Study Shows ‘Invisible’ Burden of Family Doctors

Study Shows ‘Invisible’ Burden of Family Doctors
By STEVE LOHR
Copyright by The New York Times
Published: April 28, 2010
http://www.nytimes.com/2010/04/29/business/29doctor.html?hp


A new study detailing the uncompensated work burden on family doctors points to the need to change how they are paid, medical experts say — particularly as the new health care law promises to add millions more patients to the system.

Family doctors make up the embattled front line of the nation’s health care system. They earn about half the money of specialists who focus on treating particular ailments or parts of the body. That is a reason less than 10 percent of medical school graduates choose so-called primary care, which includes general internists and pediatricians.

Worsening shortages of family doctors were being predicted even before the recent health care legislation, which opened the door to an estimated 30 million newly insured people who will begin making appointments for checkups and other care.

“There is already enormous pressure on primary care, and more is coming,” said Dr. Thomas Bodenheimer, a professor of family medicine at the University of California, San Francisco.

Comparatively modest salaries and rising patient numbers are part of the challenge, medical experts say. But so is the breadth of the unpaid work performed by family doctors. A study published on Wednesday in the New England Journal of Medicine measured that problem precisely, using computerized patient records and reporting systems to track all the tasks done in a five-physician practice over a year.

Family doctors are paid mainly for each visit by patients to their offices, typically about $70 a visit. In the practice in Philadelphia covered by the study, each full-time doctor had an average of 18 patient visits a day.

But each doctor also made 24 telephone calls a day to patients, specialists and others. And every day, each doctor wrote 12 drug prescriptions, read 20 laboratory reports, examined 14 consultation reports from specialists, reviewed 11 X-ray and other imaging reports, and wrote and sent 17 e-mail messages interpreting test results, consulting with other doctors or advising patients.

The article is the statistical answer to its title, “What’s Keeping Us So Busy in Primary Care?” The study, Dr. Bodenheimer said, “really quantifies the huge amount of invisible work in primary care.”

The study, medical experts say, also suggests the direction of changes needed if family practices are to flourish and more effectively improve the health of patients and contain costs. It starts, they say, with compensating doctors for work other than patient visits. Such work includes preventive care and helping patients manage chronic illnesses like diabetes, heart disease, cancer and asthma, which account for most of the nation’s health care spending.

The new health care legislation includes Medicare payments for preventive health and programs intended to encourage family doctors to assist patients in improving their overall health. And last year’s economic stimulus package included $19 billion in financial incentives for doctors and hospitals to accelerate the adoption of electronic health records.

Digital patient records, experts agree, can help coordinate and improve care, though using the technology in doctors’ offices is often difficult and time-consuming.

The Philadelphia practice made that difficult but worthwhile transition to electronic health records in 2004, said Dr. Richard J. Baron, the author of the journal article. His office is also part of a pilot project that compensates doctors for preventive and disease-management work, not just office visits. That program, begun in 2008, is sponsored by large insurers in the area and some local providers of Medicaid services.

The program, Dr. Baron said, has increased the revenue for his practice by about 15 percent a year. “It’s been a lifeline that provides us support to do the things we’ve been trying to do to keep our patients healthier and out of the hospital,” he said.

Similar pilot programs across the country have produced encouraging results so far, reducing total health care costs for patients with chronic conditions by 5 percent to 20 percent, according to Dr. Paul Grundy, an I.B.M. health expert who is president of the Patient Centered Primary Care Collaborative, a group of large employers, health care providers and insurers.

Dr. David Blumenthal, the Obama administration’s national coordinator for health information technology, said the study published in the New England Journal of Medicine was “full of important lessons for primary care and for the nation’s health system.”

In an e-mail message, Dr. Blumenthal said the study showed “the enormous strain” on family doctors, but also “a pathway toward escaping at least some of those burdens: the electronic health record combined with changes in workflow and payment.”