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Part One – The Problem with the Status Quo   


From the New York Times to blog, every news publication you pick up (or click on) seems to have at least one headline concerning primary care and with terms like “uncompensated pressures,” “collapsing system” and “crisis point” thrown around, it ain’t lookin’ good.  The May edition of Health Affairs entirely dedicated to primary care issued warnings with only glimpses of optimism…but at least we’ve been warned.   

One of an ever-growing list of problems with primary care is a lack of time, or at least an inefficient and inadequately compensated use of physicians’ time.  In 2008, an internist’s practice, highlighted recently in the New England Journal of Medicine, took 23.7 calls per physician per day, with nearly 80 percent of such calls handled directly by physicians, on top of receiving 16.8 e-mails per day.   

As Lawrence Casalino, MD describes in a Health Affairs article, more and more of physicians’ time is devoted to patient education on chronic conditions like diabetes, heart disease, cancer and asthma, which directly contribute to the nation’s astronomically high health care costs.  Consultations not only with patients but also with specialists take up an increasingly amount of this precious resource – but with what consequence?   

Quality of care suffers During longer visits, Casalino says, PCPs can “take the time to reflect, investigate, and learn when faced with puzzling problems, or when potentially critical diagnostic and therapeutic decisions had to be made. They would engage in many telephone and e-mail communications with patients, specialist physicians, and other health care workers, such as home health nurses.”  Patients’ whole-person and long-term health needs often take a backseat to quick decisions, pressured by a waiting room full of other patients.   

Access issues become exacerbated How many times have you been in a waiting room an hour after your appointment time?  With 40 million individuals gaining coverage under federal health reform, conditions are expected to only worsen without change.   

Physicians’ burn out and experience job dissatisfaction According to an Annals of Internal Medicine article, almost half of primary care physicians report moderately or highly stressful jobs, more than a quarter report burnout, and nearly a third were at least moderately likely to leave their practices within two years.   

Not surprisingly, primary care does not appeal to students Given that less than 10 percent of med school graduates go into primary care, as the New York Times wrote, the current health care system is reaching a “crisis point.”   

Parts 2 and 3, to be posted separately over the next two weeks, will consider possible solutions states are exploring.


As coverage expands under the implementation of the federal health care reform, the role of telemedicine—allowing health care providers to connect to patients and other providers across the country at any time of day via the Internet—is increasingly essential to ensure that access to care is adequate, particularly in rural and underserved areas.  Patient consultations that utilize telemedicine avoid many of the delays experienced in traditional health care delivery and can help to prevent unneeded emergency rooms visits. 

On April 5, Virginia Governor Bob McConnell (R) signed SB 675, which unanimously passed both chambers of the state General Assembly.  The measure requires all health insurers to cover health care services provided via telemedicine (defined as the “use of interactive audio, video or other electronic media for the purpose of diagnosis, consultation or treatment”) – excluding audio-only telephone, e-mail or fax transmission.  Virginia is the 12th state to adopt such a mandate. 

Some insurers utilize telemedicine services without a state mandate.  The Blue Cross Blue Shield plan of Hawaii, for instance, recently announced that it will become the first health plan to deploy Online Care Team Edition, an online care system to allow live, on-demand specialist care consultations in primary care provider exam rooms.  The new product moves beyond previous telehealth services—that connect patients at home to doctors via the Internet—by putting primary care physicians at the center of coordinating care.  Through this online medical home, a PCP needing to refer a patient can go online from a regular office computer, find an in-network specialist, and launch a live consultation with the physician.  American Well, the creator of the online system, says this will not only reduce the delay, inconvenience and cost associated with the traditional referral process, but also enhance physician collaboration.

Because physicians often are not reimbursed for time spent on the telephone with insurance companies or responding to patients’ emails, payment for telemedicine services can help to financially stabilize providers, particularly those in small private practices.  For a listing of telemedicine reimbursement mandates by state and additional telemedicine resources, refer to my Telemedicine Reimbursement PDF.


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