Can we solve the adult primary care shortage Can we solve the adult primary care shortage

without more physicians?without more physicians?

Tom BodenheimerTom Bodenheimer Center for Excellence in Primary CareCenter for Excellence in Primary Care

UCSF Dep’t of Family and Community MedicineUCSF Dep’t of Family and Community Medicine

Weitzman Symposium 2014Weitzman Symposium 2014

Colwill et al., Health Affairs, 2008:w232Colwill et al., Health Affairs, 2008:w232 Petterson et al, Ann Fam Med 2012;10:503 Petterson et al, Ann Fam Med 2012;10:503

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Adult care: projected generalist physician Adult care: projected generalist physician supply vs. demandsupply vs. demand

Demand:adult popDemand:adult pop’’nngrowth/aginggrowth/aging

Supply: family Supply: family med, general med, general internal medinternal med

Shortage of 40,000 by 2020 Shortage of 52,000 by 2025

NP/PAs to the rescue?NP/PAs to the rescue?

• New graduates each yearNew graduates each year– Nurse practitioners: Nurse practitioners: 80008000– Physician assistants: Physician assistants: 45004500

• % going into primary care% going into primary care– NPs: NPs: 65%65%– PAs: PAs: 32%32%

• Adding new GIM, FamMed, NPs, and PAs entering Adding new GIM, FamMed, NPs, and PAs entering primary care each year, the primary care clinician primary care each year, the primary care clinician to population ratio will fall by to population ratio will fall by 9%9% from from 2005 to 2020.2005 to 2020.

Colwill et al, Health Affairs Web Exclusive, April 29, 2008; Bodenheimer et al, Colwill et al, Health Affairs Web Exclusive, April 29, 2008; Bodenheimer et al, Health Affairs 2009;28:64.Health Affairs 2009;28:64.

Panel sizes too large to managePanel sizes too large to manage

• Average primary care panel in US is Average primary care panel in US is 23002300

• PCP with panel of 2500 average patients will PCP with panel of 2500 average patients will spend spend 7.4 hours per day7.4 hours per day doing recommended doing recommended preventive carepreventive care [Yarnall et al. Am J Public Health 2003;93:635] [Yarnall et al. Am J Public Health 2003;93:635]

• PCP with panel of 2500 average patients will PCP with panel of 2500 average patients will spend spend 10.6 hours per day10.6 hours per day doing recommended doing recommended chronic carechronic care [Ostbye et al. Annals of Fam Med 2005;3:209] [Ostbye et al. Annals of Fam Med 2005;3:209]

Results of large panelsResults of large panels • Poor access for patients Poor access for patients • Inconsistent qualityInconsistent quality• Lack of time to build relationships with patientsLack of time to build relationships with patients• Clinician burnoutClinician burnout

– Survey of 422 general internists, family physiciansSurvey of 422 general internists, family physicians• 27%: definitely burning out27%: definitely burning out• 30%: likely to leave the practice within 2 years30%: likely to leave the practice within 2 years

– Physician burnout is associated with poor patient Physician burnout is associated with poor patient experience and reduced patient adherence to experience and reduced patient adherence to treatment planstreatment plans

Linzer et al. Annals of Internal Medicine 2009;151:28-36; Dyrbye, JAMA 2011;305:2009; Murray et Dyrbye, JAMA 2011;305:2009; Murray et al, JGIM 2001:16,452; Landon et al, Med Care 2006;44:234.al, JGIM 2001:16,452; Landon et al, Med Care 2006;44:234.

The dilemmaThe dilemma

• Panel size too large for average PCP to managePanel size too large for average PCP to manage• We can’t reduce panel size due to worsening We can’t reduce panel size due to worsening

shortage of adult primary care cliniciansshortage of adult primary care clinicians• Shortage = larger panels, poorer access for Shortage = larger panels, poorer access for

patients, poorer quality, more PCP burnout, higher patients, poorer quality, more PCP burnout, higher health care costshealth care costs

• More PCP burnout means fewer medical students More PCP burnout means fewer medical students will be attracted to primary carewill be attracted to primary care

Unless we think differentlyUnless we think differently

Re-defining the adult primary care shortageRe-defining the adult primary care shortage

