HIStalk Practice Interviews Christoph Diasio MD, Sandhills Pediatrics, Southern Pines, NC

Tell me about your practice and the technology you’re using.

We’re a busy practice in a semi-rural county in North Carolina, where we take care of the rich folks in town and the incredibly poor people in town, just a very busy pediatric practice that in winter we routinely we see more than 35 patients per clinician per day.

It’s very important to us that we deploy technology that solves problems. The key problem that we identified when we started was that paper was eating the practice. As the practice got bigger, there were more places for the charts to hide. We wanted something that could help us with that.

We looked at a doctor data entry EMR. We were very unhappy with the point-and-click EMR because we felt that we couldn’t handle that level of slowdown. We also felt that our staff, which was not extremely technical, wouldn’t really enjoy that level of slowdown, either.

What we ended up doing was document imaging, starting with SRSsoft, and it’s been a great solution for us. When we were making the decision, we knew we were going to do a second office. That was an important part of being electronic. Not chasing the charts, secure electronic communication within the practice — those were all things that were huge value-adds for us, and having the faxable prescriptions so we wouldn’t have legibility issues with prescriptions. Those were all things that were a real value-add to us as to what to do electronic.

My big frustration is that so many people wanted an EMR because they were told they need an EMR, but they never asked what problems they are trying to solve. Just in the same way that you’re supposed to be trained in medical school, every time you order a test — why do you want this test? What is the reason that you’re doing it? And I very much encourage physicians to ask that same question about any technology decisions they make.

Because we had frustrations with our existing practice management company after we made the decision to do SRS, we switched to PCC, which is Chip Hart and the Vermont people. Because all the data that you need with the quality improvement, 95% of it is already in your PM database. We’ve been able to do great quality improvement work with that.

The big example right now is the Hib vaccine recall, which they just lifted the other day. It was very easy for me to run electronic reports to show me everybody three to 11 months who hasn’t had a dose of flu vaccine, who hasn’t had a dose of Hib vaccine. That is a real clinical upside, and people get these fancy EMRs, saying, “I need them,” and I say, “OK, what are you guys doing to make sure everyone’s had their vaccines?” Then I just get blank stares. People are getting these very fancy EMRs, but they’re not doing the most basic quality improvement work that could be done.

In the perfect rainbow-and-unicorn world of the future when all the computers talk to each other and the data is not in proprietary databases and you can do population data mining and you can do all these wonderful things — that’ll be great, but that’s not what exists. We can’t take the fact away that getting things much better than they are in a pure paper world doesn’t mean that you have to turn every highly trained physician into a doctor data entry monkey.

So is most of the quality reporting you’re getting right now is through your practice management system or through your EMR?

Through the PM. We have ways to do that inside the EMR, we have simplified things to do it, but honestly, we just haven’t gotten to that level because we’ve been having a lot of fun running reports inside the PM.  If you really start talking to people — I mean, all an EMR is is a database, that’s all that it is. It’s nothing exotic, it’s not anything which showed up from the moon, it’s not alien technology — it’s just a database. And that’s exactly what your PM system is — it’s just a database.

The question is, do you have structured queries to ask? The only value-add you get from doing doctor data entry is that potentially you can then ask very subtle questions of your data sets — “Show me everybody who’s got some new anti-high blood pressure medicine who then came in and had wheezing.” You can do that in a full-bore EMR, but you can also get pretty close just inside your practice management system. If your prescriptions are all electronic, you can run a list, “Show me everybody who had this medicine,” and then you can correlate it with your practice management database.

I get very skeptical about why people want to make me, as a highly-trained clinician, sit there and point and click my way through physical findings when the reality is that all that most of the usefule stuff is in the PM system as the diagnosis list. You’re really able to get all that data another way, so why should you turn your physicians into clerks?

I know you’re a big proponent of physicians really understanding the coding and documentation process. Why should doctors be on top of this? Why not just leave it to the billing staff?

The only person who knows what happens in the room is you. It’s not the billing person. Billing staff are trained that they’re supposed to defer opinions of medical decision-making to the physician that’s in the room. That’s just correct coding. As far as knowing what level to pick, you can always ask other people to do that, but when I talk about coding, if you’ve mastered the Krebs cycle, you can learn how to do coding.

