The medical home has expanded beyond the primary care physician’s office walls, upending the idea of the traditional doctor’s visit for physicians and patients alike. Additionally, the shift to telehealth, the focus on population health management, and medical technology acceleration have all impacted patient flow, finances, and communication.
When it comes down to it, primary care physicians, and the proactive and preventive services they provide, hold the key for healthcare cost containment and more personalized care. We recently spoke with four Dallas-Fort Worth primary care physicians about the challenges they face, the changes they’ve seen, and the opportunities ahead.
How did COVID-19 change your perspective on your career?
Dr. Angela Moemeka: “I launched my private practice as the Sars-CoV-2 virus was identified and began to spread. Direct patient care and office workflow would need a revamp to preserve access to care. I began to wonder about the stability of private practice as I witnessed well-established practices struggle and even close during the first few months of the pandemic.”
Dr. Jeff Bullard: “With the onset of the pandemic, suddenly the grander ‘we’ came into vision. Every day felt like a population healthcare delivery day. I am a family medicine physician, and COVID reminded me of the importance of my role as a community health connector.”
Dr. Marcial Oquendo: “COVID humbled me and everyone into understanding that there is no such thing as a ‘sure thing.’ Right as the COVID pandemic started, I was in the midst of a major transition in my career, going from employee physician to business owner and entrepreneur. For the first few months after the lockdown began, I realized that opening a traditional office was not going to be a good idea. So, I branched out and formed coalitions and mutually beneficial partnerships with other doctors that needed someone to keep things afloat during the trying times.”
Dr. Beth Kassanoff-Piper: “The pandemic gave me a new appreciation for my work team, especially my nurse and my partners, and their ability to adapt to change. COVID-19 reinforced how important it is to have a solid connection with patients so they know they can rely on my guidance in confusing times.”
What challenges did you face in shifting to remote visits?
Bullard: “The biggest challenges were around establishing new workflows, combining in-person with virtual visit scheduling and staffing assignments. We wanted our patients to have a great experience. They were stressed, and most were also experiencing telehealth for the first time.”
“Doctors today spend more time clicking boxes, looking up billing codes, and chasing metrics than spending time with patients and their families.”Dr. Marcial Oquendo, Oak Cliff Pediatrics
Oquendo: “During 2020, I went from 100 percent in-person practice to 100 percent telemedicine at the beginning of the lockdown to now a hybrid of mostly in-person visits but with a strong telehealth component. I have found that it is a great way to keep open communications with patients, even if it’s a ‘last patient of the day,’ last-minute appointment, or a ‘mother has a quick question.’”
Kassanoff-Piper: “I was concerned that both the patients and I would find telehealth to be inferior to in-person visits, but I was very pleasantly surprised at the outcome. Being able to see my patients, even if not in person, made assessing their health, and especially their mental health, much easier than just hearing them on a phone call.”
Moemeka: “We did begin offering virtual well-child visits, but many families preferred to wait it out, not wanting to risk taking children outside the home. We began to incorporate synchronous and asynchronous methodologies into our practice. I worked with our billing company to understand the coding and payment processes for these visits. Texas Medicaid led the way in paying for telemedicine visits in a very expansive sense.”
How has the pandemic changed chronic disease management?
Oquendo: “Chronic condition management via telemedicine has its pros and cons. We can continue to see the patient on a regular basis for a quick check-up and status update without them having to make a visit. However, telemedicine can limit a physician’s ability to pick up on subtle nuances that can only be seen in person—things as simple as moles or skin color, new tattoos, cutting behaviors, and scars that the trained eye would notice and would dig into.”
Kassanoff-Piper: “I stress the importance of preventive healthcare. Many patients missed their routine screenings for breast and colon cancer during the pandemic, and I continue to work with those patients to get them caught up.”
Moemeka: “In pediatrics, ADHD and asthma are the primary chronic diseases. These are all easily done remotely. New tools have also emerged to allow virtual chronic disease management to thrive, the most notable being remote patient monitoring devices. In asthma, for example, digital inhalers allow patients to track symptoms and inhaler use then share this information with their physician via portals.”
Bullard: “Physicians will typically recommend home blood pressure, blood sugar, and weight monitoring for our hypertensive, diabetic, and heart failure patients, respectively, but I believe we likely placed more value on those measurements that took place in our offices. During COVID, that shifted. As a result, we recognized the value of upping our game on home management and monitoring efforts, including increasing the time spent on disease state education with patients, coaching on the ideal way to measure and record home collected data, and helping patients navigate app selection for managing weight, diet, and exercise.”
How do you see technology impacting your practice in the future?
Kassanoff-Piper: “The greatest advantage I have seen so far is in patients who can share their glucose readings with me remotely, so we can catch up on their progress several times weekly, if necessary, rather than waiting longer periods to make adjustments. This is already improving patient outcomes.”
Moemeka: “I see the increase in wearable devices increasing health literacy for my patients and families. It eases discussions on disease management and gives a common objective language for symptoms. For example, a child using a digital inhaler can say their asthma has been worse than usual over the past two weeks but can now also show me their tracked inhaler usage each day, which tells a measurable story.”
