Macro-Innovation Begins with More, Better Primary Care Physicians

Perspective by Terrell Benold, MD. Dr. Benold has practiced family medicine for over 25 years. He currently works at the Blackstock Family Health Center and is also a faculty member for the UT Austin Dell Medical School Family Medicine Residency Program.

Austin’s Mandate: To Change Healthcare

This is a heady time in Austin, Texas for those interested in the transformation of our healthcare system.  The leaders of our new medical school have enthusiastically embraced the challenge of creating a new and improved training program for young doctors – starting from the ground up with “innovation” as the guiding theme.  Perhaps more meaningful however is the second part of that mandate created by the voting taxpayers – to also model innovation in the way we change the delivery of healthcare to the people of Austin and Travis County.

So, the possibilities here have created excitement, not just in Austin but nationwide – and we have already attracted many of these most talented and energetic people from coast to coast.

Are We Informed Enough for Macro Innovation?

I see widespread agreement about the problems within our healthcare system, foremost by far being the unsustainable cost; I see many sincere people wanting to get started and to help; I see many appeals for ideas about how to innovate.  There’s a pretty consistent understanding of what needs to work better, but I sense that the path forward to how is not at all clear.  I offer then a perspective “from the trenches.”

First though, it must be said that our healthcare system’s problems are both massive and numerous.  Thinking of innovation in terms of new technology, etc. is fine, but this is generally “micro” innovation because a technology solution usually fixes one problem at a time.  A big exception is the need for development of an over-arching electronic records system, with connectivity between Ascension Seton and St. David’s and UT’s systems, etc. Our mandate however presents us a golden opportunity to model a true macrotransformation, a total reinvention of how healthcare works – if we are informed, and bold enough to actually try.

Too Few Generalists, Too Fragmented Specialists

Everyone knows that our physician manpower in the US is inverse of what it should be.  Most observers are already aware that the parts of the country with the highest quality of care outcomes are also the areas with the lowest costs of care – and are also the areas where there is a higher proportion of primary doctors to specialist physicians.  We have far, far too few well-trained generalists, and those we have are burning out rapidly. 

We’re left with extremely fragmented, expensive, and redundant care being delivered by specialists – seemingly, one for every individual problem that a patient has.  We have endocrinologists managing simple hypothyroidism and dermatologists treating mild acne and actinic keratoses.  Neurologists are inundated by headache sufferers, and gastroenterologists by patients with irritable bowel syndrome.  Orthopedic surgeons have backlogs of patients with simple degenerative arthritis and chronic back pain.  This is not the most appropriate or efficient use of their specialized training.

I recognize that often times these patients end up in a specialist’s office because they weren’t adequately managed by the PCP in the first place.  However, what I observe is usually not a lack of knowledge on the part of these doctors, but rather a lack of time.  They are in such a constant rush that they cannot possibly take the time to properly address multiple problems at once.  The fastest and easiest way out is to simply refer everything.

Of particular concern to me is the gradual transformation of what I’ve observed among Family Medicine residents over the years.  More and more, these idealistic young doctors are learning to play the hand they’re being dealt – figuring out how to fit into a system that is dysfunctional.  The arduous job of working daily to expand their disease management and procedural skills is discouraged by a system that only demands that they move patients with maximum speed.  Increasingly, students and residents in primary care are beginning to see their role in this dysfunctional system as one that largely serves to triage patients to specialty care. 

Thus, it is becoming a “self-fulfilling prophecy” of sorts, as primary care interns’ personal career ambitions are steadily lowered.  And, increasingly many are now choosing to abandon general practice in order to also sub-specialize, in areas within the realm of their training experiences.

“Can Someone Recommend a Good Endocrinologist?”

A friend of mine, employed in healthcare, sent out an email to her medical friends somewhat out of desperation:  “can someone recommend a good endocrinologist?”  I asked her why, and she said she was dizzy.  She’d been to the Emergency Room and they directed her to a cardiologist.  After an extensive negative workup she was told to see a neurologist.  After another extensive negative workup, it was suggested to her that she find an otolaryngologist and also an endocrinologist, because she might be hypoglycemic.  

I asked her to specify her symptoms:  she was not pre-syncopal, nor experiencing vertigo.  She was not ataxic.  Instead, she described what we refer to as lightheadedness – an extraordinarily common symptom that many human beings experience – and which is generally not associated with any organic disease whatsoever.  We in primary care see this on an almost daily basis.  Though we have yet to discover the pathophysiologic mechanism of this mind-body connection, we know it is real – and yet at the same time commonly stress-related.  I pointed this out to my friend, and she clearly and immediately saw the connection from her personal life at the moment.  She was reassured and her medical odyssey ended there.  This happens all the time.

