Tom Bodenheimer,of the Center for Excellence in Primary Care at UCSF Dep’t of Family and Community Medicine talks about addressing the primary care shortage at the 2014 Weitzman Symposium

1. Can we solve the adult primary care shortageCan we solve the adult primary care shortage
without more physicians?without more physicians?
Tom BodenheimerTom Bodenheimer
Center for Excellence in Primary CareCenter for Excellence in Primary Care
UCSF Dep’t of Family and Community MedicineUCSF Dep’t of Family and Community Medicine
Weitzman Symposium 2014Weitzman Symposium 2014

2. Colwill et al., Health Affairs, 2008:w232Colwill et al., Health Affairs, 2008:w232
Petterson et al, Ann Fam Med 2012;10:503Petterson et al, Ann Fam Med 2012;10:503
0
5
10
15
20
25
30
35
40
45
50
2000 2005 2010 2015 2020
Percent change relative to 2001
Adult care: projected generalist physicianAdult care: projected generalist physician
supply vs. demandsupply vs. demand
Demand:adult popDemand:adult pop’n’n
growth/aginggrowth/aging
Supply: familySupply: family
med, generalmed, general
internal medinternal med
Shortage of 40,000 by 2020
Shortage of 52,000 by 2025

3. NP/PAs to the rescue?NP/PAs to the rescue?
• New graduates each yearNew graduates each year
– Nurse practitioners:Nurse practitioners: 80008000
– Physician assistants:Physician assistants: 45004500
• % going into primary care% going into primary care
– NPs:NPs: 65%65%
– PAs:PAs: 32%32%
• Adding new GIM, FamMed, NPs, and PAsAdding new GIM, FamMed, NPs, and PAs
entering primary care each year, the primary careentering primary care each year, the primary care
clinician to population ratio will fall byclinician to population ratio will fall by 9%9% fromfrom
2005 to 2020.2005 to 2020.
Colwill et al, Health Affairs Web Exclusive, April 29, 2008; Bodenheimer et al,Colwill et al, Health Affairs Web Exclusive, April 29, 2008; Bodenheimer et al,
Health Affairs 2009;28:64.Health Affairs 2009;28:64.

4. Panel sizes too large to managePanel sizes too large to manage
• Average primary care panel in US isAverage primary care panel in US is 23002300
• PCP with panel of 2500 average patients willPCP with panel of 2500 average patients will
spendspend 7.4 hours per day7.4 hours per day doing recommendeddoing recommended
preventive carepreventive care [Yarnall et al. Am J Public Health 2003;93:635][Yarnall et al. Am J Public Health 2003;93:635]
• PCP with panel of 2500 average patients willPCP with panel of 2500 average patients will
spendspend 10.6 hours per day10.6 hours per day doing recommendeddoing recommended
chronic carechronic care [Ostbye et al. Annals of Fam Med 2005;3:209][Ostbye et al. Annals of Fam Med 2005;3:209]

5. Results of large panelsResults of large panels
• Poor access for patientsPoor access for patients
• Inconsistent qualityInconsistent quality
• Lack of time to build relationships with patientsLack of time to build relationships with patients
• Clinician burnoutClinician burnout
– Survey of 422 general internists, family physiciansSurvey of 422 general internists, family physicians
• 27%: definitely burning out27%: definitely burning out
• 30%: likely to leave the practice within 2 years30%: likely to leave the practice within 2 years
– Physician burnout is associated with poor patientPhysician burnout is associated with poor patient
experience and reduced patient adherence toexperience and reduced patient adherence to
treatment planstreatment plans
Linzer et al. Annals of Internal Medicine 2009;151:28-36; Dyrbye, JAMA 2011;305:2009; Murray etDyrbye, JAMA 2011;305:2009; Murray et
al, JGIM 2001:16,452; Landon et al, Med Care 2006;44:234.al, JGIM 2001:16,452; Landon et al, Med Care 2006;44:234.

6. The dilemmaThe dilemma
• Panel size too large for average PCP to managePanel size too large for average PCP to manage
• We can’t reduce panel size due to worseningWe can’t reduce panel size due to worsening
shortage of adult primary care cliniciansshortage of adult primary care clinicians
• Shortage = larger panels, poorer access forShortage = larger panels, poorer access for
patients, poorer quality, more PCP burnout, higherpatients, poorer quality, more PCP burnout, higher
health care costshealth care costs
• More PCP burnout means fewer medical studentsMore PCP burnout means fewer medical students
will be attracted to primary carewill be attracted to primary care
Unless we think differentlyUnless we think differently

