By Robin Jay, BHC Editorial Director

As the 25th Annual Rosalynn Carter Symposium convened last week to discuss solutions to the broken healthcare system, presenter Larry A. Green, MD, Professor of Family Medicine at the University of Colorado, Denver, and the Chair of the Board of Directors of the American Board of Family Medicine, spoke on the topic, “Clinical Processes: Building the Health Home.”

In his compelling address, Dr. Green said it’s time to modernize primary care with redesigned, high-performance advance team work. Is there a shortage in primary care? Dr. Green offered an intriguing viewpoint: That the answer lies not necessarily in how many primary care providers there are, but what they will be doing in a redesigned primary care system. He said technology and medical advances could redefine medicine in a way that steers some subspecialty care providers into primary care. Dr. Green did say, however, that if more students don’t start filling the pipeline in primary care at medical schools, a pending shortage could loom.

In an exclusive interview with BHC, Dr. Green discussed how the University of Colorado is answering the call for more primary care physicians with a unique rural track. He also explained why we need provider payment reform. “My own opinion is that the most important thing we need to do with payment reform is to move away from fee-for-service that pays for isolated pieces of work through relative value units (RVUs) of service, to a blended payment model. It seems to me that there has been a ground swell of support for blended payment systems where the funding for taking care of folks can be moved toward the provider and the service that is needed to solve that person’s problem readily,” he said.

You’ll want to read our complete interview with Dr. Green. His insightful remarks at the Symposium left the audience on the edge of their seat and ready for more – and in our exclusive interview, Dr. Green offers just that.

BHC: Dr. Green, many people involved with healthcare reform efforts are asking if the system is going to have enough primary care physicians once the majority of the 87 million currently uninsured people get access to care. Do you have any thoughts on that subject?

Dr. Larry Green: The fundamental concern I have about the primary care workforce is not how many, but what they will be doing. I understand the workforce numbers that lead to the projections that we have a looming shortage of primary care clinicians. I believe they are correct over a period of years because of the lack of entry into the primary care fields by medical students. The evidence is solid. Where I’m a bit of a skeptic, however, is around deciding if we have a shortage until we know what they’re going to do.

We’ve entered an era of not a tweaking of the way primary care is done, but a remake. I’m humbled by the proposition of projecting out 10 to 20 years from now how many of any type of healthcare provider we’re going to need. There could be scientific developments that would make it unnecessary to do colonoscopy, to screen people for colorectal cancer with nothing other than a finger prick and a blot. What will gastroenterologists do at that point in time? So when you look at what a family physician or other primary care physician will be doing, when we get the advance primary care practice in place and we have a better idea of what they need to do to do that role properly, will we have a shortage or not? I’m unwilling to commit one way or the other.

I’ve also have been fascinated lately by learning in September that the Air Force, Navy and Army have all adopted the patient-centered medical home as their model of care. As they did that, they are organizing their delivery system such that they have one full-time primary care physician for every 1,200 patients in that system. This is very similar to what happened at the Group Health Cooperative in Puget Sound in the early 1990s. In the middle of the managed care era, they were taking care of on average about 1,150 patients or so per primary care physician.

There’s a lot of talk in the expert literature right now about the patient-centered medical home about what’s the right number of patients for a primary care physician. You can argue a case that it’s around 1,200, like the military has decided. Now, that may be high [or it] may be low. I just simply don’t know. But I do know this: Using the AMA Master File Data, and the other large national data sets, we presently have in practice enough primary care physicians to have one for every 1,160 people. So I’m a little reluctant to declare that we’re presently living with a primary care shortage.

If we don’t fill up the pipelines soon with medical students who aspire to be the best personal doctor they can be, and to work in this new model of care, we will eventually hit a point in which there’s just not going to be enough doctors.

BHC: Dr. Green, you’re a professor of family medicine at the University of Colorado. One of the things in the media I’ve heard talked about to remedy a possible primary care shortage is to reach out to students who may be interested in primary care. It seems that a lot of the funding that medical schools get is more situated toward subspecialty care. So therefore medical universities aren’t necessarily incentivized to attract primary care students. As a professor of family medicine, how do you see the outreach going at the University of Colorado for new students to go into primary care?

