Lawrence Casalino is a primary care physician. He’s also the Livingston Farrand Associate Professor of Public Health at Weill Cornell Medical College in New York City. This is a man who knows a lot about the field of primary care as both a practitioner and as an academic. While I like policy wonks, I think we need people like Dr. Casalino to be involved when we start talking about making health policy changes that will require physician buy-in to be successful. After all, who knows better how doctors think and will react to a proposed policy change than doctors themselves?
With that in mind, I read with great interest a recent piece Dr. Casalino authored in Health Affairs, which looks at the way the typical primary care doc’s day is structured and asks “Is it the best arrangement?” One thing he talks about is using the phone and email to become more efficient. He writes:
“As the number of patients for whom a primary care physician feels responsible gets larger, the number of phone calls that could be made–for both minor acute and chronic care–continues to increase…But the more time we spent doing that, the less time we had to see patients in person–and the only thing for which we were paid was when I, the physician, saw patients in person. So we didn’t make as many calls as we knew would be optimal–a moral and professional compromise, but one that seemed necessary if we were to remain in practice.”
He even wonders what the typical primary care doc’s day would look like to extraterrestrial observer:
“The visitor would notice that physicians spend at least seven years training. Their time, therefore, should be valuable. Is this the best way for them to use it? As pieceworkers running from patient to patient as fast as they can? Always with a little clock in their heads, exquisitely conscious of the seconds ticking by while a patient tries to say something? As hamsters, running faster and faster just to stay in place? Doing things that less highly trained people could be doing?”
It’s obviously a set of rhetorical questions, to which Dr. Casalino’s answer is an emphatic “No!” But what do we do to change things? Well, for starters, he suggests that physicians begin to distinguish between necessary visits and those that could be handled with a phone call or an email. He offers six criteria for defining a necessary visit, for which I’ll refer you to the original article (a subscription may be required). This will help cut down on daily visits. By Dr. Casalino’s estimate, only 8 to 10 of a primary care doc’s 20 to 30 patients a day actually need to be seen in the office. In addition, he suggests that docs take on the task of better coordinating their staff, focusing on preventive care and chronic disease management, and establishing performance improvement processes.
Then the question becomes “How do we implement this change?” Dr. Casalino gives a fairly detailed answer, so I’ll just sum it up: We have to pay for it. Doctors aren’t going to take on new administrative tasks, send emails and make phone calls if they don’t get paid for it, no matter how much more efficient it might be in theory. So we need to find a way to pay docs for making phone calls and sending emails, but a way that can’t be easily abused and that doesn’t require a huge administrative burden. Capitation is one thought. Capitation with pay for performance is another. The other thing is that we need to start reimbursing for clinical services provided at the doctor’s office by someone other than the doctor. Of course, there are lots of institutional forces that fight against these types of changes. Still, I think Dr. Casalino makes a great point.