Dr. Alan Glaseroff, Co-Director of Stanford University’s High Value Healthcare Incubator: Solutions For the Shortage of Primary Care Physicians

Van Ton-Quinlivan

Hello, I’m Van Ton-Quinlivan, CEO of Futuro Health, welcoming you to WorkforceRx, an exploration of innovations shaping the future of learning, work, and care.

Many of the efforts to improve healthcare in the US rely on shifting to a preventive, patient-centered approach to care, but achieving that shift relies in large measure on having enough primary care physicians in the mix. That’s why a chronic shortage of these practitioners is the subject of such concern for health care leaders, reformers and policymakers.

Today, we’re going to take a look at what needs to be done to improve this situation with Dr. Alan Glaseroff, a longtime family physician and health care delivery innovator. Alan is currently an adjunct professor at the Stanford Clinical Excellence Research Center at Stanford University School of Medicine and co-director of the Stanford’s High Value Healthcare Incubator.

Earlier in his career, he was co-director of Stanford Coordinated Care, where he co-developed and implemented an innovative patient-centered approach to the support of patients with multiple chronic conditions. I recently participated in a panel discussion on the future of primary care that he facilitated on behalf of the California Healthcare Foundation and I’m looking forward to turning the tables on him today and picking his brain for insights on this important challenge.

Dr. Alan Glaseroff

It’s a pleasure, Van.

Van

Well, let’s start with a look at the big picture here. The statistics are pretty grim in terms of primary care physician shortages. Just how bad do you think it is?

Alan

Well, I’ve heard different numbers, but I know my own county, which is Humboldt County in Northern California pretty well. Thirty-five thousand out of the 135,000 people living in Humboldt County can’t get a primary care physician (PCP). They’re just not available. And it’s especially a big issue because the LA Times just rated our region one and two for the best places for people to retire. Generally seniors need more comprehensive care than younger people — though that’s not always true — and people are thinking of moving here and then they go, well, what about healthcare, and then they realized that it’s not going to work out well under the current conditions.

The LA Times analysis of communities to move to didn’t even consider healthcare as one of the things they should look at.

Van

Well, I’m sure all of us think about healthcare and the availability of primary physicians, like you think of water and utilities, right? Aren’t they available everywhere? So is Humboldt very different from the demographics and shortages of other communities? Is it because it’s rural?

Alan

No, actually, we’re probably just like most places. You know, some of the urban centers who that have large healthcare delivery systems have some degree of access and in California you can have Kaiser, you can have Sutter, you can have other large medical groups that have the clout and the money to recruit. But in most places, the number is like ours, or even worse. I’ve heard the number nationally is one out of three people can’t access primary care.

Van

Ooh, that’s a startling statistic. Alan, could you give us a little bit of detail on why we have this shortage right now? Are there less people going into medicine?

Alan

Well, I’ve had the privilege of mentoring many medical students at Stanford in the last decade who arrived at Stanford expecting and wanting to go into primary care and also very interested in public health issues.  Then they get kind of beaten down over the next four or five years that they’re in school, which generally starts in the third and fourth years, or fourth and fifth if they’ve done an extra year of research.

They go from ward to ward with different roles and the people that are teaching them are generally saying, “You’re too smart to go into primary care.” Or, “Are you crazy? It’s such a hard job. Why would you do that?” A couple of years ago, one of the most amazing students I’ve worked with, right as she was considering what she was going to apply to for residency, said to me, “You’re going to be really disappointed with me, but I want to be a vascular surgeon.”

It was a crushing moment for me because she was going to be a national star had she continued. I just heard from her and she says it’s a really hard residency. Don’t know why I chose it. She’s off at Mass General, which is a Harvard hospital, doing work. Tremendously talented person. We need those people in primary care because primary care is the most important specialty there is.

Van

So, for our listeners who may be not as close to the world of medicine and healthcare, could you tell us a little bit about what is the expectation of a primary care doctor versus, for example, a specialty care physician?

