Changing the way primary care physicians spend their time is key to improving primary care in the United States, Lawrence Casalino said a May 4 Health Affairs briefing. Video and slides from the briefing, held in conjunction with the release of the journal’s May issue “Reinventing Primary Care,” are now available on the Health Affairs Web site.

“I don’t think that things like the patient-centered medical home are going to do anything to solve the problems of primary care unless there is a fundamental transformation of the primary care workday, and that is going to require fundamentally changed payment systems,” said Casalino, Associate Professor of Public Health at Weil Cornell Medical College. He spoke about his paper in the May issue, “A Martian’s Prescription For Primary Care: Overhaul The Physician’s Workday.” Subsequent blogs will discuss other portions of the briefing.

Most primary care physicians see about 25 patients a day, Casalino said. A majority of these face-to-face visits are unnecessary, “but the only way to get paid is by doing these visits, so you just crank them out as fast as you can go.” He called this “hamster care” and said that every day during his twenty years of primary care practice was like “going to war.” As a primary care physician, you understand that things are not right, but you don’t have time to think about better approaches, “and even if you could it wouldn’t matter, because the way you are paid constrains what you can do.”

In an ideal world, physicians would see only about 8 to 10 patients a day face to face; they would spend the rest of their time “in email and phone communication with patients and their families, and other health care workers; coordinating care; thinking a little bit; and working with the practice staff to put all these nice patient-centered medical home concepts into action,” Casalino said. This transformation will only be possible if physicians are paid for these non-visit activities, but most current medical home demonstration projects “give little or no extra compensation for being a patient centered medical home. You still only get paid for the visits that you provide,” he pointed out. The patient-centered medical home “will not be a generalizable model in the United States unless the payment system is radically transformed.”

Casalino’s article suggests several possible payment reforms. At the briefing, he suggested that the crucial factor in drawing physicians into primary care was less how much primary care physicians are paid, and more what they are paid to do. “I personally don’t think that primary care physicians’ incomes need to be raised to the incomes of cardiologists for us to get an influx of primary care physicians. …. If the primary care physician workday were transformed in a way that it didn’t feel each day that you were just scrambling around, with constant interruptions, knowing all day, every day, that you’re actually not doing what you ought to do … then I think that at current primary care incomes, or not that much above, we’d have more people going into primary care.”

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