A Fundamental Asset in Health Care Valuing Family Physicians

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Value of Family Physicians page 2, Family physicians are invaluable assets in the health care system Paustian et al demonstrated a reduction of 26 37 PMPM. Focused on the whole patient as compared to subspecialists for practices participating in the Blue Cross Blue Shield of. who typically focus on a single organ system family physicians Michigan Physician Group Incentive Program 9. and other primary care physicians are the main clinicians who. manage and coordinate care throughout their patients lifetime Studies that do not find an overall decrease in costs do however . and often provide the initial pathway for patients to enter the point to cost savings in some patient segments For example . health care system Family physicians and the primary care they Higgins et al did not find a decrease in overall costs but did find. offer provide the continuity of care associated with positive health an 8 to 11 reduction in payments for the impairments in the 90th. outcomes and better ratings of health care quality 1 2 They are percentile for morbidity risk 15. often the only source of routine care in historically underserved The importance of family physicians to the health care system. populations 3 The continual care and communication they provide is clear They provide the main entry point into the health care. are key components to increased patient satisfaction which system manage care across all health conditions and provide. drives patients to continue preventive health care measures 4 5 the coordinated care that keeps patients satisfied and involved. Access to the services of family physicians leads to improvement in preventive care In return their services lead to a reduction in. in health care quality and patient quality of life while alleviating health care utilization and overall costs When family physicians. the high costs associated with chronic conditions especially in have a central leadership role within value based payment. a medical home setting 6 7 Studies of care delivered in a medical systems health care quality will improve and costs will decrease . home have shown increased composite scores for quality of care. and preventive measures delivered 8 9 including a 14 higher The Danger in a Family Physician Shortage. rate of diabetic control a 12 higher rate of effective cholesterol. management an 8 higher rate of breast cancer screening and Although the value of family physicians is clear the ongoing ability. a 6 higher rate of colorectal cancer screenings 7 In addition for patients to access family physicians is not so clear Although. patients satisfaction with health care access and quality of care results show that family physicians are sought most often by. received also increase in a medical home setting 10 11 Meanwhile patients in online searches there are an increasing number of. access to family medicine and primary care has been associated searches that end unfilled 16 More importantly access to family. with increases in preventive screening tests and decreases in physicians is projected to worsen Only 30 of physicians. additional health care consumption such as pharmaceuticals are currently offering primary care services and only 25 of. emergency department ED visits and imaging tests 12 medical school graduates enter primary care residencies 17 These. figures move us away from the goal identified by the Counsel on. Investment in the medical home model magnifies the impact of Graduation Medical Education of a recommended target of 40 . family physicians and primary care services on cost reductions of physicians providing primary care services 17 Petterson et al. throughout the entire health care system The following examples calculated shortages by subtracting the number of physicians. highlight family physicians impact projected to retire from the number of physicians produced. Kelley showed a reduction in ED visits and hospital admissions to project that the United States will fall 33 000 primary care. within Horizon Blue Cross Blue Shield s Patient Centered physicians short of the additional 44 000 needed to fill demand by. Medical Home PCMH program that represented approximately 2035 18 They estimate that the number of medical school graduates. 4 5 million in cost savings 7 entering primary care residencies needs to increase by 21 18. van Hasselt et al found that PCMHs receiving the National As alarming as the total physician shortage appears these. Committee for Quality Assurance recognition were associated numbers may still underrepresent the true severity of the. with lower health care utilization and lower total annual shortage as physicians are not evenly distributed across the. Medicare payments Overall total annual Medicare payments nation Rural areas and poorer communities currently have a. were reduced by 265 per patient with most of the reduction disproportionately larger shortage of physicians and are projected. 62 due to declines in acute care hospital payments 13 to have their shortages increase even further 18 Regions already. Filmore et al showed that the integration of systemic care categorized as health professional shortage areas experienced a. management into Community Care of North Carolina PCMH 2 4 decrease in practicing physicians from 2008 to 2013 19 Even. program achieved significant cost avoidance and associated if the decline in physician numbers reverses it may not happen in. savings ranging from 63 74 per member per month PMPM a manner that benefits the most underserved areas . to 190 91 PMPM and an overall cost savings of 184 064 611 There have been alternatives that might alleviate some of the. during 4 75 years 14 shortage but these alternatives involve services that fall short. of the full benefit of continual care from a family physician One. alternative is nurse practitioner NP or physician assistant PA . Value of Family Physicians page 3, clinics Patients especially younger adults are increasingly Although practicing under a medical home model can alleviate. more likely to seek NP and PA services 16 20 While this may be some of the FFS burdens this is not an easy solution Many. adequate for common conditions and ailments NPs and PAs practices are not yet ready for the necessary transformation As. are not as prepared to diagnose and manage more complex of 2013 approximately 40 of all primary care practices offer. undifferentiated and or chronic conditions Other alternatives minimal or no medical home services 26 and most solo and small. are physicians who serve as hospitalists in the inpatient setting practices 2 to 10 providers are typically unable to make a quick. in emergency departments or in urgent care centers Current transformation i e under two years without external supports. estimates indicate that 9 of primary care physicians serve as for practice redesign care management and