Patient Care
The Doctor Shortage Calls for Innovation
The following opinion piece from athenahealth President and CEO Jonathan Bush previously appeared on HISTalk, in response to a July 28, 2012 New York Times article.
It was hard to read the recent sobering article in The New York Times, “Doctor Shortage Likely to Worsen with Health Law,” without picturing a lot of very smart people throwing their hands up in collective despair. Dr. G. Richard Olds, the dean of the new medical school at the University of California, Riverside, summed up the likely scenario in his part of California quite starkly: “We’ll have a 5,000-physician shortage in 10 years, no matter what anybody does.” Not exactly a rousing call to arms.
What, if anything, is to be done about this crisis in the making? In an article otherwise devoid of solutions, Dr. Olds hinted at an answer when he suggested that “changing how doctors provided care would be more important than minting new doctors.” As the article points out, the proportion of medical students going into primary care has declined over the past 15 years as PCP earnings have diverged from those of specialists. But that’s not the whole picture.
Along with low remuneration, a 2009 study of the work conditions of family and general practitioners identified adverse workflow as a major driver of dissatisfaction, with 53% reporting time pressure during exams and 48% burnt out from the chaotic work pace. The same 15 years that have witnessed PCP decline have seen PCPs take on an ever-rising burden of paperwork, a more complex billing landscape, and a dizzying array of new federal requirements and mandates. Despite these rising challenges and seismic shifts in health care, the organization of the typical medical practice looks much as it did 50 years ago.
The narrow focus of the PCP shortage debate on the need for primary care to expand to meet rising demand misses the more significant point that it needs to be redefined through innovations that improve efficiency and restore the sanctity of the physician-patient experience. Technology can, and should, play a central role in this process. Rather than add work to physicians’ plates and hindering productivity, as many electronic health records (EHR) still do, the EHR should reduce work for physicians and delegate it to other clinical staff. Delegating work and empowering clinicians to practice to the top of their licenses not only reduces costs overall, but frees physicians to be fully present with a patient when their complete attention and training is truly required.
Non-clinical, routine work that bogs down PCPs should be removed from the office entirely. Even in our digital age, vast amounts of paper still clog practices and consume valuable staff time. At athenahealth we know that, on average, providers must process more than 1,000 clinical faxes every month, not to mention the forests of paperwork associated with insurance claims and government programs. This routine work can be offloaded to others in the supply chain who can eliminate it, automate it, or execute it more efficiently at scale.
By finding new efficiencies through technology, delegating care, and moving administrative work out of the practice, primary care can not only become more financially sustainable but more attractive to new entrants. Innovation, not just expansion, is the key to success.
With reimbursement falling, more docs are working fewer hours and taking fewer responsibilities
Residency slots are the bottleneck. Debt loads enormous. Socilaized medicine not an answer
Incentives (many options) are needed to turn the tide
Capitalism made this country strong. Give docs their power back, and we will fix this issue
Being forced into employed situations
Have been up on athena for one year now. It has made medicine fun for me again. The amount of work that has been off-loaded is fantastic. This is true Meaningful Use. My primary care doctor friends struggle and yet are closed when I try to explain what athenahealth has done for me. They line up to become hospital employees…..
Delegating others to use the EMR does not fix the EMR.
Requiring insurance, pharmaceutical and government entities to review and minimize burdensome administrative forms, and collusive drug formularies would eliminate wasted hours and funds.
With all due respect to an innovator, everyone is missing the point. As well documented in the NEJM roundtable discussion with the late (articulate) Dr. Barbara Starfield and others, when done right, a primary care doctor (now mostly family physicians) can only manage around 500 active patients, not 2,000-4,000 patients currently required to “fill up a schedule full of 5 and 10 minute appointments that are no more the practice of medicine than a child’s lemonade stand by the side of the road. I know this is a profound thought, but it simple takes time to really know the patient, I mean really know them and all the forces that affect their health and well-being. This is a different type of medicine that is not common to our current fragmented subspecialty approach to sick care. Second, do we really need third party insurance to pay for everything involved with heathcare? There is no other area of our lives that insurance covers all costs. This is the most expensive way to pay for anything and creates around 5 people being paid for non medical services for everyone that actually provides care. I agree with Mr. Bush that in a health care system where those looking in from the outside are judging the effectiveness of healthcare we must have computer support. But does it really improve therapy and does it really make us more efficient. Only because of government and third party demands for healthcare quality parameters to be continuously reported. For the most part, patients simply want a “personalized doctor-patient relationship”. A family doctor that knows them by their first name…for life.
EXCELLENT INSIGHT! CREATING EFFICIENCY IN THE OFFICES OF PHYSICIANS WHO CARE FOR THE PATIENT AT THE INTERFACE BETWEEN THE INDIVIDUAL AND THE COMMUNITY WILL HELP TO IMPROVE ACCESS AND HEALTHCARE QUALITY AS DESIRED. OUR HEALTHCARE DELIVERY SYSTEM WILL BENEFIT UPON RECOGNITION OF THE VALUE OF PHYSICIANS WHO DEVOTE THEIR KNOWLEDGE AND SKILLS TO THE SERVICE OF THE COMMUNITY. IT IS IMPERATIVE FOR ALL ENTITIES INCLUDING BUYERS OF CARE, PAYERS OF CARE, AND ENTITIES PROVIDING SERVICES FOR CARE DELIVERY TO UNDERSTAND HOW MUCH SAVINGS WOULD BE REALIZED WITH LESS PHYSICIAN MANPOWER IF AFFORDABLE EFFICIENT SYSTEMS ARE MADE AVAILABLE TO THE PHYSICIAN. THE CURRENT PAYMENT SCHEME DOES NOT ALLOW DEDICATED PHYSICIANS TO ENTERTAIN THESE OPTIONS AS THE REQUIRED COSTS ARE OUTISDE THE AVERAGE BUDGET PERMITTED FOR OPERATIONS. WE MUST ALL UNDERSTAND WHAT IS TRULY FEASIBLE FOR THE PHYSICIAN OFFICE TO MAINTAIN VIABILITY. AFFORDABLE HEALTHCARE WITHOUT GREAT INCREASE IN PHYSICIAN NUMBERS REQUIRES SYSTEMS WHICH PHYSICIANS CAN AFFORD FOR ELECTRONIC RECORD ACCESS AND HEALTH INFORMATION EXCHANGE CONNECTIVITY.
Agree with the blog entirely as far as it goes – working at the top of one’s license is key, and hiring (or contracting) with sufficient staff to do less expertise-intensive tasks is critical. Employers, of course, are loath to do this, and entrepreneurial independents prefer to keep the money at the bottom line. The devil is in the details and the how-tos.
Vague wishes for how it used to be and the “trust us, we’ll fix it” approaches are known guarantees for failure. As flawed as Obamacare may be, it is at least a starting point. If you have a better plan, put it out there in comprehensive form.
In response to Dr. McLaughlin’s comment that Obamacare is a starting point, I agree it is flawed in so many ways, 2400 pages of the most massive tax increase in my life time. Minority lead Nancy Pelosi stated: We need to pass it to find out what was in it. Never before to my knowledge has Congress gone “nuclear” to pass a program that had such far reaching effects on our citizens. When I discussed this with Senator Kyle of my state of Arizona suggesting that the Democratic leaders may try to pass it by going “nuclear”, he did not believe it would ever happen. Whether we agree or disagree on the contents of Obamacare, any law or program that is passed without the money to pay for it should be illegal. It’s time that the federal government like the states should have to balance their budget and start the painful process of paying down the 17 trillion dollars of debt.