Dr. Chris Hakim lives in a version of the not-so-distant past.
He practices modern medicine and spends as much time as he likes with patients without issue—a departure from the growing trend in health care.
“The patient is now seeing a physician who doesn’t decide how much time he spends with a given patient,” Hakim said. “Those things are dictated by someone else. There are guidelines to everything and they come from administration.”
Over the 35 years Hakim has been working in health care, he’s learned the heartbeat of good care’s rhythm is the trust and relationship between patient and provider. His second 15 years practicing and running an independent practice with up to 25 employees, he saw how things were changing and adapted as best he could.
But those forces causing changes have been “turbocharged” in recent years, according to Hakim. The rheumatologist saw firsthand how some patients, particularly older ones, struggled to deal with the shifting landscape of obtaining care from people facing their own pressures in providing it.
The rise of administration has stretched physicians and encouraged private practices to join with systems that could provide infrastructure to meet new IT burdens and deal with government- and industry-sponsored plans so the physician could spend more time focusing on health again.
“Patients are witnessing the change of command here and who is in control, who is making all these decisions and it’s changing the experience all around,” Hakim said.
Millions of Americans stopped having a primary care provider between 2002 and 2015, according to a Harvard Medical School Researchers study completed in 2019. The sector is grappling with a wave of retirements and not enough doctors taking their places—causing an increasing reliance on a series of other health care providers with less formal training to fill that space.
They all share the drive to make people feel better, whether they are nurse practitioners or physician assistants, and they are referred to differently depending on whom you ask—physician extenders to some, advanced practice providers to others. Regardless, they are stepping up to fill the breach as a shortage of primary care physicians crests as the average age of Americans continues to grow older. This means many Americans get less face-to-face time with the dwindling number of primary care doctors.
Advanced practice providers “certainly expand our capacity and allow a team to manage more patients than they would if it was just a physician by themselves,” said Dr. Steve Pearman, vice president of medical operations for Sentara Medical Group.
“Things the way we used to do (them) are not going to work for us in the future,” Pearman said.
The physician shortage was created by a variety of issues, from a lack of residencies despite growing medical school class sizes, more pay for specialists than primary care providers despite the debt burden of becoming one of those being similar, and other factors, he said.
One of the pressures among the physician shortage is the modern reimbursement model called fee for service, Pearman said.
“The fee for service reimbursement model creates a tension between access and capacity and the way we get paid,” he said.
The transactional interaction means depending on service units times the number equals the reimbursement and primary care loses money in many ways, Pearman said.
“It’s very hard for independent primary care physicians to make money in a free for service world,” he said. “And many times, the solution to reducing costs is to reduce what they’re paying the physician rather than focusing on things like do you really need to do other procedures or surgeries. So in that sense, there is a certain amount of pressure for physicians and APPs to see a certain number per day.”
Sentara tries to find the sweet spot between volume and the necessary amount of care for a patient, he said. This also encourages systems to avoid having open spots so that they can cover their expenses and costs, but that also comes at the expense of chilling the ability of patients to see physicians the same day.
Templates exist with 15 to 20 minute slots and 30 to 40 minute slots divided by hours in the day to gauge how many patients must be seen in a day to cover expenses, he said.
“The trick is to be efficient enough to hone in on the most important things during that encounter and maybe address things outside the encounter if they pop up,” Pearman said.
He said he had APPs in his primary care practice in the ’90s and patients generally understood if they couldn’t see him and would trust and like the APP who would provide care for them in his stead.
“This transition for patients, physicians and APPs as well, is that we want to maintain a personal relationship with them,” Pearman said. However, there are visits—such as for a prescription refill—where an APP can see the protocol and can get it done.
“There are a lot of parts of care that we provide and we can decant on to other parts of the team to allow more time for me in the room with you when I see you, and other ways of communication back and forth,” he said. “So seeing patients less often does not necessarily mean it’s less personal.”
Coordination of services provide different types of access meant to address people’s needs, Pearman said. For example, in chronic care management, there are likely those who’d rather receive an in-depth call each month than wait six months to see a doctor face-to-face with a list of issues that have worsened in that time, according to Pearman.
“In some ways, if we do this correctly, it’s going to be better and more and they’ll get more touches versus less touches with one person,” Pearman said.
And he agrees the trust and relationship between providers is vital for the patient and the system.
“To me, it is the crux of how primary care reduces health care costs,” Pearman said.
In some states, such as California, there are value-based health contracts where reimbursements are based on effectiveness in preventing health issues, he said. The fee for service model, where reimbursements are based on services provided, is much more ubiquitous in Virginia, according to Pearman.
Insurance providers recognize the balance of costs and care for patients, according to Monica Schmude, president of Anthem Blue Cross Blue Shield in Virginia.
“If there’s a limit of access to care because there’s not enough providers, then certainly preventative care measures are going to be sacrificed and we’re going to have more chronic conditions,” Schmude said. “So there’s a domino effect.”
“It’s critical that every patient has a relationship with a physician,” she said.
Very low out of-pocket/no out-of-pocket costs is a major incentive that drives patients to physicians for preventative care and in commercial groups, build incentives as well for preventative care, according to Schmude.
“The goal here is to have 100% compliance—100% of their workforce has a physician relationship—that’s the place to start,” she said. “Then as a physician encounter is needed, they know where to go, they’re probably less inclined to go to the emergency room for things that are less emergent and they’re more inclined to call a physician’s office to direct that care accordingly.”
Schmude said one of Anthem’s leading proposed solutions is incentivizing physicians and other providers to “practice at the top of their license.” This means distributing tasks to those most qualified to do them—allowing the most time for the most qualified people to complete the most complicated tasks, she said.
Additionally, Anthem sees digital platforms like the one they have that can help bridge any potential gaps in care by ensuring people are able to get the care they need quickly. However, Schmude said she considers her parents as an example of how technology is not a single solution to the issue.
Again, this is where other programs and support can be provided by insurers, like Anthem, to free up provider time for patients, she said. These wrap-around programs are more based in the community, and especially for the community, not just a technological answer, she said.
These days, Hakim has a refreshing connection with the Peninsula patient community through his work as a doctor at the Lackey Clinic in Yorktown.
“That is what people I think are seeking in this world where so much of that is slipping away,” Hakim said. “And of all the places they counted on, it was going to be in their personal health care and what they thought of as a relationship-based type of interaction.”
Though there are many areas, such as personal banking, where new systems have risen to reduce costs and streamline, Hakim said. But health care is one area where those kinds of changes don’t just mean a minor difference of seeing an ATM versus a human bank teller.
Health care “was kind of holy space and you didn’t tamper with some of that, but we’re well into the process of a radical conversion there and it’s very difficult, especially for older people,” he said.
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