What Complexity Science Predicts About the Potential of Artificial Intelligence/Machine Learning to Improve Primary Care.

Primary care physicians are likely both excited and apprehensive at the prospects for artificial intelligence (AI) and machine learning (ML). Complexity science may provide insight into which AI/ML applications will most likely affect primary care in the future. AI/ML has successfully diagnosed some diseases from digital images, helped with administrative tasks such as writing notes in the electronic record by converting voice to text, and organized information from multiple sources within a health care system. AI/ML has less successfully recommended treatments for patients with complicated single diseases such as cancer; or improved diagnosing, patient shared decision making, and treating patients with multiple comorbidities and social determinant challenges. AI/ML has magnified disparities in health equity, and almost nothing is known of the effect of AI/ML on primary care physician-patient relationships. An intervention in Victoria, Australia showed promise where an AI/ML tool was used only as an adjunct to complex medical decision making. Putting these findings in a complex adaptive system framework, AI/ML tools will likely work when its tasks are limited in scope, have clean data that are mostly linear and deterministic, and fit well into existing workflows. AI/ML has rarely improved comprehensive care, especially in primary care settings, where data have a significant number of errors and inconsistencies. Primary care should be intimately involved in AI/ML development, and its tools carefully tested before implementation; and unlike electronic health records, not just assumed that AI/ML tools will improve primary care work life, quality, safety, and person-centered clinical decision making.

Scope of Practice and Location of 3- Versus 4-Year Family Medicine Residency Graduates.

BACKGROUND AND OBJECTIVES: The John Peter Smith (JPS) Family Medicine Residency Program participated in two national experiments: Preparing the Personal Physician for Practice (P4, 2007-2012) and the Length of Training Pilot, which began in 2013. In these experiments, JPS created optional integrated 4-year areas of emphasis (AOE). The objective of this study was to examine the career outcomes of JPS graduates differentiated by those who completed a 4-year AOE, versus traditional fourth-year fellowship, vs 3-year only. METHODS: We surveyed each graduate who started residency from 2007-2016 on their scope of practice. We also searched each graduate via Google to identify each of their practice sites and ascertain their status as a Health Professional Shortage Area (HPSA) or Medically Underserved Area for primary care (MUA-P). RESULTS: Of the 220 residents who entered the program as interns, 70 completed an integrated AOE (31.8%), 54 completed 3 years of training with a traditional fourth-year fellowship (24.5%, 40 at JPS, 14 at another location), and 93 completed only 3 years of training (42.3%). The overall percentage of JPS graduates who work in the United States (n=201) in HPSAs or MUA-Ps is similar to national numbers (45.3% vs 43.5% for HPSAs, 35.3% vs 33.3% for MUA-Ps). Graduates of a JPS integrated AOE track were more likely to work in a HPSA or MUA-P than other graduates (81.4% vs 38.5% traditional fellowship vs 45.6% 3-year only, P<.001; US practice sites only). Graduates of sports medicine fellowships were particularly less likely to work in HPSAs/MUA-Ps than other graduates (26.1%). Graduates of integrated AOEs provided much broader scopes of cognitive and procedural services than fellowship or 3-year graduates. CONCLUSIONS: In JPS graduates, 4 years of training with an integrated AOE had a large association with serving vulnerable populations, and providing broader cognitive and procedural services.

What do we mean, 'necessary'?-Achieving balance and recognizing limits in primary healthcare and universal healthcare.

Sturmberg and Martin make a compelling case for primary healthcare (PHC) to be the foundation for universal healthcare (UHC). They state that a system should have necessary resources, but what does that mean? Basic economic theory postulates that all resources are limited and that choices must be made between competing options. For a UHC system to be successful and resilient, it must accept that healthcare is a limited right, there will always be inequalities in healthcare delivery and outcomes, primary care physicians and their teams must accept the added burden of balancing the needs of their personal patients with the greater system, leaders and observers of healthcare systems must accept that moderation and balance will often be the best outcome even though they are difficult to measure, and leaders of healthcare systems must accept that they cannot control the system, but contribute by providing context and limited constraints, information, and resources. A deeper understanding of complex adaptive systems will best guide these necessary changes.