• Most people define it as a physician shortageMost people define it as a physician shortage• Or a clinician shortage (MDs, NPs, PAs)Or a clinician shortage (MDs, NPs, PAs)• These formulations are a These formulations are a bridge to nowherebridge to nowhere• If clinician shortage is the problem, then the only solution If clinician shortage is the problem, then the only solution

is more clinicians is more clinicians • More clinicians would help, but there will More clinicians would help, but there will nevernever be enough be enough• We must re-define the shortage as a demand-capacity gapWe must re-define the shortage as a demand-capacity gap• We address the gap by increasing capacity and/or reducing We address the gap by increasing capacity and/or reducing

demanddemand• We can do this without more cliniciansWe can do this without more clinicians

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Adult primary care: capacity vs. demandAdult primary care: capacity vs. demand

Demand for careDemand for care

==Capacity to Capacity to provide careprovide care

Thinking differently Thinking differently

It’s not only about doctorsIt’s not only about doctors

Share the careShare the care

Clinica Family Health Services

Group Health Olympia

Multnomah County Health

Dept

South Central Foundation

Univ of Utah- Redstone Newport News

Family Practice

Cleveland Clinic- Stonebridge

Quincy, Office of the Future

West Los Angeles- VA

La Clinica de la Raza

Clinic Ole

Sebastopol Community

Health

Martin’s Point- Evergreen Woods

Harvard Vanguard Medford Brigham and

Women’s and MGH Ambulatory

Practice of the Future

North Shore Physicians Group

Medical Associates Clinic

Mercy Clinics

ThedaCare

Fairview Rosemont Clinic

Mayo Red Center

Allina

23 High-Performing Practices23 High-Performing Practices

10 Building Blocks of High-Performing Primary Care

Annals of Family Medicine 2014;12:166-71

Team-based careTeam-based care

Closing the demand-capacity gap: share the careClosing the demand-capacity gap: share the care• Clinicians Clinicians • Non-clinician team membersNon-clinician team members

– Non-professionalNon-professional• MAs as panel managersMAs as panel managers• MAs as health coachesMAs as health coaches• MAs as scribesMAs as scribes

– ProfessionalProfessional• RNsRNs• PharmacistsPharmacists• BehavioristsBehaviorists

• PatientsPatients– Peer health coachesPeer health coaches– Self careSelf care

• TechnologyTechnologyBodenheimer and Smith, Health Affairs 2013;32:1881-6Bodenheimer and Smith, Health Affairs 2013;32:1881-6

Share the care: who does it now?Share the care: who does it now?

Tasks PCP RN LPN Medical assistant

Pharmacist

Orders mammograms for healthy women between 50

and 75 years old

Refills high blood pressure medications for patients

with well-controlled hypertension

Performs diabetes foot exams

Reviews lab tests to separate normals from

abnormals

Cares for patients with uncomplicated urinary

tract infections

Finds patients who are overdue for LDL and

orders lipid panel

Prescribes statins for patients with elevated LDL

Does medication reconciliation

Screens patients for depression using PHQ 2

and PHQ 9

Follows up by phone with patients treated for

depression

Totals

Share the care: preserve the relationshipShare the care: preserve the relationship

• Share the Care means that the personal clinician Share the Care means that the personal clinician does not provide all the caredoes not provide all the care

• Patients should not be asked to transfer trust from a clinician to a large team

• Historically patients trust a small team (teamlet)• The relationship changes from patient-clinician to The relationship changes from patient-clinician to

patient-teamletpatient-teamlet• Members of the larger team are involved if neededMembers of the larger team are involved if needed• Blue Shield of California Foundation survey: patients Blue Shield of California Foundation survey: patients

are willing to receive care from a team even if it are willing to receive care from a team even if it means seeing their physician less (June 2012)means seeing their physician less (June 2012)

Team-based care: stable teamlets

Patientpanel

1 team, 3 teamlets

Clinician + MAteamlet

Patientpanel

Clinician + MAteamlet

Patientpanel

Clinician + MAteamlet

RN, behavioral health professional, social worker, pharmacist, complex care manager

High-performing teamletsHigh-performing teamlets

High performing teamletHigh performing teamlet

Sharing the care with non-clinician Sharing the care with non-clinician team membersteam members

• Panel management Panel management – MAs use preventive and chronic disease registries, MAs use preventive and chronic disease registries,

and EMR health maintenance screens, to identify and EMR health maintenance screens, to identify patients with care caps and close the care gapspatients with care caps and close the care gaps

