primary care


Helping Primary Care Treat Minds As Well As Bodies

A doctor's office waiting room. (veggiesosage/flickr)

A doctor’s office waiting room. (veggiesosage/flickr)

Sometimes, medical doctors view their patients only from the neck down.

But that is unwise: Over 70% of primary care visits today are related to psychosocial issues – things like anxiety or depression manifesting themselves as chronic pain, stomach aches or heart palpitations.

And, according to Dr. Russell Phillips, director of the Center for Primary Care at Harvard Medical Center, these underlying problems create all sorts of complications. “Mental health conditions complicate the treatment of everything else,” he said. “If someone has diabetes and depression, symptoms of their depression may make it harder for them to manage their diabetes.”

Of course, the problem is exacerbated by patients not even being aware that they have any underlying conditions. Doctors have to try to solve problems that “patients can’t even name,” said Phillips. He gave a quick assessment of the system today: overworked primary care physicians struggle to treat conditions in limited time and often with limited resources.

Phillips envisions a system for addressing all of these issues that would begin with mental health: Continue reading

Hard-To-Get Primary Care: Mass. Waits Still Long, ‘No New Patients’ Common

(Source: Massachusetts Medical Society)

(Source: Massachusetts Medical Society)

In what’s become an annual ritual, the Massachusetts Medical Society has just released its check-up on just how hard it is to get in to see a primary care doctor in this state. Bottom line: Mostly pretty hard, at least for a non-emergency first appointment. You’re likely to have to wait a month or two. At more than half of practices, you’ll be told, “Sorry, we’re not taking new patients.”

One bright spot: If you have public insurance — Medicaid or Medicare — most Mass. doctors will still see you.

From the press release:

Massachusetts Medical Society President Ronald Dunlap, M.D. said “Our latest survey once again points out a critical characteristic of health care in the Commonwealth. While we’ve achieved success in securing insurance coverage for nearly all of our residents, coverage doesn’t guarantee access to care. The concern is that limited and delayed access can lead to undesirable results, as people will seek more costly care at emergency rooms, delay care too long, or not seek care at all.”

Primary Care The 2013 study shows wait times for new patient appointments with primary care physicians remain long in the Commonwealth, with the average time to see a family medicine physician at 39 days (down from 45 days in 2012) and the average wait time to see an internal medicine physician at 50 days (up from 44 days in 2012). (New patient wait times reflect the total number of calendar days, including holidays and weekends, between the interview and next available appointment.)

The study also showed that only about half or less of primary care practices – 51% of family physicians and 45% of internists – are accepting new patients in 2013. Continue reading

Why Primary Care Matters

Third year medical student Joe Nelson (with his family) writes about why primary care is key to fixing the broken health care system.

Primary Care Progress is a two-year-old Cambridge-based nonprofit that seeks to revitalize the primary care field and motivate more medical students to enter the primary care fold — with passion.

One of those students, Joe Nelson, in his third year at Baylor College of Medicine in Houston, recently wrote eloquently about why he is pursuing a career as a family physician and why primary care is the key to fixing the broken health care system.

Nelson’s “aha” moment, he writes, involves his own father, a biomedical engineer who lost his health insurance and so delayed seeking followup medical attention on an abnormal colonoscopy that revealed some pre-cancerous polyps. A few years after the test, Nelson’s dad, now experiencing some troubling symptoms like weight loss, weakness and fatigue, sought advice from his medical-student son.

Nelson writes:

In what kind of health care system can a learned, health-literate individual make an educated decision not to seek medical care in such a high-risk situation? Why is a man like my dad relegated to asking medical students for health advice?

In the medical community, we talk about access to care as though it were a separate issue from medical costs. In fact, we usually refuse to discuss cost at all. Instead, we have behemoth yet inadequate government programs like Medicaid, CHIP, and Medicare to help improve access to the care that we’ve been told is fundamentally expensive. But the elephant in the room is that if medical care were inexpensive, everyone would be able to access it. Continue reading

Report: Retail Clinic Visits Up Sharply (Flu Shots, Weekend Hours Help)

The rise of the Minute Clinic (Chapendra/flickr)

Making doctor visits pretty much as easy as shopping at the mall has led to an enormous increase in the number of Americans dropping in to so-called “retail” clinics for care, a new study has found.