revised payment 27. hospitalists with hospitals looking to increase their hiring rates In addition the cost of transformation can be prohibitive Marstolf. to avoid unnecessary hospitalizations and manage transitions et al reviewed medical home transformations and estimated. back to the community 21 While these physicians are capable of a median one time cost of 30 991 ranging from 7 694 to. handling a wider range of complications using them to alleviate 117 810 with ongoing yearly costs of 147 573 ranging from. the shortage of family physicians in primary care has the same 83 829 to 346 603 28 Patel et al estimated that 4 25 full time. problem as using NPs PAs because as their services are equivalents FTEs should be staffed per one physician FTE in the. designed around single patient visits when complications arise practice a 59 increase over the current ratio in the U S with. These alternatives falls short of the benefits of comprehensive an additional 1 5 support staff for each physician added to the. and continuous care offered by family physicians in primary care practice 29 Although medical home transformation can benefit. that help prevent further health complications primary care physicians and their patients the investment costs. may present too high of a risk for many practices . The best solution is to increase access to comprehensive . first contact and continuous primary care offered by family Even if compensation and practice setting issues are resolved . physicians This is the care shown to reduce the need for further there are additional factors that confront primary care physicians. and expensive health care services emergency department without offering a notable return One such factor is the. visits and hospitalizations While there are patches to help increasing burden of complicated electronic health records. alleviate the lack of access to family physicians they are only a EHRs which have yet to fulfill their promise of improving patient. partial replacement of family physician s services and may not be care EHRs can be a valuable health care tool that organizes. adequate as demand for primary care grows The best solution is patient records to prepare for patient visits provides alerts about. to reverse the decline in the number of family physicians care gaps to assist care management informs about health care. trends to assist diagnosis of symptoms and facilitates transfer of. information to coordinate health plans between the primary care. Barriers Facing Family Medicine physician specialists and hospitals 30 31 However the reality of. One of the clear deterrents to medical students pursuing family the current state of the industry is that difficult data entry and. medicine is the relatively low compensation compared to other poor interoperability have prevented EHRs from providing true. specialties 22 However this should not be viewed as a simple clinical benefits The use of EHRs within the practice has been. grievance with compensation The underlying issue is the current uncorrelated with maintaining or improving clinical performance . fee for service FFS system s emphasis on quantity of care over with the exception of often underutilized clinical health. quality of care Under FFS primary care physicians can increase registries 32 The use of EHRs for transfer of medical information. their compensation only by working longer hours i e disrupting has been hampered by poor interoperability of different EHR. their work life balance to increase the number of patient visits systems that deters the coordinate of care with agreed upon. conducted in a day or by electing to do more tests procedures care plans 30 31 If the effectiveness and interoperability of EHRs. and other services that may not have as high of a clinical return is improved the effort to enter data into the system can benefit. relative to their costs The FFS system provides little direct reward patient care If not the data entry becomes little more than. for improved clinical practice and quality or even cost effective additional uncompensated work that has little clinical benefit . care 23 24 Since FFS systems pay only for patient visits and. treatments FFS effectively penalizes family physicians who help Another factor confronting primary care physicians is the use. maintain patients general health and reduce the need for sick visits of complicated sometimes contradictory metric methods to. Further the FFS system focuses physicians on quick services determine a physician s value and compensation For example . which discourages treatment of some chronic conditions such there may be a disconnect between patient satisfaction metrics. as depression which require multiple longer visits to complete and metrics of clinical quality Patient satisfaction is an important. an effective treatment 24 25 In short the FFS system incentivizes factor driving patients to maintain their preventive and clinical. performing quick tasks in volume rather than rewarding the health services 5 However there is emerging evidence that. comprehensive high quality care family physicians provide current methods of gathering and analyzing patient satisfaction. data show little or no correlation with current methods for. Value of Family Physicians page 4, determining quality of care 4 5 33 If both metrics are used to In recent years there have been a number of proposals to modify. calculate physician value compensation physicians might likely payments to shift the incentives toward quality care but each one. face choices between the penalties of low patient satisfaction has drawbacks One initiative is the chronic care management. or penalties for low clinical outcomes and potentially lose fees established under Medicare The viability of this alternative. either way Indeed some patient satisfaction metrics have may be too dependent on patient willingness to consent to care. produced negative consequences such as diminished physician management and may have a break even point that is too high. satisfaction because of low patient satisfaction scores undue for small and solo practices 34 35 Another initiative is transitional. administrative burden on clinicians in administering patient care management TCM fees but TCM requires coordination. satisfaction surveys more physicians acceding to patients with hospitals that tend to be poor collaborators Those hospitals. request for discretionary services and others 4 5 33 Although have high expectations of the primary care physicians but provide. multiple factors are important to determining physicians value little help in terms of ensuring proper transition of medical records. the development of complementary metrics is crucial t. A Fundamental Asset in Health Care Valuing Family Physicians MrAeCaRAdy The Shift to Value Based Payment July 2016 Family physicians are invaluable assets in the health care system Focused on

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