The people that are coming to audit your coding are never going to be physicians. If you’re lucky, it’s an RN, but most likely it’s not anyone clinical, and it’s someone who, if you’re lucky, graduated high school. For physicians to say that they just can’t learn this is not realistic.

It doesn’t mean that every physician needs to be a coding guru, but there are certain very basic and simple things that we are all absolutely capable of doing. You ever see a lawyer who doesn’t know how to bill? It’s just something we have to know. It’s part of controlling your destiny.

How does the use of technology in the practice affect the quality of care you’re able to provide your patients?

More access to information, access to charts at home at night when you’re on call, the ability to electronically audit data, again, using the practice management system to find children that are delayed on vaccines. One of the big things now are the people who believe Jenny McCarthy instead of the Centers for Disease Control, the American Academy of Pediatrics, the Advisory Community on Immunization Practices, and basically every scientist who’s ever studied vaccines.

There are certain populations of people who just stopped coming to the doctor any more. They’ve stopped coming for check-ups any more. Unless you have a way to find those people, you can’t educate them appropriately. There are a lot of physicians who would say, “Gee, we have hardly any people who are refusing vaccines,” but then you go and you look, and I can find patients who came in for sick visits but never came for check-ups.

Other quality improvement stuff — it’s easier for the telephone nurse. Our telephone nurse sits on the phone and talk to parents all day. She’s able to see the charts, she can see what happened at the office yesterday, she can send e-mail messages that are secure inside our systems and permanently affiliated with the charts to the doctor that saw the patient a week ago that she has questions about.

You basically go from working in serial to working in parallel. Lost chart safaris have gone away, so you always have availability of the chart when you’re seeing the patient. Before, maybe it was in billing, maybe it was with the phone nurse because they were doing a prescription refill. So that kind of access to information is there. You have all that even without doing a full-blown EMR.

And how do you personally interact with the EMR? What type of information are you putting in and how are you putting it in?

We’re continuing to document on our same paper templates that have been refined in over 40 years of the practice history, so we get to document things the way I want it. If I want to ask about well water, I don’t have to argue with a programmer in New Jersey that I want to ask about well water. It’s an element that I can create right there and have all that set up.

As far as how we put data in, we do do some data entry when patients transfer in or if they get vaccines at another practice. We do enter that into our PM system and it also gets double-entered into the EMR, which is obviously not your first choice. But I’d much rather spend a little bit of staff time on that than to slow my physicians down every patient every day.

We enter all our problem lists and we do all our prescribing electronically through the computer now. That’s another way technically that we’re entering data in the EMR. And then we are able to poll the database and say, “Show me the list of everybody who’s on a certain medicine,” I can say, “Show me what doctor and everything they prescribe.” You can really do a lot of quality improvement stuff, just finding out what’s going on in your practice, whereas in the paper world, you never could do that.

Your SRS EMR is not CCHIT certified. Why risk the potential loss of ARRA funding by going with a non-CCHIT product?

Because it’s vaporware. ARRA funding is the ultimate vaporware. No one knows what it means. $44,000 is all that pediatricians get because we’re not as important as adult doctors. It’s basically irrelevant to me. Even as a lowly little pediatrician, I bill so much more than that in a year’s time. For you to make me do something that slows me down — that dog just doesn’t hunt; it’s just not going to happen. I don’t really believe it’s relevant.

I think the other problem with CCHIT is that the big vendors got together and had their own little clubhouse. They’re basically doing what makes sense to them and they’re deciding themselves what a good product is, which is so backwards of how the process ought to run that it’s even hard to comment on. Nothing is certified because you’ve had a 7% adoption rate. I would argue that the market is the ultimate certifier. If the people out in practice look at  CCHIT EMRs and say, “There’s no way I can do this; it slows me down too much”, it’s game over.

I don’t really see it as relevant. That’s just not enough money for it to be worth it for me to do this. This is just a major gift to the EMR industry and it’s the guy whose head of the VA said, “We’ve basically had major market failure,” and that’s why you’re having to pay people to adopt EMRs that slow them down. A one-time payment or a couple years’ payment is just not going to be enough to convince me that I should do something that doesn’t make sense to me.

