- Aging population, living longer with more disease or conditions
- Adverse lifestyle choices (e.g., "smoking and poor diet that lead to cardiovascular disease, cancer and diabetes")
- Acquisitions as driven by the technological Imperative—e.g., new drugs and medical procedures
- Appropriate or Inappropriate--a reimbursement system that "often rewards" either, indiscriminately
"The big question is why doctors have become more likely to send their patients to specialists. Part of the answer.... has to do with health care becoming more complex, with new technology that demands more specialty care. Physicians have also found themselves with more preventive tests and screenings to handle, which may cut into time to deal with other issues. And, part of it likely has to do with the economics of referrals: Doctors who have an ownership stake in their practice are 50 percent more likely to refer to a specialist, which would increase the total revenue generated by a given patient."
- Structural—medical home, physician-hospital integration, and accountable-care organizations;
- Payment—for care coordination, in and outpatient bundled case rates, pay-for-performance, and "other 'shared savings' proposals, and various forms of prospective payment or capitation";
- "Tools" that facilitate and monitor either or both of the above such as medical information systems (e.g., EHR, acuity-adjustment, episodes of care and comparative-effectiveness data). He adds: "Comparative-effectiveness information is more likely to be accepted by society as a tool for appropriate clinical decision making rather than as a mechanism for coverage determinations."
Although he pushes for group practice to effect these reforms, these goals and objective belong to the provider community, regardless of structural differences.
It is important, in this context to also review some of the hidden, non-reimbursable costs involved in the business of medicine: image and laboratory test interpretation, prescriptions, phone and other consultations, form completion, negotiating on behalf of patients with insurance companies' utilization managers, responding to patient care–oriented messages; and create, review, edit, and sign EMR documents, etc.
"Nonvisit" care or non-clinical activity may reduce the need for some office visits and may help improve patient outcomes. It certainly contributes to the office workload, but it is not reimbursed.
"Provision of primary care requires a substantial number of tasks beyond face-to-face patient interactions. Although vital to the actualization of health care reform goals (eg, increase preventative care, better manage chronic diseases, improve health care quality, decrease hospital readmissions), much of this work is unrecognized. Efforts to improve practice efficiency and increase access to primary care providers must take into account these important but under-appreciated tasks."
Dyrbye LN, West CP, Burriss TC, Shanafelt TD. "Providing Primary Care in the United States: The Work No One Sees." Arch Intern Med. 2012;172(18):1-2. doi:10.1001/archinternmed.2012.3166. [Pub online Research Letters | Oct 8, 2012]
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