Primary Care Transformation Pioneer Dr. Tom Bodenheimer on Need for More Team-Based Health Care

Tom Bodenheimer

[Music]

Margaret Flinter : Welcome to Conversations on Health Care with Mark Masselli
and Margaret Flinter , a show where we speak to the top
thought leaders in health innovation , health policy , care
delivery and the great minds , who are shaping the health c are
of the future. This week , Mark and Margaret speak with Dr.
Tom Bodenheimer , Co - D irector of the Center for Excellence in
Primary Care, and Professor Emeritus of Family and
Community Medicine at UC , San Francisco. He's a renowned
expert on transforming p rimary care, which is seriously under -
funded in the U.S. health care system. He calls for more
resources, better deployment of health care teams and health
coaching for better overall outcomes.

Lori Robertson also checks in , the Managing Editor of
FactChec k.org , who look s at misstatements spoken about
health policy in the public domain , separating the fake from
the facts , and we end with a bright idea that’s improving
health and well - being in everyday lives. If you have comments ,
please e - mail us at [email protected] or find us on
Facebook , Twitter , or wherever you listen to Podcast. You can
also hear us by asking Alexa to play the program Conversations
on Health Care .

Now , stay tuned for our interview with Dr. Tom Bo denheimer
on Conversations on Health Care .

Mark Masselli : We're speaking today with Dr. Tom Bodenheimer, Co - D irector
of the Center for Excellence in Primary Care, and Professor
Emeritus of Family and Community Medicine at the University
of California , San Francisco. He's a general internist who spent
32 years in primary practice in San Francisco's Mission District ,
before turning his focus to researching ways to improve
primary care. Dr. Bodenheimer has written and co - authored
hundreds of published papers a nd several books on health and
health policy, including understanding health policy and
improving primary care. He earned his Master's of Public
Health from UC Berkeley , his medical degree from Harvard and
did his residency in internal medicine at UC San F rancisco
School of Medicine. Dr. Bodenheimer , welcome back to
Conversations on Health Care.

Dr. Tom Bodenheimer: I'm delighted to be here .

Mark Masselli : Tom, we are so happy that you're with us today. You're just --
you're one of our heroes. Y ou're also v ery humble about the
work that you've done . Y ou've really become nationally known
for your work on team - based care. I know our audience would

Tom Bodenheimer

love to hear about the work that you're doing at the Center for
Primary Care Excellence. W e had the opportunity to have you
here for a couple of days and heard you talk about the struggle
that's happening in p rimary c are, but also the hopes and
aspirations that people like you had been writing about , have
been preaching . A s you sai d in your own words, you've been a
me ssenger. I'm wondering if you could just share a little bit
about that work and your thoughts on p rimary c are ?

Dr. Tom Bodenheimer: Center for Excellence in Primary Care, we do both research
and practice improvement. O ne area that we've been very
intereste d in is , we feel like many people, especially doctors, I
must say , their relationship with patients is one of , " I want you
to do what I tell you to do , a nd if you don't do it, you're no n
compliant. " Sadly, that's still very much alive . W ell today , it
impac ts not only p rimary c are, but all of medicine. I think the
thing that I've been most interested in doing is what we call
health coaching. You'll f ind out what people are willing and
able to do, and then work with them and make a collaborative
plan on how t hey can improve their healthy behaviors. We
never tell them that they're not doing what we want them to
do, because it's about what they want to do. Ultimately, it's
their choice. W e've done randomized controlled trials on
health coaching and people who ge t this health coaching have
better diabetic control and hypertensive control than people
that don't get health coaching.

We also do , what we call , practice coaching. H ealth coaching is
working with patients , practice coaching is working with
practices , and they're kind of similar . L ike, you can't tell a
medical practice you have to do this to get better. You have to
see what they're willing and able to do. A bout seven or eight
years ago, a couple of us from the Center for Excellence in
Primary Care started visiting , what we call , bright spot
practices , p ractices that are really good. We went to about 25
different practices around the country. W e kind of took those
observations of these practices, and created a model , which
we call , T he Ten Building Blocks of High Performing Primary
Care . T he sort of the basic building blocks is ; number one, if
you don't have good leadership, nothing good is going to
happen. Number two is data - driven improvement, you have to
have data, and you have to use it to improve . The da ta just --
can't just sit there in the computer, you've got to use it. The
next one is empanelment, making sure that every patient is
linked to a p rimary c are provider . T he fourth one is team -
based care. The rest of the building blocks are like access,
con tinuity of care , care coordination. W e ask practices to
assess how they're doing on the different building blocks, and

Tom Bodenheimer

that kind of tells us what they need to work on. We have a
four - day training to train leaders and practices on the different
building blo cks and how they can use them to try to improve
their practices.

