantly less than current panel sizes.

Finally, we need a payment system that minimizes unnecessary paper work, and allows physicians to write meaningful notes rather than bean counter notes. We would like to minimize overhead and have sparse office staff. I could imagine 1 receptionist/scheduler/telephone caller and 1 great nurse. Perhaps one could use a 3rd staff member. I cannot imagine justification for more staff.

So let us imagine a job where you have responsibility for 1200 patients (I picked that number somewhat arbitrarily). You have no insurance forms to fill out and no billing. You are guaranteed a salary dependent on the number of patients your follow. If patients leave your practice, your salary decreases until you attract replacement patients. Then you cannot increase your panel size above a prescribed number, because we know that overall quality decreases when you have to shorten visits.

Would this job, assuming a good salary, attract medical students and residents? Would this job encourage current primary care physicians to continue practicing? Would this job improve “job satisfaction”? Would this job improve patient satisfaction?

I believe this model is the answer. Some would argue that physicians will game the system. That is always possible. Some physicians do not like caring for patients, and are just doing a job. Most physicians that I have trained and met would do a great job. We get frustrated when we have to see too many patients and do clearly stupid paperwork. Our frustration almost always ends once we go into the room. We like patients and want to help them. We need to reinvent the payment system for the benefit of patient care.

Related posts:

  1. Why primary care payment needs a different model
  2. I disagree with @DrVal – retainer medicine is the answer
  3. Pulling primary care out of insurance
  4. Universal health care will require fair pay for primary care
  5. In which I continue my debate with Dr Val

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9 Responses to How should we pay for primary care?

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Michael Kirsch, M.D.

October 20th, 2009 at 7:37 am

I enjoyed the tour of your medical fantasy. Now, wake up and attend to your paperwork pile, play phone tag with patients, fill out various forms, appeal insurance company denials, see patients on time, guarantee perfect outcomes for all and hope you don’t get sued! It not ‘if we were starting from scratch’, but ‘where do we go from here’? http://www.MDWhistleblower.blogspot.com

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pcb

October 20th, 2009 at 8:58 am

” First, we want to maximize the time physicians spend interacting with patients. We are trained to care for patients and most internists (and family physicians) love spending time with patients”

db,

I agree with this and think it is a key point. However, many of the medical home models I’ve seen as pilots are actually going in the opposite direction. Physicians are pushed to be more “supervisors” of a “care team.” Patient panels actually increase in size, and physicians spend less time with each patient. Other members of the care team are expected to be doing much of the direct patient interaction, patient education, and counseling, “freeing up” the physician to provide oversight and focus on the complicated patients.

I see a fork in the road developing regarding new models of care. Those who advocate for the “care team” model, and those who advocate for a smaller panel size, more personal interaction (in whatever form) between the physician and patient.

I think it’s pretty clear which direction would revive interest in primary care among medical students, but I fear the momentum is going the other way.

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Dr. Bob (FP)

October 20th, 2009 at 11:42 am

I think this is really the core of the medical home movement. Some pilots have intentionally decreased panel size. This study (Am J Manag Care. 2009;15(9):e71-e87) from the American Journal of Managed Care decreased the panel size from 2300 to 1800, increased average visit length from 20 to 30 minutes, showed increased quality of care, less physician & staff burnout, more satisfied patients, and no increase in cost.

The margin behind the medical home should be a blended payment model with 3 components. A risk adjusted per member per month to cover fixed costs, per visit reimbursement to cover variable costs, and a bonus based on objective measures like patient satisfaction, clinical measures, & cost efficiency. It works in Denmark, it will work here as well.

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Clinton

October 21st, 2009 at 10:43 pm

I traveled across the country as a medical student to find a model of care with ZERO staff — the “Ideal Micro-Practice”, or “Ideal Medical Practice” (IMP) cuts out a lot of overhead with an online appointment system and 30-60 minute appointments.

This is certainly a new way to approach things, but at the same time, it is going back to the basics — when the primary care doctor was the first point of contact in the health care system. Now, the patient has to call, the secretary to make an appt, see the nurse to check in and get their vital signs and chief complaint recorded and by the time the doc comes in, they have to tell their story again for the 2nd or 3rd time.