– Standing ordersStanding orders are needed to empower the MAs are needed to empower the MAs– Best done within the teamletBest done within the teamlet– Quality of preventive services improvesQuality of preventive services improves [Chen and [Chen and

Bodenheimer, Arch Intern Med 2011;171:1558] Bodenheimer, Arch Intern Med 2011;171:1558]

Clinician confidence that medical assistants Clinician confidence that medical assistants will do a good job on panel managementwill do a good job on panel management

2012 Survey of 231 PCPs2012 Survey of 231 PCPs

Source: System Transformation Evaluation Survey (STEP). 2012. Available at http://familymedicine.medschool.ucsf.edu/cepc/

Preventive services: new wayPreventive services: new way

• MA (panel manager) checks registry every monthMA (panel manager) checks registry every month• If due for mammo, MA sends mammo order to patientIf due for mammo, MA sends mammo order to patient• Result comes to MA, if normal, MA notifies patient Result comes to MA, if normal, MA notifies patient • If abnormal MA notifies clinician and app’t madeIf abnormal MA notifies clinician and app’t made• For most patients, clinician is not involvedFor most patients, clinician is not involved• For women 40-50 who want or need mammogram, For women 40-50 who want or need mammogram,

clinician is involved for discussionclinician is involved for discussion• Similar for colon cancer screeningSimilar for colon cancer screening• Requires standing ordersRequires standing orders

Sharing the care with non-clinician Sharing the care with non-clinician team membersteam members

• Health coaching Health coaching – MAs trained as health coaches can assist patients with chronic MAs trained as health coaches can assist patients with chronic

conditions to become informed active participants in their care conditions to become informed active participants in their care [Margolius et al, Annals of Family Medicine 2012;10:199; Ivey et al, Diab Spectrum 2012;25:93; [Margolius et al, Annals of Family Medicine 2012;10:199; Ivey et al, Diab Spectrum 2012;25:93; Gensichen et al, Ann Intern Med 2009;151:369; Willard et al, in press]Gensichen et al, Ann Intern Med 2009;151:369; Willard et al, in press]

• Example: diabetesExample: diabetes– Closing the loop to check for understanding (50% don’t remember Closing the loop to check for understanding (50% don’t remember

what happened in the clinician visit)what happened in the clinician visit)– Know your ABC numbers (A1c, BP, Cholesterol)Know your ABC numbers (A1c, BP, Cholesterol)– Know your ABC goalsKnow your ABC goals– Know how to get from your number to your goalKnow how to get from your number to your goal– Behavior change goal-setting and action plansBehavior change goal-setting and action plans– Know your medications, and med adherence counselingKnow your medications, and med adherence counseling

• Difficult to do on teamlet unless 2 MAs per clinicianDifficult to do on teamlet unless 2 MAs per clinician

Health coaching in the teamlet modelHealth coaching in the teamlet model

Chronic care: hypertension: new wayChronic care: hypertension: new way

• MA checks registry every monthMA checks registry every month• Patients with abnormal BP contacted for pharmacist, RN, Patients with abnormal BP contacted for pharmacist, RN,

or health coach visitor health coach visit• Health coach: education, med adherence, lifestyle changeHealth coach: education, med adherence, lifestyle change• If BP elevated and patient med adherent, RN/pharmacist If BP elevated and patient med adherent, RN/pharmacist

intensifies meds by standing orders intensifies meds by standing orders • If questions, quick clinician consultIf questions, quick clinician consult• Health coach f/u by phone or e-mailHealth coach f/u by phone or e-mail• Clinician barely involvedClinician barely involved• Blood pressure control improved with this innovationBlood pressure control improved with this innovation

[Margolius et al, Annals of Family Medicine 2012;10:199][Margolius et al, Annals of Family Medicine 2012;10:199]

Share the care:Share the care: MA acts as scribe while MD does physical exam MA acts as scribe while MD does physical exam

EMR pushes more work to physician, leading to EMR pushes more work to physician, leading to vast amounts of time spent documentingvast amounts of time spent documenting

If changes are not made If changes are not made to reduce these time to reduce these time penalties on primary penalties on primary care physicians there care physicians there will be no primary care will be no primary care physicians left to physicians left to penalize.penalize. Clement J McDonald Clement J McDonald MD, Arch Intern Med 2012;172:285-287 MD, Arch Intern Med 2012;172:285-287 (Clem McDonald created one of the (Clem McDonald created one of the first EMRs in the 1970s)first EMRs in the 1970s)