Margaret Flinter: Well, Tom, I think one of the inputs into all this work was a
project that we had a chance to work on together this leap
project, learning from effective ambulatory practice s or
exemplary ambulatory practices from the Boston suburbs to
the heartland , all over the country , really tried to look in real
time in real life , w hat were they doing that was different? I
w onder if you want to just call out a couple of practices with a
concrete example of how those building blocks ended up
manifested ?

Dr. Tom Bodenheimer: Yeah . O ne I can think of is West County Health Center in
Sebastopol, California, which is in Sonoma County, just a little
bit north of the Bay Area. T his practice had i ncredible teams.
There was one clinician , which would either be a nurse
practitioner or a physician . T here is a nurse on every team.
There's a medical assistant on every team . T here's a front desk
person , like a receptionis t on every team. T he teams were
s table. In other words, we made -- the teams always work
together . P atients , who are patients of that team, always see
that team , a nd the team only sees the patients that are on
their panel . T he team can really see , what's happening to their
whole panel of patients ? W hat percent of their patients are in
good control for their diabetes ? W hat percent of their patients
have their cancer screenings done up to date ? T hen , people
who don't have those things, the medical assistant and the
front desk person can cont act them and try to bring them in to
do those things that are -- that we call care gaps that are not
taken care of. T he teams in that practice were really
inspirational. The nurses would often go out to people's
homes, and they could interact electronicall y with the clinician
on the team, especially , frail , elderly people , y ou learn so
much in the home that you cannot learn when they come into
the clinic. T he home visits were a key part of that . H aving so
many nurses in the practice really allowed the pract ice to do
many more things th a n practices with fewer R Ns . Another one
was Asian Health Services in Oakland , where they had patient
navigators who spoke, I think something like six or seven
different Asian languages for all of the different Asian
languages in the community around the health center. Great
stuff.

Mark Masselli : Well, that's great. F or people who might be tuning in now, and
they're hearing us talk about coaches and teams, they might

Tom Bodenheimer

be thinking you 're talking about baseball. T eams are very
impo rtant , a nd every member of the team has an important
role. T eams just don't happen , because you call them teams. It
requires some ingredients to make every member of the team
operate at the top of their license. Can you talk about some of
those core qualit ies that people need to do ? I assume no
different than a good baseball team , t hey're out there
practicing . W hat are some of the core qualities that they may
want to do a gut check to see if they have ?

Dr. Tom Bodenheimer: W e think of teams as sort of -- in three sort of components of
teams. W hat's really important is that they have a stable
structure. The same people always work together, the patients
always come to their team. T hat's a big problem in p rimary
c are, because you have people who are part - time , and
especially , in practices where the y're residents who are
learning to be physicians, and they come into these practices
and they feel uncomfortable, because they're just starting. I f
they have a team that's always there for them, and they know
the peop le on the team, they feel comfortable . T hen there's
team culture. T here are many ways to measure team culture.
It's basically, how do people get along with each other and
how people work with each other. We've created a very
simple sort of seven questions scale about team culture . It's
very simple things and many practices. Questions like , I feel
like we're all in it together . S imple stuff , but some teams score
very low on team culture. The culture is not good , things don't
go well.

T hen the final thing is what we call share the care . Share the
care is , how many of the functions that primary care needs to
do are done by the physician on the team or by the nurse on
the team or by the medical assistant on a team or by the
behaviorist, and so forth. F irst we as ked people, we g ive 10
particular things tha t all p rimary c are practice need to do, like ,
colorectal cancer screening, or helping people with diabetes
with their behavior change, or answering the phone in such a
way that people can get a good appointment. W e asked
people to fill out who's actually doing that function. Ten years
ago, it was like the physician, the physician , the physician was
doing everything. Then we asked them, " How would you like
the team to work ?" Everyone was like, "W ell, we would like
the pharmacist to do a lot of stuff. We'd like the nurse to do a
lot of stuff ." T he medical assistant to make sure that everyone
has all of their cancer screenings, all their immunizations, but
that's their responsibility. O ver time, what we found is , the
way that is happening now is that more functions are
distributed compared with 10 years ago , when it was all the

