September 16, 2022
Dear Interested Readers,
Rethinking How We Deliver Care
In last week’s letter, I tried to describe the disappointments and controversies currently associated with ACOs. Like a serialized Netflix presentation I want to begin by reviewing how that letter ended. The last paragraph read:
Finally, ACOs can’t succeed without a vigorous process of continuous improvement that mines the experience of clinicians and integrates that knowledge with data about the population being served. It is rare to see effective integration between what clinicians and frontline healthcare professionals know that needs to be improved and the data about the populations they serve and the effectiveness of their system of care. ACOs were never going to be a success by just doing less and providing everyone with access to a system that is making no effort to improve. No system of finance or conceptual framework for the organization of care will ever deliver patient-centered, safe, equitable, timely, efficient, and effective care without the participation of practicing healthcare professionals in the work of solving the problems associated with the care of populations. The fundamental idea behind ACOs isn’t the problem. The problem is one of vision and understanding. Peter [Kriff] had the right idea. He knew that for ACOs to be successful clinicians needed to understand why we get unacceptable results with unacceptable variation for an unacceptable expense and realize that they were the only solution and accept the challenge of achieving the Triple Aim. I still believe that ACOs are the most likely path to a better system of care.
As a centering exercise and for continuity of thought, I need to go back once again to Dr. Robert Ebert’s insight from 1965:
“The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”
When I think about today’s healthcare challenges I always return to the reality that things will not change until healthcare professionals, especially physicians, accept the responsibility for improving the “conceptual framework and operating system” of care delivery. How we deliver care, through a process that has not changed much in the last two hundred years, is a root cause problem that affects the cost, quality, safety, equity, timeliness, and efficiency of care.
My great great great great grandfather, Dr. Ebenezer Childs, practiced medicine in Shelburne Falls, Massachusetts in the early 1800s. He saw patients one at a time fee-for-service. His office records suggest that was often paid in kind or not at all. My great grandfather, Dr. Cato Baxter Wiseman, was the only doctor in Rutherford County, North Carolina in the early 1900s. The only change in the care delivery model between my great grandfather’s practice in North Carolina and Dr. Childs’ practice in Massachusetts over one hundred years earlier was that my great grandfather made his house calls in a car and not a buggy. He owned the first car in the county. One hundred years later the biggest change in care in many rural areas is that most patients come to the office. The delivery of primary care for many Americans has not changed much in two centuries. The failures of our current methods of delivering care are the primary drivers of why patients often feel our concerns are centered on our own needs and their needs are a secondary concern.
Structural changes in the processes of care delivery will be required if our patients are ever going to feel that the activity is centered on them and their needs and not focused on the primary needs of the system. The truth behind Dr. Ebert’s profound observation is that until we come up with a better delivery model and a more appropriate finance methodology we will not develop care processes that will provide optimally for the health needs of the population.
I discovered Dr. Ebert’s pronouncement in 2008 when I was given access to his papers at the Countway Library at Harvard Medical School by Barbara Ebert, Dr. Ebert’s widow. By that time I had felt for a long time that our method of care delivery was inadequate and unsustainable. Reading Dr. Ebert’s words was like finding the balm of Gilead. Dr. Ebert’s analysis was buried in a letter he had written to the president of the Commonwealth Fund. At the time he wrote the letter, he was seeking financial support for the launch of the Harvard Community Health Plan (HCHP) which would be his very successful attempt to demonstrate that care delivery and outcomes could be improved by a better operating system and finance mechanism.
I am actually happy that the time is approaching when it will be obvious to the majority of practitioners that our current system of care is unsustainable and that sooner or later we will have no other option than to change how we practice because how we practice is damaging caregivers and is more frequently denying patients the care they need. Change is inevitable because within the current model of care workforce issues currently limit the services we can provide and practically limit the number of patients we can safely serve.
