Primary care doctors are like speed daters. They rush from one patient to another, trying to glean a person’s health status from a brief physical exam and a short chat. The job isn’t easy and, as many primary care doctors will tell you, not very satisfying.
These doctors are compensated in large part based on how many patients they see, so it’s not uncommon for one to care for several thousand patients and see 20 to 30 of them a day. Despite all the stress and responsibility, the $150,000-to-$190,000 range for the average salary of a primary care doctor — those board-certified in family or general internal medicine — is a third of what radiologists, cardiologists, and orthopedic surgeons earn.
On paper, Massachusetts has plenty of primary care physicians: 126 per 100,000 residents, well above the national average of 88, according to the 2007 State Physician Workforce Data Book. But research conducted by the Massachusetts Medical Society indicates that the state is nevertheless facing a critical shortage of primary care doctors. Many of the doctors listed in the Workforce Data Book have moved on to other fields and are no longer providing primary care, and the number of medical students choosing the field is plummeting.
Dr. Robert Jandl, a primary care physician in Williamstown, loves his work. But he says the fast pace and the endless bureaucratic hurdles that come with tending to his patients wear him down.
“The days have become just beastly long,” he says. “I start out every day with a lot of energy, but I get to a point where I just want to scream because I’m being asked to do the most ridiculous things.”
Jandl conducted a survey of the 79 full- or part-time adult primary care doctors in Berkshire County and found his concerns were not unique. Forty-six percent of the doctors said they were dissatisfied with their practice, 63 percent said they would probably or definitely not go into primary care if they started over again, and 91 percent said they had reservations or would recommend against others going into the profession.
Dr. JudyAnn Bigby, the state’s secretary of health and human services, says Massachusetts is beginning to explore alternative treatment and payment systems to improve the lot of the primary care physician. One of the approaches is being developed by Dr. Allan H. Goroll, a primary care physician and an associate professor of medicine at Harvard Medical School.
Goroll says the crisis in primary care is one of the chief reasons for the US health care system’s poor performance. The country spends more on health care than any other nation in the world, yet it ranks 25th or lower on most measurements of health outcomes. Instead of old-fashioned doctoring, Goroll says, patients are getting a lot of unnecessary and expensive tests and procedures.
The 62-year-old Goroll, who has been practicing and teaching primary care since 1976, says a primary care doctor shouldn’t be running from patient to patient, but instead be the quarterback of a health care team, calling the “plays” for his or her patients. Gorroll says that whether making a pass to a cardiologist, handing off to a nurse practitioner, or hanging on to the ball and navigating the patient through a difficult illness, the primary care physician should be focused less on face-to-face meetings and more on helping patients get the care they need in the most cost-effective way.
Primary care doctors should also be compensated like quarterbacks, Goroll says. In a 2007 Journal of General Internal Medicine article co-written with several colleagues, Goroll suggested that primary care providers receive monthly payments for each patient, with the payment amount adjusted up or down depending on the patient’s expected level of care. Goroll also called for incentive payments for practices that meet benchmarks on cost-effectiveness, patient satisfaction, and health outcomes. Payments to primary care providers would go up by an estimated 40 percent under Goroll’s proposal, but overall health care costs are expected to drop as costly tests, procedures, and emergency room visits are eliminated.
It’s a revolutionary proposal, so bold that several journals rejected his article. “Many people said, ‘What’s Goroll smoking?’” he says.
Yet Goroll is not deterred. He is seeking financing for a series of field tests of his model. He says radical change is necessary because the current system is in meltdown.
I spoke with Goroll at his sixth-floor office in the Wang Ambulatory Care Center at Massachusetts General Hospital. What follows is an edited transcript of our conversation.
COMMONWEALTH: What’s the life of a primary care physician like these days?
GOROLL: It’s a far cry from what originally attracted people to come into the field. The job description that inspired people to become primary care physicians was one of having an important role in the life of patients. Not dissimilar from the fabled role of the old GP, or general practitioner, which was to know the person well, to know their family, to be with them through health and through illness, to be their advocate, to combine science with humanism, and to help solve human problems. Primary care today is a far cry from that. It is now a volume-driven, short-encounter, pressured experience full of administrative hassles, financial worries, and payment for the wrong things.
CW: What do you mean by “payment for the wrong things”?
GOROLL:: We get paid on a volume basis, not on a value basis. We get paid for how many people we see. We don’t get paid for how well the patient does, what value we create in the patient’s life, or the value we create in the health care system. This has created what many doctors call a kind of unsustainable treadmill existence of work, where there are rapid short encounters with many, many patients. There’s often inadequate time to do the job right. Doctors are unhappy. Patients are unhappy. Nobody benefits.