The report, published online in the journal Health Affairs, found a four-fold increase in retail clinic visits from 2007 to 2009. In that year alone nearly six million patients visited such clinics, the new study found. An earlier, related report by the same authors noted 1.48 million retail clinic visits in 2006.

Patients who visited these clinics (most of them with health insurance but without a primary care doc) did so for convenience and more flexible hours, the study notes; most often they sought simple acute care or preventive care, like getting a flu shot.

According to the study:

Retail clinics have rapidly become a fixture of the U.S. health care delivery landscape. We studied visits to retail clinics and found that they increased fourfold from 2007 to 2009, with an estimated 5.97 million retail clinic visits in 2009 alone. Compared with retail clinic patients in 2000–06, patients in 2007–09 were more likely to be age sixty-five or older (14.7 percent versus 7.5 percent). Preventive care—in particular, the influenza vaccine—was a larger component of care for patients at retail clinics in 2007–09, compared to patients in 2000–06 (47.5 percent versus 21.8 percent). Across all retail clinic visits, 44.4 percent in 2007–09 were on the weekend or during weekday hours when physician offices are typically closed. The rapid growth of retail clinics makes it clear that they are meeting a patient need. Convenience and after-hours accessibility are possible drivers of this growth.

Continue reading

‘Healthy San Francisco’: A Different — Better? — Model For Health Reform

Let me tear off my provincial Massachusetts blinders for a moment to say: We’re far from the only national laboratory for health reform. And something deeply interesting is going on in that fair city on the left-coast Bay, San Francisco.

So interesting, in fact, that the program, “Healthy San Francisco,” is a finalist for a major award from Harvard Kennedy School, the Innovations in American Government Award given out by the Ash Center for Democratic Governance and Innovation. (Winner to be announced early next year.) The 16-minute presentation above to the award judges provides a succinct overview, but here’s my one-liner: Unlike Massachusetts, San Francisco didn’t try to get everybody insured; it just aims to provide health care to the uninsured people who need it — not just in emergencies, but long-term, primary and specialist care.

I spoke with Berkeley health economist Richard M. Scheffler, who evaluated “Healthy San Francisco” for the innovation awards, about how the program works, and it certainly has its limits — including the city limits: It doesn’t extend beyond them. But what struck me is that, beginning in 2007, the program aimed to address health care delivery issues that we in Massachusetts are only getting to in a sweeping way now, such as the question of whether everyone should have to have a primary-care “medical  home.”

It also struck me that, though employers and taxpayers foot the bill, Healthy San Francisco addresses the problem of the uninsured by focusing mainly on them, and arguably affects the broad population less than in our health-insurance-for-all state. Readers, what do you think? Would something like Healthy San Francisco work elsewhere, beyond the bounds of that famously liberal city? Would you want it to?

‘The mandate is on the employer, not the individual as it would be in Massachusetts.’

My chat with Richard Scheffler, lightly edited:

So what’s so cool about ‘Healthy San Francisco” that it merited being an award finalist? It strikes me as such a dramatically different model from Massachusetts, much more narrowly targeted…?

What’s cool about it is that, as you mention in your question, it’s a very different approach than Massachusetts — or even the Obama plan. The Massachusetts model is fundamentally based on trying to help people obtain health insurance. But it does nothing about the access problem: the plight of safety net hospitals, lack of primary care doctors, overuse of emergency rooms, uncoordinated care. So San Francisco, to compare it to an insurance approach, it’s what you’d call an ‘access approach,’ It’s actually to provide access to health care. Continue reading

Primary Care Has A Cinderella Moment

Long the lower-paid and under-appreciated workhorse of medicine, primary care had a definite Cinderella moment yesterday at Harvard Medical School. And it seemed to hint at a whole new era to come, in which primary care stops being such a medical Rodney Dangerfield.