Tom Bodenheimer

physicians doing everything. W e are making some progress i n
team - based care . W e need to make much more progress.
T here are barriers to other pe ople taking on these functions.
For example, in fee for service situations, nurses and
pharmacists pretty much can't get paid , s o they're an expense.
T hat's a barrier . T here are regulatory barriers . L ittle by little, I
think a lot of practices are trying t o redistribute the care
among the team.

Margaret Flinter: Well, another area that you have long paid attention to and
lamented the slow progress is trying to devote more of the
spend to p rimary c are . H ow would you reallocate the spend,
so that p rimary c are actually got the resources that it needed,
as of course, most of the high performing countries around the
world already do ?

Dr. Tom Bodenheimer: I mean, the other thing countries in Europe do is , they spend a
lot more in other social services. I t actually turns out . I f you
spend more on education than on health care, you'll have
better health care. I n terms of the social determinants of
health and the whole community world in which health care
lives, we -- probably we should be spending more money on
other social services. It turns out that in the United States, 5%
to 7% of that goes to p rimary c are as opposed to other
countries, like in Europe, the sort of an average is like 12%
goes to p rimary c are. I f you increase the percent of the health
care dollar go ing to p rimary c are in the United States from like
5% to 12%, that's like, billions and billions of dollars that would
go to primary care, which would allow us to do many of the
things that we ' re asked to do. We used to just take care of the
patient who's in front of us right now. Now , we're asked to
take care of populations, and make sure that those
populations are as healthy as possible. H aving more money is
not the only thing we need to do , because we also need to
reorganize our teams and make sure peopl e have access and
make sure that people have continuity of care , but more
money would really allow us to do a lot more than we're doing
now. T o me, primary care physicians and nurse practitioners
and physician assistance , w ho have these panels of like 2 ,00 0,
2, 500 patients , they're really heroes that really doing this
work, which is almost undoable at the number of patients that
they have to see. I think primary care practitioners who are
working day - in and day - out are really the heroes of our
healt hcare sy stem.

Mark Masselli: That's great. We're speaking today with Dr. Tom Bodenheimer ,
Co - Director of the Center for Excellence in Primary Care at the
University of California, San Francisco, and Professor Emeritus

Tom Bodenheimer

of Family and Community Medicine. Tom, you wer e talking
about managing populations and that requires access to a lot
of data. I think we've seen oftentimes , Margaret , here that
we're not only a healthcare organization, but we're an IT
company in many ways , because data is so important , and
you've real ly been a champion of the use of data in thinking
about how you coach , how you manage teams in the like, talk
to us and to the clinicians who are listening about b est
p ractices in leveraging data and most importantly, how it can
help improve patient outcom es.

Dr. Tom Bodenheimer: L et's just take a particular issue , like say, let's take colorectal
cancer screening, which we know reduces the rate and
increases the longevity of people who are going to get colon
cancer. I t's a very, very important thing that al l primary care
practices should pay attention to, and try to work as much as
possible that all of their patients over the age of 50, get
regular colorectal cancer screening. I f you have a good IT
system as you do, you can measure that for all your patients
and you can see how you're doing over time. T hen you also
have to drill it down , not just to your whole organization, but
to each team , so you can compare how different teams are
doing. H ow do you use the data for improvement? Well, you
talk about it in t he team , "O kay, our colorectal cancer
screening rate i s only 45%. Our goal is 80% ." One organization
that does data better than any other is University of North
Carolina Family Medicine Residency Clinic in Chapel Hill . T hey
have data on all these things . T hey drill the data down to the
teams . They drill the data down to each provider . A ll the data
is on the walls. Everyone knows what everyone else's data is.
It's all transparent. T he other thing is , they want to make sure
that all of their patients are offe red to get colorectal cancer
screening. E ach team has a whiteboard up right above where
the team is working , and the whiteboard says, "T oday, there
are six patients coming in who are overdue for colorectal
cancer screening. So, m ake sure the medical assist ants who do
this, make sure that you really work with those six patients. "
T hen at the end of the day they say, "W e got five out of the
six. " I t's really taking the data , and like , making it very patient
specific to us e, not only to im prove the work of a t eam and o f
the clinicians in general, but to really make sure that every
single patient has all of these things that they should do to
keep healthy.