Even now, the pandemic has forced us to recognize that we can’t equitably serve the entire population. Because of workforce issues, it is obvious that just throwing money at the problem will not yield the outcome we desire in an acceptable amount of time. Ebert knew that money and resources were not the answer in 1965. He said: The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money.
It is obvious that we are approaching a moment that demands change, whether we desire it or not. If the system continues to function in its usual way, we will not be able to provide services and acceptable care for all the people who currently have coverage that theoretically grants them access to care. The pandemic was a preview of what is to come. The situation would be worse if we needed to offer appointments to the ten percent of the population who are currently uncovered because we passed some new policy of universal access like Medicare For All. The future will be difficult. The longer it takes for us to recognize that systems changes are required, the greater the problem will become.
You may not be touched by the access problem if you have a long-standing relationship with a hard-working clinician in an excellent system of care like Kaiser. In a system like Kaiser’s or in the one Dr. Ebert tried to build, there are programs of chronic disease management, patient education, and outreach for routine testing and follow-up that free physicians to give more time to direct patient contact. An environment like Kaiser’s is a recruiting asset. Kaiser is the exception and not the rule in American medicine today. If you move to where I live or to almost any other rural area in America, you will have trouble finding a PCP. On the National Rural Health Association website we read:
The obstacles faced by health care providers and patients in rural areas are vastly different than those in urban areas. Economic factors, cultural and social differences, educational shortcomings, lack of recognition by legislators and the sheer isolation of living in remote areas all conspire to create health care disparities and impede rural Americans in their struggle to lead normal, healthy lives.
Workforce Shortage Problems
- Ease of access to a physician is greater in urban areas. The patient-to- primary care physician ratio in rural areas is only 39.8 physicians per 100,000 people, compared to 53.3 physicians per 100,000 in urban areas. This uneven distribution of physicians has an impact on the health of the population.[2]
- There are 30 generalist dentists per 100,000 residents in urban areas versus 22 per 100,000 in rural areas.[3]
Saying that things are better in urban America is not saying much. Let’s do the numbers. 53.3 physicians per 100,000 patients suggests panel sizes that average 1,887. If you only have 39.8 physicians per 100,000 patients you have average patient panels of 2,513 and every day will be difficult for the healthcare professionals and patients.
In our organization, we discovered that problems developed for clinicians and patients within the usual system of care as adult primary care panel sizes approached 2000. In pediatrics, the breaking point was lower at around 1400 patients. I doubt that the experience of care is always acceptable in a panel of 1500 to 1800 if the population includes a significant number of older patients or patients who require extra attention to adequately manage their chronic diseases. Even if we could put every adult into a practice of less than 1800 and every child into the practice of a system that limited the panels of pediatricians to 1400, numbers that are currently acceptable, the solution would not be sustainable because the number of working physicians is declining at a rate that is faster than we are producing replacements.
We have an old physician workforce. According to a recent survey, the average physician age is 53. The average age in “general medicine” is 58. Even the AMA agrees that we have a problem that is only going to get worse. Primary care is not the only problem. There is a very serious deficit of general surgeons and concerns about rural shortages in many specialties like dermatology. In a recent AMA publication entitled “Doctor shortages are here—and they’ll get worse if we don’t act fast,” the author Andis Robeznieks writes:
“Because it can take up to a decade to properly educate and train a physician, we need to take action now to ensure we have enough physicians to meet the needs of tomorrow,” AMA President Gerald E. Harmon, MD, wrote in a recent Leadership Viewpoints column. “The health of our nation depends on it.”
The U.S. faces a projected shortage of between 37,800 and 124,000 physicians within 12 years, according to The Complexities of Physician Supply and Demand: Projections From 2019 to 2034 (PDF), a report released by the Association of American Medical Colleges (AAMC).
Specific AAMC projections by 2034 include shortages of:
- Between 17,800 and 48,000 primary care physicians .
- Between 21,000 and 77,100 non-primary care physicians.
This includes shortages of:
- Between 15,800 and 30,200 for surgical specialties.
