Two Steps Forward, Three Steps Back

doctor-563428_1280By Angela Gargus

The last few years has brought certain buzz words and concepts to the forefront in the medical field – things such as the triple aim, population health management, and patient-centered medical homes.  All wonderful concepts but hard to establish with declining reimbursement and increased regulatory burdens.  Every day I hear physicians complain about the amount of data collection required of them to meet Meaningful Use, PQRS or HEDIS requirements.

When patients are scheduled 15 minutes apart, by the time the nurse has taken the vitals and roomed the patient, at least one third of the visit is gone.  This gives the provider 10 minutes to perform the exam and ensure all required data points are completed.  The meaningful part of the visit, where the physician and patient are supposed to develop the patient’s plan of care together (per the health-home concept) is already past the patient’s allotted appointment time.

To do everything in a visit that is required while still meeting the needs of the patient requires longer visits.  Longer visits mean less patients seen in a day which translates into less revenue and longer wait times for appointments.  For our practice, electronic health records decreased the number of patients which could be seen by 40%.  The addition of PCMH and meaningful use further decreased the numbers by 15%.  For us, that is a 55% reduction in visits per physician over the course of six years.

This reduced access is a major barrier to care at a time where the population is aging rapidly and there is a primary care physician shortage.  The medical students we see on clinical rotations give data collection requirements and regulations as the main reasons for not going into primary care.  Those that do choose primary care plan to work as hospitalists or in concierge medicine.

My suggestion for a solution is to remove some of the data collection elements from the primary care physicians.  Place these elements into a home health type environment but without the skilled need and home-bound requirements.  Allow each patient to have at least one, maybe two, in-home visits per year that do not require a physician’s order.  A registered nurse could address such things as preventative care, weight, nutrition and medication adherence as well as provide a functional assessment to determine the patient’s ability to remain independent at home.  Initial screenings for depression and substance abuse could also be performed – all in the privacy of the patient’s home.  Another idea would be for a nurse or social worker to provide parenting support and education on the care of newborns, including the importance of timely check-ups and immunizations.  All information collected would then be shared with the patient’s primary physician and insurance company as needed.

To improve our healthcare system, we need to be looking at how we can utilize the resources and systems already in place – not creating new pieces in a system that still doesn’t talk between all its parts.


Angela Gargus’ essay was submitted as part of the 2015 Costs of Care, HFMA, Strata Decision Technology, and Yale New Haven Health’s contest entitled The Best Care, The Lowest Cost – One Idea at a Time.

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