Alan

Well, there are a lot of differences, financial and otherwise, in the United States. But the thing about primary care is you have to have relatively shallow knowledge over a large area of knowledge. In specialty care, you get to become very knowledgeable about a very narrow piece of medicine. And in some ways, the specialist role is much easier. They do the same thing every single day. In primary care, every day is different. In the work that we do — a lot of which is helping people deal with chronic conditions that they have…things like hypertension and diabetes and asthma and chronic obstructive pulmonary disease and things that are long-term illnesses that if they self-manage well, they’re going to have a much better outcome than if they don’t as patients — our job is to empower the patients to take better care of themselves.

Specialty care has elements of that, but much more of it is technical where if you’re a surgeon, the patient’s asleep and then you’re doing your thing with them. But you don’t have to change their behavior longer than the ninety days post-surgery that they’re still responsible for the surgery. So it’s a very difficult job, but it’s also incredibly joyous and wonderful. I haven’t regretted the decision that I made at all, but I also saw the problems. And the more I brought it up in the community I lived in, they would say, “Why don’t you become the medical director or the chief medical officer? “ And I just started saying yes to opportunities and ended up having a wonderful career. I have no regrets.

Van

So, among physician innovators like yourself as well as policymakers and healthcare leaders, there’s been a lot of effort to try to improve this situation for years now. It’s not just about the pay, right? I mean, why do you think these efforts have failed so far?

Alan

Well, I’m of the era where I grew up watching Marcus Welby on TV and before that, Dr. Kildare who was an internist. There was also a show, Ben Casey about a neurosurgeon. I thought that what Dr. Kildare was doing was a lot cooler than what the neurosurgeon was doing. To me, the joy is having a long-term, continuous relationship with the patients that I see. The payback emotionally and living in the community I live in has been fantastic. But the job is broken now and a lot of it is because there’s so much administrative work falling on the physician’s hands.

I’m not going to continue only focusing on physicians because nurse practitioners and physicians assistants are very much in the same role doing the same work. I’m not a doctor-centric provider. I’ve known very, very smart PAs and nurse practitioners, and I’ve known doctors who were not the best in the world, so I understand it’s really up to the individual.

The job is broken though, and administratively it’s common that providers put their kids to sleep and then they are on the computer for two or three hours after dinner till they go to bed only to have to do it again the next day. We’re underpaid and at the moment we’re receiving approximately 5 % of the how much a patient costs in a given year in terms of payment and it probably needs to be somewhere around 15%. A lot of people have discussed that, but the problem is, in order to pay primary care more, somebody else has to be paid less and it turns out they’re not so eager to give up their funding in the current payment model.

Hospitals are the place where most of the money is spent and they get a huge chunk of things and their prices are going up very quickly due to the consolidation of hospitals, and often not-for-profit hospitals, all over the country. I just saw an article today that discussed the consolidation of hospitals and the hospitals buying up doctor practices in order to capture the market. That money has to come from them and insurance companies — which  are sort of the middleman in the whole thing rather than the evil part that everybody sees — and then policies around Medicare and payment.

When Medicare began, it just asked doctors, ‘how much are you worth? Tell me what you want for this or that procedure.’ That’s how it started. The primary care people were getting $15 a visit, and now it might be all the way up to $50 a visit. In order to keep your office open — even if you’re working for a clinic or some other setting where you’re not directly the owner of the practice — you have to see three to four people an hour, which when you include all the computer work, is about fifteen minutes a visit if you’re lucky and that’s not what primary care is about. Primary care is about relationships and building trust with patients, knowing who they are as people, and have them trust you so that you can help guide them through the craziness of American healthcare at the moment.

Van

So if the economics of healthcare delivery is not going to sort itself out anytime soon — and for all the communities that need access to primary care and can’t find a physician to knock on the door of — are there any emerging approaches to improving access to primary care services, particularly for the underserved and marginalized communities?

Alan

Well, I’m really glad that you asked this question because the answer fortunately is yes. The style of practice has historically been doctors doing everything. Perhaps in the old days, there was a nurse in the office, but most practices don’t have many nurses in their offices. What they have now are medical assistants, (MAs) who are people with high school education and generally lots of lived experience. The answer is creating models of care in communities that are joyous for the people doing the work and not just for the physicians. It can be done and I’ve done it.

