Blackwelder is also a practicing family physician in Kingsport, Tenn., and says as a trained physician, he may pick up on an issue with a patient's health that a nurse practitioner may overlook or attribute to something else unrelated to the visit.
"If I'm doing a well-child visit, for example, I'm noticing things differently than a nonphysician provider would."
Blackwelder says there is a place for NPs and others in a practice to help alleviate the patient load, but he firmly believes that the answer to primary care pressures is team-based care, led by a PCP.
Many modern care models include aspects of team-based care. Reliant, for example, puts PCPs at the center of its model, and Dignity's CI networks aim to coordinate patient care beginning with a PCP. But the biggest hurdle providing this type of care is the payment system, says Blackwelder.
"One of the biggest barriers is the reality that our current system pays for volume, and that has created some significant challenges all over the country in that we're not used to recognizing the value of primary care especially in the setting that physician-led teams can bring to the table," he says. "So as we transition from paying for volume to paying for value, the system we're trying to get away from doesn't have a way for me to easily document and be paid appropriately for it."
Blackwelder's complaint about not getting paid for the work he does to help manage patient care is echoed by many physicians. But that is changing, at least for Medicare patients. In 2015, physicians will be able to use a newly created "G-code" that the Centers for Medicare & Medicaid Services outlined in late 2013. The new code reimburses doctors for 20 minutes of care per month given outside of a face-to-face visit for Medicare beneficiaries who meet certain requirements. CMS calls the new code a milestone toward care coordination, but it may be more akin to a baby step if the administrative work physicians put in to manage their patient population exceeds 20 minutes.
Primary care's trailblazer
Some PCPs are not waiting for the government or insurers to catch up to the reality of how their daily practices are run. Instead, Tom X. Lee, MD, is meeting patients' demand for a high-tech, high-touch doctor visit with One Medical Group, a primary care practice he founded in San Francisco in 2005 that has since expanded to 27 sites in San Francisco, Boston, Chicago, Washington, D.C., New York City, and most recently, Los Angeles.
One Medical Group has been described as concierge medicine without the concierge price tag. But Lee describes it as a completely reengineered doctor's office.
"We are not concierge," he says. "Concierge is really designed for the affluent; ours is designed for everybody. It's a primary care system focused on delivering higher-quality care and service at lower cost. The way we manage that is through overhead reduction … and support systems."
The "support systems" are proprietary technologies Lee helped develop. The $199 annual membership fee that patients pay helps support noncovered services that are supported by technology. That in turn reduces the administrative burden and gives patients what they want now, which is access. Patients can make same-day appointments online or through the One Medical app. They can email their physicians directly, view lab results, access their medical record, request prescription refills, and request treatment for common issues—all from a smartphone.
Efficiency is what Lee focuses on most, and One Medical Group's offices are nearly paperless.
"What people underestimate is the complexity of workflow in healthcare in general, but particularly in outpatient and primary care," he says. "Unfortunately, traditionally the way doctors evolve is they have a very simple office to start, but through growing administrative and clinical complexity, they have hired staff and layered process on top of process and have continued to use legacy systems like paper and fax that are less efficient in today's world of technology."
Lee's concentration on maximizing One Medical's efficiency has reduced administrative staff from four employees per physician to two, or fewer in some offices. Lee does not want doctors spending time on paperwork; he wants them spending time with patients—a key measure he keeps track of constantly.
"In my mind, time is the key investment that we're making right now," he says, noting that a typical 10-minute doctor visit is not enough time to listen to a patient, make a diagnosis, and manage the patient's care.
"Our general bias is that in the office visit, time is the missing ingredient, and we've added that back. We're seeing 15–16 patients a day, about 30 minutes on average."
One reason Lee has been able to expand his model of primary care so quickly comes from his deep connection to Silicon Valley. After medical school, he earned his MBA from Stanford University, and while there developed Epocrates, the drug and medical reference app that debuted on Palm technology but has successfully migrated to smartphones. It is one of the most common apps physicians use today with more than 1 million downloads.
The success of Epocrates showed investors that Lee was a smart bet when it came to healthcare; venture capitalists have given him $77 million to date to invest in One Medical.
It is easy to point to the money and the technology Lee has had access to as the reason why he's been able redesign primary care for his patients, but he insists that those resources alone would not have produced such a result.
"It's a combination of process, technology, and people; all of those elements are interacting together," says Lee. "I think there are a lot of ideas in healthcare and not many people doing them. We're actually putting the ideas into action."
Lee's vision for designing a primary care practice is rooted in the days of his residency at Boston-based Brigham and Women's Hospital. He was disappointed at what he saw—heavy administrative burdens that interfered with a physician's ability to treat and care for patients. So instead of going into private or group practice, Lee headed to business school to find out how to run a practice the way he wanted to.
Now that he is, and getting attention for it—Forbes dubbed Lee one of its 12 Most Disruptive Names in Business in 2013—he wants people to know that his solution to redesigning primary care is not turnkey.
"It's hard to do," he says. "You can't model it. This isn't, frankly, assembly line production. Assembly line production is very moldable; you can calculate changes. The workflow that comes into doctors' offices is a lot more complicated."