I am a future family physician and I am keenly interested in how the IMP model will play out along side the PCMH model. PCP as Dr. Everything vs PCP as supervisor to numerous midlevels…

Deferring education and counseling to other providers may have the unintended consequence of adding in obstacles between the doctor and patient forming a strong relationship with each other. Perhaps for some overworked MDs, this is desirable.

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solo dr

October 22nd, 2009 at 7:17 am

I have a smaller practice of around 2000 patients as an FP. I am on track to have a salary of over $300,000 for 09 from this smaller practice. I have colleagues who claim to have a panel of 4000 patients but who barely break $200,000/year. I only have 1 medical assistant and frequently answer the phone and/or email patients. It does not save time to have messages get lost in the translation. Patients directly contact me after hours with questions, and none of them have abused the privilige. An exchange only stops about 15% of the calls and wastes time and money.
I have learned to be efficent with the HMOs that pay $40-$53 for a 15 minute office visit and frequently work through my lunch hour doing paperwork/filling out forms etc.
I have looked into the PQI Medicare payment bonuses, tried it for a month, and realized it was adding 30-60 minutes a day of administrative work for an anticipated bonus of around $2,000 a year. Most new models of primary care require government reporting of quality issues that really do not measure quality.
In my practice, simple UTI/Sinus infection patient visits may only require 5-10 minutes. The key is not to let the UTI/Sinus visit turn into a regular T2DM/HTN/Chol or well physical visit, when that patient should get the 30 minute comprehensive visit a couple of weeks later. I can spend 5-10 minutes with an established patient, but I also have slots carved out to spend 20-40 minutes with an established patient.
I have no NP or PAs and keep the overhead very low. I am in a high risk practice area, where my malpractice insurance is $30,000 a year, including my 25% discount for not being sued and for doing CME but is high secondary to a top 5 state for lawsuits. My number one overhead is my malpractice insurance.
For me this is an ideal practice. I enjoy seeing my patients and offer same day and next day appointments to most patients. I have fewer patients using ER/urgent care centers and fewer admissions, as I can see a patient daily in the office, if needed. I also directly admit patient to the hospital, such as the hot gallbladder or the acute appendicitis patients, each who I admitted a couple of weeks ago. I can take care of most CHF/Pneumonia patients as an outpatient. 98% of my revenue is from my office practice, where I have reasonable input and control without too much insurance or any hospital interference. I am the only solo doctor in a 10 mile area who is not owned by one of the hospitals, and yet my salary is 40-50% higher than the owned doctors. I also have a balance of plenty of time to see my patients without having to meet revenue numbers eatch month.

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Robyn

October 24th, 2009 at 6:08 pm

It is sometimes interesting hearing doctors speak frankly among themselves. Let me throw out another model. I live in a reasonably affluent area in Florida (bad state for malpractice insurance but otherwise nice place to live – no income tax among other things). My area – coastal NE Florida – has grown like “topsy” in the last decade. For every 20 doctors who have moved in – there are about 19 doing cosmetic work (some are board certified – some aren’t – but who cares – most patients don’t seem to). And only 1 doing anything that has to do with primary care and real medicine – especially when it comes to specialties that deal with aging (e.g., there are 5 rheumatologists serving a population of over a million in the metro area – and 2 are at Mayo).

How about setting up a concierge practice? No third party payers. I don’t know if 2000 patients is an ok number of patients. It’s been mentioned above so let’s say it is. Charge each patient $1000/year for certain basic services (like an annual comprehensive checkup – a less comprehensive midyear – one or two short little deal emergency visits – like I cut myself and need a tetanus booster). Anyway – you get the drift. And that’s $2 million a year gross. Enough to get a decent office – hire the 2 necessary people (the phone/paperwork person and the PA type person) – and have a nice take-home income.

From my patient’s POV – it has become harder and harder to find a good primary care doc these days – and it will only get harder in the future. And $1000/year is less than most people – affluent or not – spend on cable TV and iPhones. Heck – a cosmetic doc won’t even sneer at you unless you look like at least $3000 walking through the door. Put the $1000 on a credit card monthly – which is $83.34/month. Like a cable bill.

Anyway – as my generation starts to go on Medicare (I’m 62) – it will be harder and harder for us to find good primary care docs (or any primary care docs at all). And unless the economy ruins all of us – I think there are enough of us willing to spend a few dollars to get decent primary care – care where our doctors get paid paid more than the guys who mow our lawns. And we don’t have to wait in crowded waiting rooms with huddled sniffling masses in flu season waiting for our 10 minutes with the doctor.

