Opportunity Knocks: A Primer on the Primary Care Shortage

The answer, it turns out, is still emerging. History may provide an apt starting point.

Specifically, before the fee-for-service era push for maximum productivity and imaging utilization, the core assets of radiology included an understanding of imaging technology, test interpretation and provision of actionable knowledge based on the imaging exam. Radiologists were the doctors’ doctor and were often consulted for many clinical questions; the reading room was a hub of clinical activity.

Fee-for-service reimbursement, coupled with the advent of PACS, relegated radiologists to a smaller, but immensely profitable, role. Radiology thrived. Imaging services were a revenue generator for most hospital enterprises. The radiology department adopted a narrow focus on productivity and efficiency. That, in turn, impacted interactions with referring physicians. As radiologists isolated themselves in the reading room, in-depth consultations with clinicians became the exception rather than the rule.

“The fee-for-service reimbursement model has promoted volume over value,” wrote Richard Afable, MD, MPH, of St Joseph Health, Irvine, Calif., and Michael N. Brant-Zawadzki, MD, executive medical director of physician engagement at Hoag Hospital in Newport Beach, Calif., in the July issue of Journal of the American College of Radiology. “Thus, radiologists are pressured to read an ever-increasing volume of studies while disregarding important clinical responsibilities. This has divorced radiologists from their traditional role as consultants to physicians and patients and as integrators of the patient experience between referring physicians and specialists. Radiologists have become piece workers, the ‘read’ becoming their main output.”

Nevertheless, clinical consultation remained an important part of the radiologists’ job. However, not all clinical consults are created equally.

Paul J. Chang, MD, medical director, enterprise imaging, at The University of Chicago Medicine, offers the contrast between a call for a consultation from a referring surgeon and one from a primary care doctor. “My approach to reports and image review is aligned with the surgeon’s. Our discussions tend to be very efficient and short.”

The consultation with a primary care physician is an entirely different story. Most calls tend to take much longer than a call with a surgeon. That’s because the image serves as the entry point for an in-depth conversation about the disease process, with the physician often asking the radiologist a series of questions, including:

• What is the disease?
• What do I do?
• Who do I call?

“This conversation takes a lot of time,” Chang explains. “In the fee-for-service world, physician education is considered a burden because it distracts the radiologist from relative value units (RVUs).”

Part of the problem is the pressure of the primary care environment. Managed care allotted physicians a mere 12 minutes per patient, notes Brant-Zawadzki. “All the primary care physician could do was figure out where to send them, so they could get to the next patient.” Radiology and laboratory testing became the go-to diagnostic services, hence the dramatic rise in utilization through the 1980s and 1990s.

Healthcare reform and accountable care, however, de-emphasize volume and RVUs and instead focus on value. “Before, healthcare providers made more money when the patient got sick enough to go to the hospital. Now, we will make more revenue if the patient never gets to the hospital, which means preventing strokes, heart attacks, mastectomies and so on,” says Chang.

This model requires a different mix of ingredients, including prevention and education, a mainstay of primary care.

Yet, primary care physicians are in short supply, so success will hinge on extending primary care physicians. The dilemma may set the stage for radiologists to carve a new role. The opportunity is multi-faceted. Primary care physicians often require help navigating imaging and the healthcare ecosystem, says Chang. “Radiology is perfectly positioned to provide those services because that’s what we do.”

An oft-touted strategy to extending primary care is greater deployment of traditional physician extenders like nurse practitioners and physician assistants. The need for education and navigation services may be even greater among physician extenders. That’s because primary care physicians begin their careers in the same setting as specialists in the inpatient world, so they understand how the system, including imaging, works. In contrast, nurse practitioners and physician assistants are usually trained in the outpatient world and lack that content. “Their experience gap with advanced imaging and imaging consultation is going to be greater.”

Compounding the challenge for physician extenders is the emergence of new healthcare settings such as retail clinics. These clinics are often staffed by physician extenders who are isolated from physicians who might be available for consultation. “The clinic staff needs help with the filtering process to determine whether or not additional physician management or imaging is necessary,” offers Brant-Zawadzki.

Take, for example, a patient who visits a retail clinic with back pain—the second most common reason for a primary care visit, says Brant-Zawadzki. The provider might decide the patient needs imaging and send him or her to a physician to order an X-ray, CT or MRI. In this case, utilization and costs increase. Involving a radiologist in the process could provide the decision support to prescribe Advil and a two-week wait before imaging. And in a more acute case of back pain with fever, the radiologist could recommend an MRI with contrast. Both results improve care, and help control utilization and costs at the population level.

Written guidelines may partially bridge this gap. However, guidelines don’t allow for variations at the patient level nor do they allow the provider to seek expert advice, says Brant-Zawadzki.

“Clearly, there is an opportunity for radiologists to bridge these gaps,” he adds.

A final angle on the opportunity is utilization management. Two questions often emerge in a primary care visit: does the patient need an imaging study, and if so, which one? Radiologists can provide a filter between primary care and imaging to determine which patients can be discharged from primary care, which patients require imaging and which patients require follow-up visits with either the primary care provider or a specialist. “This is a tremendous opportunity for radiologists to return to the consultative role they had before commoditization relegated radiologists’ duties to basic reading and reporting,” says Brant-Zawadzki.

Chang agrees. Imaging is the gateway into subspecialty care and further healthcare utilization. “Before that gateway was a positive because it brought more revenue. Now it needs to be monitored correctly [to deliver value and cost-effectiveness.]” Radiologists, who are connected to the entire healthcare ecosystem and understand the larger disease processes and their connections, might be in the ideal position to monitor the gateway.