Vast amounts of time spent documentingVast amounts of time spent documenting

• Scribing• Assistant order

entry• Re-engineering

the prescription renewal work out of the practice

• I come in to my doctor for an I come in to my doctor for an examination, but it seems all examination, but it seems all he wants to do is examine the he wants to do is examine the computer.computer. Patient 3/2/12Patient 3/2/12

• I used to be a doctor. Now I I used to be a doctor. Now I am a typist.am a typist. Internist Anchorage ALInternist Anchorage AL

• I really like my doctor of over I really like my doctor of over 10 years, but rarely get to talk 10 years, but rarely get to talk with her face to face; as I’m with her face to face; as I’m talking, she is typing. Annoys talking, she is typing. Annoys the hell out of me.the hell out of me. Patient, 12/30/10Patient, 12/30/10

Hey doc, I’m here too

Scribes to reduce documentation timeScribes to reduce documentation time• University of Utah “Care by Design”• Right person/right job• MAs receive additional training• MA takes history using EMR templates• MD reviews history does physical exam and MA

enters findings into EMR• MD calls out lab, imaging, prescriptions and MA

enters them as pended orders that MD quickly Oks• Profits up, patient satisfaction up, provider

satisfaction up, quality measures upBlash et al, UCSF Center for the Health Professions, April 2011

The best way to reduce burnoutThe best way to reduce burnout

Closing the demand-capacity gap: share the careClosing the demand-capacity gap: share the care• Clinicians Clinicians • Non-clinician team membersNon-clinician team members

– Non-professionalNon-professional• MAs as panel managersMAs as panel managers• MAs as health coachesMAs as health coaches• MAs as scribesMAs as scribes

– ProfessionalProfessional• RNsRNs• PharmacistsPharmacists• Physical therapistsPhysical therapists• BehavioristsBehaviorists

• PatientsPatients– Peer health coachesPeer health coaches– Self careSelf care

• TechnologyTechnology

Team-based care: stable teamletsTeam-based care: stable teamlets

PatientPatientpanelpanel

Clinician/MAClinician/MAteamletteamlet

PatientPatientpanelpanel

Clinician/MAClinician/MAteamletteamlet

PatientPatientpanelpanel

Clinician/MAClinician/MAteamletteamlet

Health coach, behavioral health professional, Health coach, behavioral health professional, social worker, RN, pharmacist, panel manager, social worker, RN, pharmacist, panel manager,

complex care managercomplex care manager

Share the care with professional team Share the care with professional team members using standing ordersmembers using standing orders

• RNs treat uncomplicated UTIs, URIs, STIs, and low back pain without RNs treat uncomplicated UTIs, URIs, STIs, and low back pain without clinicians: equal quality and better patient satisfaction clinicians: equal quality and better patient satisfaction

• Physical therapists manage low back pain with better functional relief Physical therapists manage low back pain with better functional relief and patient satisfaction compared with physiciansand patient satisfaction compared with physicians

• RNs or pharmacists can care for a sub-panel of patients with diabetes, RNs or pharmacists can care for a sub-panel of patients with diabetes, hypertension, hyperlipidemia with minimal clinician involvementhypertension, hyperlipidemia with minimal clinician involvement

• Behaviorists in primary care improve depression outcomesBehaviorists in primary care improve depression outcomes• RN complex care managers can provide much of the care for time-RN complex care managers can provide much of the care for time-

consuming, complex, high-utilizing patientsconsuming, complex, high-utilizing patients• These changes can add 10-20% capacity without more clinician timeThese changes can add 10-20% capacity without more clinician time

Saint et al, Am J Med 1999;106;636; Overman et al, Phys Ther 1988;68:199; Saint et al, Am J Med 1999;106;636; Overman et al, Phys Ther 1988;68:199; http:http://impact-uw//impact-uw.org.org; Bodenheimer and Berry-Millett, RWJF Synthesis Project, December Bodenheimer and Berry-Millett, RWJF Synthesis Project, December 20092009; ; Bodenheimer and Smith, Health Affairs 2013;32:1881-6Bodenheimer and Smith, Health Affairs 2013;32:1881-6

Share the care with patients:Share the care with patients:peer health coachespeer health coaches