- Between 3,800 and 13,400 for medical specialties.
- Between 10,300 and 35,600 for other specialties.
The numbers are scary. The first response seems to be to better utilize “physician extenders” or if you prefer “mid-level clinicians” or “advanced practice clinicians (APCs)”– NPs and PAs. HCHP piloted the use of APCs in the early 70s. Throughout my entire practice career, I shared my practice with an APC “practice partner.” I was lucky to have very long-term partnerships. In 33 years I just had two partners, an NP first and then a PA. Both were outstanding clinicians. Substituting more midlevel clinicians will help access, and improve care, but it is likely not the solution to the larger workforce and access problems.
I now see an NP for my routine annual care and use Epic’s “My Chart” function to communicate with my providers, but there is a continuing controversy over whether or not we have enough mid-level clinicians to take up the slack created by the looming physician shortages. In an essay by a PA entitled “Are We Overproducing NPs and PAs?” the author reminds us that we are experiencing doctor shortages now because from the late seventies until the nineties we failed to increase our “production” of doctors because we feared overproducing doctors! PAs and NPs are critical to the future of care and he advises that we not make the same mistake again. How many NPs and PAs we should produce and how to properly train them, how much practice autonomy to grant them, and how to most effectively use them remain questions that don’t have consensus answers so that there is tremendous variability in how they are empowered and deployed.
In a September 2022 Medical Economics report on the looming concerns about understaffing in primary care the concept of augmenting the declining numbers of doctors in primary care with midlevel clinicians is given significant consideration. The author, Todd Shryock, writes:
Nurse practitioners and physician assistants keep taking on more primary care responsibilities, often without supervision of a doctor
Who is in charge of primary care?
Many primary care physicians might say they are. After all, they have spent years building relationships with patients, sometimes treating multiple generations of the same family and learning as much about their private life as their medical history during office visits. Who better to give a diagnosis than someone who knows not only the patient’s ailments but where and how they live, and what nonmedical factors might be affecting their overall health?
But other primary care doctors know this nostalgic view of patient care is heading the way of house calls and the little black bag. Gone are leisurely discussions with patients aimed at pinpointing root causes of health issues. Now, there are corporate RVU goals, patient quotas and productivity spreadsheets. Time for patients is spent instead with electronic health record screens, administrative paperwork and computer systems that often cannot communicate across departments, let alone across the street.
To make matters worse, there simply are not enough primary care physicians.
The article reviews the evolving shortages and references articles and opinions similar to those that I have presented to you from the AMA, the AAMC, and the federal government’s Health Resources and Services Administration. Everyone agrees that we have a problem. It is my opinion that we have a problem within the problem. As physician organizations and health systems fail to assume responsibility for resolving the problem of access to primary care, consumers and entrepreneurs are moving into the void with solutions that may address immediate access issues, but these developments may not be the best long-term strategies to improve the health of the nation in a manner envisioned by the Triple Aim. The article continues:
The result, predictably, is that the patient loses. Monthlong waits to see a primary care physician, rushed appointments, increasing costs taking money out of patient paychecks, and rising copays add up to frustration with the health care system.
Patients want a quick appointment to find out whether their case of the sniffles is anything to worry about; they do not want to be told they cannot see a doctor soon because they are caught up in the macroeconomics of the country’s inefficient health care system.
So, what happens? The patient takes charge. “Patient” is just a medical term for “consumer,” and today’s consumer does not want to wait…
This demand is driving retailers like CVS and Walmart to get into the primary care game by opening clinics. The consumer wants medical care without a wait, and big corporations and private equity see an opportunity. Inevitably, someone will fill the gaps created by the shortage of primary care physicians.
So, who is in charge of primary care? The consumer, and that has led to a surge of nonphysicians willing to provide such care, often with little or no supervision from doctors thanks to increasing public pressure on legislatures to act…
From there the article goes on to give a pretty good analysis of the evolution of mid-level clinicians and the concerns raised by using them to augment the declining numbers of doctors.
