Report from CEO Terry McGeeney

Thinking "Inside the Box"

Primary Care is under tremendous pressure today just fighting for survival. There is ever increasing evidence that the US Healthcare system is in real trouble. Costs are the highest world wide, quality is near the bottom and a recent study reports that US life expectancy is 46th in the world among developed countries. Another recent article correctly pointed out that the more doctors a patient sees, the less chance a patient has of doing well. There is something terribly wrong with this picture.

It is becoming increasingly obvious to many that all patients need access to quality health care, all patients need a medical home to coordinate care and all patients need a personal physician in the context of a medical home. All great observations, but reality soon follows.

There are not enough primary care physicians now and there will be even fewer going forward, based on recent residency Match results. Many physicians choose primary care because they value engaging in a relationship with the patient that is unequaled in any other area of medicine. The problem is that relationships don't pay the bills. The current US health care system does not value primary care and cognitive services at the level that makes primary care sustainable even in the near future. A recent article by CNN stated that while specialists in other countries make 30% more than primary care physicians, in the United States that figure surges to 300% while simultaneously providing some of the lowest quality in the world.

There is significant momentum for change at the national level but that will take time. Today's primary care physicians are faced with today's realities and need to work hard to remain financially viable today.

One of the observations from the National Demonstration Project is that in spite of all of the inequities in the payment systems of today, some Family Medicine practices are doing much better than others financially. We always talk about thinking outside the box and certainly we should do that when thinking about changing the US Healthcare system, but when it comes to practices we need to first think "inside the box". We need to address the issues we can address.

Some recent statistics from the AAFP are enlightening. A recent survey indicates that the average Family Physician makes approximately $150,000 per year and sees around 2.5 patients per hour. Other studies suggest that the average FM salary may be more in the $160,000 range, but either is woefully inadequate. What we have come to understand is that the system pays physicians for seeing patients and not for all of the important care that is being provided throughout the day. That said, in today's world a primary care physician simply can't make a living seeing 2.4 patients an hour.

Physicians correctly say "I can't make the treadmill or hamster wheel go any faster, seeing more patients is not an option". While working harder or going faster is certainly not a viable option in most practices, seeing more patients may be. Physicians can only see 2.4 patients an hour because they are overwhelmed with everything they are not paid to do.

Some physicians and some practices have learned how to manage these challenges and consequently do much better financially. Since the goal is to free up physician time for him/her to do what he/she does best — see patients — successful physicians and practices set up processes to allow others to do what does not require 4 years of medical school and a 3 year residency.

When we at TransforMED look at practices' processes and flow, it is appalling how much time physicians spend going to the printer, looking for handouts, talking to reps, going to the sample closet, getting to work late and multiple other "little things" that add up to a real time commitment by the end of the day. There are other things that are not so little and take a great deal of uncompensated time such as refills, medication and referral authorization, FML and Disability forms, etc. While these are certainly a burden, office processes can minimize the time requirements to that physicians can do what physicians are trained to do.

• Refill protocols are a great tool to allow nursing staff to manage prescription refills.


• Medication samples that most likely will not be covered by payers create an additional staff burden. Simply writing for generics and meds on formulary save a trip to the sample closet and the inevitable follow up calls and authorization requests.


• Workload can be further reduced by medical record documentation clearly giving directions to nursing staff relative to medications, testing and plan.


• Process management and appropriate delegation can also be successful in managing authorizations. An accurate medical record that anticipates the issues can be very valuable to the support staff and keep the issues off the physician's desk. One would hope than when an issue does make it to the physician's desk, the appropriate chart and information is there the first time.

Physicians rarely take time to reflect or evaluate. The old saying that they are too busy wrestling alligators to consider draining the swamp certainly holds true. But it doesn't take a great deal of time to do a real-time reality check. As you go through your day ask yourself: "Did I need to perform that activity personally? Did an inefficient action of mine actually create that extra work or piece of paper?" The answer will many times be yes.

Not only should the physician constantly reflect on process improvement and practice efficiency but also the entire team should be challenged to do so. This is a tremendously powerful tool. This combined energy can find ways for the physician to see patients, do what he/she went to medical school for and get paid for it within the existing system. Thus the TransforMED model of care focuses on teamwork. Every member of the office staff, including the receptionist who greets the patient as they walk in the door, should be part of the team. And the entire team should be focused on the patient's needs, rather than the clinical staff's needs — and certainly not just the physician's. Staff should also be trained to anticipate physician needs and patient needs and not wait for the physician to spell them out. This is often not the case in inefficient practices and the reason often given by staff is that the physician is too unpredictable to anticipate. Job satisfaction actually goes up for staff when they are perceived as valuable and allowed to work at their maximal potential.

There is also great opportunity to improve practice revenue over and above creating the opportunity for physicians to see patients.

• Practices often don't recognize that every chart pull costs money — up to $7 in some environments to pull a chart (which may involve looking for it for hours), acting on it and re-filing it. Often there are several chart pulls just to get that med from the sample closet approved.


• Every time a bill is resubmitted it is a cost that often can be avoided.


• Unused space is an overhead issue that is often ignored. Every square inch of space in an office should be maximally utilized for as many hours per day as possible. It's interesting to note that when a practice needs to increase capacity by hiring providers it often is a forgone conclusion that more space is required. A viable option that should always be considered is to extend hours, which is good for patients and good for the practice.


• It is also often a forgone conclusion that when a practice encounters a problem, the solution is to hire more staff rather than look at the processes that led to the problem. There is also great opportunity in making sure that all staff members are functioning at their maximal training level. It is amazing how often high RN salaries are paid just to get patients roomed or mid-level providers are used just to see overflow.

There is a lot going on "outside the box" but unfortunately in many practice environments there is not much momentum for change and maximizing opportunity "inside the box". It is not about working harder but working smarter. It is not about spending more, but spending less more wisely.

Once the basics are addressed – practice management, finances and teamwork – the practice will be more financially viable, staff will be happier and time will be created to plan and strategize for things outside the box. A practice with a strong foundation it is better situated to leverage opportunities such as virtual or e-visits and the tremendous efficiencies gained from a well-implemented Electronic Medical Record. More and more studies emphasizes that the key to EHR is "well-implemented" and that is unlikely to occur without a good grasp on office efficiencies and processes.

Family Medicine practices are very complex ventures with a team that possesses a wide array of skill sets and a multitude of issues that must be dealt with simultaneously. Certainly this is not an easy environment to manage, but well worth the effort "inside the box". It should not be managed just by the physician but by the team — with the right members of the team playing the right role at the right time.