It is time to dethrone the office visit as the king of primary care physician compensation and how the work of a primary care physician is defined.
Several months ago, a reporter asked me how many patients I see in a typical day. I told her that the question should not be how many patients I see each day, but how many patients I take care of each day, a number that is significantly greater.
Why office visits rule is no mystery. For decades, they were the primary source of revenue and activity for outpatient primary care practices. If a patient wanted care, they had to make an appointment. Office visits were easy to count and bill. While there was non-face-to-face work, it was usually non-billable and took up a small part of the work day.
The workflow and business models of the 1990s, when I entered private practice, were all about office visits. Today, patients are able, encouraged, and expect to be cared for outside of the traditional office visit. They are more engaged in their care, messaging us via portals, accessing their test results directly, and sharing data from their blood pressure machines and glucometers. Additionally, outreach to patients beyond visits is at the heart of population medicine and advanced primary care. These place additional demands on primary care physicians’ time outside the exam room.
The evolution of patient care
How have health care organizations handled this evolution? Despite proclamations that they are “patient-centered,” many are still “visit-centered.” Under this paradigm, any care that is not provided in an office visit is considered to be “administrative work,” an imposition that is valued less than seeing a patient in an exam room.
Office visit “productivity,” or its alter ego the work RVU (wRVU), remains at the center of the primary care physician’s life, as it was in the 1990s. Some practices build time into physicians’ schedules for the non-visit work, but it is usually inadequate and undercompensated (or uncompensated). Rather than seeing fewer patients and potentially facing pushback or financial penalties from loss of wRVUs, physicians do the non-visit work before and after office hours, during lunch, or weekends, contributing to the frustration and unhappiness that we see today.
Primary care physicians’ cognitive work and the value to patients and the practice from non-face-to-face care are significant, so why is it marginalized?
The administrative burden
Complicating matters, efforts to reduce the burdens on primary care physicians do not distinguish between tasks related to taking care of the patient and those related to taking care of the system. Meaningful clinical work such as providing advice in a portal message is lumped with non-medical tasks such as signing an order to get a patient a new wheelchair tire.
While I agree that we should get low-value activities such as prior authorizations, forms, and routine refills off physicians’ desktops, and that we should use team-based care to support physicians, I have concerns about initiatives that offload important clinical care that physicians provide outside the exam room, instead of simply getting office visits out of the way. Why not better enable primary care physicians to take care of their patients regardless of where that care is delivered instead of creating new barriers?
A diversified revenue stream
Unlike when I entered practice, today the revenue stream to health care organizations is diversified. New payment models are built around panel size, cost of care, and quality, reducing the dependence on billable encounters. They provide opportunities to look at the work of primary care physicians differently, recognizing the value of non-face-to-face care by providing and paying for the time to do it.
The last compensation model that I worked under was a step in that direction, basing compensation on patient panel size. However, it did not let go of the past, as there were also wRVU thresholds that needed to be met. Other organizations have gone further and structured compensation and scheduling so that doctors can do doctors’ work, whether it be in the exam room or at the keyboard, without the wRVU stresses that contribute to career dissatisfaction.
At the macro level, delivery reform stresses paying for outcomes instead of volume. Yet at the physician level, we are still stuck at volume, which is contributing to the demise of primary care.
Defining the future
Put more succinctly, if a primary care physician commits to taking care of a panel of patients and gets the job done as judged by validated clinical measures, cost of care, urgent care or emergency department use, and patient feedback, why should how many patients they see in the office matter?
Patient care that is provided outside traditional office visits needs to count as much in compensation formulas and schedules no less than office visits do. Accepting that principle may be more important to the future of primary care than reducing hassles, giving everyone a scribe, fixing the RUC, eliminating educational debt, or opening new medical schools.
Yul Ejnes is an internal medicine physician.