LG: If I may, I’ll just be specific to the University of Colorado. When the AAMC proclaimed that we were facing a physician shortage, and that we needed more medical schools to expand their class sizes, my home university, the University of Colorado, expanded its class size. But it did so by connecting it to the important policy issue that we needed to train more physicians for the rural practice.

The expansion led to the establishment of, I think, about 24 new slots, but it was tied to the recruitment and outreach to students from rural areas who were interested in rural practice. And that expansion then was used to try to recruit students on the basis of what has been learned over the last 30 or 40 years about what predicts practice in rural areas. And then they developed a rural track and a new rural program. And they cultivate these students from the day they enter until the day they leave. In the immersion experience in rural communities, they distribute the curriculum to be outside the academic health center, to be in the communities where they can experience the phenomena of getting sick, getting well, being treated, not being treated, getting prevention and not getting prevention in rural communities.

We have reason to believe that this will increase the graduation of students from medical school inclined for rural practice. The model for this was developed at Jefferson University in Philadelphia, Pennsylvania, years ago, and it has a substantial evidence base that would make one predict that this type of thinking could help with this.

BHC: Dr. Green, today at the 25th Annual Rosalynn Carter Symposium on Mental Health Policy, you spoke about the need to modernize the primary care role and that the primary care ideal was developed back in the 1830s in France and that it is really time for a tune-up. Can you talk about that, and also the statement in which you said it was a good time for us to start working together? What did you mean by that?

LG: There is a book called The Birth of a Clinic by Michel Foucault, and by “the clinic,” he really meant this notion that you would organize resources someplace where a person who thought they might be sick or were sick would be taken, where they would assemble the knowledge and technology to take care of them. If I am representing his views correctly, he tethers the crystallization of that approach to doctoring in France in the 1830s in France, and that’s why I made that statement.

Now, I would not want to be misunderstood to say there have been no changes in primary care for 180 years. All sorts of things have changed. But the basic construct is still tethered to this notion that care has to be provided at a place and the patient has to go there. And what we now know in the information age of the 21st Century is that much of what people need does not require geographic proximity.

So when you start thinking about how to get subspecialty psychiatrists, for example, to a population in the old way of thinking about the clinic, the question would be how do you get a psychiatrist into the clinics so that when the patients come in, you’ll have a psychiatrist present? But in the new design, a lot of the care will be asynchronous and it can come from all sorts of locations.

We heard some examples in the Symposium today about how you can quickly get a text message that guides medication selection or adjusting a medication for someone. That message may be coming from a thousand miles away, but it can be personalized to apply directly to the patient who needs that information and needs that adjustment right now. And this might be in Salina, Kansas, and the consultative help may be coming from Chicago. That’s what I mean about that it would be okay if we broke free of these old ways of thinking.

Also, the clinic was mostly designed to take of desperately ill people. We need to refocus the care on the avoidance of disease. That original clinic was focused mainly on acute care and disasters as they occur. And we know that we really need to focus on chronic care and things that people don’t die of but live with for decades.

So the workforce is there, the technology is there. It’s really a splendid, propitious moment to be able to rethink that and reconstruct it in light of all that we have learned of a period of more than 100 years. I believe that America’s brightest and best students will immediately warm to the possibility of being part of innovation and the creation of high-performance healthcare that’s superior to anything that’s existed before, things that their parents could hardly even dream of. I think that they’ll want to be part of that. They’ll want to sculpt it; they’ll want to influence it; they’ll want to be participants in it.

I think my generation’s responsibility is to engage them in this redesign, this remake of primary care. The students today are very, very smart. They have different ways of thinking than us old guys. The period is just such fertile territory to move our country’s healthcare system from what is very mediocre performance to really ramping this thing up. The redesign of primary care is only the redesign of the largest platform of formal healthcare delivery in the country. Who would not see that as a great way to spend your heartbeats – to spend what you learn in medical school and college, in community development, information technologies, biochemistry, genetics, on getting that done right?

BHC: Let’s talk about integration. As we move toward healthcare reform, how do we get primary care physicians, mental health specialists and addiction treatment specialists to work together and communicate as a team, rather than in silos of fragmented care?

