At the Intersection of Health, Health Care and Policy
, 29, no.5 (2010):785-790Health Affairs
analysis & commentary A Martian's Prescription For Primary Care: Overhaul The
Lawrence P. Casalino
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By Lawrence P. Casalino
ANALYSIS & COMMENTARY
A Martian’s Prescription
For Primary Care: Overhaul
The Physician’s Workday
ABSTRACT What would a Martian arriving on earth think about how U.S.
primary care physicians spend their time? She or he would probably
reach the same conclusions as this essay: that a new model for primary
care should not be based on physicians’ seeing a high volume of patients.
On the contrary, physicians should see a relatively small number of
patients, perhaps eight to ten daily. Thus liberated, they could spend
more time with patients who need it; could have adequate time to
communicate via phone and e-mail with patients, physicians, home
health nurses, and other providers; and could actively coordinate the care
of the practice’s population of patients. Although articles about new care
models such as the patient-centered medical home imply that physicians
should work differently, they rarely mention this fundamental
transformation of the workday. I suggest reasons for this omission and
ways to overcome barriers to redesigning physicians’ workday.
get a babysitter, or travel to my office, then wait
with me. And we could keep in closer touch with
patients who would benefit from frequent con-
tact with us.”
This is the way I began to think decades ago,
during my first year in practice. Nothing during
medical training had prepared me for these
thoughts. I knew nothing about health policy
or practice redesign. We had no Internet or
e-mail. Nevertheless, within a few months of
beginning as a young family physician, I found
the logic of this line of thinking inescapable.
My medical assistant independently came to
the same conclusion.Why were patients having
to come to the office when a few minutes on the
phone would have made it clear that they had a
f someone would just pay me—and my
a good part of each day on the phone
with patients…That way, we could take
care of many more patients. Patients
wouldn’t have to take time off from work, or
routine upper respiratory infection, or uncom-
hours from their day—again and again—so that
we could discuss in person their blood sugar,
routinely checking at home?
Furthermore, why was I spending so much of
my time teaching my patients how to manage
their asthma, or their diabetes, or their anti-
coagulation meds, or many othercommon prob-
lems? Yes, this education is crucially important,
But most patients need to discuss them repeat-
edly to really understand them.
it, again and again, trying to squeeze the discus-
sion into an office visit during which multiple
trusted my medical assistant, who did an excel-
lent job teaching them how to manage their
chronic illnesses.Why couldn’t she spend more
time doing this—on the phone and in person?
HEALTH AFFAIRS 29,
NO. 5 (2010): 785–790
©2010 Project HOPE—
The People-to-People Health
Lawrence P. Casalino
the Livingston Farrand
Associate Professor of Public
Health at Weill Cornell
Medical College in New York
MAY 201029:5HEALTH AFFAIRS
History & Background
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Having developed this way of thinking, did we
change the way we took care of patients? We did
continue to make ever larger numbers of phone
calls, and many of these calls substituted for
visits. But we didn’t make as many calls as would
have been optimal for patients, and we did con-
tinue to see patients for office visits for which
calls could easily have substituted.
Why?Wewereconstrainedby a cruelbut little-
discussed fact. As the number of patients for
gets larger,the number of phone calls that could
be made—for both minor acute and chronic
care—continues to increase. By my third year
in practice, my medical assistant and I could
easily have spent virtually the entire day making
useful phone calls to patients. But the more time
we spent doing that, the less time we had to see
patientsinperson—and theonly thingfor which
we were paid was when I, the physician, saw
patients in person. So we didn’t make as many
calls as we knew would be optimal—a moral and
professional compromise, but one that seemed
necessary if we were to remain in practice.
Enter The Martian
A Martian arriving on earth, observing primary
care practitioners at work, would undoubtedly
cians spend at least seven years training. Their
time, therefore, should be valuable. Is this the
best way for them to use it?1As pieceworkers
running from patient to patient as fast as they
can? Always with a little clock in their heads,
exquisitely conscious of the seconds ticking by
while a patient tries to say something? As ham-
sters, running faster and faster just to stay in
place?2Doing things that less highly trained
people could be doing?
If benevolent, the Martian might say: “Wait a
minute. Let’s wipe the slate clean. Let’s forget
about the way that physicians have traditionally
practiced, go back to the drawing board, and try
cians, their staff, and their patients. How can
primary care physicians’ time best be used?”