7. Re-defining the adult primary care shortageRe-defining the adult primary care shortage
• Most people define it as a physician shortageMost people define it as a physician shortage
• Or a clinician shortage (MDs, NPs, PAs)Or a clinician shortage (MDs, NPs, PAs)
• These formulations are aThese formulations are a bridge to nowherebridge to nowhere
• If clinician shortage is the problem, then the only solutionIf clinician shortage is the problem, then the only solution
is more cliniciansis more clinicians
• More clinicians would help, but there willMore clinicians would help, but there will nevernever be enoughbe enough
• We must re-define the shortage as a demand-capacity gapWe must re-define the shortage as a demand-capacity gap
• We address the gap by increasing capacity and/or reducingWe address the gap by increasing capacity and/or reducing
demanddemand
• We can do this without more cliniciansWe can do this without more clinicians

8. 0
5
10
15
20
25
30
35
40
45
50
2000 2005 2010 2015 2020
Percent change relative to 2001
Adult primary care: capacity vs. demandAdult primary care: capacity vs. demand
Demand for careDemand for care
==
Capacity toCapacity to
provide careprovide care
Thinking differentlyThinking differently
It’s not only about doctorsIt’s not only about doctors
Share the careShare the care

9. Clinica Family
Health Services
Group Health Olympia
Multnomah County
Health Dept
South Central
Foundation
Univ of Utah-
Redstone
Newport News
Family Practice
Cleveland Clinic-
Stonebridge
Quincy, Office of
the Future
West Los Angeles-
VA
La Clinica de
la Raza
Clinic Ole
Sebastopol
Community
Health
Martin’s Point-
Evergreen Woods
Harvard Vanguard
Medford
Brigham and
Women’s and MGH
Ambulatory
Practice of the
Future
North Shore
Physicians Group
Medical Associates
Clinic
Mercy Clinics
ThedaCare
Fairview Rosemont
Clinic
Mayo Red Center
Allina
23 High-Performing Practices23 High-Performing Practices

10. 10 Building Blocks of
High-Performing
Primary Care
Annals of Family Medicine
2014;12:166-71
Team-based careTeam-based care

11. Closing the demand-capacity gap: share the careClosing the demand-capacity gap: share the care
• CliniciansClinicians
• Non-clinician team membersNon-clinician team members
– Non-professionalNon-professional
• MAs as panel managersMAs as panel managers
• MAs as health coachesMAs as health coaches
• MAs as scribesMAs as scribes
– ProfessionalProfessional
• RNsRNs
• PharmacistsPharmacists
• BehavioristsBehaviorists
• PatientsPatients
– Peer health coachesPeer health coaches
– Self careSelf care
• TechnologyTechnology
Bodenheimer and Smith, Health Affairs 2013;32:1881-6Bodenheimer and Smith, Health Affairs 2013;32:1881-6

12. Share the care: who does it now?Share the care: who does it now?
Tasks PCP RN LPN Medical
assistant
Pharmacist
Orders mammograms for
healthy women between 50
and 75 years old
Refills high blood pressure
medications for patients
with well-controlled
hypertension
Performs diabetes foot
exams
Reviews lab tests to
separate normals from
abnormals
Cares for patients with
uncomplicated urinary
tract infections
Finds patients who are
overdue for LDL and
orders lipid panel
Prescribes statins for
patients with elevated LDL
Does medication
reconciliation
Screens patients for
depression using PHQ 2
and PHQ 9
Follows up by phone with
patients treated for
depression
Totals

13. Share the care: preserve the relationshipShare the care: preserve the relationship
• Share the Care means that the personal clinicianShare the Care means that the personal clinician
does not provide all the caredoes not provide all the care
• Patients should not be asked to transfer trust from a
clinician to a large team
• Historically patients trust a small team (teamlet)
• The relationship changes from patient-clinician toThe relationship changes from patient-clinician to
patient-teamletpatient-teamlet
• Members of the larger team are involved if neededMembers of the larger team are involved if needed
• Blue Shield of California Foundation survey: patientsBlue Shield of California Foundation survey: patients
are willing to receive care from a team even if itare willing to receive care from a team even if it
means seeing their physician less (June 2012)means seeing their physician less (June 2012)

14. Team-based care: stable teamlets
Patient
panel
1 team, 3 teamlets
Clinician + MA
teamlet
Patient
panel
Clinician + MA
teamlet
Patient
panel
Clinician + MA
teamlet
RN, behavioral health professional, social worker, pharmacist,
complex care manager