My wife is also a family doc and we jointly created an amazing clinic at Stanford called Stanford Coordinated Care that used medical assistants having their own panels of patients. They stayed in touch with the patients between visits. They helped motivate them in activities that would make them more healthy. They were the person that the patients turned to. In some models the nurse practitioner also plays this role.  We were able to trust the nurse practitioners, the MAs and other people on the team to deal with the patients and then ask us if they had questions. So, a lot of the administrative burden and answering all the messages and phone calls didn’t fall strictly on our plate, and that really helped.

The patients loved what we were doing. There are all these surveys that are done asking the patients ‘did you like your visit?’ We were at the top of the scale at Stanford and the top of the scale nationally for six straight years. In the 99th percentile across the board. It’s really fun to work in a place where the people working in it love it and then the patients come in loving it and are thankful for what they’re getting.

We had figured out that we would deal with every day’s work by five o’clock. After five o’clock, we took call on our own patients, but they only called when they really needed to. We never got called saying, “Hey, the prescription didn’t get called in,” or “Hey, I’m at the lab and they don’t have an order for my lab test,” or “I’ve been waiting all day for a call back from you and you haven’t called me, so I’m calling again after hours.” None of that ever happened.

By around three o’clock, the ‘float medical assistant — meaning that they were moving around looking at the whole operation every day — would go around to each person saying, ”Do you need help to be done by five o’clock?” If someone said they could use help, another person would say, “I’m done, so I can help you.” It allowed us to share the work, and at the end of every day, work was done. You’d come back the next day and do the same thing.

Messages would come in on what’s called the patient portal, and we answered every message by the end of the day. Fifty percent of the messages were answered by the MAs themselves, not by me answering all of them.

In terms of team function and quality improvement, the approach that we took included meetings that we had on Friday mornings and the MAs were the ones presenting all the new patients. They’d say, “This is the patient and their family is here, their support comes from here, what they really care about is this.” The physician’s job was to not talk too much and allow the story to come out about the patients. Then other members of the team — we had a behavioral health therapist, we had a physical therapist, we had a clinical pharmacist — and they would say, ‘I can help in this case,’ or ‘please refer the patient to me within the team.’

All of these people reported within the team, not to their leadership within the hospital system and it was the best thing ever. We had no turnover. People didn’t leave. In Stanford, at least at that point in time, MAs turned over on an average every year. People loved their job.

We taught this to many other entities while we were there. We’d bring in teams from around the country for an immersion experience for two days. One team from the Navajo Nation came and we were working with them about what they were gonna do and describing the role for the medical assistants. A young woman who was in a community health worker role said at the end of the session, “I’m so glad because I was gonna go to nursing school to be more helpful to my people, but it’s a three hour trip from where I live in Arizona and I’m a single mom and I didn’t know how I was going to be able to do that. Now I see I can stay home and I don’t have to change my job. I get to just grow my job.”

That was one of my favorite moments in the whole teaching of what we’ve been doing.

Van Ton-Quinlivan

Alan, in my day job as a Futuro Health CEO, we underwrite hundreds and hundreds of individuals from diverse communities to get their healthcare credentials in these allied health roles, including medical assistant. So it’s a position where we produce high volume. So, if you are taking a medical assistant that is traditionally trained versus one that participates in this coordinated care, what is the difference in the skill set or even the aptitudes of those who would go into these roles? I’d love to get a before and after comparison.

Alan

Well, so it’s a funny story. At Stanford at the time, we heard that medical assistants were told to get the patient in and out of the room. Don’t talk to them much other than to make sure their name and birth date matches and they are the patient who’s supposed to be seen. If you’re talking too much and helping the patient too much, you’ll be written up. If you do it twice, you’ll be on probation, and if you do it a third time, you’ll be fired. We went around to the directors of all the other clinics and said, “Send us the people that are getting in trouble for doing too much.” Those are the people we hired and they were phenomenal. They came with natural aptitude and life experience.

One example is an incredible woman named Delilah Coleman. She had grown up in New York and she was of Puerto Rican background. Her mom was a single mom who had nine kids and they had foster kids on top of that so there were up to fifteen in the house. She was the second oldest and ended up riding herd over all the kids in the house and helping her mom do that. That’s a great background for being a care coordinator or a health coach or a CHW…whatever the word is that you’re using for it. I think maybe half of the MAs have that aptitude and are seeking jobs like that.

