No longer should primary care physicians be considered the specialists that patients visit only for a cold or a sprained ankle. More and more, they are taking the reins in managing all types of care.
Carolyn Lopez, M.D. (left), president of the Chicago Board of Health; Thomas Warcup, D.O., medical director for Carolina Advanced Health; and Carroll Haymon, M.D., medical director in the Seattle office of Iora Primary Care, talked about new approaches physicians can take to improve the public health.
But as long as payment policies are slow to change, many physicians remain caught in the cycle of simply completing one procedure after another. As part of the Health is Primary campaign,(www.healthisprimary.org) a panel of physicians spoke last week on Capitol Hill about how they have changed their care delivery methods in ways that both improved patient health and provided the physicians a greater degree of career satisfaction.
The campaign is a product of Family Medicine for America's Health,(fmahealth.org) a partnership of the AAFP and seven other family medicine organizations that shows the public how a strong primary care system will let family physicians achieve the triple aim of better health, better care delivery and lower costs.
Panelist Thomas Warcup, D.O., medical director for Carolina Advanced Health in Chapel Hill, N.C., said he is handling 15 percent of his patient visits through telemedicine. However, he cautioned, a lot of physicians are reluctant to use telemedicine extensively because of state regulations regarding what constitutes a patient visit.
- As part of the Health is Primary campaign, a panel of physicians recently spoke on Capitol Hill about how they have changed their care delivery methods.
- Technology is facilitating innovations such as telemedicine, but payment models need to catch up, said one panelist.
- Partnerships with elected officials can make physicians' efforts to improve public health more powerful, said another panel member.
Warcup said he would like to conduct more visits using telemedicine but noted that insurers are reluctant to pay for substantially more given the fear that the number of claims will spike, bolstered by visits that are not medically necessary. As a consequence of that hesitancy, Warcup said he often has to see patients in the office even if the consult could be better handled electronically.
"You have to engage patients in a meaningful way where they are," he said. "That makes economic sense."
Beyond single-patient visits, Warcup is using an electronic health record (EHR) system that allows him to "risk-stratify" particular populations, such as patients with hypertension or diabetes. A patient's condition is identified as either red, yellow or green, indicating the degree of risk associated with his or her condition.
One important aspect of the patient-centered approach to care is creating an environment that is convenient for patients, said Warcup, so he supports the concept of open-access scheduling.
Some forms of technology can help with the physician-patient relationship, but others can leave physicians feeling "like they are just clicking through boxes," said Warcup. Meeting the certification requirements for patient-centered medical homes and complying with standards for meaningful use of EHRs takes considerable time, and if a physician wants to get reimbursed for chronic care management, the paperwork is substantial.
Although Warcup called his profession "extremely rewarding and never dull," he acknowledged that some physicians can become disillusioned over time.
Panelist Carolyn Lopez, M.D., president of the Chicago Board of Health and a former speaker of the AAFP Congress of Delegates, described how her hometown launched Healthy Chicago in 2011, a public initiative designed to promote changes in health behavior.
A key goal of the program was to reduce smoking rates among the city's youth. Research indicates that 80 percent of adult smokers start smoking by age 18, so city officials sought to reduce tobacco's influence early on, she said. One tactic officials adopted was to increase the local tax on cigarettes until the total price of a pack rose to $12 or more.
The city's smoking rate among high-school students, which was 13.6 percent in 2011, fell to 10.7 percent as of mid-2014. Rates among adults dropped from 22 percent to 17 percent during that period.
With strong support from the Illinois AFP and other groups, Lopez took a forceful stand by hosting a press conference to urge city officials to address e-cigarette sales to minors. She said the effort persuaded several aldermen to change their votes in favor of strict regulations. The Chicago City Council also ended up restricting sales of flavored tobacco and menthol cigarettes within 500 feet of a school. The city also banned e-cigarette sales to minors, said they can be sold only behind the counter at retail stores and prohibited their use in public indoor facilities.
Making Patients Comfortable
Carroll Haymon, M.D., medical director in the Seattle office of Iora Primary Care, said she heard the same types of frustration from medical residents, so she worked for improvement. Haymon, who was a residency instructor for 10 years, heard residents say they thought they were being trained properly but could not practice the way they wanted to.
"I said, 'Let's build a clinic where physicians can do medicine the right way,''' Haymon said, noting that Iora facilities, which operate in six states, are designed to make patients feel comfortable, and staff monitors patient satisfaction closely.
Instead of scheduling patients at 15-minute intervals for an entire day, Haymon and her staff begin each day by not seeing patients. Instead they meet for an hour to discuss the patients who might have the greatest need for follow-up care and assign "worry scores" to identify that level of need. Patients who are at a skilled nursing facility or who have been recently discharged from a hospital, for example, receive close attention. She said the concept is radical for a primary care practice.
"Most of what drives health care is long-term chronic care," Haymon said. "It works well when it's planned, when it's based on evidence and when we encourage patients to be self-advocates."
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