Once you’ve seen one medical practice, you’ve seen one medical practice, and so you really need something that works inside the culture and the way that practice operates. It’s kind of like, “Who’s the person driving the train here?”

My response is that EMR has to work with the way I practice. I should not have to totally change the way that I practice just to document. No physician should ever be sitting in a room while a patient is telling them a simple or a complicated medical story, and ever have in the back of their mind, “How am I going to enter this into the computer?” It should not be creating diagnostic areas where we are squishing our brains into these little pegs, into these little holes that are set up by programmers who have no understanding of the practice of clinical medicine. That’s unfortunately the reality that I think we still have today. It’s just not enough money.

The other thing is, what is the real upside? The most important question you ever ask is why are people using these EMRs that can’t do meaningful quality improvement reports? Everyone claims they can, but their quality reports are like, “Show me everybody who hasn’t had a mammogram who’s over whatever age.” That’s great, but that’s not really relevant to me as a pediatrician. I’ve got simple, flexible technology that work well for me.

The other issue is that pediatrics is the red-headed stepchild in American medical care. It’s a very low-dollar thing, very few people are interested in it, so I’m not really afraid that the government is mandating that I have to have that EMR. At the end of the day, if they’re going to come out with a major mandate, people are just going to say, “I’m not going to do that” and they’re going to quit.

No one is getting paid to buy an iPhone. People are getting iPhones because it’s a fun technology that makes sense. That’s the thing that you need to do if you really want to drive EMR adoption — you have to have products that work well. And we shouldn’t look at technology as if there’s just one path. We should look at people that are doing document imaging and other things that makes sense to them that still give them 24/7 availability of medical records, electronic prescribing, knowing exactly what lab tests they’ve ordered, ability to birddog and chase referrals to consultant results, referrals to laboratory testing. You can do all that without doing full doctor data entry.

I’m just struggling to find out why CCHIT matters. It’s as if the Big Three automakers all got together and decided they were going to build their cars a certain way and certify that as the way they were going to make cars. You think that’s more relevant than whether the consumer wants to buy it?

What you really need is a governmental organization led and driven by physicians who decide what are the key criteria that are relevant to medical care. I find the whole concept that we’ve had CCHIT for how many years now and the same vendor can’t electronically transfer electronic records on one patient to the other same vendor — they can’t even do that, and they have a certifying body called CCHIT? It just seems ridiculous.

Anything else you’d like to share?

You have to ask, “Why are you doing things?” Everyone’s getting these EMRs because they’re supposed to, but they don’t really ask what they’re going to get for it. I go to meetings and say, “OK, guys, you’ve all got these fancy EMRs. How many of you are doing recalls for all your asthma patients if they haven’t had a flu vaccine by October 1?” And you can hear the crickets chirp.

And I go, “Why the hell are you doing it? What is the reason?” The answer is that you really should come up with a list of what you want out of an EMR, and then you should ask if you can get there without getting a full-bore EMR that is a proprietary software that has you locked in with them forever. It’s just craziness. And pediatricians also have to maintain their records for 25 years because we have to get the age of majority plus a certain number of years, which varies state to state. It’s a lot more of a commitment for a pediatrician to maintain a system for forever than it is for adult medicine where you need to maintain it for seven years or whatever.

News 7/23/09

Zynx Health and eClinicalWorks announce a partnership to provide Zynx AmbulatoryCare order sets to ECW clients.

Healthy Advice Networks launches PracticeWire, a wireless solution that delivers real-time health content to physicians all day via wall-mounted flat-screen monitors. The monitors are placed in a practice’s back office where it displays medical news throughout the day. Practices can also incorporate their own content, such as details on standards of care and regulatory guidelines.

The HIMSS Electronic Health Record Association re-elects Greenway’s Justin Barnes as chair, adds GE’s Mark Segal as vice chair, and appoints Epic’s Carl Dvorak as an executive committee member.

Sound advice from CPA and consultant Reed Tinsely on what it takes to successfully implement EMR: “A large part of success/failure is that someone of authority in the practice has to take accountability to direct all the physicians that EMR is either go/no go for the entire group…the organization cannot be divided once an implementation decision has been reached.”  More here on Reed’s blog.

