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Reinventing The Primary Care Workday

May 12th, 2010

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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1 Response to “Reinventing The Primary Care Workday”

  1. BGladd Says:

    Nice post.

    I went to an Elder Law attorney for consultation and then work on establishing legal guardianship over my dementia-addled dad. The one hour initial consult was $300. The entire guardianship deal set me back about $4,000.

    A physician is supposed to assess your situation and decide upon a course of treatment in ~20 minutes, taking in voluminous data and analyzing them for accurate diagnosis and remediation. And then hope he or she will get the eighty bucks or so reimbursement in timely fashion.


    I am now doing workflow analytics for primary care within the new ARRA / HITECH Regional Extension Centers program. Trying to “Lean Up” outpatient practices so they can pare down the puny 20 minutes even more (or at least increase the doc-pt face time within the std visit).


    Who adds more value to humanity, physician or lawyer?

    Asked and Answered.

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