The Last Internist

Is Primary Care Internal Medicine dead?

Michael Wagner, MD FACP

Chief, General Internal Medicine

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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

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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.

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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

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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

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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).”

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Choices

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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

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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

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“If you don't know where you are going, any road will get you there.”Lewis Carroll

“The future is today.” William Osler

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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

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Deconstructing Primary Care

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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

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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

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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

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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

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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