Wednesday, April 28, 2010

The Busywork Burden of Primary Care Physicians: A Review and What Population-Based Care Management Organizations Already Know

Everyone knows primary care physicians are a legitmately grumpy and depressed lot, but does it really come down to being overworked and not being paid well compared to their specialist colleagues? To get some better insight about what's really going on, check out the April 29 New England Journal article by primary care internist Richard Baron titled "What's Keeping Us So Busy in Primary Care? A Snap Shot from One Practice." The entire manuscript is available on line gratis. There's also this report in The New York Times with some additional interview tidbits.

Using an electronic record's patient encounter database from a five person community-based Philadelphia practice called Greenhouse Internists, Dr. Baron looked at how a typical doc's day gets filled:

24 patient phone calls per physician per day, with 80% of them handled personally and mostly involving medical advice, dealing with insurance issues or talking to other docs about patients.

17 emails per physician per day, mostly dealing with test results or patient inquiries.

12 prescription refills per physician per day outside of a face-to-face patient encounter.

20 lab reports per physician per day. If any are abnormal, they'd need to be attended to, often the same day.

11 imaging reports per patient per day.

14 outside physician consultation letters or notes per physician per day. If there are recommendations, they'd also need to be attended to.

By the DMCB's count, that's 98 paperwork events per day. Even if each took one to two minutes to accomplish (and it doesn't) that's about three hours that are not involved in patient care. It's also important to note that Greenhouse Internists is not a struggling physician-owned practice saddled with poor management. They have Level 3 NCQA PCC-PCMH recognition and are the smart guys behind this insightful 2005 Annals article Electronic Health Records: Just around the Corner? Or over the Cliff?

This snapshot is quite credible and the DMCB suspects most community-based primary care physicians will readily identify with the numbers described above.

What does this tell us?

Quality, Not Quantity: The actual paperwork is not necessarily mentally or physically taxing and the DMCB suspects Greenhouse has money coming in. Rather, it's the mismatch between professional work expectations and the reality of modern practice management. The DMCB can't blame docs for seeking alternatives outside of primary care and doubts more money alone is the answer

Don't Drink the Kool-Aid: While astonishingly disconnected utopians continue to promise that the electronic record and the patient centered medical home (see here and here) will fix all that ails primary care, note that Greenhouse already have both and still have to funnel busy work to the docs. Despite The Time's interview with the author saluting both the EHR and the PCMH, the DMCB notes that the workload described above was happening despite the EHR and PCMH.

Now You Know Why: Care management organizations, quality assurance mavens, non-physician administrators, managed care executives, pharmacy benefit managers, policymakers, politicians, C-Suite types, advocacy groups, electronic record vendors, regulators, academics and anyone else with a good idea that will take just a little bit of a physician's time may now appreciate why docs can be so resistant to taking on another task - no matter how small it is. This is death by a thousand cuts.

Successful disease and care management organizations painfully learned about the importance of physician attitudes long ago. They already know that, to succeed in this environment, their programs need to not only deliver outcomes for their sponsors, but unburden physicians as much as possible with a flexible service mentality. What's more, they're already at work learning to align themselves with the PCMH and EHR to take up even more slack. Their perspective is one of "all hands on deck."

The DMCB has seen disease management nurses aid physicians by getting to patients figure out what to do for themselves, independently communicate and interpret important lab results and run interference with their sponsoring health insurance companies. When done right, physician satisfaction surveys (for example here, here, and here) run counter to the canard that all docs routinely dislike disease management.

Afterall, it's easy to see why they like anything that can help them with 3 plus hours-a-day of busywork.

1 comment:

Phil 314 said...

Units of work aren't the problem, reimbursable units are.

Two broad comments with detail:
1)There's enough $$ in the system already. the problem is that hospitals and specialists take large pieces of the pie. PCP's in a different era felt phone calls, Rx refills were just part of practice. Now with less $$ in direct patient visits they struggle with that viewpoint. So the task at hand is to "take" money from hospitals (reducing bed days, reducing admissions) and specialists (more complex management in primary care, less specialty procedures)
2)Do physicians need to do the non-direct patient care activities. In an ideal system the "chronic disease management program" would manage the labs for the CHF, DM etc pts and only need physician sign-off. That begs a larger question: In the Medical Home is the physician the "captain of the ship" or just a "highly trained, key team member who is focused on direct patient care"?