Reengineering Primary Care (Again)

A few years ago primary care was all about being Patient Centered. But that turned into a bureaucratic set of superficialities that didn’t do half as much for patients’ experiences, let alone outcomes, as many of its proponents had envisioned.

Now, other forces are making us reexamine not only how we do things, but even what we are doing.

Our clinic’s Federal grant for next year will be smaller. A provider is leaving. Medicare is starting to shift from paying us a per visit fee to paying us for reaching randomly chosen quality targets. The mandates of what to fit into each visit are growing continually – very specific alcohol habits, physical activity level, sexual orientation, and on and on.

We only have so many providers, so many nurses and medical assistants and so many exam rooms. Practices around us are losing providers faster than we are, and more and more patients want to enroll with us.

The Patient Centered Medical Home recognition we achieved promised to give us some modest bonus payments, but it also cost us money in its nit-picking implementation, and now we are facing financial issues that overshadow such symbolic bonuses as PCMH incentives. It is simply time to roll up our sleeves and redefine the basics of what we do while trying to figure out how to meet the increasing demands from the community we serve.

We have previously paid lip service to the idea of having staff members work to the top of their license, because we have been stuck in the notion that only providers can enter orders and sign off reports in the electronic medical record, for example. We hold our providers to productivity targets that could easily be much higher with more support staff and more effective work flows, not only in terms of units of service but also “covered lives”.

The time has come for all of us to sit down, management with providers, nurses, medical assistants and clerical staff to look at our unique situation, our resources, our patients and start from scratch:

What can we do, here and now, and what do we envision in our own future, to better serve our patients?

If we don’t have enough providers and don’t expect to get many more – increase support staff and liberate us from unnecessary clerical tasks.

If we don’t have enough exam rooms, create check-in stations between the reception and the clinic area. Use technology to let patients check in via tablets or their own smartphones in the waiting room or even from home before they show up.

If we don’t have enough people to answer the phone to triage and make same-day appointments, open blocks of time for walk-in care, and divide providers’ time between protected time for time-consuming patients and intense stints doing urgent care.

Invest in building better EMR templates for faster documentation.

If we can’t afford or don’t want scribes to follow each provider into each visit, allow use of a paper visit form and hire one data entry person to input a stack of such forms at the end of every day if that might increase provider productivity.

In other words: Imagine local solutions for local needs.

The other day I read these encouraging words in the Harvard Business Review:

“The lesson for leadership is clear: Design your practice to maximize physician capability. Productivity, cost effectiveness, and satisfaction will follow.”

PCMH wasn’t the solution, because its recognition criteria were too rigid. Maybe the latest crises we are facing will turn into opportunities to bring some real life and passion into the next round of changes we must make in how we serve our patients and our community.

As a doctor, I solve problems all day long. As a Medical Director, I welcome the opportunity to bring my experience to the table where all of us can brainstorm in order to redefine, redesign and reengineer what is still a pretty inefficient system.

3 Responses to “Reengineering Primary Care (Again)”


  1. 1 Brian Pierce MD December 10, 2017 at 2:24 pm

    I’ve tried tweaking several complex practices with too much built up patient demand and not enough staff or revenue to make it sustainable in the long run.
    Are you really shocked that the payers didn’t come through for primary care practices that jumped through the hoops of PCMH and all the latest acronym programs? Why would it be different this time?

    Maybe your problem isn’t too few staff people but too many.

    Physicians and patients need to rethink how they receive and pay for primary care. Consider a return to a simpler, affordable, effective doctor patient business relationship.

  2. 2 Joe Hill December 10, 2017 at 6:44 pm

    Don’t hold your breath. All of these “innovations” weren’t designed to improve patient care, they were designed to decrease unit cost. And we, as providers, foolishly bought into it. We delivered great, quality care that was cost effective long before all the whiz kids, bean counters, and visionaries started redesigning the “metrics”. I am sick of it and intend to retire as soon as I am able.

  3. 3 vanslix December 16, 2017 at 2:41 am

    And this is exactly why I am heading towards a cash based practice. Fewer people between me and the patient. None, actually.


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