The first step that needs to be taken is that there needs to be a broader and deeper concern that we have a problem that will be hard to solve, deserves immediate attention, and will not resolve itself. Workforce issues and supply chain issues are growing concerns across every industry in our economy. I do hear people saying that we need more nurses. I don’t hear as much concern addressed to the access problem in primary care. In a way, it feels like global warming. We all know that the weather is worse, but we keep talking about the problem as if global warming is a future concern. Workforce issues in medicine should be treated like an active forest fire and not a distant concern like when the rising oceans will begin to make New York and Miami more like Venice. Access to primary care should be a huge current concern.
A 2019 JAMA Network article revealed falling percentages of patients with a PCP between 2002 and 2015. Only 75% of Americans had a PCP in 2015. The percentage of Americans under 30 with a PCP was only 64%. Those numbers suggest a failing system of care. Bringing the problem close to my home, Dartmouth Health recently announced that it had no primary care practices in its core region that were accepting new patients. The “freeze” is unlikely to last long, although the fact that it occurred at all underlines the significant workforce problems of today. If ignored, those problems can only be worse in the future. Dartmouth’s chief clinical officer tried to explain the situation:
“Right now, we are taking a pause on scheduling new appointments,” Dr. Ed Merrens, Dartmouth Health’s chief clinical officer, said in a Friday interview.
Merrens said the pause was necessary for several reasons, including an increase in demand from new residents who have recently moved to the Upper Valley and the workforce shortage that has worsened amid the COVID-19 pandemic. He also said that Dartmouth Hitchcock care teams are working through a backlog of patients who may have delayed care earlier in the pandemic.
In addition to recruiting more primary care physicians, DH also is seeking medical assistants, licensed nursing assistants and nurses for primary care, Merrens said. Health care providers have more options in terms of the type of work they do, he said. For example, some are choosing to provide telemedicine, he said. He also said patients want to be able to communicate with their care team in different ways, through in-person appointments, as well as texting, messaging and talking on the phone.
Where do we go from here? It seems unlikely that we will ever “produce’ enough MDs to staff our current model of care where we try to manage a mix of complex chronic problems and preventative care with one-on-one office encounters with a doctor or a midlevel clinician. The percentage of Americans who have a PCP that provides them adequate preventative and chronic care will continue to slide in a geometric fashion as more clinicians suffer burnout or retire.
Could it be that we are misusing our MDs, NPs, and PAs? It has long been my opinion that rather than continuing efforts to staff a model of care that has never delivered optimal results, we should take the current crisis in access as an opportunity to recognize that we could redesign healthcare to better leverage the professional assets that we have and can be expected to have.
The core strategic concept in the book Moneyball was that in a nine-inning baseball game each team got 27 outs. The insight was that none of those outs should be wasted. In an office practice, it is not unusual to have a dozen or more patients scheduled in the morning and then again in the afternoon. Before the day starts, the doctor is set up for a disaster. To survive, many doctors have learned to pad their schedules with follow-up appointments that are the equivalent of “wasting outs.” They catch their breath as they review recent lab tests with patients or do other “follow-ups” that could be managed just as well without the use of one of those valuable appointments. Access is a function of the number of clinicians times as many appointments as can be scheduled. With the realities of the limits of human endurance could we change the system so that the doctor sees the patients with problems that a doctor needs to see and use other health professionals to perform many of the tasks that a doctor does in a fee-for-service system? Could we design a care model that patients like where a doctor could be supported by several mid-levels and other medical professionals including social workers, community workers, patient liaisons, and other providers of the immediate access patients need to manage a panel of 5,000, 7,000, or even 10,000 patients? No matter what we do, we need to be wise in the way we use our scarce caregiver resources.
One of the biggest “wrong turns” of the last 25 years has been the evolution of “concierge practices.” I can’t imagine a model of care that has less equity. Practice sizes are often limited to a few hundred patients who are willing to pay more for the access they want. I can’t imagine being a concierge physician and should avoid further descriptions of my many ethical objections to the model. I would rather think about a redesign of the system for true equity with attention to the patient, and better safety, efficiency, effectiveness, and timeliness of care.