The scene: The first annual innovations conference at the medical school’s Center for Primary Care, a new institution created with the help of a $30 million anonymous donation.

The speaker: The new provost of Harvard, Dr. Alan Garber, freshly imported from Stanford and, it just so happens, himself a primary care physician who kept practicing through his years at Stanford even as he also focused on health policy and economics.

The acoustics were hard, so here’s the text of the clip above. Dr. Garber had begun by noting that it appears that national health reform is here to stay, and that it pushes medicine away from “fee for service” — payment for each procedure — and towards more global or overarching forms of payment and care.

I believe that there is no group of physicians that is better positioned to lead the efforts toward these new forms of payment, and toward surviving and thriving with the new payment requirements, than the primary care physicians.

And you can even see the recognition of this fact by the specialties, many of whom are clamoring, for example, to be designated as patient-centered medical homes.

So it’s an unfamiliar situation for many of us who’ve been in primary care for some time. We have to seize this opportunity. Continue reading

China And The U.S. Face Similar Health Care Challenges

Dr. Su Xu, Director, Shanghai Minhang District Health Bureau

By Martha Bebinger

There are striking similarities in the vast and complex health care reform efforts that are underway in China and in the US. Leaders from both countries gathered at Harvard this week to compare notes and discuss collaboration.

The two countries are expanding insurance coverage and each is worried about rising costs. On costs, where patients go for care makes a big difference in China as it does in the US. A key challenge is how to persuade patients they don’t need to go to a hospital, especially high end hospitals, for routine care.

I had a glimpse of this problem in Shanghai early one morning last year. I had just arrived and was awake at dawn. From my hotel window, I could see a small crowd of people gathering outside the hospital across the street. There were lining up hours before the hospital opened, I learned later, to see a primary care doctor. Continue reading

Unanimous Committee Thumbs Up For Primary Care Bill

Rep. Jeffrey Sanchez

This just in from the office of Rep. Jeffrey Sanchez, co-chair of the committee:

BOSTON—The Joint Committee on Public Health voted unanimously in favor of “An act supporting the practice of primary care in the commonwealth.” Sponsored by Representative Jeffrey Sánchez, co-chair of the Committee, the bill eases statutory burdens to maximize the role of physician assistants and nurse practitioners in order to improve access to care for patients and free up physicians’ time for complicated cases requiring their expertise.

“While Massachusetts’ 2006 health reform made incredible gains in coverage, further work is required to transform the health care workforce into a more team-based approach to primary care,” Sánchez said. “As the Commonwealth moves forward in payment reform, it is crucial that we have a strong primary care workforce that can ensure all our residents are healthy and have access to quality care.”

In the context of payment reform, the Rand Report to the Special Commission on the Health Care Payment System projected savings up to $8.4 billion over 10 years if we enhanced patient care through increased utilization of nurse practitioners and physician assistants.

Increasing the number of primary care practitioners requires a multi-faceted approach. The bill reported out of Committee was amended to include a special commission on family physicians and other primary care physicians in community care settings.

As Rachel wrote here in April, the Massachusetts Medical Society opposed several bills this session that sought to enhance the status of non-physician providers, from nurse midwives to physicians assistants, arguing that they could endanger patients. (Jeff Sanchez’s response to their opposition is here.)

On other bills, from the public health committee:

The Committee also favorably reported bills relating to the scope of practice of optometrists and podiatrists, allowing for these providers to treat more conditions within the scope of their education and training, increasing access to these services.
Other bills reported favorably include An Act to eliminate racial and ethnic health disparities in the Commonwealth, An Act to establish community based grant programs to eliminate racial and ethnic health disparities in the Commonwealth and An Act to increase routine screening for HIV.