Primary Care Physician Characteristics Associated with Low Value Care Spending.

BACKGROUND: Previous work has shown that $210 billion may be spent annually on unnecessary medical services and has identified patient and hospital characteristics associated with low value care (LVC). However, little is known about the association between primary care physician (PCP) characteristics and LVC spending. The objective of this study was to assess this association. METHODS: We performed a retrospective analysis by using Medicare claims data to identify LVC and American Medical Association Masterfile data for PCP characteristics. We included PCPs of adults aged 65 years and older who were enrolled in Medicare in 2011. We measured Medicare spending per attributed patient on 8 low value services. RESULTS: Our final sample contained 6,873 PCPs with 1,078,840 attributed patients. Lower per-patient LVC Medicare spending was associated with the following PCP characteristics: allopathic training, smaller Medicare patient panel, practiced family medicine, practiced in the Midwest region, were a recent graduate, or practiced in rural areas. The largest associations were seen in Medicare patient panel size and geographic region. The average per-patient LVC spending was $14.67. LVC spending among PCPs with small patient panels was $3.98 less per patient relative to those with larger panels. PCPs in the Midwest had $2.80 less per patient LVC spending than those in the Northeast. CONCLUSION: Our analysis suggests that LVC services are associated with specific PCP characteristics. Further research should assess the strength of these associations, and future policy efforts should focus on systemic interventions to reduce LVC spending.

Family physicians' suggestions to improve the documentation, coding, and billing system: a study from the residency research network of Texas.

BACKGROUND AND OBJECTIVES: The study's aim was to ascertain family physicians' suggestions on how to improve the commonly used US evaluation and management (E/M) rules for primary care. METHODS: A companion paper published in Family Medicine's May 2014 journal describes our study methods (Fam Med 2014;46(5):378-84). RESULTS: Study subjects supported preserving the overall SOAP note structure. They especially suggested eliminating bullet counting in the E/M rules. For payment reform, respondents stated that brief or simple work should be paid less than long or complex work, and that family physicians should be paid for important tasks they currently are not, such as spending extra time with patients, phone and email clinical encounters, and extra paperwork. Subjects wanted shared savings when their decisions and actions created system efficiencies and savings. Some supported recent payment reforms such as monthly retainer fees and pay-for-performance bonuses. Others expressed skepticism about the negative consequences of each. Aligned incentives among all stakeholders was another common theme. CONCLUSIONS: Family physicians wanted less burdensome documentation requirements. They wanted to be paid more for complex work and work that does not include traditional face-to-face clinic visits, and they wanted the incentives of other stakeholders in the health care systems to be aligned with their priorities.

Family physicians' opinions on the primary care documentation, coding, and billing system: a qualitative study from the residency research network of Texas.

BACKGROUND AND OBJECTIVES: The study's aim was to deepen our understanding of family physicians' perceptions of the strengths and weaknesses of the widely used US documentation, coding, and billing rules for primary care evaluation and management (E/M) services. METHODS: This study used in-depth, qualitative interviews of 32 family physicians in urban and rural, academic, and private practices. Interviews were initiated with a series of grand tour questions asking participants to give examples and personal narratives demonstrating cost efficiencies and cost inefficiencies relating to the E/M rules in their own practices. Investigators independently used an immersion-crystallization approach to analyze transcripts to search for unifying themes and subthemes until consensus among investigators was achieved. RESULTS: The majority of participants reported that the documentation rules, coding rules, and common fees for procedures and preventive services were reasonable. The E/M documentation rules for all other visit types, however, were perceived by the participants as unnecessarily complicated and unclear. The existing codes did not describe the actual work for common clinic visits, which led to documenting and coding by heuristics and patterns. Participants reported inadequate payment for complex patients, multiple patient concerns in a single office visit, services requiring extra time beyond a standard office visit, non-face-to-face time, and others. The E/M rules created unintended negative consequences such as family physicians not accepting Medicare or Medicaid patients, inaccurate documentation, poor-quality care, and system inefficiencies such as unnecessary tests and referrals. CONCLUSIONS: Family physicians expressed many problems and frustrations with the existing E/M documentation, coding, and billing rules and felt the system undervalued and unappreciated them for the complex and comprehensive care they provide. Findings of this study could inform improved guidelines for primary care documentation, coding, and billing.

