Delegated Care and The 21 Hour Work Day For Primary Care Providers
No wonder we are facing a looming shortage of primary care physicians, the ones we do have don't have time to sleep. According to the Physicians Foundation, in 2014 81% of physicians say they are overextended or at full capacity and 44% plan to reduce patient access to their services. There are not enough hours in a day for providers to do their job so they are cutting back on patients seen, retiring, working part-time and even closing their practices to new patients.
While some doctors have to cut back, their number one concern is still caring for their patients, with 76% of physicians reporting their greatest satisfaction came from patient interactions. Physicians want to spend time with their patients doing things that matter and are willing to cut back in order to do so.
To put numbers on the gap between what needs to be done and what can be done, this Duke University Study from the Department of Community and Family Medicine states:
Primary care faces a dilemma. On the one hand, the average primary care physician’s panel size is too large for delivering consistently high quality care under the traditional practice model. Estimates suggest that a primary care physician would spend 21.7 hours per day to provide all recommended acute, chronic, and preventive care for a panel of 2,500 patients. The average US panel size is about 2,300.
A well-known trend has been the emergence of concierge doctors, who have patient panels of between 600-1000 patients. But this is still the minority of practices, and doesn’t address two key issues--we would have to double the number of primary care physicians in the US in short order, and most Americans would have a difficult time paying for that service.
Another path that a variety of supporters have suggested is the delegated care model. The delegated care model assumes that tasks are assigned to the least expensive resource that can competently fulfill the task. Law firms, accountants, and consultants have operated in this model for decades. The Duke research goes on to estimate that if certain tasks were delegated, such as preventative and chronic care services, a physician could reasonably service a panel of close to 2000 patients.
Another point of view that advocates the same change in the primary care model, is from the Clayton Christensen Institute. They suggest that many chronic care management tasks can be delegated to other clinical staff, and that primary care physicians can move into specialist areas to have the most meaningful patient experience and to keep their head above water financially.
So, with an understanding that more must be delegated, why doesn’t it happen? In a word, money. The old fee for service model, with few exceptions, only lets physicians bill for care in the office environment, which led to the treadmill we are on today. The newer shared savings models accommodate new care structures, but require a large investment with an uncertain payoff. Fortunately, CMS has recognized this dilemma, and has started to reimburse for qualified clinical help to care for the patients when the patient is away from the physician. (see With New Chronic Care CPT Code 99490 is CMS Getting Serious About Chronic Care).
Getting the most out of patient visits
The doctor and the patient want the time they spend together to be meaningful. Neither party wants a physician to fill out forms that either the patient or someone with less qualifications can take care of. Likewise, patients are happy to discuss ongoing care from the comfort of their homes with qualified personnel that work with their physician. The delegated care model can advance the quality of care for the patient and allow time for a full night's rest for the doctor.