IOW – it’s back to the old days – like when I was growing up. You saw your family doc – he presented a bill. You paid. Only difference is in a concierge practice – you are basically “on retainer”. Want to know how different things were back then? When I was a kid – I lived in a middle class suburb In New Jersey – and family doctors had their offices in the “basements” of their side-to-side split level homes.

FWIW – I opened my own law office when I was about 24 – and my husband opened his when he was in his early 30’s. He supported me until I got off the ground – and then I returned the favor for him.

Even if my concept falls flat on its face in a particular case – what do you have to lose when you’re relatively young (which is – realistically – the only time you’ll be willing to take a risk like this)?

BTW – my new family doc (have had her for about 3 years since my old family doc retired due to illness) -has said she will “grandfather” in me and my husband (and other existing patients) when we go on Medicare. But she won’t accept any new Medicare patients. And I reckon if the government passes rules that say – if you see one – you have to see them all – she will go to a concierge practice – and I will gladly pay her whatever she charges for her services. Robyn

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Çilingir

October 26th, 2009 at 10:03 am

Deferring education and counseling to other providers may have the unintended consequence of adding in obstacles between the doctor and patient forming a strong relationship with each other. Perhaps for some overworked MDs, this is desirable.

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Bitkisel

October 26th, 2009 at 10:04 am

I have fewer patients using ER/urgent care centers and fewer admissions, as I can see a patient daily in the office, if needed. I also directly admit patient to the hospital, such as the hot gallbladder or the acute appendicitis patients, each who I admitted a couple of weeks ago. I can take care of most CHF/Pneumonia patients as an outpatient. 98% of my revenue is from my office practice, where I have reasonable input and control without too much insurance or any hospital interference.

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anonymous

October 31st, 2009 at 8:26 am

to robyn
great idea to start concierge practice. but ime, it is difficult to get 2000 patients to cough up $1000, unless you already have existing patients that you have a great relationship with. to get 2000 patients who can and will pay, you would need to practice in the area for quite some time. and unfortunately this ‘retainer’ fee is frequently the first thing to go when tough times hit. it can be tough to cultivate patients to join your practice if you can’t take any new ones at the time you are talking to them.

the challenge for young docs is that a lot of them have hundreds of thousands in loans that demand attention immediately and create a fear of taking on more business loans to get started (age 29-32 ish rather than 24 in your case, starting a new family etc), esp in the current medical environment (you might argue that makes it easier to take on the risks, but a lot of people in medicine are fairly risk averse). they don’t know beans about running a practice and still have to learn that and prepare for specialty certification testing simultaneously. imo, that is best learned in someone else’s practice–billing, hr, practice management issues, negotiation with insurance (malpractice at least, possibly health insurances), compliance, reporting, emr, malpractice issues, technology issues, ie phone/voice mail, night services, hospital policies, meeting new docs so you have a network you trust to refer to, personal practice style, possibly clia and osha, etc in the first few years. after you pass those first few years, then you are into middle age and it is too late to take those risks.

being a small business owner, you know billing for 2 mil does not equal receipts of 2 mil. it might be that in a carefully selected population you could bounce out the 15-20% that didn’t pay fairly quickly, but that takes time. people say they are willing until it comes time to write the check. lastly, i think people in medicine have a hard time turning off their altruistic gene and refusing patients they like for economic reasons.

i’m doing okay (not in primary care) but 50% of my patients don’t pay anything. i don’t give them worse treatment, but if i were more financially driven i could make my life a lot easier by not seeing them. unfortunately some of these guys have got used to not paying anything and now expect free health care.
but robyn- i tell you what.

if you can gather 2000 of your friends who are willing to cough up $1000/year, i’m sure my wife (primary care doc) would be happy to move to florida. i would be happy to retire. maybe motivated patients could hire physicians that way. sort of forming your own health care cooperative–i would suggest hiring two part timers to make sure there was vacation coverage and in case someone quit you wouldn’t be left in the cold. if you really had $2mil (gross) to work with, you could definitely find at least 2 and maybe 3 no problemo.

anyways thanks for sharing thoughts from a patient perspective.

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