15. High-performing teamletsHigh-performing teamlets

16. High performing teamletHigh performing teamlet

17. Sharing the care with non-clinicianSharing the care with non-clinician
team membersteam members
• Panel managementPanel management
– MAs use preventive and chronic disease registries,MAs use preventive and chronic disease registries,
and EMR health maintenance screens, to identifyand EMR health maintenance screens, to identify
patients with care caps and close the care gapspatients with care caps and close the care gaps
– Standing ordersStanding orders are needed to empower the MAsare needed to empower the MAs
– Best done within the teamletBest done within the teamlet
– Quality of preventive services improvesQuality of preventive services improves [Chen and[Chen and
Bodenheimer, Arch Intern Med 2011;171:1558]Bodenheimer, Arch Intern Med 2011;171:1558]

18. Clinician confidence that medical assistantsClinician confidence that medical assistants
will do a good job on panel managementwill do a good job on panel management
2012 Survey of 231 PCPs2012 Survey of 231 PCPs
Source: System Transformation Evaluation Survey (STEP). 2012. Available at http://familymedicine.medschool.ucsf.edu/cepc/

19. Preventive services: new wayPreventive services: new way
• MA (panel manager) checks registry every monthMA (panel manager) checks registry every month
• If due for mammo, MA sends mammo order to patientIf due for mammo, MA sends mammo order to patient
• Result comes to MA, if normal, MA notifies patientResult comes to MA, if normal, MA notifies patient
• If abnormal MA notifies clinician and app’t madeIf abnormal MA notifies clinician and app’t made
• For most patients, clinician is not involvedFor most patients, clinician is not involved
• For women 40-50 who want or need mammogram,For women 40-50 who want or need mammogram,
clinician is involved for discussionclinician is involved for discussion
• Similar for colon cancer screeningSimilar for colon cancer screening
• Requires standing ordersRequires standing orders

20. Sharing the care with non-clinicianSharing the care with non-clinician
team membersteam members
• Health coachingHealth coaching
– MAs trained as health coaches can assist patients with chronicMAs trained as health coaches can assist patients with chronic
conditions to become informed active participants in their careconditions to become informed active participants in their care
[Margolius et al, Annals of Family Medicine 2012;10:199; Ivey et al, Diab Spectrum 2012;25:93;[Margolius et al, Annals of Family Medicine 2012;10:199; Ivey et al, Diab Spectrum 2012;25:93;
Gensichen et al, Ann Intern Med 2009;151:369; Willard et al, in press]Gensichen et al, Ann Intern Med 2009;151:369; Willard et al, in press]
• Example: diabetesExample: diabetes
– Closing the loop to check for understanding (50% don’tClosing the loop to check for understanding (50% don’t
remember what happened in the clinician visit)remember what happened in the clinician visit)
– Know your ABC numbers (A1c, BP, Cholesterol)Know your ABC numbers (A1c, BP, Cholesterol)
– Know your ABC goalsKnow your ABC goals
– Know how to get from your number to your goalKnow how to get from your number to your goal
– Behavior change goal-setting and action plansBehavior change goal-setting and action plans
– Know your medications, and med adherence counselingKnow your medications, and med adherence counseling
• Difficult to do on teamlet unless 2 MAs per clinicianDifficult to do on teamlet unless 2 MAs per clinician

21. Health coaching in the teamlet modelHealth coaching in the teamlet model

22. Chronic care: hypertension: new wayChronic care: hypertension: new way
• MA checks registry every monthMA checks registry every month
• Patients with abnormal BP contacted for pharmacist, RN,Patients with abnormal BP contacted for pharmacist, RN,
or health coach visitor health coach visit
• Health coach: education, med adherence, lifestyle changeHealth coach: education, med adherence, lifestyle change
• If BP elevated and patient med adherent, RN/pharmacistIf BP elevated and patient med adherent, RN/pharmacist
intensifies meds by standing ordersintensifies meds by standing orders
• If questions, quick clinician consultIf questions, quick clinician consult
• Health coach f/u by phone or e-mailHealth coach f/u by phone or e-mail
• Clinician barely involvedClinician barely involved
• Blood pressure control improved with this innovationBlood pressure control improved with this innovation
[Margolius et al, Annals of Family Medicine 2012;10:199][Margolius et al, Annals of Family Medicine 2012;10:199]

23. Share the care:Share the care:
MA acts as scribe while MD does physical examMA acts as scribe while MD does physical exam

24. EMR pushes more work to physician, leading toEMR pushes more work to physician, leading to
vast amounts of time spent documentingvast amounts of time spent documenting
If changes are notIf changes are not
made to reduce thesemade to reduce these
time penalties ontime penalties on
primary careprimary care
physicians there will bephysicians there will be
no primary careno primary care
physicians left tophysicians left to
penalize.penalize. Clement J McDonaldClement J McDonald
MD, Arch Intern Med 2012;172:285-287MD, Arch Intern Med 2012;172:285-287
(Clem McDonald created one of the(Clem McDonald created one of the
first EMRs in the 1970s)first EMRs in the 1970s)