CW: How many patients does a primary care doctor see in a day?
GOROLL: They may see 20 to 30 patients a day. That would not be unusual at all. In fact, some primary care doctors would say that’s an easy day. That means the average visit is very short. It’s probably in the 10-to-12-minute range. On a good day it may be 20 minutes. For many patients who are very sick, especially the elderly, that’s hardly enough time to get the job done properly.
CW: What is a doctor paid for those visits?
GOROLL: A primary care doctor who sees a patient for up to about 35 minutes for a series of complicated medical problems will be paid $75. Physician payment for a diagnostic or interventional procedure that takes the same 35 minutes will often be anywhere from $400 to $1,000. But the responsibility of the physician performing that procedure pretty much ends when the patient leaves. For the primary care doctor, it’s 24/7.
CW: What does that price discrepancy say about our health care system?
GOROLL: The system pays very little for doctoring and pays very richly for procedures. The net result is that Americans get a ton of procedures and actually very little doctoring. That leads to our being No. 1 in the world in cost. We are somewhere between No. 25 and No. 35 in quality and health status of the population. The reason for that is that we get exactly what we pay for. We pay for procedures and we get tons of procedures at high cost. We don’t pay for doctoring, and the net result is that we actually scare people away from those fields that depend predominantly on talking to patients, examining them, counseling them, and coordinating their care.
CW: How do you define doctoring?
patients, Lorraine Baron.
GOROLL: Despite all of our technology, proper diagnosis fundamentally depends on getting the story from the patient accurately and in unblemished fashion and then performing an examination that begins with the physical exam. Skipping those steps and just taking a picture can not only be valueless but also misleading. The initial encounter is essential to developing some idea of what the patient may have. Then you can design an intelligent evaluation plan that may include high-tech and may not, but it helps to selectively apply the technology we have. Right now we just have technology that we apply uncritically, and it’s driving up costs. Imaging costs in the United States have now exceeded pharmacy costs, and they are growing exponentially. It’s part of the reason why health care costs are going up without an associated increase in quality.
CW: What’s the administrative burden of the primary care doctor?
GOROLL: There’s a lot. First of all, you have to document what you’ve done. That means you have 5 to 10 minutes of detailed recordkeeping for each visit, especially for patients who have multiple medical problems. Second, there’s often a lot of paperwork around the coordination of their care, and that all flows through the primary care doctor. The primary care doctor has to sign off on almost everything — physical therapy, a visiting nurse, a parking sticker for a handicapped plate, a brand name drug instead of a generic. Then there are physical therapy reports, permissions for this test or that test, and on and on. Just a billing form can take five minutes to fill out. The amount of time spent in administration comes close to the time spent with the patient. It’s extraordinary the amount of paperwork that flows over the desk. And to date, there’s almost been no payment for coordination.
CW: How bad would you say the problem is?
GOROLL: We are in the eighth inning of a national disaster. The first generation of primary care doctors was trained in the 1970s, and they are about to retire. Many have already left the field to work for hospitals, insurance companies, and foundations. In eastern Massachusetts, it’s nearly impossible to find a primary care doctor today. In fact, doctors can’t find personal physicians. We are basically an endangered species.
CW: Are medical schools producing new primary care doctors?
GOROLL: Most students around 2000 began opting out of primary care. It used to be that 50 percent went into primary care. Now it’s down to less than 10 percent, and one survey suggested that less than 2 percent plan to go into general internal medicine. There’s a virtually empty pipeline of new primary care doctors.
CW: Why do you think primary care doctors are so important?
GOROLL: Primary care doctors are the quarterbacks of the health care delivery system. They are responsible for assessing the overall situation and deciding what makes the best sense for the patient. They are ultimately responsible for calling the play, so to speak. Not having a quarterback makes a patient tremendously vulnerable. The health care delivery system is extremely complex, and navigating it without the help of someone who is knowledgeable of you and your needs and who is committed to making sure that things go right for you is very problematic. It’s one of the reasons why there is a lot of wasted care, poorly coordinated care, bad outcomes. Barbara Starfield, who is a professor at Johns Hopkins, has actually done a study of the impact of primary care on health care outcomes. She and her colleagues reviewed all the published data and reached three conclusions. Where primary care is available to patients, their health status is better, their health costs are lower, and there is fairness and equal access to all health care. Does primary care add value? The overwhelming answer is yes.
CW: What kind of primary care practice do you think is needed?
GOROLL: The agenda for primary care is a very ambitious one. It’s not only the evaluation of medical problems as they come up, but it’s also screening, it’s counseling, it’s coordination. Because there’s so much that needs to be done, it can no longer be done by one person. So everybody has recognized the need for practice transformation. How we take care of patients needs to be changed from the Lone Ranger model to more of a team model.
