Primary care physicians are underpaid and under-performing because the operational and clinical model of the primary care office is "utterly and completely failing," according to Jeffrey Brenner, MD, executive director of the Camden Coalition of Healthcare Providers and the medical director for the Urban Health Institute at Cooper Hospital – both in Camden, N.J.
Brenner's research has focused on "super-utilizers" – the segment of the population that uses a disproportionately high amount of hospital and ER services. He recently shared his views with René Letourneau, editor of Healthcare Finance News, a sister publication of PhysBizTech. The transcript of that conversation follows.
Q: Can you tell me about your research?
A: As we began to look at the data in Camden, we managed to get hospital claims data from three local hospitals, and there was clearly a subset of patients that were outliers that had very extreme numbers of admissions to the hospital and/or ER visits. We got really curious about these patients and really wanted to understand more about them -- what was driving them to go to the ER and hospital -- and see what we could do about it. We began one patient at a time building an intervention in one of America’s poorest cities. Camden is a very, very poor city.
Q: Did you find any trends among these super-utilizers?
A: The biggest trend we found was a trend of complexity and that there wasn’t one simple answer as to why people go to the ER and hospital. People want a nice, pat, easy answer, but the way I would describe it is that there are risk factors to being a high utilizer of the ER and hospital. If you are blind, if you are deaf, if you are in a wheelchair, if you are disabled, if you are older, if you have co-morbidities, if you have a low literacy level, if you don’t have family support, if you don’t have a car, if you are an addict, if you are mentally ill, all these things are compounding risk factors. These things add up and if you’ve got four or five of them, you become a more extreme, high utilizer…What we have found is driving this is that our healthcare system doesn’t do a good job of meeting the needs of very sick patients. We are really good at cutting, scanning, zapping and hospitalizing sick people. We are not good at talking to them; we are not good at educating them, coordinating care for them. The system doesn’t really meet the needs of these patients.
Q: Is there a greater need for coordinated primary care?
A: It’s partly about primary care. Primary docs are underpaid, under capitalized and under performing, but the current business, operational and clinical model of the primary care office is utterly and completely failing. Primary care docs are running from room to room to room treating head colds instead of paying really close attention to the sickest patients. When a primary doc walks in the room, he or she makes more money from treating a head cold than from treating an extremely sick patient…If I can run into a room and treat a head cold, I’ll make way more money for that visit. If I walk into the room of a patient that’s in a wheelchair, that doesn’t speak English, that’s just been in the hospital, that’s confused about the meds, I could be in there for 40 minutes, and then I am going to have tests, follow-ups, phone calls, coordination – all that work is unpaid. So we have really an utterly failed model of primary care. And, if that patient has three or four specialists, there is nothing about how we pay the specialists that encourages them to coordinate with each other so they each start and stop medications that conflict with one another, they order duplicate tests. There is just no one quarterbacking.
Q: Are there solutions that you are advocating?
A: Whenever you are in a corner, you innovate, innovate, innovate. We need to really rethink, redesign and challenge basic assumptions about how we deliver care, and we are going to need new payment models to support that. The three elements we’ve seen that go into this work are very significant data – we don’t like to share data in healthcare, we don’t free the data at the community level. We need a lot of engagement. Hospitals need to have clear goals about saving money. Right now a hospital works the same way as a hotel or an airline, which is they get paid based on occupancy. As long as that is true, we are not going to have meaningful engagement between the stakeholders to reduce costs and improve quality. The last piece is a need for really significant clinical redesigns so we are going to have to fundamentally rethink all the basic pieces of how people move through the delivery system and how the delivery system works.
Q: Do you think there needs to be changes to reimbursements?
A: If we don’t do that, none of this is going to get fixed. The problem is that even if you change the way we pay for healthcare, the hospitals and doctors would wake up in the morning and wouldn’t have the foggiest idea what to do. We’ve got a chicken-and-egg problem here. If the providers get out and deliver a different product, they are going to go out of business. But if the payment system is changed, it does not necessarily mean the providers are going to change overnight…We are going to need a transition period here where we innovate new models of delivering care.
Q: Do you have any hopes for the ACO model?
A: I think we are going to see some real successes around the country and that is going to up the pressure on the rest of the country to get its act together. I’m not sure if the ACO model is going to fix all of this because there are certain regions of the country where I think hospitals and doctors just aren’t ready to do this work. I’m concerned that what is really going to happen is that the system is just going to collapse and you are going to see some pretty massive failures. And once that happens, you’ll see more room for innovation and more willingness to innovate.
Q: Are there ethical challenges that concern you when you think about changing the healthcare system?
A: I think it is kind of an ethical sweet spot in that this is a population that has a lot of need, and you can actually do the right thing and end up saving money in the process…Frankly, I think it’s unethical that we are not delivering better care and we are wasting so much money in the process.