In our training, we would ask people, “Why did you choose your role? Why did you come into healthcare? Why are you a medical assistant?” And we would hear these stories. Women would say, “I came across the border with my mother and I was undocumented. And then my grandmother came. When my mother got documented, I cared for my grandma when she was sick and then eventually she died.  I thought I really would love to be a healthcare person. I’d love to be a nurse.” Then they would discover how expensive it is to be a nurse, and if they were undocumented, they couldn’t access it. So they got jobs as medical assistants instead.

They would tell these stories about why they were there. The physicians and everybody else was in the room, and the physician’s eyes would pop open. I had no idea that’s why you’re doing this job. They knew the person’s name. They chit-chatted occasionally with them. But they had no clue about the commitment that the people come to their jobs in health care with.

Then we trained them, and the training included approaches to behavior change. We weren’t part of the motivational interviewing cult, but we used to help people set their own goals and then ask, “Well, what are you going to do about it? “And they’d say, “Well, I’ll do it on Monday.” Then we’d say, “Can I call you on Tuesday to see how it went?” You know, that kind of thing.

We also trained them in charting, so they were in the room scribing and charting every visit. We trained them in doing point of care testing in the clinic. So you’d never see a patient that didn’t have an A1C test, which was a test of diabetes damage in the prior three months. We always got that done because they were able to do that.

They learned about quality improvement and we utilized a process borrowed from Lean manufacturing called A3 thinking — A3 being the size of a big piece of paper in a printer. We were having a problem with not getting the charts before the patient’s first visit. So we asked the woman who was the receptionist in our clinic who had this responsibility as part of her job, tell us how you think it could be fixed. We trained her in this A3 process, which asks three questions:  What’s the problem? What do you think is the cause of the problem? What should we try to see if it works? They went through that process, presented it back to the rest of the team. My job was to say, “Boy, that looks great,” and to be encouraging.

Within three weeks, we didn’t have another chart that hadn’t come on time and this is just one example of many, many, many things that they were able to do in quality improvement. And then we put everything we were working on in a graph on the wall, and it would be updated weekly or monthly depending on what it was and they could see how they were doing and they could see how they were doing compared to the other MAs in the clinic.

It wasn’t about, you know, the ones who were doing better were better than the people who weren’t, but it was, “What are you doing that’s making it work so well?” And then you could discover that. So the quality improvement, the behavior change…all that is right in their bailiwick.

What they are not allowed to do by scope is to diagnose and assess problems but they’re really good at collecting symptoms. Someone would call up and say, my stomach hurts. Well, how long has it hurt? What makes it better or worse? Have you tried anything? How was that? They would gather that information and they would turn to the nurse in the clinic and ask, “What should I do?” The nurse might say, “Let’s get the doctor involved.”  And they would do it. It worked so well and people stayed within their scope.

Then, you can hire people from the communities that the patients are from. That could be Latinx people, it could be people from Asia, it could be people of color from the United States. Being able to match people by race and ethnicity really helped because it comes with sort of built-in trust, generally, which is really powerful. That’s the future. We need these models in order to get more people interested in primary care.

Van

Absolutely. Your answer was super descriptive. Putting on a different hat, I chair the California Council on Healthcare Workforce Education and Training. Is that curriculum to create this type of medical assistant publicly available to others, or is that proprietary?

Alan

A lot of the protocols that we used sit on our website, which was called Stanford Coordinated Care under the Clinical Excellence Research Center site, which is where I work now.

Van

Let me ask another follow on question. If all the medical assistants were skilled up in this way, you can imagine that they can walk into a situation where others weren’t trained on that team based care model. So, is it a situation where in order to properly adopt this, you have to train both sides…the new hire, but also the incumbent.

Alan

You raise an excellent point. The whole team has to buy into this and the institution has to buy into it and then we need to do a lot of proselytizing about it. Because my experience is that about 40% of people thinking about going to medical school, for instance, entertain primary care as their choice, but by the time they leave at Stanford, it’s somewhere between 5% and 10% keep holding onto it. The reason that they tell me that they switch — and going back to that woman I was talking about who became a vascular surgeon — her experience with primary care was going to work in a free clinic, which was chaos. You don’t see patients for long. It’s not continuity of care. It’s not about relationship building, though that happens there. It was the broken model that made her choose to not go into that and so we need to train the whole team because it’s much better way to do it.

