Revitalizing Primary Care, Part 2: Hopes for the Future

Thomas Bodenheimer

doi:10.1370/afm.2859

Article Figures & Data

Tables

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Table 1.

The Impact of Diffuse Improvement Initiatives

	Panel Size	Access	Burnout	Primary Care Spending
PCMH	Studies are limited.³ PCMH practices have a broader scope of practice than non-PCMH practices, meaning they do more work to care for their panels.⁴	Waiting times for new patient appointments are similar for PCMH vs non-PCMH practices.³	In VHA, burnout was slightly lower with greater PCMH implementation.⁵ Clinician burnout in safety-net clinics increased with greater PCMH adoption, though staff morale improved.⁶	While some insurers paid small incentive payments to PCMH practices, many did not.
ACO	No data was found on panel size in ACO vs non-ACO primary care practices.⁷	Patient satisfaction (including timely access) was similar between ACO and non-ACO care except 1 study showing better access in ACOs.⁸ Timely access was not different between commercial ACOs and non-ACO providers.⁹	A 2020 review found little evidence on ACOs and clinician experience.⁸	Shared savings coming to an ACO may go to hospitals, specialists, and ancillary services, rather than to primary care. ACO savings are unlikely to improve primary care spend.
CPC+	Many CPC+ practice leaders could not accurately report panel size.¹⁰	90% of CPC+ physicians reported that their patients enjoyed after-hours access and electronic access compared with 80% of non-CPC+ physicians. Patients’ experience of access was not reported.¹¹	No difference was found between CPC+ and non-CPC+ practices on physician-reported burnout.¹¹	Medicare made enhanced payments to CPC+ practices, which added to those practices’ revenues and increased Medicare expenditures.¹¹

ACO = accountable care organizations; CPC+ = Comprehensive Primary Care Plus; PCMH = patient-centered medical homes; VHA = Veterans Health Administration.

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Table 2.

The Impact of Focused Improvement Initiatives

	Panel Size	Access	Burnout	Primary Care Spending
Care management	Care management does not change panel size but care managers (RNs, pharmacists, or behaviorists) assist clinicians in a major way to care for their panels.	Patient visits to care managers can add capacity and thereby improve access.	VHA physicians performing care management functions without help from a team is associated with increased burnout while RN care management eases the burden of burnout.¹²	Medicare care management codes require too much documentation and too much time spent for inadequate payment.¹³ Overall, reimbursement for additional personnel needed to perform care management is either absent or insufficient.
Open access		A systematic review found that average wait times drop. Elderly patients may be lost to follow-up.¹⁴ Access gains may be lost over time if practice realities cause capacity to decline.¹⁴
Telehealth		It is unclear whether telehealth adds primary care capacity. Telephone and video visits including documentation may or may not be shorter than face-to-face encounters.¹⁵	Because virtual visits may have fewer staff involved, more responsibility rests on clinicians.	Clinicians worry that telehealth will reduce primary care revenue.¹⁶

RN = registered nurse; VHA = Veterans Health Administration

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Table 3.

Contrasting Bellin Health’s Team Model With the Traditional Model

	Traditional Model	Bellin Health Model
Composition of core team	1 clinician, 1 medical assistant	1 clinician, 2 medical assistants (CTCs)
Who is in the patient visit?	Patient and clinician	Patient, clinician, and CTC
How does the visit proceed?	MA rooms patient, performs a few functions such as medication reconciliation, and leaves	CTC spends 10-15 minutes with the patient before the clinician enters, setting the agenda, taking the history, reconciling medications, identifying and closing care gaps. When the clinician enters the CTC scribes. When the clinician leaves the CTC explains the after-visit summary, may do teachback and health coaching, and helps with navigation.
Who documents the visit?	Clinician does 90% of documentation	CTC does 90% of documentation, entering findings and pending orders. Clinician quickly checks the chart and sends off orders.
Who answers most in-box messages?	Clinician	CTC can answer many of the messages without taking clinician time because CTC was in the visit, knows the patients, and is trusted by the patients
Training	Standard medical assistant training	CTC training is intensive; poorly trained CTCs could sink the program
How is the additional team member paid for?		Doing little documentation, clinicians have time to see more patients, paying for the extra team member
Quality metrics		Cancer screening, immunizations, chronic disease metrics improved with team care
Is patient access affected?	Before the model was implemented, 71% of patients received a timely appointment	With the team model adding capacity, 97% of patients receive timely access.
How is clinician satisfaction affected?	Before the model was implemented, physician satisfaction was 70%	With the team model, physician satisfaction reached 90%

CTC = care team coordinator; MA = medical assistant.

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Table 4.

Interprofessional Team Facilitators and Barriers

	RNs	Pharmacists	Behaviorists	Physical Therapists
Workforce and training	RNs may enter a period of shortage following COVID. Most nursing schools train hospital nurses and provide little ambulatory care education. 81 Fewer than 10% of RNs work in ambulatory care.⁸²	The nation has an adequate supply but 5% in ambulatory care.⁸³ Pharmacists are trained to provide such primary care functions as medication management.	National shortages are projected for psychologists and licensed clinical social workers. They are trained for ambulatory behavioral health but only 20% of primary care practices have a social worker.⁸²	PTs are experts in ambulatory musculoskeletal management Nationally, a surplus of PTs is projected.
Regulations	Many state laws restrict RNs’ authority to care for appropriate patients independently.	Most states allow pharmacists to initiate/modify medications under Collaborative Practice Agreements.⁸⁴	Behaviorists are authorized to perform all appropriate functions except prescribing.	All 50 states allow patients to see a PT without referral; PTs can perform all relevant services except prescribing.⁸⁵
Business case	RNs are more of an expense than a revenue producer. Medicare care management codes provide some payment but not enough.⁸⁶	Pharmacists’ billing is limited, meaning that pharmacists are often a net expense to primary care practices.	In a recent survey, 3 out of 30 practices with behavioral health integration had a positive business case, 10 lost money, and the rest did not know.⁸⁷	PTs in primary care cannot bill, but patients seen by PTs in primary care can be referred to a physical therapy practice where PTs can bill.

PT = physical therapist; RN = registered nurse.

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Table 5.

RN Co-Visits

Clinica Family Health in Colorado initiated RN co-visits in 2014, with nurses able to perform 8 co-visits per day. The RN takes the history, the clinician enters, and the RN becomes the scribe. The clinician leaves, the RN explains the care plan and arranges follow up services. Twenty- to 30-minute visits take 10 minutes of clinician time, the visit is billed as a clinician visit, and clinician documentation time is minimal. Capacity grew by 17% at 1 site and 12% at another. Patient access improved. Clinicians reported leaving work on time, with charting completed. RN and patient satisfaction were high.⁸⁸

RN = registered nurse.

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Table 6.

Demand and Capacity for Interprofessional Teams

In Part 1, we offered a thought experiment. A clinician’s panel of 2,000 patients generates a demand of 6,000 visits per year. Working 200 days per year and seeing 20 patients per day, the clinician has the capacity of 4,000 visits. Demand exceeds capacity and patient access is poor.

Now, assume that 1,000 of the visits are for diabetes, 1,000 for hypertension, and another 1,000 for uncomplicated back, knee, and shoulder pain. Imagine that registered nurses, pharmacists, and physical therapists can independently care for two-thirds of these visits, for a total of 2,000 non-clinician visits. Capacity increases to 4,000 plus 2,000. Capacity equals demand. Access has improved, and burnout has decreased. These numbers may not be realistic, but they make the point that interprofessional teams can improve access without increasing burnout.