Bullard: “I see a day in the near future when doctors and patients will be discussing the patients’ progress in their lifestyle app, reviewing data from their remote monitoring blood pressure device, and having a group video visit that includes the doctor, the patient, a spouse or caregiver, and a care team member such as a dietician or a specialist.”
Oquendo: “I believe in the not-too-distant future people will have their own digital-first-aid-kit, with digital otoscope that can send pictures to the pediatricians to check for ear infections, inexpensive Bluetooth stethoscope adapters for phones through which parents can stream of a child’s breathing by following a simple interface app on the screen, and thermometers that can share today’s temperature trends so doctors can look for improvement.”
How will a shift to value-based care impact your practice?
Bullard: “We are champing at the bit for this type of change. The impact of COVID was that it shined a bright light on so many of the things that are wrong with the way care is delivered. The disconnect between what works and what’s valuable to the doctor-patient relationship and those that make decisions about how the business of healthcare will operate is unfortunate; I think the shift to value-based care can narrow that gap.”
Oquendo: “The reality is that the current system is designed for big players; more than half of the physicians in Texas are employed and not independent. The incentive to include small groups or solo practices has not yet been felt. New models will have to emerge to bridge that gap while also navigating the legal barriers that keep offices from gaining any leverage in the value-based contracting model.”
Moemeka: “As a general pediatrician, value-based care has been the theme for decades. The new shift is to value-based payments. For my practice, this means streamlining population health management—not only understanding the who, what, and when of gaps in care but also linking with community partners to address the why.”
“Value-based care has been the theme for decades; the new shift is to value-based payments.”Dr. Angela Moemeka, Mark9 Pediatrics
Kassanoff-Piper: “I work hard in my practice to provide care tailored to each patient’s specific situation and to create that unique relationship with patients that encourages them to work with me toward better health. This, in turn, leads to better management of their chronic health conditions and, ultimately, better care overall, which is recognized in value-based care payments.” how do you incorporate mental health and whole-person health into your practice?
Oquendo: “A combination of different interactions is how we achieve a true whole-person health approach. Rarely before have we had a window inside a patient’s home. This is important in getting the whole picture, especially as socioeconomic determinants of health are directly linked to your home, your internet access, and living conditions. Mental health has been the biggest sequelae from this pandemic, particularly in teens and young adults. Telemedicine for mental health is going to stay and will be the main form of accessing therapy and treatment moving forward.”
Moemeka: “I take into consideration the family background and psychosocial environment affecting my patients. It is difficult to care for my patients otherwise. A 2-year-old doesn’t just walk into my office alone and leave with antibiotics for their ear infection. Instead, that 2-year-old comes in with a parent who is tired from not sleeping for several nights due to their child’s ear pain and irritability, and possibly a parent who is worried about missing another day of work to care for a febrile child who cannot return to daycare. Similarly, an 11-year-old with chronic abdominal pain may be challenged by the transition to middle school and manifesting symptoms of anxiety and stress.”
Kassanoff-Piper: “It is so important to understand the whole person, including their home environment and their stressors. I get to know my patients very well and ask detailed questions about these factors and their mental health so that I can give advice that fits them specifically. Many patients will not bring up the subject unless directly questioned. A large number of my patients have had increased anxiety and depression through the pandemic, and not all realize how great that impact is on their health.”
Bullard: “We have taken an integrative approach to care, including fully integrated mental health. In 2007, we started a brain health center, which now includes a counselor and psychologist, treatments for difficult-to-treat depression patients, and a full suite of assessment and treatments for the most common mental health and cognitive issues our patients face.”
What area of medicine is not getting enough attention, and why?
Oquendo: “Physician burnout. Doctors today spend more time clicking boxes, looking up billing codes, and chasing metrics than spending time with patients and their families. Primary care and preventive medicine have become a numbers game and all about economy of scale, when it should be the other way around. Making doctors become computer clerks and having them spend several hours a day entering data into templates—for insurance companies to decide what gets reimbursed and what doesn’t—will only lead to more burnout, with worse outcomes for both the medical community and patients.”
“We could do a much better job dealing with the health of our communities if we focused on proactive versus reactive care.”Dr. Jeff Bullard, MaxHealth Medical Associates
Moemeka: “Health equity for children does not get the attention it needs, mainly because people see children as primarily healthy. We know hundreds of millions of children are uninsured and underinsured, lacking access to the basic care that’s needed to maintain health. We know trauma impacts children in ways that lead to chronic disease and morbidity as adults. We know the first 1,000 days of a child’s life are critical for brain growth and development. These facts all float around us as health inequities that do not get the policy focus needed to effect change.”
Kassanoff-Piper: “Doctors must address patients’ anxiety and depression, as well as underlying circumstances, such as their work and home responsibilities, what help they have at home, and whether they can afford medications, to help them achieve better health.”
Bullard: “We could do a much better job of dealing with the health of our communities if we focused on proactive versus reactive care. We do what we are paid to do; as a result, we primarily see patients when they are already sick. Suppose we could instead spend our energies understanding a patient’s daily behavior or situational challenges that impact their health, and work with them before they develop a chronic disease. That could help bend the cost curve. To do this, we must invest more in primary care.”
Contact Will Maddox at [email protected]