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The Human Cost of Physician Burnout: It’s Worse Than You Think

The Human Cost of Physician Burnout: It’s Worse Than You Think

This article is the second in a three-part series on physician burnout. The first installment focused on the financial costs of physician burnout. This second article focuses on the human or personal side of physician burnout.

Ready to quit

In early 2019, Dr. Miller was preparing to quit his hospital-owned practice near Cincinnati to launch his own concierge practice (we’ve changed his name to protect his privacy). Dr. Miller loved his patients, he didn’t want to do this, but he was trapped in a patient care model that was failing him. He found it impossible to provide the care he wanted to his patients while maintaining a life outside of medicine. The updating of patient’s charts in the EHR was totally dominating his evenings and weekends. He was single and hadn’t been on a date in months. 

As his frustration and dissatisfaction peaked, he decided to make the difficult change to a concierge model. The disruption for him, his patients, and his soon-to-be-former employer would be very costly, but he just couldn’t take it anymore. 

Nationwide problem

Sadly, stories like Dr. Miller’s are repeated all across the country. Long-term unresolved job stress has led doctors to feel exhausted, overwhelmed, cynical, and detached. A recent Mayo Clinic Proceedings article concluded that doctors are 50% more likely to battle emotional exhaustion than the average American worker. Primary care physicians are particularly susceptible – they’re 40% more likely to experience burnout than specialists.

As a result, many physicians are looking for an exit. They are seeking administrative jobs to reduce patient time or have accepted a half-day or even a full day of “admin catchup time” to avoid the negative impact on their families, to the detriment of their paycheck. Other doctors are simply retiring earlier than planned to escape the grind. Still others are transitioning to different practice models altogether. Many fantasize about quitting medicine and starting a new career. Collectively, these escapes reduce patient access without solving the underlying problems that precipitate burnout.

For physicians that are unable to escape, many feel the walls closing in month after month. They become disenchanted with their profession, even hating medicine. They detach from their families and friends. Medscape’s National Physician Burnout & Suicide Report of 2019 found nearly 4% of US doctors (35,000!) are clinically depressed. Tragically, some have even turned to suicide to end the misery. One doctor commits suicide in the U.S. every day – the highest suicide rate of any profession. And the number of doctor suicides – 28 to 40 per 100,000 – is more than twice that of the general population. It’s no surprise that solving physician burnout ranks in the top 5 on most hospital CEO’s list of priorities.

Unfulfilling work

Burnout starts with long hours: the average physician works 52.6 hours per week, or 30% more than the average US worker. It’s even worse for the 40% of doctors that work more than 60 hours each week. However, having persevered through medical school, long hours are not the sole cause of burnout. The nature of the work is just as much of an issue. With more and more time dedicated to data entry in EHR charts, many doctors have gradually lost their personal connection with their patients – they’ve lost the “Joy of Practicing Medicine”.

The tremendous pressure to close charts causes many physicians to feel they are simply a cog in the healthcare machine with no higher purpose than capturing revenue. They long for the day when they felt like a valuable knowledge resource, like a practitioner of medicine with an essential vocation. What they thought they were signing up for is NOT what they are experiencing.

Irritable and isolated

Physicians’ families have a front row seat to the destructive power of burnout. Spouses, kids, parents, and friends all see the internal battle between a desire to deliver quality care for their patients and their need for a personal life. 

After a full day of patient visits (often feeling pressured and running behind by the end of the day), many physicians come home, feed the kids, help with homework, rush the kids to bed, and then jump back on the computer for 2-3 hours of additional chart work. Spouses are forced to pick up the slack, often causing more stress and friction at home. 

Burnout manifests itself in increased isolation, greater irritability, more time away from home, less communication, less time together, a drop in physical intimacy, and emotional separation. Frayed relationships at home only add more pressure on the physician. A real-world solution is desperately needed.  

The solution: It’s simpler than you think 

Given the breadth and depth of the problem, a variety of solutions have been tested to combat physician burnout, often having little or no effect. Sadly, many so-called solutions fail to tackle the underlying issues and instead apply “Band-aids” like meditation, breathing exercises, and relaxation techniques. 

A recent InCrowd Survey asked physicians what they wanted their hospital administrators to do to help them combat physician burnout. Their #1 response (at nearly 66%) was to add more staff to help ease the administrative/documentation burden. Any serious attempt at solving the burnout problem needs to take this information seriously.

One common approach is hiring a scribe for each physician to interface with the EHR, a bit like a “human app” added to the computer. While this is a step in the right direction, the scribe model comes with a significant limitation: because the doctor is still in the exam room throughout the entirety of every patient visit, scribes don’t provide a boost in productivity sufficient to pay for their additional cost. As a result, hospital executives choosing this solution simply add more cost to primary care offices which are usually already operating deeply in the red. 

A better and more financially sustainable solution is to implement the Team Care Medicine (TCM) Model. The TCM Model is gaining traction nationwide and has been proven to significantly boost physician productivity and reduce/eliminate physician overtime (often referred to as “pajama time”). For example, a six-doctor primary care practice in the Midwest launched the TCM Model and within six months had reduced average “pajama time” by nearly 80% (see below).

Even as they reduced after-hours work, these providers were able to see more patients each day. As illustrated below, their average visit volume increased by 35%.

Best of all, these physicians are experiencing a restored “Joy of Practicing Medicine”. They’re reestablishing connections with their patients and with their families. Remarking on happy physicians, happy patients, and happy administrators, one doctor called it a “Win, win, win!”

After launching the TCM Model, Dr. Miller abandoned his plan to switch to concierge medicine. With his charts current before the end of each workday, he’s started exercising again and is enjoying a long-term romantic relationship. This was unthinkable just 6 months earlier!  

The TCM Model has been implemented in hundreds of doctor’s practices across the country. Here are just a few of their comments about its benefits.

 

“The executives and administrators see the upside of increased productivity, the quality of care is better and I’m having fun. I enjoy practicing medicine again.”   

Patrick Anderson, MD

Richmond, IN

 

“[Now] I go home with nothing to do but play with my children and I have no reason to come in on Saturday.” 

Travis Howell, MD

Winston-Salem, NC

 

“I realized this was the model we needed to adopt. Not only for our patients, but also for our own well-being.”

William Byars, MD

Greenville, SC

 

“As for my personal side, the TCM Model allows me to have a life outside of medicine, which I didn’t have before.”

Dick Albert, MD

Mebane, NC

 

“I love it…I am having ‘fun’ again!” 

Jerry Dempsey, MD

Cincinnati, OH

 

How does it work?

In the TCM Model, the role of the physician is upgraded from overloaded work horse to team captain. The clinical support staff (usually MAs) are equipped to operate up to the limit of their license, performing 7 new skills that relieve the physician of unnecessary administrative burden. With a larger team of higher functioning clinical support staff, the physician is able to focus on the patient (not the EHR), to focus on diagnosis and care decisions (the reasons they went to med school), while the MA experiences more meaningful work and the practice enjoys higher revenues. For more information, go to www.teamcaremedicine.com.

In Their Words: An Executive’s Perspective on the TCM Model

We are continuing our series of interviews with providers across the country as more and more practices adopt the TCM Model. In this edition, we hear from Dr. Thomas DeMarco, Vice President of Peninsula Regional Medical Group (Maryland). He completed his degree at the University of Louisville, an internship at the University of Pennsylvania, and returned to the University of Louisville to complete his residency. Dr. DeMarco adopted the TCM Model in 2019. What follows are his reflections.

 

Our Love/Hate Relationship with Provider Productivity

Our Love/Hate Relationship with Provider Productivity

This is the first in a series of communications on productivity and its far-reaching effects on our individual futures and the future of healthcare. In upcoming blogs, we’ll examine the link between productivity and an effective medical home, discuss some of the impediments to greater productivity and then see what it looks like in the exam room.

The driving factor in lack of access

There’s always talk about improving access, but low productivity, the driving factor behind reduced access, doesn’t get much respect. It should. It’s estimated that 38 percent of primary care visits in 2015 were unnecessarily diverted from the PCP office to the ED, urgent care centers and retail clinics. That’s a lot of lost visits, to the detriment of the practice – and especially to the patient because fragmented, limited care is no substitute for the kind of cost-effective quality that comes with continuous, comprehensive care.

What’s to love about productivity?

Getting back to our love-hate relationship with productivity, the “love” part is a matter of economics. While there are some exceptions, compensation has historically been based on the number and intensity of services provided. Metrics and methodologies can vary, but for the most part, the more patients seen, the more the likelihood of financial success. Although we continue moving toward fee for outcome-based payment models and next-era indicators for productivity, the wRVU standard remains in place for the majority of employed physician and physician owner practices.

And what is it that we hate?

As it turns out, there’s a darker side to this straightforward work-pay relationship. For primary care providers who already feel maxed out, it’s the vision of the hamster wheel. You hear the word “productivity” and you think of an industrial age assembly line, complete a conveyor belt, bringing endless numbers of patients in and out of the exam room. This scenario may be a bit extreme, but a system that incentivizes volume without supplying support staff with the specific skills need in primary care exam rooms can end up creating a negative impact on the missions of preventive medicine, wellness, education and basic patient care itself.  As a result, productivity is not only distinct from, but may also be anathema to quality and service.

If that isn’t bad enough, increased productivity carries the threat of overwhelming the already fragile work-life balance that providers often struggle to maintain. That’s why discussions of productivity can create concerns in the areas of both professional and personal satisfaction.

Why greater productivity is a necessity

In recent blogs, we’ve talked about how pursuing the Institute for Healthcare Improvement’s Triple Aim remains critical for maximizing overall health system performance and a reliable constant in the ever-changing map of healthcare. We’ve also discussed the value to primary care providers of capturing more acute care patients who might otherwise seek to have their medical needs met at retail clinics or urgent care centers due to limited access at their provider’s practice. The common element in both of these objectives and the most effective way to achieve this improved productivity.

However, without a corresponding increase in the kind of efficiency that supports productivity – and in turn leads to greater access – our ability to attain the Triple Aim, along with our hopes for meeting the needs of acute care patients will never reach fruition. And as we will discuss in the next blog, neither will our ability to bring the medical home to an effective reality.

Uncommon Bedfellows: Access, Expanded Hours, and Provider Wellness

Uncommon Bedfellows: Access, Expanded Hours, and Provider Wellness

In the first installment in this two-part look at the role of acute visits in primary care, we focused on the benefits of building this capability. In this continuation, we’ll discuss what needs to be in place in order to get there.

Improving access for acute, same day patients offers important benefits to practices and patients alike, but it takes a little thought and effort. The good news is, the mechanics are well within reach. I promise not to delve into queuing theory, wait-time metrics or any elements of what can be the surprisingly complex subject of medical scheduling. But I will share with you a bit of my own practice experience.

Opening up an adequate block of time at the end of the morning and another at the close of the afternoon…

…allowed us to better balance acute patient needs with organizational resources. What’s amazing is that these blocks were the easiest and most pleasurable part of patient visits for my clinical staff even though there could be 6-8 patients scheduled for each hour-long block.

This approach, which did not include a move to a true open access model, enabled us to stay on track with our scheduled patients and then see acutes collectively. Generally, it offered enough choice to accommodate individual patient schedules. If not, we could usually bring them in whenever they could make it and adapt accordingly because of the efficiency of our exam room process.

Utilizing high-functioning assistants who are empowered with the specific skills needed inside the exam room…

…is the single most important factor contributing to timely and consistent access for acute care patients. By building a more effective team in the exam room, providers can focus on direct patient care, those things that are commensurate with training and skills – and not the non-provider activities that can represent up to 60% of the patient encounter.

For example, in the typical routine (non-acute) primary care visit, the provider spends 10-15 minutes with what would be considered exclusively provider responsibilities and 10-20 minutes with non-provider responsibilities. Now, with the staff handling all the non-provider responsibilities inside the exam room, the provider is free to move on and see the next patient much more quickly.

I’ve seen improved exam room protocols work effectively in my own practice and in scores of other primary care and specialty practices with which I’ve been involved on an educational and training level. However, it’s important to note that the kind of transformation needed for more acute care capacity as well as all other patient visits isn’t simply a function of adding personnel. It involves true process redesign and a commitment to culture change, with a bit of professional flexibility and patience thrown in.

Expanded hours…

…have to be part of the solution if a patient’s need for access is going to be truly met by a familiar primary care provider. By building a more efficient team inside the exam room, increased productivity will allow for shortened shifts as well as fewer shifts per week. The result is that a small group of providers will have evening and weekend access collectively for their patient panels while promoting a very healthy work/life balance for providers individually.

Extended weekday and weekend hours and greater flexibility in overall scheduling are providing additional options and removing more of those times when, as the urgent care promotions put it, “your primary care provider is unavailable or you’re unable to make a timely appointment.” It’s not always easy, but an improved exam room process and the productivity that goes with this make expanded hours eminently doable.

Realizing that the time and energy spent on seeing more acute visits is not a distraction…

…but rather an opportunity with a range of inherent benefits is the most important step in preparing a practice for increasing acute visits.

Despite ongoing uncertainty in the direction of health reform, the four legs of the primary care table continue to be competence, continuity, accessibility, and affordability. A practice without timely access to a familiar provider when a patient perceives an urgent need is like a table with only three legs. Missing that access leg doesn’t make for productive quality-based primary care any more than it forms a solid, reliable and well-functioning table.

And speaking of tables, we’re leaving too much on them if we’re not ready to increase access for same-day, acute care patients.

In Their Words: An Executive's Perspective on the TCM Model

In Their Words: An Executive’s Perspective on the TCM Model

 

We are continuing our series of interviews with providers across the country as more and more practices adopt the TCM Model. In this edition, we hear from Dr. Thomas DeMarco, Vice President of Peninsula Regional Medical Group (Maryland). He completed his degree at the University of Louisville, an internship at the University of Pennsylvania, and returned to the University of Louisville to complete his residency. Dr. DeMarco adopted the TCM Model in 2019. What follows are his reflections.

 


The TCM Model has changed our provider’s outlook on practicing medicine and increased their productivity.

3 MIN VIDEO

 

 

 

Reprioritizing Exam Room Goals

All in Good Time (Management): Reprioritizing Exam Room Goals

There’s a prevailing opinion among providers that time is equal to care; the more time a provider gives a patient, the greater the level of care or genuine compassion he or she has. That’s just not true. The quality of care we provide to our panel is what determines success—not the amount of time we spend in the exam room.

Starbucks hasn’t come to the exam room

Our inappropriate focus on socializing with patients has led many of us to prioritize the unnecessary goal of what I call a “Starbucks moment.” We’re under the impression that patients want and deserve unlimited time to relax, catch up and discuss anything that’s on their mind during a visit, regardless of how long it takes. And perhaps some of us have come to believe we deserve a “break” too—a respite from the demands of our busy schedule, spent in the company of a patient with whom we have a genuine, enjoyable connection.

We must remove this idea of socializing from the context of appropriate medical care. The strength of a provider/patient relationship isn’t dependent on the amount of time spent with patients, it’s founded upon and maintained by the right balance between personal connection, timely access, and competent medical care. Personal involvement is critical for a provider to know the patient and make the right decisions for his or her care. But unlimited time not only fails to produce better health outcomes; it negatively impacts access for the rest of the panel.

Trust is the intangible component that makes the provider/patient relationship unique and health producing, not the amount of time spent together in the exam room. Patients generally consider provider competency a given because of the amount of education and training every provider receives, but timely access and communication are the key to building trust. No matter how good the provider, if she/he is not available to the patient, the patient loses trust. What patients want and need, besides competency, is timely access to a provider in whom trust has been developed – a familiar provider.

(A small caveat here. There will be instances when unlimited time is the right solution for patients with special circumstances or emergency concerns. But those exceptions shouldn’t drive day-to-day operations.)

Priority management

As I’ve written previously, time management begins with priority management. And if we’re going to fix primary care, we must begin by rethinking our priorities. So what are the exam room priorities for providers?

  • Maintain personal involvement with each patient to create or sustain health
  • Create access for the panel (in other words, see all the patients in the panel who need to be seen on a particular day) [links to TCM schedule content offer]
  • Make the necessary medical decisions for patients when they need care rather than refer to another provider
  • Empower clinical staff to accomplish all the ancillary (or non-provider) work inside the exam room
  • Communicate with patients in a timely manner (accomplished with participation of the clinical staff)

None of the goals above challenge or threaten the personal connection between providers and patients, and they actually incentivize greater trust by giving patients the care they need when they need it. And all of these priorities address the concerns of the individual patient as well as the rest of the panel, leading to better population health and meaningful provider/patient relationships.

Keeping the main thing the main thing

Primary care providers must begin thinking in terms of time and work within appropriate boundaries to give patients the access and quality of care they need to become and remain healthy. This means reorienting priorities inside the exam room and elevating health-producing strategies over “feel-good” moments that don’t actually create health.

The value of this cultural change in the exam room has enormous potential to transform our primary care delivery. Reprioritizing the goals of the exam room will lead to the improved access, health outcomes and cost-effectiveness our patients, panels, systems and society so desperately need.

In Their Words: By the End of the Day On the EHR, My Head Was About to Explode

In Their Words: By the End of the Day On the EHR, My Head Was About to Explode

We are continuing our series of interviews with providers across the country as more and more practices adopt the TCM Model. In this edition we hear from Jim Kolp, DO, Board Certified in Family Medicine and Osteopathic Medicine. He completed his undergraduate work at the University of Cincinnati, completing medical school at the University of Akron and Ohio University, and a family medicine internship and residency at Ohio University. He is affiliated with The Christ Hospital Physicians (Ohio) and he adopted the TCM Model in 2019. What follows are his reflections.

 


We have happy doctors and happy patients. The doctors are more productive (they’re making some more money), patients are getting better quality time, and the hospital system is increasing its capacity. It’s a win-win-win!

3 MIN VIDEO

 

 

 

Hope for Atul Gawande and Doctors Across America

Hope for Atul Gawande and Doctors Across America

In a recent New Yorker article entitled, “Why Doctors Hate Their Computers”, popular author and surgeon Dr. Atul Gawande skillfully explores the pain caused by the electronic health record (EHR) system at his hospital system in Massachusetts. Sadly, he concludes the piece with a vague exhortation that we must “insure that people always have the ability to turn away from their screens and see each other,” while offering no tangible solution to the long hours, lost patient connections, and burnout that he observes around him. Fortunately, proven solutions exist and they’re right under his nose.

Familiar Problems

In his typical, accessible style, Gawande explains how “a system that promised to increase my mastery over my work has, instead, increased my work’s mastery over me.” Finding records and adding new information to the EHR has consumed more and more time and attention, resulting in significant take-home work and frustration by doctors. Meanwhile, patients and physicians alike are frustrated that the personal connection has been lost as eye contact is replaced by staring at the computer screen. It’s a familiar refrain by doctors all across the country as burnout approaches epidemic levels.

Band-Aid Solutions

In an effort to unshackle providers from the EHR, some have hired scribes to document the patient exam. Gawande describes the approach exquisitely, saying “This fix is, admittedly, a little ridiculous. We replaced paper with computers because paper was inefficient. Now computers have become inefficient, so we’re hiring more humans.”  The problem, of course, is that scribes don’t fundamentally change the equation for the provider; they’re basically just a very expensive voice recognition software that’s “installed” on the the computer through the keyboard.

Answers in Plain Sight

As a doctor himself, it’s not completely surprising that Gawande only speaks in terms of individuals rather than teams. Even as he interviews doctors, patients, office managers, hospital administrators, and even a virtual scribe/MD in India, Gawande fails to connect with any of the thousands of nurses and medical assistants (MAs) that work in the same exam rooms as the doctors at his hospital. All too often these colleagues are overlooked by the doctors they serve. Nevertheless, the path to restoring the joy of the doctor-patient relationship, to a healthy work-life balance, and to overall career satisfaction is to engage with these nurses and MAs, to invest in them, and to begin to work as a true exam room team. This is the critical answer in plain sight.

Change isn’t easy. Providers must be persuaded to delegate many tasks and to re-conceptualize themselves as team leaders, rather than solo performers. In order to practice up to the limit of their license, MAs need thoughtful coaching and equipping. Only then can they take on new functions, like independently collecting patient data and then presenting the patient’s case to the provider (in the presence of the patient), much like a med student on rotation. Implementing a comprehensive exam room workflow that includes steps like these (e.g. the Team Care Medicine (TCM) Model) is attainable with the guidance of an experienced implementation consulting partner. That’s the real hope for Gawande and doctors across the nation.

Opening Up Patient Access By Working Smarter, Not Harder

Opening Up Patient Access By Working Smarter, Not Harder

CHALLENGE

Primary care patients at a large health network in the Southeast could rarely see their known provider for acute visits, and usually resorted to competing urgent care centers for such needs. In addition, regularly scheduled patient visits meant long lines in the waiting room and equally long wait times in the exam room.

Management desired to expand patient access but recognized that demanding more effort from their overworked providers and staff would simply push them across the line into full-fledged burnout. Management also wisely recognized that small incremental steps would not achieve the desired result; deep-seated process transformation and culture change would be required. So, they turned to Team Care Medicine (TCM) to help expand patient access.

ENGAGEMENT

Consultants from TCM partnered with executives and with practice managers to develop a customized TCM Model™ transformation program to maximize the performance of each primary care exam room team. Over the course of three months, all aspects of the practice’s operation were considered, including staffing levels, workflow processes, facility constraints, EHR settings, and provider incentives.

TCM consultants and trainers then executed the launch plan, working with each provider-led team to transform the patient visit through interactive classroom sessions as well as coaching in the exam room during live patient visits. Over the next few weeks, the Medical Assistants (MAs) expanded their activity to practice up to the limit of their license as Team Care Assistants (TCAs). Their role in each patient visit expanded to include many new tasks, including independent collection of the patient’s preliminary medical data, scribing of the provider’s physical exam and care plan, and management of the visit.

In parallel, providers learned to become team leaders that delegate non-physician tasks, relying more heavily on their newly empowered and expanded support staff. With greater team efficiency, they were able to take on additional visits each day and to move through each examination on schedule and with greater focus. And with the EHR tasks delegated to the TCA, providers went home each night with their charts fully up to date.

IMPACT

The custom TCM Model transformation project achieved the desired expansion in patient access.The initial pilot program training group enjoyed an increase in wRVUs per provider FTE of 17% in the first year and 38% by the third year, compared to the baseline control. Meanwhile, total costs per wRVU have held steady. Providers and staff enjoyed better quality of life, too; as one physician put it: “I have no reservation offering my wholehearted endorsement of the TCM Model. It has benefitted my patients, my practice, and my personal life.”

Seeking to further increase patient access, improve financial performance, and enhance staff well-being, management recently partnered with TCM to expand the transformation program across the enterprise, with similar results being reported across the system.

Transforming Exam Room Workflows Improves Patient Experience

Transforming Exam Room Workflows Improves Patient Experience

CHALLENGE

Though already exhibiting solid patient satisfaction scores in most categories, leaders at a regional health system in the Upper Midwest recognized that, in the spirit of continuous improvement and in pursuit of the Quadruple Aim, further improvement was needed. Patient satisfaction scores for ‘Access’ and for ‘Visit Efficiency’ were the weakest of all categories surveyed. Patients wanted more punctual appointments and more capacity to schedule urgent visits with the patient’s own physician.

However, with many of their providers already facing burnout from long hours, management recognized that it would be essential to work smarter, not harder.

Perceiving that truly meaningful change to the exam room process would require cultural change, technical training, and new tools, management turned to Team Care Medicine (TCM) to help drive the patient experience to the next level.

ENGAGEMENT

TCM developed a customized TCM Model™ transformation program to maximize the performance of each primary care exam room team. Over the course of three months, all aspects of the company’s system were considered, ranging from staffing levels to workflow processes to facility constraints to EHR settings to provider incentives.

Once the plan was developed, TCM worked with each provider-led team to transform the patient visit. Over the next three months, the Medical Assistants (MAs) were trained to practice up to the limit of their license as Team Care Assistants (TCAs). Their role in each patient visit expanded to cover many new tasks, including independent collection of initial patient data, scribing of the provider exam, and management of the visit.

In parallel, providers learned to become team leaders that delegate non-physician tasks, relying more heavily on their newly empowered and expanded support staff. With greater team efficiency, they were able to take on additional visits each day and to move through each examination on schedule. And with the EHR tasks delegated to the TCA, providers once again looked their patients in the eye, rather than staring at the computer screen.

IMPACT

A year later, proprietary patient satisfaction scores were consistent with the objectives of the transformation. Patient surveys revealed the desired improvements in ‘Access’ and in ‘Visit Efficiency’. The newly-minted TCAs were thrilled to see a leap in patient satisfaction with the ‘Nurse Assistant’ category, pushing them to the top of all survey categories. Executive sponsors were pleased to see the gains in patient access and visit efficiency translate into stronger revenues, with wRVUs climbing 41% per provider leading to a strong ROI from launch of the TCM Model.

© 2020 Team Care Medicine