Dr.Reece’s Pieces, May 2, 2010

Key Words – electronic medical records, uncompensated care, medical errors, reducing variation, physician performance, best practices, physician emails and phone calls, Medicare, Medicaid, sustainable growth rate, physician shortage, primary care. Physicians Foundation, American Association of Medical Colleges, Massachusetts health plan

Daily Report – An EHR study of a small practice documents that primary care doctors spend an inordinate amount of time on non-reimbursable paperwork and non-clinical activities. Perhaps doctors should be compensated for these activities. A Physician Foundation national survey of 300,000 primary care doctors indicates doctors are unhappy campers and are either bailing out or not entering primary care. Who is going to care for those 34 million newly insured and those 13,000 babyboomers each day entering Medicare in 2011? Something must be done – and soon to care for these folks.


HERE”S WHAT PRIMARY CARE DOCTORS DO ALL DAY, AS DOCUMENTED BY ELECTRONIC MEDICAL RECORDS. Wall Street Journal Health Blog, New England Journal of Medicine, - It must be true. EMRs say so. Doctors spend an inordinate amount of time not seeing patients, and on non-revenue producing activities. The patient-doctor encounter is never over, in other words, until the paperwork is done. You can think of EMRS in many ways. Positively, as a tool for cutting medical errors, reducing care variation, providing best practice information, judging physician performance. Negatively, as poor investments, unwelcome distractions, impersonal barriers between doctors and patients, poor vehicles for communicating with patients, other doctors, or hospitals, or recording patient progress. But say what you will. EMRs are wonderful for documenting what doctors actually do. Ask Richard Baron, MD, an internist in a small group in Philadelphia. Using electronic health records, he documented exactly how many phone calls, emails, prescription refills and lab reports he and his colleagues handled during an average day in 2008. Published in the New England Journal of Medicine, his analysis gives a peek into the “invisible” work not involving a patient visit. Here’s a breakdown of the metrics per doctor, per day:

• 23.7 telephone calls, most of which the doc handled directly

• 16.8 emails, most for interpreting test results

• 12.1 prescription refills, not including those part of a patient visit

• 19.5 lab reports

• 11.1 imaging reports

• 13.9 consult reports

At Baron’s practice, these results prompted the hiring of a registered nurse to do “information triage” and inclusion of emails and phone time in the productivity calculation in the practice’s compensation system, among other changes.
Dr. Richard Baron, the study's author, "said his practice, like many U.S. practices, is paid via a patchwork of Medicaid, Medicare -- the U.S. government health insurance plans for the poor, disabled and elderly -- as well as private insurance. Electronic health records have helped but his office still employs four medical assistants, five front-desk staff, a business manager, a billing manager, a health educator and two full-time clerical staff. … Currently doctors are usually reimbursed only for a patient visit, but Baron does not advocate being paid per phone call or per prescription. Instead, how about an annual fee per patient, asks Baron" (Fox, 4/28).

And how about a “management “ fee based on the number of patients on the practices’ rolls? That is the way primary care doctors are compensated in some European countries.

UNCOMPENSATED CARE ISN’T THE ONLY THING BUGGING DOCTORS, IT IS HOW WE ARE GOING TO FIND ENOUGH DOCTORS TO CARE FOR THOSE 34 MILLION NEWLY INSURED AND HOW DOES CONGRESS PROPOSE TO PAY THE DOCTORS, The PhysiciansFoundation. Org. Here, expressing that point of view, is an Op-ED piece Louis J. Goodman, PhD, President, The Physicians Foundation and Timothy B. Norbeck, Executive Director, The Physicians Foundation, that appeared in multiple national newspapers – including the Tampa Tribune, The Chicago Sun Times, Newsday, and the Atlanta Constitution. The OP-ED is entitled, “The Newly Insured, Who Will Care for Them?

“Now that the health care bill has passed and the smoke has cleared from the acrimonious debate—if only for a little while—it seems appropriate to reflect on what has happened and how this significant legislation will impact our health care system.”

“We don’t know of anyone who would oppose, on moral grounds, insuring everyone, and that includes us at the Physicians Foundation (PF). Some have argued, however, that the overall cost of the legislation may be prohibitive. While that argument goes beyond our expertise, we do believe that there is an important and relevant issue that has been ignored in this debate. “

“Many groups and think tanks seem to agree that there is a present shortage of practicing physicians in the United States, especially those in primary care. These same entities, including the Association of American Medical Colleges (AAMC), point to what they envision as serious shortages amounting to as many as 100,000 physicians over the next ten or fifteen years.”

“The Physicians Foundation is a 501(c)(3) organization created in 2003 to help physicians, in an increasingly difficult practice environment, to continue delivering high quality health care to their patients. The physician shortage is a huge concern to us—and its effect on patients and physicians alike.”

“In 2008, the PF, in collaboration with Merritt Hawkins & Associates, undertook a comprehensive survey of all primary care physicians in the U.S. The results were rather dramatic and considerably distressing about the difficulties they are encountering in sustaining their medical practices. What was also very telling and relevant to the discussion on the physician work force were the following:”

“• 63% said that increasing paperwork has caused them to spend less time per patient, and

• 76% said they were either at “full capacity” or are “overextended and overwhelmed,” and

• Less than 6% of physicians assessed their colleagues’ morale as positive and 78% reported that over the past five years the practice of medicine has become less satisfying.”

“Because of these factors, 49% of physicians reported over the next one to three years their intention to reduce the number of patients they see or to stop seeing patients entirely due to retirement, working part-time or by seeking non-medical jobs.”

“The entire survey may be found on the PF website (www.physiciansfoundation.org). It is also available in a new book entitled: In Their Own Words, published by Morgan James. In it, physicians explain that the difficulty working with managed care organizations, liability insurance/ defensive medicine, non-clinical paperwork, increasing demands on their time, onerous government rules and regulations, declining reimbursements at a time when their practice costs are escalating and a shortage of primary care physicians are growing impediments to the delivery of patient care in their practice environment. In view of the influx of 30 million more insured patients into our health care system, the above findings are sobering to say the least! How will there be enough doctors available to take care of everyone?”

“For the past 25 years, the number of physicians completing training in the U.S. has remained flat at about 24,000 per year. During that time, a handful of new medical schools have been added, and enrollment is gradually increasing. AAMC has initiated a plan to grow medical school enrollment by 30% by 2015, but that won’t help unless the number of medical residencies available for them, now fixed by law, is increased as well.”

“To its credit, Massachusetts attempted to insure all of its residents in 2006. According to the Massachusetts Medical Society (MMS), the Bay State is now suffering a “critical shortage” of primary care physicians.” Not surprising to anyone, however, is that expanded insurance coverage for everyone—regardless of its noble objective—has caused an increase in demand for medical services. But there hasn’t been a corresponding increase in the number of doctors to treat them. Many Massachusetts residents now have the insurance coverage but can’t find a physician. The MMS also found in its 2009 survey that 56% of Massachusetts physicians in internal medicine are not accepting new patients. And new patients who are fortunate enough to secure an appointment with a primary care doctor have an average waiting time of 44 days!”

“It is obvious that the U.S. physician work force and medical residencies available must be increased—and rather quickly---in order for physicians to cope successfully with 30 million new patients. Washington heretofore has basically ignored an issue that will greatly impact patient care and which must be addressed now. As noted in Shakespeare’s “Henry Vl”, “Delays have dangerous ends.”