CW: What’s the team model?
student Rachel Lapidus.
GOROLL: What we’ve had to date is that doctors have had their schedules taken up with patients needing routine care, and they have not had the time to see people with new problems. So where do those patients go? They go to the emergency room, where costs are 10 times higher. If we want primary care to function properly, we need modern teams that are multidisciplinary: physician, nurse practitioner, physician assistant, health educator, pharmacist, physical therapist, social worker. They should be working as a team. They don’t all need to be under one roof, but they need to be united by access to the patient’s information, usually by an electronic health record. That’s a modern practice. In the original modern concept of primary care, team-based multidisciplinary practice was part of the model right from the beginning. It got torn down by a payment system that only paid for a face-to-face visit with a single person. If you had two people seeing the patient in that visit, payment could only be generated for one person, so it discouraged the very care we would like. The problem is, we have a payment system that is absolutely anathema to the kinds of outcomes we would like.
CW: Are you saying patients should see nurse practitioners and physician assistants instead of a physician?
GOROLL: Some people have proposed that. The problem is that they can do some of the work, but they don’t have the training in medicine that is necessary to do diagnosis. So they can’t be quarterbacks. They can have a supportive role, a facilitating role. They can be a very valued member of the team, but they are not a replacement for a primary care physician.
CW: Aren’t the proposed CVS walk-in clinics an attempt to provide primary care for minor problems?
GOROLL: It can be very, very problematic to deliver care that way because the practitioner at the CVS doesn’t know the patient’s medical background and is operating in a vacuum with no coordination of care. In my view, it’s a symptom that primary care is in crisis when we can’t handle those folks in a convenient, low-cost way.
CW: How big of a raise would primary care doctors get under your proposal?
GOROLL: Payments to primary care practices would increase by as much as 40 percent, and a physician could see his or her pay jump 25 percent, to nearly $250,000. The net effect on total health care spending would be about a 3 percent increase, but the bet is that the extra 3 percent investment would lead to sharp reductions in the estimated 30 percent of total health expenditures that represent wasted spending on unnecessary procedures, inefficiency, lack of coordination, and avoidable complications. The issue of money and primary care is not that primary care doctors are eager to make more money. It’s not that. It’s that they need the money to do the job right.
CW: What kind of payment system are you talking about?
GOROLL: The desired outcomes are personalized care, coordination, and efficient cost-effective care that gets good health outcomes. Why don’t we pay comprehensively for comprehensive care? Instead of paying for piecework, pay people for taking care of the patient. Much of the care is not face-to-face and is not à la carte. It is comprehensive.
CW: But aren’t you suggesting a capped fee for each patient? And wasn’t that tried before with capitation?
GOROLL: Capitation was a form of comprehensive payment, but it had some fatal flaws. The problem was that capitation in the 1990s had only one bottom line — the bottom line. The only outcome was saving money. What they did was say, “If you save money over and above what we collected, we’ll give it back to you.” It had nothing to do with the patient experience, with health outcomes, with cost-effectiveness. It had only to do with saving money. It wasn’t quarterbacking. It was gatekeeping. And if we lost the game, it didn’t matter.
CW: But wasn’t capitation based on the expected cost of outcomes?
GOROLL: No, capitation actually was little more than a lump sum of the fee-per-visit payments for a year. So one of the flaws was it was a lump sum of inadequate payments. That didn’t make them any more adequate. Not only that, it was not risk-adjusted.
CW: Risk-adjusted?
GOROLL: We’re calling for two things. First, a comprehensive payment that is heavily risk-adjusted. So the difference between what you get for taking on the care of a sick person versus the not-sick person may be an order of magnitude — 10 times more. Without risk adjustment, there is a perverse financial incentive to shun the sick or needy patient. Second, the only objective under capitation was cost saving. We would change that to focus on desired outcomes. We would pay a bonus for access, patient satisfaction, medical outcomes — that is, good quality outcomes — and cost-effective care. For example, did we make sure that there were no unnecessary emergency room visits? Did we control the blood pressure and diabetes well? We also risk-adjust the bonus, so if we are taking on people who are very difficult to care for, we’re not being held to the same standard of outcome as someone who’s easy. So our model is risk-adjusted comprehensive payment — with a major bonus of 25 percent that is also risk-adjusted for achieving socially desired outcomes in the areas of cost, quality, and patient access. It’s not payment by volume, so it’s not that hamster-wheel treadmill environment. It’s a team thinking smartly about how to get the best results for our patients. That may not mean every patient who has a cold has to come to the office. It also may mean we may go to the patient when necessary to get the best outcome, to make house calls.