Mark Masselli: That's great.

Margaret Flinter: I've always thought of you as somebody who found
tremendous joy and satisfaction in practice as a physician. Y et ,

Tom Bodenheimer

you said yourself that you reached a point where you were
burned out , and we hear this all over the country, it's gone
from being talked about as burnout to moral injury. B asically ,
comes when people ar e emptied out of their ability to
continue working compassionately and at their full robust
ability. When you left practice, one of your commitments was
to really try and improve primary care for the sake of the
patients and the people who care for them. S hare your
thoughts on burnout with us.

Dr. Tom Bodenheimer: Back when I was practicing -- I left practice in 2002 , t he word
burnout didn't exist. W hen I think back , I can think about days
when I really felt burned out , but it's not every day, it goes up
an d down. T he best way to measure is to use the Maslach
Burnout Inventory , and that's basically saying , so there's a
bunch of statements like I feel completely exhausted every
day, once a week, once a month. I t really looks at how
common it is. T here are two parts of burnout that are quite
separate. One is the exhaustion part and the other is what's
called cynicism. Exhaustion is just too much work and there is
too much work in primary care. T hat's a big thing. It's not easy
to figure out how to reduce that w ork. O ne of the reasons why
we want to spread things across the team is to reduce the
work of the clinicians who are getting burned out without
increasing the burnout of the other team members.

The other part of it, though, is really much more pernicious
and that is people who can't stand the work that they're doing ,
part of it is, I hate my work. W hat's happened partly as a result
of electronic medical records is that physicians are spending
about half of their time dealing with electron ic medical record
documentation, which is 150 inbox messages you get every
day in addition to seeing the patients face to face. I f we can
get rid of all that documentation and desk work , we will --
number one, reduce the amount of work and reduce the work
that people hate. T here are ways to analyze what these
different inbox messages are and try to figure out which ones
can be reduced. In terms of the documentation , there are
different things that people have tried , people try scribes for
doing the documentation in the electr onic medical records .
T here is a team based structure , in which you have t w o
medical assistan ts per clinician , in which one of the things that
the medical assistan t do is reduce the docu mentation burden
on physicians. T his is something we really need to wo rk on.
Every practice has to measure the burnout and try to figure
out what to do about it.

Mark Masselli: I want to pick up on Margaret's statement about joy . Y ou also

Tom Bodenheimer

found as a Peace Corps physician is somebody who's worked in
the Mission District been concerned about immigrants .
A dvocacy is very important in addition to practice, right? Talk
about the joy that you get and the responsibility that you have
to be enga ged in the larger conversation?

Dr. Tom Bodenheimer: Yeah . I mean, burnout is sort of one end of the spectrum and
joy is the other end , and we try to move toward the joy end of
the spectrum as best we can. To me, most of the joy in
practice that I remember comes from having long - term
relationships with patients. I ncreasing the amount of time th at
people have making th e se relationships with patients brings
more joy. T eaching brings joy , and teaching in healthcare is
very much experiential. It's like teaching right there , than and
there. It's not like sitting in a classroom, teaching people
seeing patients . I just love teaching the UCSF m edical students
that would come . W e had these first year students who would
come , they didn't know anything. I had this one student, she
was fluent Spanish speaker , and many of our patients were
Spanish speaking as I was . I said, " Well, why don't you go and
see this patient?" She went to see the patient. She was very
wonderful, very empathetic, to come out , to talk about with
the patient. Then when the end of the interview, the patient
says, "C ould I see her now? Co uld she be [PH 00:19:12] my
primary care doctor?" T hose things bring joy.

Margaret Flinter: Well, that’s a great ending . We've been speaking today with
Dr. Tom Bodenheimer, the Co - Director of the Center for
Excellence in Primary Care, and Professor of Fami ly and
Community Medicine at the University of California, San
Francisco. You can learn more about his groundbreaking work,
go to profiles.ucsf.edu/thomas.bodenheimer or follow the
work of t he Center for Excellence in Primary Care on Twitter
@ ucsfcepc . Tom, thank you so much for your enormous
contribution to the advancement of high quality care for all of
the education and training of medical students and residents
and other students of the h ealth professions over the years,
and for being a guest with us here on Conversations on Health
Care .