Family physicians' perceptions on how they deliver cost-effective care: a qualitative study from the Residency Research Network of Texas (RRNeT).

BACKGROUND AND OBJECTIVES: The aim of our study was to deepen our understanding of the factors that may explain the observational literature that more primary care physicians in an area contribute to better population health outcomes and lower health care costs. METHODS: This study used in-depth, qualitative interviewing of family physicians in both urban and rural, academic, and private practices. Interviews were initiated with a series of grand tour questions asking subjects to give examples and personal narratives demonstrating cost-effectiveness and cost inefficiencies in their own practices. An iterative open-coding approach was used to analyze transcripts to search for unifying themes and sub-themes until consensus among investigators was achieved. RESULTS: Thirty-eight respondents gave examples of how their decision-making approaches resulted in improved patient outcomes and lower costs. Family physicians' cost-effective care was founded on two themes-characteristic attitudes and skills of the physicians themselves and a thorough knowledge of the whole patient. Family physicians also felt their approaches to gathering information and then making diagnostic and treatment decisions resulted in fewer tests and fewer treatments ordered overall. Family physicians also delivered care in less expensive facilities and generated lower overall charges for physician fees. CONCLUSIONS: Family physicians perceived that their approaches to patient care result in medical decision making priorities and care delivery processes that contribute to more cost-effective health care. These outcomes were achieved less by providing preventive services and strictly adhering to guidelines but rather by how they individualized the management of new symptoms and chronic conditions.

What could family income be if health insurance were more affordable?

BACKGROUND AND OBJECTIVES: Adjusted for inflation, household income has been relatively flat since the mid-1990s, but the inflation rate of employer-sponsored health insurance has been greater than both household income growth and general inflation for 50 years. We estimated the effect on average family income if health insurance inflation matched the general inflation rate since 1996, and those savings were given to employees as income. METHODS: We used data from the Medical Expenditure Panel Survey, the Milliman Medical Index, and other federal sources to model the relationship between private health insurance costs and household income over the last 15 years. RESULTS: If the cost of family health care costs had kept pace with the Consumer Price Index (CPI) rate since 1996, the average family income could have been $8,410 higher in 2010 ($68,805 versus $60,395), 13.9% more than actual earnings. CONCLUSIONS: If health care costs had not exceeded the CPI rate since 1996 and if all the excess costs were converted into employee wages, median family income could be substantially higher today.

Who will have health insurance in the future? An updated projection.

The passage of the 2010 Patient Protection and Affordable Care Act (PPACA) in the United States put the issues of health care reform and health care costs back in the national spotlight. DeVoe and colleagues previously estimated that the cost of a family health insurance premium would equal the median household income by the year 2025. A slowdown in health care spending tied to the recent economic downturn and the passage of the PPACA occurred after this model was published. In this updated model, we estimate that this threshold will be crossed in 2033, and under favorable assumptions the PPACA may extend this date only to 2037. Continuing to make incremental changes in US health policy will likely not bend the cost curve, which has eluded policy makers for the past 50 years. Private health insurance will become increasingly unaffordable to low-to-middle-income Americans unless major changes are made in the US health care system.

The influence of research compensation options on Practice-based Research Network (PBRN) physician participation: a North Texas (NorTex) PBRN study.

