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From “Winnie The Pooh”: Edward Bear And Primary Care

Here is Edward Bear, coming downstairs now, bump, bump, bump, on the back of his head, behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there really is another way, if only he could stop bumping for a moment and think of it. 

– From A.A. Milne’s “Winnie the Pooh and the House at Pooh Corner.”

Internists, I expect, will identify with Edward Bear.

Richard Baron’s study in the NEJM on the amount of work he and his colleagues do outside of an office visit — the “bump, bump, bump” of a busy internal medicine (IM) practice — has resonated with many of his colleagues.

Jay Larson, who often posts comments on this blog, did a similar analysis for his general IM practice in Montana, and found that for every one patient seen in the office, tasks are done for 6 other unscheduled patients. Jay writes: “So really there [are] internists [who] are managing about 130 patients per day. Not much consolation when they only get paid for 18 per day.”

The “bump, bump, bump” of everyday practice includes:

– Prescription renewals and pharmacy callbacks.

– Calls to family caregivers.

– Return calls to worried patients.

– Review of lab studies.

– Follow-ups with consultant physicians.

– Pre-authorization requests from insurance companies.

– 15-minute office visit on top of 15-minute office visit, all while dealing with the other bumps of a harried day.

And what do they get paid in return? $65 for a mid-level office visit (Medicare payment rate).

The good news is that people are beginning to think of ways to finance and organize primary care that — that at least in theory — would improve outcomes and reimbursement, lower costs, and increase patient and physician satisfaction. These include patient-centered medical homes and accountable care organizations. Common elements of these models include:

– Team-based care under a physician’s supervision, so that some of the “bump, bump, bump” work of physicians might be managed by an advance practice nurse, physician assistant, or other qualified non-physician, allowing physicians to spend more time with the more complex patients who really need to be seen by them.

– Paying physicians for to the work outside of an office visit and for achieving better outcomes, efficiently, to reduce the “bump, bump, bump” of having to generate an office visit in order to get paid.

– Better care coordination, to reduce the “bump, bump, bump” of duplicate testing, unnecessary referrals and return visits, and incomplete information sharing between a patient’s primary care physician and other specialists involved in their care.

The challenge with these models, though, is that internists are so busy taking care of their patients, in a system that undervalues their work and imposes way too many bumps to the back of their heads, to stop bumping for a moment and think of a better way.

Question: Is there another way to organize care that would involve fewer bumps to the back of internists’ heads, if only we could stop bumping for a moment and think of it?

*This blog post was originally published at The ACP Advocate Blog by Bob Doherty*


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