The primary proposition

Not so fast, say the experts on the other end of that consultative call. For starters, the primary care physician shortage does not exist in a vacuum. A handful of specialists, including general surgery and geriatrics, are also in short supply, according to the Council on Graduate Medical Education in Rockville, Md. Nurses and other physician extenders also are in short supply, adds Arthur Garson, MD, director of the Center for Health Policy at the University of Virginia School of Medicine in Charlottesville. The U.S. nursing shortage is projected to grow to 260,000 registered nurses by 2025, according to a study published in the July/August 2009 issue of Health Affairs.

At the same time, policy and demographics are exacerbating the issue. The Patient Protection and Affordable Care Act will swell the number of insured Americans, adding 27 million people to health insurance rolls by 2017, according to the Congressional Budget Office.  And the population is increasing and aging, which means more patients with chronic conditions and increasingly arduous demands on the healthcare system, says Jeffrey J. Cain, MD, president of the American Academy of Family Physicians.

One senior citizen turns age 65 every eight seconds, translating into a rate of 13,000 Medicare-eligible persons every day, HealthLeaders reported in December 2010. The rate of senior citizen physician visits is three times that of people in their thirties or younger.

“The approach to all of these shortages has to be leverage,” explains Garson. “The first person who has to be leveraged is the patient. We need to encourage the patient to eat appropriately, quit smoking, take medications and stop using the emergency room as a clinic.”

Radiologists alone can’t facilitate this rescue; a team-based approach to care is required. Multiple models for this approach are under development, including the patient-centered medical home and grand-aides.

Cain outlines the benefits of the patient-centered medical home. The goal, he says, is straightforward: higher quality care at lower cost. “One of the biggest challenges is the complexity of the healthcare system in the U.S. Multiple specialties are trying to manage the same patient.” This can confuse the patient and lead to additional and duplicative testing as multiple providers try to manage patient care. A quarterback who can coordinate care is needed, says Cain.

He sees the primary care physician filling the quarterback role. “The highest quality healthcare is provided at the lowest costs when nurse practitioners, physician assistants and primary care physicians work in a collaborative team.” Radiologists also have a key role to fill, he continues. The pressures to contain costs will increases from all corners—insurers, government and internal leadership. Radiologists will need to participate in the medical home by helping healthcare systems and providers make decisions about appropriate, cost-effective testing.

Garson, too, uses a team analogy. The team begins with the patient and includes grand-aides, nurses, nurse practitioners, generalists and specialists. Grand-aides function as nurse extenders and fill a communication and education role with the patient.

The University of Virginia has deployed the grand-aides model to successfully contain a tough target: congestive heart failure readmission. Nationally, approximately 25 percent of these Medicare patients are readmitted within one month of discharge. Hospitals are addressing the issue to improve patient care and also because the Centers for Medicare and Medicaid Services began issuing penalties for readmission in October 2012, with potential 1 percent penalties on aggregate payments for all discharges in 2013 increasing to 2 percent in 2014.

“It turns out that a fair number of early readmissions are due to a lack of appropriate communication about the medical regimen,” says Garson. The University of Virginia sends grand-aides to the patient’s home to educate the patient. Costs of these nurses’ aides are approximately one-third of a nurse, and the per-patient cost is about half that of using higher level staff for basic care management tasks. Since the program model was launched, the university has reduced its heart failure readmission rate 62 percent.

Other team members also serve as extenders. The primary care physician may extend the specialist. Perhaps some moderately uncomplicated patients with heart failure can be cared for by primary care physicians rather than specialists, offers Garson. However, many elderly patients with multiple chronic conditions require both generalists and specialists. To do so efficiently and cost-effectively requires leveraging staff and homing in on appropriate use. “Everyone is going to have to stop performing tests and exams that don’t need to be done,” says Garson. This requires knowledge, decision support and communication.

However, the team model is still evolving. “Teams are going to have different types of competencies. Radiologists need to help everyone practice appropriate care, and step in when they can perform a task better, quicker or more efficiently than any other member,” says Garson, who adds that defining these roles requires research and data.

IT to the rescue?

While Garson wisely calls for research and data to determine the most effective and efficient construct for teams, other developments also are essential.

Chang charges that current IT infrastructure is not rich enough. Computerized physician order entry (CPOE), although it enables decision support, also has minimized information available to the radiologist. Unlike a written script which contains clinical context, CPOE relies on drop-down menus, which are efficient for the ordering physician. But while a script for an imaging exam might contain patient information such as Crohn’s disease, diabetes and belly pain, CPOE can reduce the context to belly pain.

Chang and colleagues undertook a research project and leveraged natural language processing (NLP) to extract problem lists, pathology and laboratory results and other reports in previous imaging exams to create an augmented clinical history. When Chang’s research team compared this augmented clinical history with CPOE indications for the exam in 32 neuro CT cases, they found 34.4 percent of cases with NLP-augmented histories were rated significantly more complete than CPOE-only cases. “We need to strengthen clinical context by directly accessing it from the EMR via PACS.”

EMRs also remain somewhat problematic, adds Cain, as many EMRs function only to edge of the healthcare system. “We need technology to evolve to allow seamless communication beyond the hospital walls or healthcare system.”

At the same time, radiologists also need better communications tools to enable rich, efficient connections with providers in various roles and settings. One possibility may be tapping natural language processing in radiology reports to create an enhanced report with hyperlinks to answer common questions for primary care providers. This rich report also could include a link for patient education, a radiation exposure report and an invitation to email the radiologist. “The report does not have to be dead and static. It can be a living portal to allow rich collaboration,” explains Chang.

“The primary care physician shortage forces us to address clinical collaboration. Radiologists are going to have to go back to rich collaboration with physicians, but we have to leverage modern IT to do so. It’s a great opportunity. We shouldn’t squander it.” HI