25. Vast amounts of time spent documentingVast amounts of time spent documenting
• Scribing
• Assistant order
entry
• Re-engineering
the prescription
renewal work out
of the practice
• I come in to my doctor for anI come in to my doctor for an
examination, but it seems allexamination, but it seems all
he wants to do is examinehe wants to do is examine
the computer.the computer. Patient 3/2/12Patient 3/2/12
• I used to be a doctor. Now II used to be a doctor. Now I
am a typist.am a typist. Internist Anchorage ALInternist Anchorage AL
• I really like my doctor of overI really like my doctor of over
10 years, but rarely get to10 years, but rarely get to
talk with her face to face; astalk with her face to face; as
I’m talking, she is typing.I’m talking, she is typing.
Annoys the hell out of me.Annoys the hell out of me.
Patient, 12/30/10Patient, 12/30/10

26. Hey doc, I’m here too

27. Scribes to reduce documentation timeScribes to reduce documentation time
• University of Utah “Care by Design”
• Right person/right job
• MAs receive additional training
• MA takes history using EMR templates
• MD reviews history does physical exam and MA
enters findings into EMR
• MD calls out lab, imaging, prescriptions and MA
enters them as pended orders that MD quickly Oks
• Profits up, patient satisfaction up, provider
satisfaction up, quality measures up
Blash et al, UCSF Center for the Health Professions, April 2011

28. The best way to reduce burnoutThe best way to reduce burnout

29. Closing the demand-capacity gap: share the careClosing the demand-capacity gap: share the care
• CliniciansClinicians
• Non-clinician team membersNon-clinician team members
– Non-professionalNon-professional
• MAs as panel managersMAs as panel managers
• MAs as health coachesMAs as health coaches
• MAs as scribesMAs as scribes
– ProfessionalProfessional
• RNsRNs
• PharmacistsPharmacists
• Physical therapistsPhysical therapists
• BehavioristsBehaviorists
• PatientsPatients
– Peer health coachesPeer health coaches
– Self careSelf care
• TechnologyTechnology

30. Team-based care: stable teamletsTeam-based care: stable teamlets
PatientPatient
panelpanel
Clinician/MAClinician/MA
teamletteamlet
PatientPatient
panelpanel
Clinician/MAClinician/MA
teamletteamlet
PatientPatient
panelpanel
Clinician/MAClinician/MA
teamletteamlet
Health coach, behavioral health professional,Health coach, behavioral health professional,
social worker, RN, pharmacist, panel manager,social worker, RN, pharmacist, panel manager,
complex care managercomplex care manager

31. Share the care with professional teamShare the care with professional team
members using standing ordersmembers using standing orders
• RNs treat uncomplicated UTIs, URIs, STIs, and low back pain withoutRNs treat uncomplicated UTIs, URIs, STIs, and low back pain without
clinicians: equal quality and better patient satisfactionclinicians: equal quality and better patient satisfaction
• Physical therapists manage low back pain with better functional reliefPhysical therapists manage low back pain with better functional relief
and patient satisfaction compared with physiciansand patient satisfaction compared with physicians
• RNs or pharmacists can care for a sub-panel of patients with diabetes,RNs or pharmacists can care for a sub-panel of patients with diabetes,
hypertension, hyperlipidemia with minimal clinician involvementhypertension, hyperlipidemia with minimal clinician involvement
• Behaviorists in primary care improve depression outcomesBehaviorists in primary care improve depression outcomes
• RN complex care managers can provide much of the care for time-RN complex care managers can provide much of the care for time-
consuming, complex, high-utilizing patientsconsuming, complex, high-utilizing patients
• These changes can add 10-20% capacity without more clinician timeThese changes can add 10-20% capacity without more clinician time
Saint et al, Am J Med 1999;106;636; Overman et al, Phys Ther 1988;68:199;Saint et al, Am J Med 1999;106;636; Overman et al, Phys Ther 1988;68:199; http:http:
//impact-uw//impact-uw.org.org; Bodenheimer and Berry-Millett, RWJF Synthesis Project, DecemberBodenheimer and Berry-Millett, RWJF Synthesis Project, December
20092009;; Bodenheimer and Smith, Health Affairs 2013;32:1881-6Bodenheimer and Smith, Health Affairs 2013;32:1881-6