Making The Best Use Of Time
One obvious solution would be for physicians to
see patients in person only when this is neces-
sary, and to use the rest of their time in other
ways. Necessary visits are easily defined.
should see patients in person (1) for a first visit;
(2) when it may be necessary to engage in some
physical maneuver for diagnostic purposes—
such as palpating the abdomen, listening to
the heart, or performing a skin biopsy; (3) for
joint; (4) when the patient has problems for
which lengthy discussion would be helpful;
(5) whenfor psychologicaloremotionalreasons
(6) when face-to-face visits are necessary to
thirty patients a day, and some see many more
than that.3How many of these visits are neces-
been studied, although there is evidence that
care via telephone or e-mail can be effective.4,5
Based on my own experience and the limited
literature available,6,7I suspect that only eight
to ten visits a day, more or less, are necessary.
Redesigning The Workday Themost detailed
the physicians’ workday comes from GreenField
Health, an innovative five-physician group in
Portland, Oregon. At GreenField, wrote one of
those physicians, Charles Kilo, in a 2005 article
in Health Affairs, “approximately 80 percent of
our patient contacts occur via phone and e-mail,
with only 20 percent occurring in visits. Since
visits require more time, this translates into ap-
proximately half of a clinician’s time being dedi-
cated to visits and half to phone and e-mail
How differently would the vast majority of
America’s primary care physicians spend their
time under such arrangements? Freed from the
tyranny of the ten-to-fifteen-minute visit, they
would have longer visits with patients when this
would be helpful. They would take the time to
reflect, investigate, and learn when faced with
puzzling problems, or when potentially critical
diagnostic and therapeutic decisions had to be
e-mail communications with patients, specialist
physicians, and other health care workers, such
as home health nurses.
How Else Should Time Be Spent? There are
three additional answers to the question of how
primary care physicians should spend their time
but that have developed during the quality im-
provement movement of the past decade.
First, physicians would spend time coordinat-
ing the activities of their staff, who would them-
selves spend time helping patients learn to
manage their chronic illnesses.
Second, at least some physicians in the prac-
tice would spend time creating and supervising
systematic processes aimed at maximizing the
extent to which the practice’s entire population
of patients received indicated preventive care
and care management for chronic illnesses.
History & Background
HEALTH AFFAIRS MAY 2010
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Third, physicians would spend time using
measurements of the practice’s performance—
generated internally or externally, or both—to
identify and act on areas for improvement.
Physicians and their staff practicing in this
way would communicate with many more pa-
tients than they do at present by trying to cram
in as many visits as possible. Their workdays
would be much less chaotic and much less pres-
sured. They could work shorter days while feel-
patients with high-quality, efficient, accessible,
and convenient care—and not just the patients
who happened to schedule an office visit.
These ideas are not new. Thomas Boden-
heimer, Kevin Grumbach, Charles Kilo, and
Joe Scherger, in particular, have advocated
them.7–10Surprisingly, given these ideas’ radical
have received very little attention, even in ar-
ticles that describe new models of primary care.
New Models Of Primary Care
During the past decade, there has been increas-
ing attention to developing new models of pri-
mary care practice.
EdwardWagner and colleagues at the MacColl
Institute for Healthcare Innovation developed
the influential Chronic Care Model (CCM),
which emphasizes practice redesign through
the use of information technology (IT), regis-
tries, and nonphysician staff to improve care
for a practice’s population of patients.11
In 1999 Donald Berwick and colleagues at the
Institute for Healthcare Improvement began the
Idealized Design of the Clinical Office Practice
project.12Ideal Medical Practices is a recent off-
shoot, founded by physicians L. Gordon Moore
nent provider organizations like Group Health
and Kaiser Permanente have attempted to
redesign their primary care practices, although
at this time their primary care physicians still
focus primarily on office visits.15–17
medical home, which overlaps to a considerable
much attention.18,19Numerous demonstration
projects, including the large TransforMed proj-
ect of the American Academy of Family Physi-
cians,20are under way. The recently passed
health reform legislation gives the secretary of
health and human services broad authority to
launch new pilot projects based on the patient-
centered medical home.
This model, like the other models described
above, advocates that practices rely heavily on
health IT, including e-mail and telephone com-
munication with patients. It also promotes the
use of nonphysician staff, coordinated by physi-
to the practice’s population of patients.
Reallocation Of Primary Care
These models strongly imply that physicians
should allocate their time quite differently than
they do now. Strikingly, however, the published
cal home models rarely, if ever, directly ad-
dresses the allocation of physicians’ time.
