The Last Internist
Is Primary Care Internal Medicine dead?
Michael Wagner, MD FACP
Chief, General Internal Medicine
2
Objectives
• Outline the qualities of a primary care physician• Review the origins and creation of a new specialty –
Hospitalist Medicine• Explore the current predicament of primary care internal
medicine• Discuss the drivers and future of general internal
medicine
Jan 2009 M Wagner MD
Disclosures
• Chief, General Internal Medicine• Associate Professor of Clinical Medicine• Consulting Medical Director, EmCare Inpatient Services• Founding Member, Phoenix Group• Member, Public Policy Committee, Society of Hospital
Medicine• Physician consultant, McKesson
Jan 2009 M Wagner MD3
Biases
• National view– Evaluated >200 hospitals and medical staff for developing
hospitalist programs– Developed or managed >60 hospitalist programs
• Importance of community, non-academic hospitals– 80% of US hospitals are not teaching hospitals
• CEO of a national practice management company– Develop reproducible and sustainable practice models– Understanding of the primary business drivers in healthcare today
Jan 2009 M Wagner MD4
Biases - National experience
5 Jan 2009 M Wagner MD
Mental exercise
• What are the essential qualities of a primary care internist?
Compassionate Accessible
Continuity of care Knowledgeable
Relationship Responsive
Complete Responsible
Practical Flexible
Coordinator Listener
6
Physician – Archetypes
General Internal Medicine – Traditional model
Emergency
Care
Nursing home and
home based care
Hospital care
Office based care
General Internal Medicine
Nursing home and
home based care
Hospital care
Office based care
Emergency
Care
General Internal Medicine
Hospital care
Office based care
Emergency
Care
Nursing home and
home based care
Case – Part 1
• A 60 bed hospital in a rural community has decided to explore the creation of a hospitalist program. The hospital has an active primary medical staff consisting of 8 internists and 6 family medicine physicians. The next nearest hospital is 35 miles away. Several of the primary care physicians have expressed increasing frustration with the work load they are carrying since they have been unable to recruit a new generalist in over two years.
• The hospital is exploring either to build the program themselves or contract with a national practice management company.
11
Hospitalist medicine – essentials
• Defined as a physician who devotes his/her time to care of hospitalized patients
• Provides admission to discharge care and continuous coverage
• Structured role and integration with nursing and ancillary services
• Growth of programs has been driven by the unassigned ED admissions and referrals from overworked primary care physicians
Growth in numbers of hospitalists
13
Source: Society of Hospital Medicine
Growth in relationship to established specialties
Jan 2009 M Wagner MD14
30,000 hospitalistsestimated by 2010
Source: AAMC
Hospitalist Medicine – Ideal conditions
Jan 2009 M Wagner MD15
Investment - >$90,000 / FTE hospitalist
Unassigned patients and primary care overload
Reproducible and scalable clinical model
MD Workforce
Hospitalist medicine – re-cap
• Fastest growing specialty in medicine– 0 to 20,000 since 1996 when Hospitalist name first described
• Reproducible clinical/business model• Well organized national voice – Society of Hospital
Medicine• Physicians have accepted as career choice• Growth has occurred without a meaningful change in
reimbursement at the payer level
January 16, 2009 M Wagner MD16
General Internal Medicine
Hospital care
Office based care
Emergency
Care
Nursing home and
home based care
General Internal Medicine
Office based care
Emergency
Care
Nursing home and
home based care
Hospital care
Case – Part 2
• Representing a national practice management company, I present the benefits of a well run hospitalist program to the hospital administration and physician leadership of the medical staff.
• After the presentation, two physicians who were introduced as General Internists, approach the presenter and say “if you are given the contract to build the hospitalist program, we want to apply to become full time hospitalists. We have decided to close our practices and if the hospital cannot get the program up and running in the next six months we plan on joining the newly started program at another hospital (the one 35 miles away).”