We trained many different organizations in this between 2012 and 2016 and a lot of them adopted it. The best example is a system up in Green Bay, Wisconsin called Bellin Health. They were a star of the Medicare ACO movement, the original heroes of that movement. They came to us saying that two of our great docs have told us they’re going to retire early and we are really worried about it. So they came and spent a very intensive two day time with us. Then the physician who was going to run the project came back and spent weeks with us. The last I heard they had implemented this model in 150 clinics across their network. So it can scale.

Our goal was not to scale within Stanford because Stanford wasn’t that interested in it. They were a specialty institution. But what we were able to do is spread it to Federally Qualified Health Centers, to Intermountain Health in Salt Lake and Utah and Colorado. And we were able to spread it to a charity clinic in Arkansas, which was a really interesting one.

Lots of different organizations picked up on elements of it, but the dream is how to spread it far and wide. It just became difficult to do that and operate the clinic. So my focus now is more on spreading. I’m no longer seeing patients, though I get calls from my old patients or emails all the time, especially the ones who don’t have a primary care doctor nowadays.

Van

I know it’s particularly hard in the Bay Area to find one.

Alan

And I would think the Bay Area has more primary care than most places. I live in Humboldt County, which is six hours north of Stanford. My work at Stanford is all remote, which has allowed me to play the grandparent role quite well. My wife and I have our two kids and four grandchildren here, so I get to do that, and I get to do this work that I love. So, it’s been a good time for me.

Van

We’ve learned a lot about the care team and the configuration of the care team and the evolution of skills in order to adopt the models that you’ve laid out. Why don’t we wrap up with a question around the future of care? Knowing all that you know about the trends in primary care, if your nephew or someone in the community were to approach you with an interest in entering the field of medicine, what career advice would you have?

Alan

I would definitely point people towards primary care because there is no more satisfying job if you have control over the method of delivery. I anticipate that payment models will change from a ‘get paid for each 15 minute segment’  to more of a ‘be responsible for populations of people and their health.’  We know what works in that regard. In the clinic that we had at Stanford, we almost eliminated admissions and ER visits because we knew what was coming and avoided it. You can’t avoid a car wreck or injuries or things like that, and cancer happens to people, but the chronic illnesses are the big thing that primary care health care can help with. You can see it coming and we’re able to prevent it. I think as the payment models change, the successful care models will do well.

The startups in healthcare often are people wanting to do the new models rather than the old models. I’m very suspicious about hospital-owned practices because hospitals ultimately — unless they’re paid very differently — like admissions to the hospital. There’s this phrase called ‘heads in beds’ that is a sign of the economic viability of a hospital.  They like ER visits and our job is to decrease those things. At Stanford, we almost eliminated them and it was so amazing to see our data.

Also, our quality metrics were through the roof and it was all done by the medical assistants managing their panels. Docs would come up to me because this was all visible to everyone and our quality was at the top. People would say, “How do you do that?” And I would say, it’s easy. I don’t touch it, was my answer.  I think good ideas happen at some point, but they happen in fits and starts unless the economic and policy world is really ready to scale it wide. So it may be for the next decade or so we’ll have a relative lack of people, but I’m sure within ten years, this will have won out, much like evolution.

Van

Well, thank you for that optimistic view of the future of care and what amazing work you had done at the Stanford Coordinated Care Center.

Alan

Well, I hadn’t met you till we had the meeting two weeks ago that we attended and worked together on. What you’re doing is exactly the right thing. Why aren’t community colleges training the right workforce? How do we get that to happen? The problem is that clinicians always think they have to do all these things themselves and it’s too hard. But the communities need to take this up and produce it.

Your work is just so important to the future, Van, so I was really glad to meet you, and I look forward to a long-term relationship.

Van

Likewise, Alan, thank you so much for sharing all of your insights and good works and inspiring us with the models that you have laid out. It makes us optimistic about the future of healthcare. Thank you for being with us today.

Alan

And thank you for the opportunity.

Van

I’m Van Ton-Quinlivan with Futuro Health. Thanks for checking out this episode of WorkforceRx.  I hope you will join us again as we continue to explore how to create a future-focused workforce in America.