Redesigning the care model was what Dr. Ebert was hinting at when he suggested that the answer to healthcare’s deficiencies was not some combination of more personnel, more facilities and more money. He said that healthcare problems could only be solved by a system change. He alluded to organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.” A sustainable, better, more effective, and more just system of care was his objective. He launched HCHP in 1969 and referred to it as the equivalent of a “moonshot.” It is time to return to the moon, and time to return to serious widespread efforts to redesign our approach to ensuring the health of the nation.
The pandemic demonstrated that a system that was financed by fee-for-service payment for office visits, tests, and elective operations is vulnerable to failure and can not reliably meet the health needs of the nation during a pandemic. Value-based payment is in evolution. ACOs are a step in the right direction, but in time finance could track back to something more obviously like capitation or payment for the care of a population, but with guardrails to insure that quality was not compromised, care was not denied, and that patients were satisfied with their access and the attention given to their concerns.
My final opinion is that whatever evolves, the solution will require physicians to be more actively involved than they have wanted to be up till now. I know that the last thing a tried doctor wants to do is to go to a meeting to work on a plan to evolve a better way to organize and deliver care, but leaving the work to policy wonks and politicians who have never assumed the care of an individual has less likelihood of delivering an improved delivery system than an infinite number of monkies with typewriters producing something like Shakespeare’s Hamlet.
One advantage that we now have as we approach a vigorous redesign of healthcare is that there are far fewer physicians in solo or small group practices. Consolidation has occurred but without its advertised financial dividends and without an improvement in healthcare provider workplace issues. If anything, burnout is a systems problem. It is my hope that physicians will come to realize that the flip side of burnout is poor access and outcomes for their patients. Progress on one problem could theoretically yield progress on both. What is certain is that a failure to address the access problems will only make the burnout and workforce problems worse as patients suffer and seek to find their own solutions to a critical problem.
A Citizen’s Duty
It was drizzling off and on when I snapped the picture that is today’s header. I liked the scene of last-minute campaigners trying to win votes for their favorite candidates. The campaigners are congregated just outside our municipal building which houses the police station and an assembly hall that doubles as our polling location. Most of the enthusiasm and drama was in the Republican primary where MAGA candidates faced more traditional Republicans for a chance to unseat Maggie Hassan, one of our two Democratic senators, and our two Democratic congressional representatives.
Our moderate Republican governor easily won renomination and tried to use his endorsement to help more moderate Republicans win the nominations for the two House seats and the Senate seat. He failed in that objective. I do have to give him some credit because earlier this year he opposed and vetoed attempts by the Republican state legislature to gerrymander our congressional districts to assure at least one Republican victory. Despite that act of decency, my vote for governor in November will go to Dr. Tom Sherman who is a state senator and a practicing gastroenterologist. I am disappointed to report that the pundits say that Dr. Sherman is unlikely to win against our popular governor who is from a very politically powerful family.
Tuesday was the last day for state primaries in the 2022 midterm elections. Rhode Island and Delaware finished neck and neck with New Hampshire. It occurred to me that New Hampshire is fighting hard against other states to maintain its “first in the nation” presidential primary, but seems quite comfortable being last in the nation for the off-year primaries. The last month has been dreadful as non-stop attack ads from both parties appear every time you try to watch television. I expect that is going to get even worse over the next two months.
I am dreading a fall full of political ads, but I am looking forward to the fall foliage. As the days get shorter and cooler, I have regrets for not fishing or sailing more this summer, but it was a very full summer of walking, biking, and swimming. We had several wonderful family visits that included the chance to do a little sailing with all three of my grandchildren. The days fly by and the benefit of that reality is that before we know it summer will return! Enjoy the fall and turn off all the election ads.
Be well,
Gene