19
Choices
20
Hospitalist Medicine Primary Care Medicine
The generalist
Choice: Primary Care vs. Hospital Medicine
Primary Care IM Hospital Medicine
Full time work commitment 18.75 days/month 15 shifts/month
Patient encounters per day 20-30 pts per day 15-18 pts per shift
Average compensation $150,000-$180,000/yr $180,000-$220,000/yr
Overhead Office, staff, equipment, supplies, billing, medical malpractice
Billing and medical malpractice
Non-visit clinical work >100 documents/day Minimal
Administrative work Common - Prior authorizationsReferrals, FMLA, PT-1, Disability forms, etc
Minimal - Inpatient payment denials
Panel size 1,500 to 2,500 0
Workday Controlled by schedule Controlled by patient need
21
Snapshot of work generated
Based on EMR data from January 15, 2008 to January 15, 2009
Document type
Total number of documents since
January 2008
Average number per day for all of GMA
Ratio compared to office visit volume
Number compared to average volume of 20 patients per day
Office Visit 63,932 256 1.00 20
Coumandin 9,058 36 0.14 3 Phone Note 75,103 300 1.17 23 Rx Refill 20,861 83 0.33 7
Letter - Results 39,310 157 0.61 12 Medication list 14,845 59 0.23 5 External Correspondence 18,726 75 0.29 6 Internal Correspondence 10,241 41 0.16 3 Other letter 39,543 158 0.62 12
Lab Report 258,036 1,032 4.04 81 Imaging Report 17,115 68 0.27 5 Pathology Report 4,052 16 0.06 1
Hospital Admission* 3,530 14 0.06 1 Emergency Report* 9,002 36 0.14 3
Totals (excluding office visit) 519,422 2,078 8 162 Other notes* 87,631 351 1.37 27
Causes of burnout in medical professionals
Dissatisfaction with primary care
• Burden– Non-visit clinical work without support– Administrative paperwork– Technology
• Compensation• Respect• Role models• Control
Jan 2009 M Wagner MD24
“If you don't know where you are going, any road will get you there.”Lewis Carroll
“The future is today.” William Osler
Jan 2009 M Wagner MD25
The New Internist
The evolution of general internal medicine
Michael Wagner, MD FACP
Chief, General Internal Medicine
General Internal Medicine
Office based care
Emergency
Care
Nursing home and
home based care
Hospital care
Strategic analysis
Strategic Drivers• Aging and chronic illness
burden increase
• Shrinking MD workforce
• Reduction in health care dollars/patient
Responses • Increasing non-visit clinical
work
• Increasing ratio of patients per primary care MD
• Application of evidence based care to make quality and utilization more uniform
28
Deconstructing Primary Care
29
Urgent Care
Health Screening
Primary Care Role
Chronic Care
1.Visit and non-visit work2.Disease/condition care
management3.Multidisciplinary teams
1.Non-visit work is substantial2.Screening based on accepted
guidelines3.Requires coordination with
specific screening services (Mammo, Endo)
1.Visit based work2.Access is essential3.Physical space designed for
urgent care4.Triage and collaboration with
ED and hospital for transfers
Transition analysis
30
Current state Future state
Accelerants1. Investment2. MD workforce3. Hospital medicine
Concerns 1. MD-Patient relationship
Wildcards1. Retailization2. Health Care reform3. Technology4. Remote monitoring5. Non-physician providers6. Organizational acceptance
“General Internist”• Visit focus• Office and staff visit focused
Strategic Drivers1. Aging and chronic illness burden increase2. Shrinking MD workforce3. Reduction in health care dollars/patient
The New Internist• Management of the medically
complex patient• Office and staff restructured
to provide visit AND non-visit based care
• Multidisciplinary teams
The New Internist - Role
• Expert in the care of the medically complex patient – Manages patients with complex medical conditions across the
spectrum of healthcare services and over time
• Team player – Works in collaboration with a multidisciplinary and integrated team
• Nursing• Social work• Home based services• Nutrition
The New Internist – Practice structure
• Physician is part of the multidisciplinary team and is the medical leader– Direct patient care– Clinical guidelines, protocol development
• Practice is structured to support visit and non-visit clinical work– Information technology
• Integrated EHR, e-prescribing, patient portal– Staff
• For visit work focused on efficient patient flow• For non-visit work – phone/electronic staff, case management
– Space• Practice supports lifestyle needs of providers• Continuous professional development program• Transfer of care relationships with specialists/hospitals that provide a
higher level of care (applicable to rural and community facilites)
The patient – physician relationship
• Minimal• Radiology• Anesthesia
• Episodic• Consultants• Hospitalist• Urgent care• ED
• Continuous• The New Internist• Pediatrics• Family Medicine• Some specialty care
Jan 2009 M Wagner MD33
What is the value of a continuous relationship between a patient and physician?
Wildcards
• Retailization– CVS – Minute clinics– Specialty hospitals, clinic
• Health Care Reform• Technology
– Electronic health records– Remote/tele health
• Non-physician providers• Organizational acceptance
– Shared belief system– Organizational adoption– Label
Jan 2009 M Wagner MD34
Label
•Chronicist•Chronicalist•Degenerist•Maladist•Ambulist• Internist
Conclusions – The New Internist
• General Internal Medicine is in a unique position to redefine the role of the “Internist”
• Our training in the breadth of medicine and our interest in forming long term relationships with patients will enable Internists to provide the most effective primary care foundation for adults
• Supporting this new Internist will require restructuring their practice to handle visit and non-visit clinical work, and to shift from a visit based to a population based management approach
36
Practice evolution
• Strategic importance• Platform for physician recruitment and retention• Electronic health record with integration• Quality integrated into clinical operations• Reorganize staff and augment with multidisciplinary team
members• Space re-configuration• Reorganize physician work schedule to account for non-
visit work and team participation
The Goal
• Expand primary care capacity
• Transform the operations of the practice
• Increase organization value by increasing patient engagement with the Medical Center
Growth of Tufts Medical Center
Double the size of primary care in Boston and the associated contribution to Tufts Medical Center