I went because after years of being an ardent supporter of team-based primary care, I decided last spring to switch to practicing geriatrics in a solo micropractice.
This is a career development which I still consider with mild surprise. I was after all (and continue to be) a huge fan of Tom Bodenheimer's work proposing that primary care should be delivered by high-functioning teams, rather than by overwhelmed clinicians trying to do everything themselves.
However, finding a high-functioning team to join is not so easy. Part of the problem is the still-predominating fee-for-service payment system, which generally doesn't reimburse medical work that isn't provided face-to-face and by a "billable provider" (i.e. physicians, NPs, PAs, but not RNs). This can really cripple outpatient geriatric care, which I believe ideally would involve plenty of phone follow-up, care coordination, and nurse-led coaching interventions.
Of course we now have a move towards accountable care organizations (ACOs) and value-based payments, but it's not yet clear how this trend will mean for the experience of the average on-the-ground primary care clinician. (Will ACOs be yet another stakeholder complaining about what we didn't do? Or will they lead to substantive support in helping us do our work well?)
Furthermore, even when funding mechanisms support a team-approach to primary care, one still needs the team to be high-functioning. As most people who've worked on teams can tell you, not all teams work well. This is especially true in primary care, where healthcare providers may be asked to take on very different roles without getting adequate coaching and support in making the requested changes. (To his credit, Bodenheimer is well aware of the rhetoric-reality gap when it comes to teamwork.)
What's a clinician to do when she wants to provide high quality outpatient care but is worn out by primary care as usual?
My answer -- for now -- is to try an independent micropractice. The micropractice is the brainchild of Dr. Gordon Moore, a family medicine doc who realized that by leveraging technology to strip his practice setting down to a minimum of staff (as in, none) and overhead, he could practice better primary care. Better, as in, his patients were happier and he was happier. In particular, Moore found that this model:
- Improved access, leading to better care and better patient satisfaction. Being the only one answering the phone means a clinician can respond quickly to patient requests, and is always in the loop.
- Allowed more attention to direct patient care. A small lean practice requires less management and coordination, especially when technology is effectively leveraged to handle administrative work.
- Facilitated longer patient visits. The average primary care practice spends 50% of revenue to cover overhead. Less overhead means less need to pack in revenue-generating visits every day, which means a clinician can earn a decent salary while giving patients longer visits (often resulting in higher patient satisfaction, provider satisfaction, and better care).
This last point, however, is what makes many primary care wonks nervous. Longer visits may mean happier patients, but if a clinician can make a living caring for a smaller patient panel, many start to worry about exacerbating the looming shortage of primary care providers.
Still, the micropractice model in many cases has led to macrosatisfaction for patients and physicians, and that is no trivial thing.
In fact, in listening to Gordon present this past weekend on the key tenets of Ideal Medical Practices (he has very sensibly broadened the IMP term and focuses on what constitutes ideal outpatient medical care, rather than on micropractices per se), I was struck by how well the IMP concepts dovetail with what I hear patient/consumer advocates saying they want.
What I see patients/consumers clamoring for, and how the IMP model meets the need:
- Access: they want to be able to reach their healthcare provider promptly, as needed.
- IMPs offer excellent phone access and usually open access scheduling.
- Relationship: they want to feel that the healthcare provider knows and understands them, and they want to be able to work with a compatible provider repeatedly.
- IMPs prioritize the patient-physician relationship; in small IMPs almost all patient needs are met by the patient's usual provider.
- Patient/consumer centered care: they want the healthcare to be organized around their priorities, and not just what the provider, or healthcare system, thinks should be the priorities.
- IMPs emphasize care that is driven by the patient's needs, goals and values. Many use the "How's Your Health?" online questionnaire to regularly provide clinician's with the patient's self-assessment of health and needs.
- Technology: they want healthcare providers to communicate via email and other new technologies, and to keep up with emerging technologies that might improve health and care coordination.
- Virtually all IMPs use technology to maintain a high-efficiency/low-overhead practice. Most IMP providers are available to patients through some form of messaging.
- Coordination: they want their primary healthcare provider to communicate, connect, and coordinate with other providers.
- Technology often facilitates this.
- Support in self-management: they want providers to help them feel empowered and confident in their ability to self-manage their health.
- By leveraging a collaborative relationship, a focus on patient-centered care, and technology, IMPs are generally able to successfully address this need.
In short, IMPS generally offer a smaller intimate practice setting which is well-suited to providing the close and collaborative patient-physician relationship that historically has been the foundation of good primary care. Just as many of us enjoy patronizing smaller local businesses, especially if we get to know the owners, patients often enjoy a smaller independently owned practice.
So if patient engagement really is the "blockbuster drug of the century," as David Chase proclaimed in Forbes magazine last month, then IMP practices should certainly be on the radar of those looking for high-quality primary care.
What about team-based patient-centered medical homes? Well, those are a good concept too, but transforming practices may take some time. (You can read about lessons learned from the National Demonstration Project here.)
In the meantime, yours truly is trying out the micropractice/IMP model for herself, and will keep you posted on how it goes. Fortunately for me, the IMP community is largely focused on providing practical assistance to other clinicians trying to start or maintain IMP practices, so I've been getting some much appreciated support and advice. ((Disclosure: the IMPs have formed a nonprofit group, and I paid to become a member last April, which gives me access to some members-only informational resources.) I'd certainly heartily endorse this creative and spunky group to other clinicians contemplating a similar practice shift. Thanks IMPs!
|Me with Dr. Anna Maria Izquierdo-Porrera, a geriatrician with an amazing practice in Maryland (www.care4yourhealth.org)|
|Dr. L. Gordon Moore, who is now doing really fascinating work for Treo Solutions (negotiating improved payment models with big payors). Who wouldn't listen to a man in tie-dye?|