How Do We Measure Physician Expertise, Anyway?

A colleague of mine used to quip that “specialists are an inch wide and a mile deep, and generalists a mile wide and an inch deep”.  He wasn’t trying to make any serious point by saying it, but this kind of general misconception is actually at the heart of our system’s problems.  Primary physicians aren’t a mile-wide and an inch deep; rather, they are more expert in common problems – as this story illustrates.  To not understand this leads logically to the next problem, which only fuels and justifies the previously outlined problem of specialist glut.  For if generalists are simply “an inch deep” in all things, then it mistakenly follows that any more advanced medical personnel could do this job, acting simply as triage agents / screeners.

Shortage of PCPs and Rise of Physician Extenders

We are experiencing the confluence of a severe shortage of primary doctors with a chronic undervaluing of their skills and experience as noted above.  The consequential outcome has arisen with extraordinary rapidity, including here in Austin:  physician extenders (nurse practitioners and physician assistants) being employed in their absence.  PA’s and NP’s are extremely valuable members of the healthcare team where they are utilized appropriately.  In specialty care offices, physician extenders can become highly trained in a very limited menu of diagnostic and therapeutic choices.  In these settings, there is typically a small set of tools used repeatedly and a very limited formulary of drugs and treatments to master.  This is especially true in offices where the physicians are more efficiently engaged in the performance of complex procedures requiring their advanced training.

However, asking a PA or NP to simply step in and deliver general primary care is the situation that is least appropriate for them.  And, the outcome again is much higher costs.  This is commonly observed:  lab testing, imaging, referrals, and prescribing are all inversely related to a doctor’s experience and to the amount of time he/she spends with a patient.

The bottom line is that what we are currently doing is 180 degrees in the wrong direction.  The tightening of outpatient physicians’ margins per patient encounter, coupled with the ever-growing hassles engendered by our chaotic health insurance systems has led these doctors to resort to “churning” – that is, the practice of seeing the same patients more and more frequently and for shorter visits.  The total number of patients cared for is the same – but the number of visits is higher, resulting in added charges.

A Wrench in the Mix: Bad Electronic Health Record System Design

Poorly designed EHR systems have tremendously compounded the problem and made the situation more desperate.  The outcome is burned out docs, very dissatisfied patients, unhappy staff and higher staff turnover, higher referral rates, higher rates of hospitalization, higher lab and xray utilization, and higher overall costs.

Solutions: Reimbursement Models Are Key, and Some Doctors Have Broken Free

Fortunately, some doctors have managed to break free of this self-defeating system in the same manner, but in different settings.  Studies have shown that lower cost, higher overall quality care outcomes, higher patient, staff, and physician satisfaction are ALL associated with models of care and reimbursement where there are deliberately fewer and longer office visits.  These doctors are encouraged to take the time to listen to their patients and teach them, comprehensively manage common problems themselves (including taking the time to do simple needed procedures themselves), organize/update patients’ medications, and coordinate informational exchanges with specialty consultants.  Email and electronic portals can be freely used for much more efficient care, without hurting the practice financially.

Concierge or “boutique” practices, though not broadly applicable to all settings of course, also do still reflect the basic high and efficient performance of these models.  And, the overwhelming success of these models has appropriately encouraged the push to reward “Value instead of Volume.”

In a similar fashion, corporations have directly contracted with primary care physician groups to great mutual benefit.  Specialty care needs are reduced and middle bureaucracies are bypassed.  Travis County, for its employees, has done something like this also.  With just two in-house Family Medicine physicians, trained here in Austin, they have cut health care costs dramatically.

Solutions: Improvement Starts at Home (and with a lot of Great PCPs)

It’s important to note that these improved practices didn’t come about from business or government bureaucracies.  They were partly aided by investment in academic research and partly aided from technological advances, but only to a minor degree.  If we’ve learned anything over these past decades of struggle, it’s that insurance companies and government cannot “manage” healthcare.  (This is in no way a political statement about payers of healthcare.)  They will presumably also be unable to parse out what constitutes “value” in the way its first steps are currently being attempted.

So, where do we start the process of macro-innovation, transforming into an exemplary new healthcare delivery system in Travis County?

  • Eschew the temptation to simply re-package silos of specialty care.
  • Don’t waste time and resources pursuing change for change’s sake, without having a clear understanding of its expected impact (especially regarding costs of care).
  • Go out and get as many well-trained primary care physicians as you can find.
  • Try hard to grow this number for the future with very significantly augmented primary care residency positions.
  • Encourage the acceptance of new payment models that will incentivize these doctors to take the time to do what they were trained to do, well.