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Value in Primary Health Care

There was a very interesting article in the November 2013 issue of “Health Affairs” by Scott A. Shipman and Christine A. Sinsky M.D. (Expanding Primary Care Capacity By Reducing Waste And Improving The Efficiency Of Care pg 1990-1997). Looking at typical primary care & internal medicine practice they conclude that providers spend a great deal of their time in “non-value adding work” NVAW that could be eliminated or done by other staff. Some of the benefits of their recommendations include; improve physician satisfaction, reduce evening and weekend hours, reduce staff overtime, provide more services, and serve more patients. They note the challenge the recommendations present to some practices, but note “However, the notion that the physician should be directly in charge of every aspect of care is becoming increasingly outdated.” I have worked the last 3 years with a FQHC (Federally Qualified Health Center) providing primary medical, dental and behavioral health services. Our core medical services are provided by board certified family practice physicians and nurse practitioners (ARNP). We implemented team based care years ago with a behavioral health specialist, team assistant, certified medical assistants, and a masters level behavioral therapist on each team. A version of this team approach is not uncommon at FQHC and progressive private practices around the country. I also had opportunities to collaborate with a broad group of community providers from private practice and health systems. It became very clear that the FQHC in the group were accustomed to a very different practice style than the majority of those in private or large system practices. As I read the “innovations” discussed in this article it sounded mostly very familiar, having implemented many of the ideas years ago. I also remarked that other practices might find the ideas very foreign, and perhaps even threatening. A foundational premise is that each team member practices at the top of their license. This should be applied to all staff, licensed or not. This mental model suggests that none of us should be involved in NVAW, and no patient focused practice can afford to pay licensed staff to do clerical work. This is consistent with a Lean approach to care design. Specific recommendations include delegation of preventive counseling, patient coaching, and aspects of chronic care. Deliver care by phone, secure messaging, use web tools for screening, and protocol driven E&M of common acute conditions. Some groups have hired “flow managers” who help ensure the seamless flow of patients through the practice with minimal waste, and others dramatically expand the role of team assistants and CMA. Physical design ideas include team based office space instead of private offices, printers in exam rooms, and standardized equipment and supplies in each exam room. The authors note that if we could save 30 minutes per day of provider time we could provide over 30 million more visits per year without adding a single provider or working a minute of overtime. The key requirement is to open our minds to new possibilities as we continually increase the efficiency and effectiveness of our practice. I highly recommend the article.

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