OBJECTIVE: To study the effect of two compensation approaches, continuing medical education (CME) credits (5 hours) or monetary ($150), on the participation rate of a physician needs assessment study. METHODS: Physicians representing family medicine, internal medicine, pediatric, and geriatrics specialties, and practicing in ambulatory primary care clinics affiliated with the North Texas Primary Care (NorTex) PBRN clinics, were recruited to complete a survey relevant to their subspecialty and to conduct a self-audit/abstraction of five medical records. Physicians were recruited from four health care systems, and the recruiting methods varied by system. Study outcome was the rate of study completion by type of incentive. RESULTS: One hundred five of 211 (49.8%) physicians approached to participate gave consent and 84 (39.8%) completed the study. There was no difference in the number of physicians randomly assigned to monetary compared with CME compensation for giving consent to participate (adjusted odds ratio = 1.42, confidence interval = 0.69, 2.93). However, physicians in the monetary compensation group were more likely to complete the study after giving consent (adjusted odds ratio = 4.70, confidence interval = 1.25, 17.58). This monetary effect was also significant from the perspective of all physicians approached initially (adjusted odds ratio = 2.78, confidence interval = 1.16, 6.67). DISCUSSION: This study suggests that future PBRN investigators should receive monetary compensation for the opportunity cost of adding research activities to their already busy practices. This compensation may be especially vital for PBRNs to complete more ambitious projects requiring a significant time commitment from the participating physicians.

Recruiting Practice-based Research Network (PBRN) physicians to be research participants: lessons learned from the North Texas (NorTex) needs assessment study.

INTRODUCTION: The purpose of this study was to examine strategies for recruiting physician subjects in a practice-based research network continuing education research study, using different recruitment methods at four systems, or health plan arrangements. METHODS: The North Texas Primary Care Practice-based Research Network Needs Assessment Study consisted of a survey and five self-directed medical record abstractions. Physicians were recruited to be research subjects from four systems, using different recruitment strategies. χ(2) was used to determine differences in physicians consenting and completing the study between systems. Kruskal-Wallis was used to determine differences in time from first contact to consent and number of contacts required before consent between systems. RESULTS: One hundred five of 211 physicians (49.8%) consented to participate, of which 90 (85.7%) completed the survey. There was a significant difference by system in the number of physicians who consented (P = .04) and number of contacts required pre-consent (P < .001) but not in the number of physicians completing the study or time from first contact to consent. DISCUSSION/CONCLUSIONS: Success of recruiting physicians to be research subjects varied between systems using different recruitment methods. Lessons learned include using clinician champions to make initial contact, establishing a relationship with clinic personnel, distinguishing the research team from a pharmaceutical representative, establishing a preferred contact method, and collecting study materials on a set timeline.

Research funding and mentoring in family medicine residencies.

BACKGROUND AND OBJECTIVES: This study's purpose was to measure the current status of research funding and mentoring in family medicine residencies and to ascertain what resources are needed to increase residencies' research output. METHODS: This was a cross-sectional survey of family medicine residency program directors in the United States. We measured grant funding sources, availability of mentors, the likelihood programs could qualify for National Institutes of Health (NIH) K awards, barriers to research, and how these factors varied by program type. RESULTS: The response rate was 66% (298/453). Medical school-based programs were much more likely to report that their family medicine faculty wrote funded research grants than were community-based medical school affiliated programs (76% versus 32%). The majority of both program types reported that research mentors were available (85% versus 60%). Very few programs of either type were likely to meet the minimum requirements for NIH K01, K08, or K23 awards (29% for medical school programs versus 3% for community programs). The most commonly reported specific resources needed to increase research output were time, money, and more faculty (range 86% to 92% between program types). CONCLUSIONS: The majority of family medicine residencies did not receive grant funding for research, reported that time and money were the most significant barriers to research, but were ineligible to receive support from NIH K awards. More realistic funding mechanisms are needed to support residency-based research faculty.