I reviewed the published principles of the
patient-centered medical home,18the Future of
Family Medicine report,21the five articles listed
chronic care model articles,22the American
Academy of Family Physicians’ patient-centered
centered medical home, and eight recently pub-
lished peer-reviewed articles about the Chronic
Care Model (references for these eighteen ar-
ticles are available as an Online Appendix).24
Although these sources often suggest that the
chronic care and medical home models should
lead to greater use of communication with pa-
tients outside the traditional office visit, not a
single article took this idea to its logical conclu-
sion: that these new models of practice would
the primary care physician’s workday.
Redesigning physicians’ workday should be
good for both patients and physicians. Redesign
cians’ workday are likely to fail.
E-Mail Communication The limited evidence
available suggests that physicians fear that e-
mail communication with patients, as well as
many other elements of the chronic care and
and too long.15,25,26This fear is well founded. Ab-
sent payment reform, physicians must continue
to see large numbers of patients per day. In this
context, attempts to add e-mail communication
and elements of the chronic care and medical
home models do add work for physicians.
Role Of Nonphysicians Having nonphysi-
cian staff do more patient education, outreach
for preventive care, and other such tasks could
not reimbursed. Most practices cannot afford to
the practice is paid only for what physicians do.
MAY 201029:5HEALTH AFFAIRS
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Why Isn’t Redesigning The Physician
Workday A More Prominent Issue?
I suggest that there are four reasons why the
redesign is rarely mentioned.
Payment Structure First, as long as practic-
es are paid primarily for services provided by
physicians during in-person visits, it will not
be possible to fundamentally change the way
physicians spend their time. So this issue is sim-
ply not practically relevant now for most physi-
cians. Even in demonstration projects involving
the chronic care or medical home models, reim-
bursement is typically overwhelmingly based on
office visits with the physician.
cultural—may be a factor. It may be that most
primarycarephysicians can’t at present imagine
a different way of practicing.25Moving quickly
all, or virtually all, they are paid to do.
Additionally, physicians receive intense train-
ing in the “individual physician” model of qual-
ity, whose motto goes something like this: “I am
responsible for my patient; quality is what I do
for the patients who show up in front of me,
primarily while they are in front of me.” This
view of quality is necessary but not sufficient.
Unfortunately, physicians receive little or no
training in what could be called the organized
process view of quality. This would say, in effect:
“Quality is not just what I do during face-to-face
visits, but what my organization does for all of
our patients—both during and between visits.”
Lack Of Training Third, most physicians and
nonphysician staff lack the training and experi-
ence to work in a fundamentally different way.
Thus, in many practices, it is probably hard to
imagine how nonphysician staff could provide
productively use time not spent in face-to-face
visits with patients.
Patient-Centeredness Fourth, the focus of
practice redesign and quality improvement has
been, and increasingly is, on “patient-centered-
ness.” The thinking seems to be as follows: Prac-
tices have alwaysbeen organized around
physicians’ preferences; now let’s organize
them around patients’ preferences. The patient-
centeredness framework is essential, but if little
attention is paid to physicians’ workday, it can
lead to recommendations that would make that
day even longer and more pressured.
Overcoming The Barriers
There are cognitive, financial, training, and IT-
related barriers to redesigning the physician
As noted above, and described in detail in an
excellent qualitative study by Timothy Hoff,25
certain obstructions confront primary care
physicians who have spent their careers seeing
patients as fast as possible and interacting in
traditional ways with their staff. They lack the
time, the concepts, and, absent major payment
changes, the financial incentives to think about
fundamentally redesigning their workday. The
first step in moving toward redesign will be to
make the possibility much more visible.
Make Payment Neutral To The Mode Of
Care The ideal way to give physicians the oppor-
tunity to redesign their workday would be to pay
view, they are indifferent about whether a pa-
tient is seen face-to-face or not, and indifferent
about who (physician, nurse, medical assistant)
provides a particular service for the patient. The
goal would be to enable the practice to experi-
ment with the mix of face-to-face and other serv-
ices and the mix of physicians and staff best able
to provide high-quality care for the practice’s
population of patients.
Mixed Payment Methods If the right ratio
could be found, a mixed payment method—pay-
ing physicians both fee-for-service for seeing pa-
tients and a monthly, per patient, risk-adjusted
capitation fee—could achieve this end.27,28Some
the fee-for-service/capitation ratio and the risk
adjustment were perfect, practices would still
have a financial incentive to simply pocket the
scoring well on measures of quality and patient
experience are included.