Dr. Tom Bodenheimer: I'll thank you for all that you're doing. You're wonderful
organization.

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Mark Masselli: At Conversations on Health Care , we w ant our audience to be
truly in the know when it comes to the facts about healthcare
reform and policy. Lori Robertson is an award winning
journalist and Managing Editor of FactCheck.org, a

Tom Bodenheimer

nonpartisan, nonprofit consumer advocate for voters that aim
to re duce the level of deception in U.S. Politics. Lori, what
have you got for us this week?

Lori Robertson: The Census Bureau in September released its report on health
insurance coverage in the United States in 2018 , finding that
the rate and number of the un insured increased from 2017 to
2018 , t he first time it has found a yearly increase since the
Affordable Care Act was enacted in 2010. In 2018 , 8.5% of
people were uninsured for the entire year. That's up from
7.9% in 2017 and it's an increase of about 1.9 million people.
Most Americans with insurance get their coverage from
private health insurance companies. 67.3% of people have
private coverage with most getting that coverage through
their employment. Those with Medicaid coverage dropped
0.7 % points from 2017 to 2018 and the percentage of children
without insurance went up by 0.6%. The Census Bureau also
released information on income and poverty , finding that the
median household income in 2018 , $63,179 , wasn't
statistically different from 2017. That come s after increases in
the median household income for the three years prior. T hat's
my fact check for this week. I'm Lori Robertson, Managing
Editor of FactCheck .org.

Margaret Flinter: FactCheck.org is committed to factual accuracy from the
country's major political players and is a project of the
Annenberg Public Policy Center at the University of
Pennsylvania. If you have a fact that you'd like checked, e - mail
us at chcradio.com , we'll have FactCheck.org's Lori Robe rtson
check it out for you here on Conversations on Health Care.

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Margaret Flinter: Each week C onversations highlights a bright idea about how to
make wellness a part of our communities and everyday lives.
One in five Americans will suffer a diagnos able mental health
condition in a given year, and most often don't seek
treatment. Seeing a rise in mobile apps aimed at behavioral
health entering the marketplace , University of Washington
r esearcher , Dror Ben - Zeev thought a comparative effective
anal ysis study would be a good idea.

Dror Ben - Zeev : With the objective of having a head to head comparison
between a mobile health intervention for people with serious
mental illness called FOCUS and more traditional clinic - based
group intervention. T he study real ly gets at some of the core
differences between mobile health and clinic - based care.

Mark Masselli: More than 90% of the mobile app group engaged in the online

Tom Bodenheimer

program, which was a series of text messages, offering coping
strategies and self monitoring of symptoms, along with weekly
colons with a behavioral health clinician.

Dror Ben - Zeev : The second thing we wanted to see is after people complete
care, are they satisfied with both intervention . P robably the
most important piece of the study are the clinica l outcomes.
90% of the individuals who were randomized into the mobile
health arm actually went on to meet a mobile health specialist
to describe the app to them and train them how to use it and
use the intervention app , that's assigned to them at least
on ce. Whereas in the clinic - based arm, we saw that only 5 8%
of the participants assigned to that clinic - based intervention
ever m ade it in for a single session.

Mark Masselli: Both groups of patients saw roughly equal results from their
completed treatment, but the mobile group was m ore likely to
engage in therapy.

Dror Ben - Zeev : The very existence of a group can be quite helpful, but f or
others, the interaction is anxiety provoking. W hen it comes to
the clinical outcomes, in both intervention arms , people
im proved both in terms of reduction in their symptoms and
the di stress associated with symptoms.

Mark Masselli: A targeted mobile app aimed at facilitating access to clinical
care for those experiencing serious mental illness symptoms,
improving access to in tervention for behavioral health needs.
Now , that's a bright idea.

[Music]

Mark Masselli: You've been listening to Conversations on Health Care. I'm
Mark Masselli.

Margaret Flinter: I'm Margaret Flinter.

Mark Masselli: Peace and health.

Margaret Flinter: C onversations on Health Care is recorded at WESU at
Wesleyan University, streaming live at chcradio.com , iTunes,
or wherever you listen to podcasts. If you have comments,
please e - mail us at [email protected] , or find us on
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