CW: Who would do the risk adjusting?
GOROLL: It should be done objectively and scientifically. We are working with actuaries to design a fair risk-adjustment system.
CW: Who determines the desired outcomes?
GOROLL: We would have a consensus process. As professionals, we feel we can specify the medical outcomes, but outcomes regarding patient satisfaction, cost, and efficiency should be arrived at by consensus with patients, purchasers, and payers sitting around a table. By paying for outcomes, we would encourage the things we want from our health care system. Right now, all we encourage is volume and expensive procedures.
CW: So you’re hoping to give incentives for good doctoring, right?
GOROLL: The pay of primary care doctors would go up commensurate with the value they create. Good quarterbacks and good teams are worth a lot of money. The irony now is that we pay good “quarterbacks” nothing, and we pay other people who don’t create as much value, or a different type of value, six times more. That makes no sense. We can’t continue to expect good people to take on the quarterback role if they’re getting paid one-sixth the amount.
CW: But how can you predict outcomes for patients? Aren’t they all different?
GOROLL: That’s what actuarial science is, and that’s what insurance companies are supposed to provide. There’s a whole science of risk determination, and we haven’t applied it here the way that we should. It’s central to payment reform. There’s a whole science around it.
CW: How has your proposal been received?
GOROLL: From most practices and my students, the attitude has been, “Where can we sign up?” But there are some doctors who are very afraid of taking on this new responsibility. I view them a little bit like slaves after emancipation. The old system was intolerable, but it was one you knew. This new system is going to require a lot of hard work and some courage because you’re going to be the quarterback. My colleagues have bemoaned the fact that they no longer get any respect, but they have stepped back from being quarterbacks and turned into folks who are basically operating 9-5 walk-in minor medical practices. At that scaled-down role, that’s like a 747 pilot driving a bus.
CW: I heard some journals were reluctant to publish your article.
GOROLL: Many people said, “What’s Goroll smoking? This is really pushing the envelope.” But we have no choice because the system is melting down. Without fundamental change, we are going to have a health care delivery system that will collapse like the banking system. It’s actually very similar to the banking system situation. We are paying large dollars for the wrong things. We are not valuing things properly. Many people would argue the meltdown is happening. Just look at the Connector’s performance. [The Commonwealth Connector is a state agency helping residents find health insurance.] Its costs are escalating greater than they thought it would. That’s because we don’t have a primary care infrastructure able to take on new patients. The newly insured can’t find primary care, so they are going to emergency rooms where costs are 10 times higher. So costs are going up dramatically.
CW: Would your proposal bring doctors back to the primary care field?
GOROLL: I see us recruiting a new generation of primary care doctors who will be very comfortable with teams and with health information technology, but also committed to the traditional role of being somebody’s doctor.
CW: What about health insurers? What are they saying?
GOROLL: The payers are saying, “Show us the return on investment.” We need to do the pilots to document what the return on investment is. We’re proposing we field test the new models.
CW: Have you started any pilots yet?
GOROLL: We have assembled a group of nine practices — three in the Albany area and six in Boston — willing to be the pioneers in this effort. We have formed a coalition called the Massachusetts Coalition for Primary Care Reform. But we are having the usual troubles of finding the equivalent of early venture money. We’re looking for about $10 million altogether. One insurer in Albany, the Capital District Physicians Health Plan, has agreed to give the three practices in its area the difference between current revenues and what it takes to implement our new payment model. They realize that this is the future, and they want to be part of it. We are in conversations with other prospective sponsors, including other payers, the state, health care networks, and private parties. We have to do proof of concept.
CW: How would a pilot work?
GOROLL: We will replace the current piecework payment system with a risk-adjusted monthly comprehensive payment, supplemented by a risk-adjusted bonus of up to 25 percent for achieving desired outcomes. The practices will work as teams in trying to accomplish the outcomes and control costs. The pilots will last two years, allowing the collection of data involving about 125,000 patients cared for by about 100 physicians.
CW: Haven’t others made similar proposals?
GOROLL: The other proposals are more incremental in nature. They leave volume in place and then give primary doctors a management fee for the coordination they do, and a bonus. The basic structure isn’t changed. It’s still volume-based.
CW: It sounds as if getting away from a volume-based system won’t be easy.
GOROLL: It’s true, but that’s the fundamental flaw in the current system. Many players have figured out how to make money with the current system, so they are reluctant to change. But we need a new social contract, payment for value, not volume. There are wonderful opportunities here. We are basically starting a revolution in how primary care is practiced and paid for. That is, we think, central to strengthening our health care delivery system.