32. Share the care with patients:Share the care with patients:
peer health coachespeer health coaches
• Patients trained as peer health coaches can add capacityPatients trained as peer health coaches can add capacity
• VA diabetic patients paired with peers had greater glycemicVA diabetic patients paired with peers had greater glycemic
improvement than patients with nurse care managersimprovement than patients with nurse care managers
[Heisler et al, Ann Intern Med 2010;153:507][Heisler et al, Ann Intern Med 2010;153:507]
• Latino diabetic patients with peer-led classes: betterLatino diabetic patients with peer-led classes: better
glycemic control than usual careglycemic control than usual care [Philis-Tsimikas et al, Diab Care[Philis-Tsimikas et al, Diab Care
2011;34:1926]2011;34:1926]
• Diabetes patients with a peer coach had greater HbA1cDiabetes patients with a peer coach had greater HbA1c
reductions than usual care patientsreductions than usual care patients [Long et al, Ann Intern Med[Long et al, Ann Intern Med
2012;156:416]2012;156:416]
• Low-income diabetic patients with low-income peerLow-income diabetic patients with low-income peer
coaches achieved better glycemic control than usual carecoaches achieved better glycemic control than usual care
patientspatients [Thom et al, Ann Fam Med 2013;11:137-144][Thom et al, Ann Fam Med 2013;11:137-144]

33. Training peer health coachesTraining peer health coaches

34. 0
5
10
15
20
25
30
35
40
45
50
2000 2005 2010 2015 2020
Percent change relative to 2001
Adult primary care: capacity vs. demandAdult primary care: capacity vs. demand
Demand for careDemand for care
==
Capacity toCapacity to
provide careprovide care
Thinking differentlyThinking differently
Sharing the careSharing the care adds capacityadds capacity
Patient self-carePatient self-care reduces demandreduces demand
Share the careShare the care
Self careSelf care

35. Reducing demand through self careReducing demand through self care
• Home pregnancy kits, home HIV testingHome pregnancy kits, home HIV testing
• Internet sites (good and not good)Internet sites (good and not good)
• More OTC medicationsMore OTC medications
• Patients with home blood pressure monitors whoPatients with home blood pressure monitors who
self-titrate their medications can achieve betterself-titrate their medications can achieve better
blood pressure control than that achieved by MDsblood pressure control than that achieved by MDs
• Patients on anti-coagulation who home-monitor andPatients on anti-coagulation who home-monitor and
self-titrate warfarin doses can achieve better INRself-titrate warfarin doses can achieve better INR
control than MDs.control than MDs.
McManus et al, Lancet 2010;376:163; Heneghan et al, LancetMcManus et al, Lancet 2010;376:163; Heneghan et al, Lancet
2012;379:322.2012;379:322.

36. Add capacity, reduce demand through technologyAdd capacity, reduce demand through technology
• Much panel management can be done by computersMuch panel management can be done by computers
rather than MAs. Computers identify care gaps, remindrather than MAs. Computers identify care gaps, remind
patients. MAs needed only when patients don’t respond.patients. MAs needed only when patients don’t respond.
• Computers can be programmed to authorize med refillsComputers can be programmed to authorize med refills
without expenditure of human effortwithout expenditure of human effort (Healthfinch.com)(Healthfinch.com)
• Patient self-care for uncomplicated UTI is safe andPatient self-care for uncomplicated UTI is safe and
effective. Patients enter UTI symptoms into aeffective. Patients enter UTI symptoms into a
kiosk/vending machine.kiosk/vending machine. If no red flags, 3 days ofIf no red flags, 3 days of
antibiotics are dispensed from vending machine. Noantibiotics are dispensed from vending machine. No
involvement of health care personnel.involvement of health care personnel.
• Cell phone otoscopes allow parents to dx peds earCell phone otoscopes allow parents to dx peds ear
infections or send to clinician via patient portalinfections or send to clinician via patient portal

37. Take-home pointsTake-home points
• The “primary care physician shortage” must beThe “primary care physician shortage” must be
re-conceptualized as a demand-capacity gapre-conceptualized as a demand-capacity gap
• Capacity can be increased by sharing largeCapacity can be increased by sharing large
amounts of care with non-cliniciansamounts of care with non-clinicians
• Patients not only receive, but can provide carePatients not only receive, but can provide care
as peer coachesas peer coaches
• Demand can be reduced through growth of selfDemand can be reduced through growth of self
carecare
• Technology can facilitate this transformationTechnology can facilitate this transformation
• In the future, primary care will be dramaticallyIn the future, primary care will be dramatically
differentdifferent

38. The Building Blocks ofThe Building Blocks of
High-PerformingHigh-Performing
Primary CarePrimary Care
Think differentlyThink differently