• Patients trained as peer health coaches can add capacity Patients trained as peer health coaches can add capacity • VA diabetic patients paired with peers had greater glycemic VA diabetic patients paired with peers had greater glycemic

improvement than patients with nurse care managers improvement than patients with nurse care managers [Heisler et al, Ann Intern Med 2010;153:507][Heisler et al, Ann Intern Med 2010;153:507]

• Latino diabetic patients with peer-led classes: better Latino diabetic patients with peer-led classes: better glycemic control than usual care glycemic control than usual care [Philis-Tsimikas et al, Diab Care [Philis-Tsimikas et al, Diab Care 2011;34:1926]2011;34:1926]

• Diabetes patients with a peer coach had greater HbA1c Diabetes patients with a peer coach had greater HbA1c reductions than usual care patients reductions than usual care patients [Long et al, Ann Intern Med [Long et al, Ann Intern Med 2012;156:416]2012;156:416]

• Low-income diabetic patients with low-income peer Low-income diabetic patients with low-income peer coaches achieved better glycemic control than usual care coaches achieved better glycemic control than usual care patients patients [Thom et al, Ann Fam Med 2013;11:137-144][Thom et al, Ann Fam Med 2013;11:137-144]

Training peer health coaches Training peer health coaches

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2000 2005 2010 2015 2020

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Adult primary care: capacity vs. demandAdult primary care: capacity vs. demand

Demand for careDemand for care

==Capacity to Capacity to provide careprovide care

Thinking differently Thinking differently

Sharing the careSharing the care adds capacity adds capacityPatient self-carePatient self-care reduces demand reduces demand

Share the careShare the care

Self careSelf care

Reducing demand through self careReducing demand through self care• Home pregnancy kits, home HIV testingHome pregnancy kits, home HIV testing• Internet sites (good and not good)Internet sites (good and not good)• More OTC medicationsMore OTC medications• Patients with home blood pressure monitors who Patients with home blood pressure monitors who

self-titrate their medications can achieve better self-titrate their medications can achieve better blood pressure control than that achieved by MDs blood pressure control than that achieved by MDs

• Patients on anti-coagulation who home-monitor and Patients on anti-coagulation who home-monitor and self-titrate warfarin doses can achieve better INR self-titrate warfarin doses can achieve better INR control than MDs.control than MDs.McManus et al, Lancet 2010;376:163; Heneghan et al, Lancet McManus et al, Lancet 2010;376:163; Heneghan et al, Lancet 2012;379:322.2012;379:322.

Add capacity, reduce demand through technologyAdd capacity, reduce demand through technology

• Much panel management can be done by computers rather than Much panel management can be done by computers rather than MAs. Computers identify care gaps, remind patients. MAs needed MAs. Computers identify care gaps, remind patients. MAs needed only when patients don’t respond.only when patients don’t respond.

• Computers can be programmed to authorize med refills without Computers can be programmed to authorize med refills without expenditure of human effortexpenditure of human effort (Healthfinch.com)(Healthfinch.com)

• Patient self-care for uncomplicated UTI is safe and effective. Patient self-care for uncomplicated UTI is safe and effective. Patients enter UTI symptoms into a Patients enter UTI symptoms into a kiosk/vending machine.kiosk/vending machine. If no If no red flags, 3 days of antibiotics are dispensed from vending red flags, 3 days of antibiotics are dispensed from vending machine. No involvement of health care personnel.machine. No involvement of health care personnel.

• Cell phone otoscopes allow parents to dx peds ear infections or Cell phone otoscopes allow parents to dx peds ear infections or send to clinician via patient portalsend to clinician via patient portal

Take-home pointsTake-home points• The “primary care physician shortage” must be The “primary care physician shortage” must be

re-conceptualized as a demand-capacity gapre-conceptualized as a demand-capacity gap• Capacity can be increased by sharing large Capacity can be increased by sharing large

amounts of care with non-cliniciansamounts of care with non-clinicians• Patients not only receive, but can provide care Patients not only receive, but can provide care

as peer coachesas peer coaches• Demand can be reduced through growth of self Demand can be reduced through growth of self

carecare• Technology can facilitate this transformationTechnology can facilitate this transformation• In the future, primary care will be dramatically In the future, primary care will be dramatically

different different

The Building Blocks of The Building Blocks of High-Performing High-Performing Primary CarePrimary Care

Think differentlyThink differently