Pay Via Capitation Analternativewouldbeto
pay primary care practices entirely via capita-
tion.29This would avoid the problem of getting
the fee-for-service/capitation ratio right. But be-
stint on services provided—for example, by re-
ferring patients to specialists when the primary
care practitioner could in fact care for them—a
fully capitated method would have to include
strong incentives for high quality, for patient
experience, and for the overall cost of the prac-
tice’s patients’ care.
Pay For E-Mail And Phone Contacts An-
other alternative would be to maintain the cur-
rent fee-for-service system but add payment for
services such as e-mail and phone calls and for
those provided by nonphysician staff. This elim-
but would add administrative burdens for prac-
tices and payers and would be difficult to mon-
itor for abuse. Most important, it would impose
the opinion of the payer about what the proper
History & Background
HEALTH AFFAIRSMAY 2010
on October 30, 2015 Health Affairs by content.healthaffairs.org
mix of services should be, and about who should
provide them, instead of encouraging practices
to find the best mix for their situation and
ConciergePractices A final alternative
would be to have practices charge patients a
monthly fee for the privilege of belonging to
the practice. These practices, frequently called
“concierge” practices but now also using other
names, do redesign primary care physicians’
workday. They drastically reduce the number
of patients for whom a physician provides care;
reduce the number of patients seen perday; pro-
vide longer visits; and increase e-mail and tele-
phone access to the physician.
However, these concierge-type practices do
not appear to do much in terms of team-based
care that aims proactively to improve the health
of the practice’s population of patients. Indeed,
some practices have no staff except for a single
physician. The generalizability of this model re-
mains in doubt. Many patients cannot afford the
monthly fee to belong to the practice. Addition-
ally, if all primary care physicians practiced in
this way, the shortage of physicians to take care
Medical home demonstration projects to date
tend toward a mixed payment model, although
cal home” paymentis far toosmallto support re-
design of the physician’s workday. My objective
is not to argue for a particular form of payment,
but simply to emphasize that the design of the
payment method for medical homes should
explicitly consider the likely effect on the struc-
Training And Information
It will not be possible for primary care physi-
cians’ workday to be effectively redesigned un-
less physicians are comfortable working in new
nary team”). These staff members will also need
the training to educate patients, help coordinate
care, and carry out other activities necessary to
improving individual and population health. At
least some of the physicians in the practice also
should be competent in quality improvement
and the uses of IT.
If physician practices were paid differently,
they could begin immediately to communicate
more with patients by phone and e-mail, even in
practices that do not have an electronic health
record. However, an electronic health record
that could help with such tasks as creating regis-
tries of patients with particular conditions,
tracking patients, and measuring the practice’s
staff to use the time available in a redesigned
workday more effectively.
tal redesign of the physician’s workday.
A Martian observer could take an even more
radical approach, and ask why physicians are
and e-mail communication with patients not be
outsourced to other countries where labor is
much less expensive?
I would explain to the Martian that physicians
are important to the model as leaders of the
practice teams and for their ability to deal with
patients whose conditions are more compli-
cated. The model proposed depends on patients’
having at least some face-to-face contact, and an
ongoing relationship, with physicians and staff.
ship with a physician is beneficial.31It is also
difficult to understand how workers in another
be able to use organized processes to systemati-
cally improve the health of the practice’s popu-
lation of patients.
Models for redesigning primary care should fol-
low through to their logical conclusion: radical
change in the ways in which primary care physi-
mean that physicians will simply perceive these
models as yet another time-consuming product
of policy wonks that would add work to their
already overburdened day.
Medical home demonstrations that do not
fundamentally change the payment model for
primary care practices, and in which the physi-
cian’s workday remains largely unchanged, are
unlikely to yield favorable results. Even if they
do, spread of the patient-centered medical home
model to the general population of primary care
practices is unlikely if the medical home simply
adds more work to the physician’s day.
Models are more likely to spread if, like the
Chronic Care Model and the patient-centered
medical home, they have a name. Perhaps there
physician workday. “Martian redesign” is a bit
far out; perhaps physician workday redesign
could be called the “C3 model,” for communica-
tion, coordination, and care.
Primary care physicians in practices using the
MAY 2010 29:5 HEALTH AFFAIRS
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C3 model would see many fewer patients in per-
son. They would use the time saved to focus on
communication via phone, e-mail, and longer
office visits; on coordination of care; and on
caring for the practice’s population of patients.
nel and organized processes suggested by the
chronic care and patient-centered medical home
models, suchas registries,patientand physician
reminders, and nurse care managers. The C3
model would not be an independent model,
but rather an essential, and ideally widely recog-
nized, component of efforts to transform prac-
tices using concepts from the chronic care and
medical home models.NOTES
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History & Background
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