Time To Check On Your Primary Care’s Quality; Latest Statewide Ratings Are Out

Hot off the presses: New data that let you compare your primary care doctor to others statewide on 25 national measures of care, from diabetes to asthma to depression to the simple sore throat. WBUR’s Martha Bebinger reports:

Primary care doctors in Massachusetts are above the national average when it comes to providing preventive care, but there are still wide gaps in the quality of care they deliver.

“What that means is that you’re not getting the same care when you go to different doctors,” says Barbra Rabson, the executive director at Massachusetts Health Quality Partners (MHQP). “As patients we need to look and see how our physicians are doing because we want to make sure we’re going to physicians that are providing the best possible care,” adds Rabson.

MHQP surveyed more than 4,000 primary care doctors for this latest score card on the quality of physician care. The findings show, for example, that many physicians prescribe antibiotics for a sore throat without knowing if their patient has strep. Patients can look for their physician’s results here.

Here’s how MHQP sums up the latest data:

Primary care physicians in Massachusetts are making strides to improve overall care by closing gaps in variation, according to MHQP trend data. For example, colorectal cancer screening is one area of improvement. The screening rates have improved by eight percentage points over the last three years (from 69 to 77%) and variation among medical groups has shrunk by 10 percentage points (from a 47 point difference to a 37 point difference).

But there are areas where not all health care in Massachusetts is the same. When measuring how often a group tested children with a sore throat for strep when prescribing medicine, some groups gave the recommended care 100 percent of the time, while others did so only 37 percent of the time. A variation of 63 percentage points means that patients do not get the same care in every doctor’s office and that some doctors provide patients with a more appropriate level of care.

And here are some wonderfully succinct points fromthe MHQP release: Continue reading

Six Bold Predictions About The Looming Health Reform

Dr. Marc Bard of Navigant

On Tuesday, Dr. Marc Bard, chief innovation office in Navigant’s health care practice, explained five key points about the Accountable Care Organization, the coming thing in Massachusetts health care if the Patrick administration has its way. Today, Marc makes six bold predictions about what will happen as the state attempts its next major phase of health care reform:

1. New partnerships will sweep across the landscape.
The academic medical centers lack the primary care base they need to provide fully integrated care, and of course community health systems lack the high-level tertiary care; neither one of them can be a complete system of care. So the first thing you’re going to start to see is more consolidation. You’re already seeing it on the insurance side with Tufts and Harvard Pilgrim merging, and you’re going to start to see it with providers. And that’s going to call into question restraint of trade and get the attorney general involved, because some of these systems are going to look closer and closer to monopolies.

2. More tension in the system
In today’s’ environment, for the most part, providers of care are contractually pitted against payers of care. They’re a little like dogs and cats. They’ve never gotten along terribly well for obvious reasons, and they generally didn’t mind battling each other.

Now, what is being proposed in Massachusetts creates somewhat of a zero-sum game, doctor against doctor and doctors against hospitals; and that’s a less comfortable battle. And, it’s potentially going to be even less comfortable because with the ACO, there’s going to have to be more support for primary care, and if you’re operating with a fixed global payment budget, that means that the high-end providers, the high-end physicians and hospitals, are going to take the greatest haircut. That’s reality.

And by the way, I’m a strong advocate of capitation. Of all the payment strategies that have been used over the past decades, the one that truly fostered innovation was capitation, because it required the invention of new ways to deliver care on a fixed budget. So I like responsible capitation, it’s just that I’m realistic enough to appreciate that introducing it in Massachusetts is going to be very difficult.

Think of a bell-shaped curve. There are people at one end who absolutely need the high-end procedure and no one would dispute that. At the other end, I don’t need a total hip replacement. But there are a lot of people in the middle of the bell-shaped curve. The real question is: Do they need the procedure and do they need it now? And those kinds of borderline cases are going to come under much greater scrutiny. Who really needs a stent? Who really needs a bypass? What’s the data to support bypass vs. stent? The best example is Prostate Specific Antigen testing for men. There are going to be long-term studies that ask the question, who really needs surgery or radiation and if so, when?

3. The Massachusetts reform will go a major step farther than federal health reform on ACOs. Continue reading