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How the Medical Home May Save Primary Care

 |  By Philip Betbeze  
   September 06, 2013

Years ago, with his office in chaos, Peter Anderson, MD, looked for a better way to practice primary care. He found it by developing "family team care," a model that looks a lot like what we call today the patient centered medical home.

Peter Anderson, MD, would have quit medicine in 2002 if he'd had an alternative.

Run ragged by his role as a primary care physician who served as a "gatekeeper" to his patients, frustrated by having invested early in electronic medical records yet working longer and harder, and getting poorer as he added staffing to comply with administrative responsibilities foisted upon him by payers, he was depressed and looking for an exit strategy.

"When I went on an EMR, that cut my productivity by 35%, and I was paying $2,500 a month for that privilege," he says. "I knew EMRs were the future, and I didn't go to medical school to get creamed by a machine, but that's what happened."

Instead of practicing efficient and effective healthcare, Anderson says his goal became "seeing as many patients as I could without making a mistake."

Even that was not enough. His office was in chaos, two of his nurses were openly threatening to quit, and his patients were dissatisfied. Besides that, he didn't know them.

"I had to focus more attention on the EMR than on the patient and lost patient interaction," he says. "That loss of connection was disheartening, but you lived and died by that EMR chart."

Far from a technology Luddite, Anderson was adept at using an EMR Hilton Family Practice way back in 1998 as part of the Riverside Medical group, a network of more than 80 practice locations and 325 board certified physicians and other providers in Newport News, VA.

But the EMR in his practice was adding workload without any increase in patient throughput. He had a Eureka moment one night while reviewing charts at 3 a.m. He realized it wasn't technology and the payer systems that were dragging him down—at least not fully. It was his lack of foresight in changing his practice's processes. Anderson, like many of his colleagues, knew there had to be a better way.

"This has created a tremendous amount of burnout in physicians today," he says.

He began experimenting with creating a better way to practice primary care, and it began by letting go a little bit. By now his techniques are common knowledge and frequently implemented in the journey toward patient centered medical home status, but in 2003, when he began to transfer more authority to his nurses through a team-driven approach to primary care, he was on the cutting edge, along with Paul Grundy, MD, and Michael Sepulveda, MD, who at the same time were working on the same problem for IBM.

Grundy has since become known as the "godfather" of the patient centered medical home, and, in a gross oversimplification, has pioneered physician practice transformation that focuses on the patient and delegates tasks that used to be the exclusive territory of MDs to non-physicians. The PCMH model also puts a lot of emphasis on the power of preventive medicine.

The key to Anderson's plan was simple in theory if difficult in practice: Give back some time to the physician so that he or she could focus more on the patients and less on routine activities.

Others were empowered to enter information in the electronic medical record, for example. Nurses were given increased responsibility in the exam room. In short, Anderson was creating aspects of the medical home concurrently with the more famous authors of the system, although he didn't know it at the time.

His goal was simply rediscover the enjoyment of practicing medicine before being driven to quit it altogether. He wanted more quality time with his family, he wanted to know his patients, and he didn't want his nurses to quit because of "chaos."

The morning after those two nurses, who had been with him for 20 years, said they were going to leave, he asked them both to give him six months to redesign the practice. If they still wanted to leave after that, he said he'd probably walk out the door with them. They agreed.

"The key to medicine is having a physician who knows you and sees you when you need to be seen," says Anderson, who in his darkest hour in 2003, couldn't even guarantee that his practice would be able to open the next day, given his nurses' frustration. His book on this journey, The Familiar Physician, explores the transformation in depth and provides hope for the downtrodden primary care physician.

The familiar physician is a play on the old concept of the family physician, which he says went away with the advent of managed care.

"Primary care physicians became the gatekeepers. Instead of getting patients closer to primary care, which is more cost effective, the exact opposite happened," he says. "Instead of increasing the value of primary care, the system made it so you had to get through the primary care doctor before you get the 'real care' you needed, which led to a crisis in identity and value."

In an effort to get back to what made medicine attractive to him initially, consulting, cajoling, and helping his patients, he had to delegate, which is one of the main tenets of Grundy's patient centered medical home concept.

Anderson says he just paid attention to his instincts. He came up with what he called "family team care," and taught his nurses to do everything in the exam room that a physician did not have to do.

"It cut my time in the room in half and yet gave us a better product," he says.

The first full year, his collections went up by $100,000. Given that his practice had been losing $80,000 a year, that put it back into the black. But the bigger transformation was among his staff's morale as well as his own.

For the first six months, the whole team had a special meeting each week to redesign how care was delivered in the practice. Though detailed, the meetings essentially took everything away from him except practicing medicine.

Yet 10 years after his practice made the transformation, he says too many physicians are failing to understand the power of it.

"I was in Connecticut last week and the docs are still ignoring the reality that things have to change," he says. "Their office visit looks the same as 50 years ago. What other business would still be around if that were the case?"

He says he engaged in conversation with a dermatologist, for example, who had just purchased his practice for a million dollars.

"He doesn't realize he's not going to be as busy. People won't be free to go to any derm they want to," says Anderson, who asked whether the physician was looking at trying to join any ACOs in his area. Many ACOs require PCMH designation to be included in their network, but Anderson says the physician's response was, effectively, "what's an ACO?"

"He will be in the position of being surrounded by strong ACOs and if [he doesn't] get into one quickly, he might have to declare bankruptcy," says Anderson. "That's what the system is struggling with—individual physicians. The leadership physicians get it, but the grass roots physician is working pretty hard to ignore it."

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Philip Betbeze is the senior leadership editor at HealthLeaders.


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