LG: I wish I knew an accurate answer to that. I have glimpses of what it would take. I’ve noticed, both in practice and in the other roles I’ve been privileged to work in, that a lot of the disharmony and fragmentation, disputes and territorial issues rapidly melt away when we ask ourselves to help a person who is suffering or is at risk for suffering and needs our help. In the practice setting, hospital setting or mental health setting, when someone is in desperate need of help, I’ve witnessed over and over again the willingness of nurses, receptionists, medical assistants, psychologists, surgeons, pediatricians – no one cares what track they’re from. If they can contribute to helping this patient, they’re welcome to that table.

Now go inside the beltway to Washington D.C. where we’re trying to adjudicate a $2.5 trillion budget. You don’t get proper table manners because we’re talking about a lot of money, and we’re talking about prestige, position, influence, recognition – very important things. I don’t mean to take away anything from it, but that is a different problem to solve.

So, using those as polarities, I believe that part of the solution about how we work together is that we make an agreement with each other that we will repeatedly re-anchor whatever we do around the answer to the question, “What does a person facing that problem need from the healthcare delivery system?” And then ask, “Do I have anything to contribute to that? If the answer is yes, what is it and what’s the best way I can contribute that?” I believe that the huge, vast majority of the people working in the U.S. healthcare delivery system get up every day wanting to improve lives. And when they’re given the opportunity to frame questions that way, they warm to it. It’s their culture. It’s their nature.

The healthcare delivery folks are not immune to the forces of money, but frankly, most of them didn’t enter the healthcare arena for the sole purpose of getting rich. Most of them enter it wanting to do good things for people and helping people. And then they accidentally get well compensated for it along the way.

So I think we can tap into that. I believe it’s still there. And I believe every year we bring a new group of young people into nursing school, pharmacy school, dental school, psychology programs at the medical school, who yearn for their lives and their careers to really make a difference for people.

That may sound pretty idealistic for an old gray-headed guy like me, but I believe that those ideals are alive and well in America’s youth. All we really need to do is to create an environment in which they can come, and instead of being repelled or dehumanized, awash in interdisciplinary squabbles about who’s best or who should do this or who should do that, I think that they will propel us into these new models.

BHC: In compensation models in primary care, you said physicians are often penalized for coordinating care or for doing things above and beyond. It’s been said today that most of the healthcare reform bills in Congress have worked in a primary care, patient-centered model. Does that mean that primary care physicians would be better compensated?

LG: Not necessarily. I think everyone should take heart who is in public health, mental health and primary care, that the current versions of the legislation in Washington offer hope that there could be some changes in compensation. My own opinion is that the most important thing is to move away from fee-for-service and paying for isolated pieces of work and relative value units (RVUs) of service. It seems to me that there has been a groundswell of support for blended payment systems where the funding for taking of folks can be moved toward the provider and the service that is needed to solve that person’s problem readily, rather than being tied up to say, “That’s a pharmacy service, so you can only pay a pharmacist to do that service.” Or, “That’s a mental health service, so you can only pay a licensed mental health provider for that service.”

In the new, redesigned, high-performance, advanced primary care practice, teamwork will be a hallmark. And just like in professional sports, like football, the teams that will perform the best will be the ones that have strong leaders at each position, who know their position, know their assignment, know what plays have been called, and know what their responsibilities are. In some instances, a particular player really will take the leadership role and will be responsible for executing that play. And in many instances, that is not going to be a physician. Many instances, it’s not going to be a nurse. It may be a type of provider you and I have never dreamed of at some point.

What we need is payment reform that basically just adequately capitalizes an advanced primary care model, appropriate mental health and public health prevention services and is not too explicit or too detailed about who can get that money. This goes back to your earlier question about how it’s hard to get along sometimes when it’s, “If you win, I lose.” That’s part of the beauty of the blended payment model, where you say, this is it, this is the budget; you measure your results, you define and know who your population is and you know what you need to do. And if you need to spend more money on renal dialysis because that’s the nature of your practice, and that just happens to be the nature of the population you’re caring for, that’s fine with us. And with blended models, it’s possible to look at a population in a practice, and if they have a particular morbidity, it would allow policy makers to ratchet up the payment for people taking care of the sickest people.

So, we need to get a way from paying for piecework and we need to get away from paying to sustain a program for every type of healthcare professional, and get payment that supports the people getting they type of care they need that’s right for them in their situation.

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