William Fox, MD, a self-described “dinosaur,” works in an independent internal medicine practice with two other physicians in Charlottesville, Virginia. He is rarely able to accept new patients, and when he does see one, they often have to wait months for the appointment. He accepts the burden of many pent-up needs, along with the huge administrative chore of coordinating their care with subspecialists.
“I will probably have to make multiple visits in a quick succession in order to make sure that I stabilize all the various issues,” Dr. Fox said. Doing so for a complicated new patient is nearly impossible because of time pressures, especially as it has become increasingly difficult for his patients to access subspecialists.
Dr. Fox traced the roots of the problem to a shortage of primary care physicians.
“Primary care is a vital part of healthcare and infrastructure in the United States, and it is being eroded unfortunately, as fewer and fewer medical students and residents choose to go into the primary care field,” Fox said. “And the reason it’s being eroded partly is because it is undervalued” and under-reimbursed, he added.
A study published 2 years ago in the Journal of General Internal Medicine proved what every primary care clinician already knows: The 24-hour day simply isn’t long enough.
Assuming an average panel of 2500 patients, the authors estimated the average time needed to provide currently recommended preventive care services and vaccines, chronic disease care, and management of acute illnesses. The answer: 26.7 hours a day.
However, using a team-based approach in which the necessary care was divided between physicians, advanced practice providers, and medical assistants, the physician component could be whittled down to 9 hours.
As chair of the Board of Regents of the American College of Physicians (ACP), Dr. Fox champions the ACP’s endorsement of physician-led team-based care, which improves patient outcomes and increases well-being among health professionals. But practices like his rarely have the necessary resources to support advanced practice clinicians or social workers. “Team-based care can be achieved in larger healthcare systems that have the resources to do it,” said Dr. Fox. “We need to find a way for smaller independent practices to also participate in team-based care.”
The solution? Major reform in the current fee-for-service payment structure, which incentivizes patient volume over patient outcomes. Dr. Fox co-authored a 2022 position statement from ACP outlining strategies such as prospective payment models that could achieve high-quality care and address social inequities. “We need to evolve our payment system from a fee-for-service system into a blended system where you have some population-based payments along with fee-for-service, or a fully capitated system,” he said.
Advantages of Team-Based Care
When a patient wrote on a satisfaction survey “the doctor spent more time examining the computer than examining me,” Kevin Hopkins, MD, decided he needed to change some things. Now the vice chief of Cleveland Clinic’s Primary Care Institute in Cleveland, in 2010, he developed a rudimentary team-based care model consisting of himself and two medical assistants at Cleveland Clinic.
The assistants did much of the patient intake, served as scribes while Dr. Hopkins saw his patients, and completed most of the required documentation. “I was able to see 30% more patients in a day and still take great care of them,” Dr. Hopkins said.
The concept of team-based care has evolved since then, often including some combination of advanced practice providers such as physician assistants (PAs) or nurse practitioners (NPs), nurses or medical assistants, and social workers or case managers working under the leadership of a physician. According to Dr. Hopkins, the basic strategy should be that “the physician does what only the physician is uniquely trained and qualified to do.” All other tasks, such as data entry, handling refill requests and messages from the patient portal, scheduling, or patient education, can — and should — be done by someone else.
Dr. Hopkins also serves as a senior physician advisor to the American Medical Association (AMA) and an instructor for workshops like “Saving Time: Practice Innovation Boot Camp.” His advice for clinicians who would like to streamline their workflow is to start with small steps.
“You’re not going to be able to hire all the people that you’d like to have,” he said. “I encourage physicians to look around at the people that they have and what they are currently doing as a part of their roles and responsibilities.”
The AMA Team-Based Care and Workflow website provides brief continuing medical education activities on topics such as implementing lab testing prior to office visits or advanced protocols for rooming and discharge; adopting any of these strategies can help save steps during office visits.
Dr. Hopkins said the AMA is committed to reducing the regulatory burden on clinicians. Clinical compliance officers may misinterpret regulatory requirements, putting into place overly conservative internal policies and procedures. The AMA’s “Reducing Regulatory Burden Playbook” offers advice on practices that could be stopped, such as two-factor authentication for approving or signing orders unless they are for controlled substances, or started, such as writing prescriptions for chronic daily medications for the maximum allowed length. Reducing a few clicks with each log-on to the electronic health record or reducing the number of tasks physicians must complete to log on can dramatically reduce hours spent on the computer.