Thursday, April 29, 2010

Doctor Or Administrative Assistant?

It is currently estimated that by 2025 there will be a shortage of nearly 46,000 primary care physicians in the United States.  This is of critical importance, considering that 32 million more Americans will receive health insurance coverage under the new Patient Protection and Accountable Care Act (PPACA), and they will need physicians to provide their care.

Primary care (family medicine, general internal medicine and general pediatrics) comprises the specialties that provide preventive and wellness care to avoid future illnesses and that deal with undifferentiated complaints and help determine the best approaches to diagnosis and treatment.  It's not that other specialties don't do that to some extend, but it is the foundation of what primary care physicians do.  Health care systems that are strong in primary care tend to provide better care for less cost.

It is even more concerning, then, that so few United States medical students are interested in primary care careers.  This article in the New England Journal, and this associated commentary from the New York Times, show some of the reasons for this

The article shows that this practice's physicians saw an average of 18 patients per day.  This is what most of us went to medical school for: to provide care for patients.  Beyond that, though, physicians handled nearly 24 phone calls daily, 20 lab reports, 17 e-mails, 12 refill requests, 11 imaging reports and 14 consultation reports.  This is also appropriate (mostly) because these directly affect patient care.  (I say mostly because a large portion of the phone calls involve insurance company authorizations, etc).

The problem: administrative and paperwork requirements far outweigh the patient care.  For the 18 visits, there were nearly 100 other tasks to be accomplished.  An even greater problem: physicians are not paid for those 100 non-patient-care tasks.  So, in this practice the non-reimbursed services outweighed the income-generating services by 5:1.

I suspect most physicians did not enter medicine to make a lot of money.  There are other better, easier, more lucrative careers IF one is only seeking higher incomes.  However, medical practices cannot stay open to provide medical care if they cannot pay the bills.

We desperately need to bring medical students into primary care careers, and there are many ways to do this.  However, we also need to fundamentally change the way that health care is provided and reimbursed.  Articles like those noted above show some of the challenges; now we need to look for solutions.

We need to return focus on the patient, on the heart of what makes medicine such a challenging and rewarding profession.  We need to find ways to de-emphasize these non-clinical tasks OR we need to decide that these tasks are necessary to provide care and we should reimburse for them.  Health care delivery models such as the patient-centered medical home (PCMH) would account for this and allow for reimbursement of asynchronous care (care when the patient is not directly in the office).

Whether with the PCMH or another innovative model of care, we must reinvigorate our nation's primary care workforce--both to make the PPACA successful, but also for the better health of all.

No comments: