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

 

  

 

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

 

  

 

In Their Words: Always Fresh and Ready to Start the Day

As more and more practices adopt the TCM Model, we’ve begun a series of interviews with providers across the country to understand how their practices and their lives have been transformed.  In this edition we hear from Karl Sash, MD, Board Certified in Internal Medicine and Geriatric Medicine. He did his undergraduate work at the University of Regina, completing medical school in 1993 and an internal medicine residency in 1997 at University of Saskatchewan and a geriatrics fellowship at Duke in 1999. He is affiliated with St. Vincent Hospital Evansville (Indiana) and he adopted the TCM Model in 2017. What follows are his reflections.

Remembering his initial perception of the TCM Model

My first thought was – great concept. But then you wonder how do you take time from your busy practice for the execution? At the very base of it, there’s a cultural change required which includes educating patients as to why their exam room experience will be different. Plus changing protocols and routines related to the EHR. Then there’s staff training related to the new skills required, and in our case, some additional hiring. It’s an evolution that takes some time and energy, particularly with staff that weren’t originally hired for this kind of transformed exam room. But the benefits definitely outweigh the efforts.

Investing in teammates

Moving to the TCM Model focused on maximizing the roles of our medical assistants, specifically increasing their patient-related skills. Some were enthusiastic, others more hesitant, but it wasn’t long before it all started to gel. I would say that our MAs greatly prefer the team approach now and are very comfortable with their responsibilities. I would add that it’s important for the provider to show respect for what the Team Care Assistant is doing in the exam room.

Better patient care

I’m more focused on the patient now. There’s more direct interaction, more eye contact, and more opportunity for me to see the big picture. I am working 1.5 hours less per day, seeing 2 more patients per day (my goal was to cover the expense of the additional MA), seeing 20+ complex visits per day (almost all are legitimate 214s and a few 215s), all this while managing 500 nursing home residents with NPs and hospice. What’s happening is that an innovative approach is actually creating a more traditional feel. And it all translates to better care including increased screening rates. Outside the exam room, my quality of life is noticeably better. I’m getting more sleep and more exercise. I don’t feel beat up at the end of the day. The analogy that comes to mind is that if you’re in a hospital, do you want to be cared for by a provider at the beginning of his or her shift or during the last hour? With the TCM Model, I feel like I’m always at the beginning of a shift.

In Their Words: Free To Focus On My Patients Again

As more and more practices adopt the TCM Model, we’ve begun a series of interviews with providers across the country to understand how their practices and their lives have been transformed.  In this edition, we hear from Chelsea Doyle, FNP, who practices at the Community Health Alliance (CHA) in Washoe County, Nevada.

Before being trained using the TCM Model in May 2016, Chelsea hated working behind the computer and often worked 2-3 hours every night. She felt as though she was on a burning platform and could not sustain this routine. CHA implemented the TCM Model in Spring 2017 and we interviewed her 12 months later. What follows is her story.

More flexibility, better access

CHA is a Federally Qualified Health Center (FQHC) serving Nevada’s second most populous county, including the cities of Reno and Sparks. As an FQHC we serve a vulnerable population with a large percentage of Medicare, Medicaid, underinsured and uninsured patients. We’ve always had a high, no-show rate.  

In this environment, the extra support you get from having a coordinated system of backup, from working together as a team, gives us more flexibility. And even with that less-than-predictable workflow, productivity has increased to the point where we’re seeing 3-4 additional patients each day as a result of implementing the TCM Model.

Starting out as a team — the early days

Our approach to the TCM Model included maximizing the roles of our medical assistants, especially increasing their patient-related responsibilities in the exam room.  At first, they seemed hesitant, which wasn’t unexpected, but it didn’t take long before it all started to gel.  I would say that our MAs greatly prefer the team approach now.

How the patients see it

We’ve had some patients who said they didn’t like having another person in the exam room, but they were the distinct minority. Most of them appreciate having another pair of eyes and ears available.  It gives them confidence that they’re being heard and that their care is even more thorough. They also realize that they’re getting more uninterrupted time with me, particularly more face-to-face time. I don’t want to be the person sitting in front of a computer in the exam room. It’s not what I do, or rather it’s not what I do best. As a provider leading a TCM Model-based team, you have to give up a little control but you get a lot more accomplished at the end of the day. Literally and figuratively.

Reclaiming my personal life

Before we transitioned to the TCM Model I was working through lunch and probably doing an extra two to three hours every day outside of paid time – not a good situation for the mother of young children or anyone else for that matter. The thing is, I still tend to work through lunch. It must be part of my routine. But the big difference is that I’m not doing any work at home anymore and I don’t feel the kind of stress I used to experience.  The charts are signed before I leave the office and my completion rate is practically 100%. The change has been very positive for me and definitely for my family. 

In Their Words: Providers Talk About Their Exam Room Team Experience

This blog and several to follow contain thoughts by providers who are currently using the TCM Model to create a more efficient exam room, with corresponding increases in access and improved quality of life. The initial observations come from Craig Miller, MD, a family medicine physician affiliated with St. Joseph Health System in Indiana.

Dr. Miller graduated from Indiana University and received his medical education from the Indiana University School of Medicine. He completed his residency at Memorial Hospital of South Bend and is board certified in Family Medicine. Dr. Miller has medical interests in obstetrics, skin procedures and diabetes. He’s been practicing medicine for the last 17 years.

Peter Anderson, MD, Founder and CEO, Team Care Medicine (TCM)

TCM: How has your personal life been affected by the adoption of the TCM Model? Are you experiencing any differences?

Dr. Miller: Before we transitioned to the TCM Model I never had enough time to complete administrative work without bringing it home.  No matter how hard I was working there just weren’t enough hours in the day to check all the boxes – so there’s been a dramatic and very positive difference in that area. I’ve been working with a well-trained and motivated exam room team for four years now [since adopting the TCM Model in 2014], and I feel like I have my life back. That’s been a great thing for my family, and I also think it’s made me a better physician.

TCM: How has patient access been affected since moving to the TCM Model?

Dr. Miller: As a practice, we’re seeing about 35 patients per day. I’m doing more chronic disease management as well as more health maintenance and preventive care. Overall, I would say that we’re doing a better job of taking care of the people in our community, and that’s very gratifying.

TCM: How have your patients responded to the change from a traditional provider-centric environment to one where assistants are doing most or all of the non-physician work inside the exam room?

Dr. Miller: I would call it a resounding success in that area. Our patients, including those who had been with us for quite a while, like the added interaction. They feel like they’re getting more time and attention overall.  A number of them also expressed the sense that the whole exam room experience felt more thorough.

TCM: How would you characterize the effort needed to adopt an exam room team model?

Dr. Miller: We had administration backing and a staff that enjoys learning new things and taking on new responsibilities during the patient visit. That’s not always the case so we were fortunate on both counts. There was definitely a learning curve up front that required an investment of time, energy, and financial resources. It also takes some effort to customize the TCM protocols and processes to more precisely fit your own practice. But it pays off quickly, and from what we’re experiencing, it keeps on paying off.

TCM: Could you envision yourself practicing again in a non-TCM exam room?

Dr. Miller: I could not and would not. I’d still practice, but not as a family medicine physician. There’s no going back to the way things were.

The Exam Room Team: Where Provider Productivity and Access Begin

In this final segment of a four-part series on productivity that’s included a discussion of the negativity often associated with the word “productivity”, the impact of low productivity on the medical home and five factors that function to hold productivity down, we’ll take a look at the exam room process and why it hasn’t been universally improved through a team approach.

So far we’ve created four separate blogs to look at different facets of productivity. Why are we banging this particular drum so loudly? Because to extend the analogy, in the great symphony that is the contemporary American health system, productivity is one of the most harmonious instruments we have.

Beyond its historical relationship to compensation-related metrics, productivity is the key to primary care access, including (and sometimes especially) acute or same-day appointments which might otherwise end up in urgent care or the ED.  On an even larger scale, the improved access that comes with greater productivity is a key factor in meeting current and future patient demand and consequently, the needs of our healthcare system itself. So how do we help assure that this capability will be in place? The exam room is the place to start.

Getting behind the team

The thing to keep in mind about team-based care is that it’s simple. At least in concept.  The provider’s role in the primary care exam room focuses on what she or he is uniquely qualified to do by way of training and experience. It includes performing exams, determining diagnoses and setting up treatment plans. Virtually everything else from collecting and presenting medical data to supporting the treatment plan and closing the visit, is delegated to one or more “team care assistants” including nurses, medical assistants or other well-trained clinical staff. Like I said, the basics are simple once you get past the misconceptions that are still held.

Three myths about the team care delivery model

Myth #1: Your staff can’t get proficient at the needed skills. With appropriate and adequate training, clear performance expectations and ongoing communications, staff members can effectively handle the required tasks – and can direct more of their time and attention to those activities than a physician could.

Myth #2: Having additional people in the exam room interferes with the patient-provider relationship. What we’ve found over a number of years and in an extensive number of practices is that freeing up the physician to focus entirely on the patient, (without non-clinical distractions), dramatically strengthens that vital bidirectional bond.

Myth #3: Patients don’t want anyone but the doctor in the exam room. Again, experience and related research indicate that patients overwhelmingly appreciate the extra time and attention directed to them by a larger care team.

The real change is cultural

Once again, I would emphasize that the concept of a team-based, patient-oriented exam room isn’t tough to understand or even assemble, especially once you get past those three myths. But waiting on the other side is the single, most substantial challenge to this exam room team – the historical and still potent strain of personal independence and self-assurance that exists among providers, whether they are employed or in private practice. While the potential need for staff hiring, as well as some role realignment and workflow redesign, requires effort and resources, the idea that many providers prefer performing a one-person play in the exam room instead of acting in an ensemble continues as the greatest obstacle.

In an upcoming blog we’ll look at the “Why do what I do best when I can do it all?” clinician culture and what can be done to transform it into an effective foundation for team care.

Primary Care Productivity Continues its Downward Spiral

As a quick update, this is the third in a series on provider productivity. So far we’ve talked about how “productivity” became a bad word and the negative impact of low productivity on the medical home model. Now, we’ll look at five specific factors that are causing productivity’s ongoing slide. In the final blog of the series, we’ll see what a different approach in the exam room can do to improve the situation.

Let’s look at the numbers. Since 2000, individual primary care physician productivity in terms of patient visits per week has fallen by 35% for family physicians and 28% for general internists with both groups still working 52-54 hours per week (1-3). In 2016, on average, family doctors saw 85 patients per week and general internists 76 patients per week (3). This decline comes in the face of a growing need and decreasing numbers of primary care physicians, a combination that doesn’t bode well for reversing the trend. Right now, we’re producing enough visit slots for only 65-70 percent of people who need access to primary care. Imagine if farms in America produced only enough food for 70% of our population. While a range of factors contributes to this decreasing productivity, below are what I’ve identified as the five main reasons.

5 Reasons Why Provider Productivity is Declining

1. An Aging Population

Given the numbers of baby boomers and their impact on healthcare, older adults with multiple chronic conditions, reduced physiologic reserve, and high expectations continue to challenge our practices. Delivering effective care for this large segment has demanded changes in everything from practice environment and staffing to training and scheduling. It’s also required so much time that the same-day urgent needs of the patient panel have been de-emphasized, sending patients elsewhere for episodic care from an unfamiliar provider.

2. Electronic Health Records

Few technological advancements come without unintended consequences and EHR systems are no exception. As an early adopter, I can attest to benefits in aiding patient care as well as improving the accessibility of documentation. But I (and quite a few other physicians as noted in an Annals of Internal Medicine study summarized in a June 2016 NEJM Journal Watch) can also bear witness to some of the problems related to workflow changes and disruption. The bottom line is EHRs may be critical for quality care in 2018, but the extensive time required for documentation has had a negative impact on productivity to the point where it’s fair to wonder if the potential slow-down is always balanced by the gains.

3. Individual Provider Issues

This particular barrier to productivity runs the gamut, but there are some common threads: For example, ignoring well-established business norms like reasonable visit limits will decrease the chances for an efficient and productive practice; Non-clinical socialization is also a slowdown. We all feel good about sharing a Starbucks moment but it usually comes with the caveat that someone else is denied access; Unreasonable patient expectations are another productivity slammer. We’re glad to have satisfied patients, but we sometimes let their expectations define the encounter, overriding our own goals for the visit; Finally, there are those deeply ingrained habits of independence – including the belief that the exam room is the sole domain of the physician.

4. Economics 101

It’s no surprise that quite a few practices are skating on thin financial ice. Rising operational costs and lower profits combine to compromise staff size and capabilities, which in turn, puts yet another obstacle on the road to productivity. Some administrators equate financial sustainability with limiting staff when, in fact, the opposite may be true. One reason providers are spending more than 60% -70% of their time in the exam room doing non-provider work is because they can’t afford to increase staff. This non-provider work generates almost no revenue – so not a business model you’d want to pursue.

5. Administrative Burdens

Non-medical work requirements have burgeoned since the era of managed care. The regulatory framework we operate in, particularly in areas like prior authorizations, formularies, network restrictions, quality metrics, PCMH and Meaningful Use requirements, have created a mountain of paperwork and practice hassles, all of which demand a substantial amount of time from the provider. These responsibilities combine to remove primary care providers from direct patient contact, a result that once again hampers productivity.

What to do?

These five factors have played a major role in decreasing provider productivity (despite working the same number of hours) over the past two decades. But take heart. Although these issues don’t lend themselves to an easy fix there is one area where you can exert a meaningful degree of control on productivity – your own exam room. And that’s where we’ll be going in the next blog.

Footnotes:

1) Exclusive Survey: Productivity Takes a Dip; November 18, 2005, Medical Economics

2) Medical Economics Exclusive 2012 Productivity Survey; October 25, 2012, Medical Economics

3) 88th annual Physician Report: Ambivalence Wreaking Havoc in Primary Care; April 25, 2017 Medical Economics

The Achilles Heel of the Medical Home

This is the second in a series of communications on productivity and its impact on our individual futures and the future of health care. Last time we discussed why “productivity” has a negative connotation. Now, we’ll examine the direct relationship between low productivity and the success of the medical home model, with the next post focusing on the barriers to greater productivity. Finally, we’ll see what improved productivity looks like in the exam room.

Why aren’t medical home results more uniformly positive?

Just so we are clear, the evidence gathered after a decade of medical home operation is promising, especially in terms of chronic care management, mortality, decreased ED visits and hospital admissions. At the same time, it remains insufficient and at times, equivocal. For me, the medical home, though it didn’t have a formalized name yet, is the reason I became a primary care physician. So why, after so much investment and effort, aren’t practices that are certified medical homes experiencing more dramatic improvements?  Well, here are five factors that are holding us back and all of them are related to reduced productivity.

5 Reasons Why Low Productivity is Slowing Us Down

1. Low access for a high number of people

Low productivity and reduced access to a medical home go hand in hand – and by low, I mean 14-18 patients a day. Timely, appropriate access both for the acute and chronic needs of a provider’s panel is a requisite for any effective medical home. Lack of needed access is especially critical since it impacts so many patients. In 2015, over 35 percent of primary care visits were not seen in primary care practices. That means a large segment of the population couldn’t access the benefits they could otherwise receive from a medical home.

2. A negative impact on quality

With more than a quarter of all appropriate primary care office visits currently going to Urgent Care Centers and Retail Clinics due to access and convenience issues, quality is being thwarted. The fragmented, limited care of UCCs and RCs cannot produce the same outcomes as continuous, coordinated and comprehensive care, and the literature is replete with studies showing that an on-going relationship with the same care team yields increased longevity and healthier lives, along with lower costs. 

3. Decreased patient engagement

Access when and where it’s needed is a strong determinant of trust, and relationships built on trust are much more motivational and collaborative. When rapid access is limited because productivity is low, patients are far more likely to seek care in settings where the lack of a relationship impacts everything from compliance to personal accountability and patient satisfaction.

4. Inadequate finances and staffing

The downward spiral continues into financial issues, with a focus on the leakage of acute care visits – often the most patient-pleasing and profitable of the day. Losing this income source due to low productivity/reduced access undermines the financial viability of medical homes. High productivity also creates the only reliable, long-term source of capital to supply the staffing requirements of a high-performing medical home as well as the revenue streams needed to assure acquisition of needed technology.  

5. Increased risk of burnout

A wide scope of studies indicates that chronic work disruption caused by providers doing non-provider activities, and the productivity loss that results, are prime factors in clinician burnout – with the corollary that providers are most fulfilled when they can focus on patients. PCPs in medical homes are spending more than 60% of their time doing non-provider work. Having more staff with the right skills can go a long way toward reducing or eliminating this aspect of burnout. And once again, low productivity and its companion, low efficiency, are the culprits. 

Join us in the next post when we’ll look at the barriers that many providers face on the path to higher 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

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.

© 2020 Team Care Medicine