Allscripts-Misys releases its fourth quarter number and beats Street expectations for both non-GAAP EPS and revenue. Non-GAAP EPS was $0.16, above the expected $0.15, and total revenue was $166.2 million, compared to the $160.5 million expectation. Meanwhile Allscripts and Medfusion announce a strategic agreement to provide the Medfusion patient portal for Allscripts EHR/PM clients. At the same time, Medfusion announced its purchase of Medem’s health services operations.

The number of residency graduates who are immigrants are on the rise, especially in the fields of pediatrics, internal medicine, and family practice. AAFP President Ted Epperly believes primary care specialties are less appealing to US-trained doctors because it pays significantly less than other fields. Nationally about 25% of residency graduates begin their medical training abroad. In primary care, almost half are foreign-trained.

WebMD introduces Medscape Mobile, a free medical information application for use on the iPhone or iPod Touch. Medscape Mobile includes drug information, clinical reference tools, medical news, and CME opportunities. The application will be available for Blackberries later this year.

Hayes Management Consulting and Aternity partner to help improve physician adoption of EHRs. The companies will combine the rapid prototype methodology of Hayes with Aternity’s Frontline Performance Intelligence Platform to organizations increase implementation efficiencies.

A former South Carolina office manager is sentenced to two years prison after admitting she opened a credit card in her employer’s name to buy personal items, wrote check’s from the company’s account, and took money from the company’s bank deposits. Jane Wyatt-Scott pleaded guilty to breach of trust, financial transaction card theft, and financial identity theft. In addition to prison, she must pay over $158,000 in restitution.

3M Health Information Systems and CodeRyte ink a deal to integrate CodeRyte’s outpatient computer-assisted coding technology with 3M’s Codefinder software. The new product will be referred to as 3M Codefinder Auto Edition, powered by CodeRyte technology. Rolls right off the tongue.

Advantage Healthcare Solutions and Physicians’ Service Center combine their practice management and billing operations. With the merger, the new entity will provide services to over 120 physician groups and employ almost 300 associates.

Half of consumers indicate they are willing to seek healthcare through the Internet as a substitute for face-to-face, non-emergency visits. That, according to a PriceWaterhouseCoopers report. Nearly 73% of the 1,000 surveyed would be willing to take advantage of tele-health services to track their conditions and vital signs.

And, according to BCBS of Florida, digital doctor services are on the rise. BCBS first began paying for e-visits about five years ago and today about 1,000 providers have signed up to provide e-visit services. The most common digital applications embraced by doctors and patients include scheduling appointments, sending lab results, and paying bills.

A UK study concludes that pay-for-performance programs fail to provide sustainable long-term gains in care. In a pilot program, P4P measures did result in short-term improvements in asthma and diabetes care after one year, but the rate of improvement reached a plateau by the fourth year. Also, the P4P program had no overall effect on heart disease care.

With the proliferation of on-line rating sites that include the review of physicians, more doctors are going on the defense. More than 40 websites now include doctor ratings, prompting some physicians to sign agreements that prohibit online postings or media commentary without the doctor’s prior written consent.

E-mail Inga.

News 7/21/09

Half of all physician practices, medical billers, and billing offices are unable to estimate the amount due at the time of service. And, doctors collect only about half of the balance due from patients, with the balance going to bad debt. In other words, each year doctors are not collecting $14 to $30 billion of the money they are due. A few companies now offer tools to calculate the patient responsible portion at the time of service. As consumers pick up a bigger portion of their health care costs, look for increased adoption of these type technologies.

Google Health now supports document scanning, allowing patients to upload paper medical records. Google is also partnering with Caring Connections to allow users to download free advance directive forms.

Mednax pays cash for Mid-Tennessee Neonatology Associates, a 24-provider group serving NICUs in the Nashville area.

I happened upon this blog written by an ophthalmologist who also apparently runs a practice management and consulting firm. Dr. Peter Polack offers some sound advice on ways to ensure medical records remain legally sound, once doctors transition from paper charts to EMR.  The key is ensuring EMRs are not altered, which requires automated audit features to track who accesses a patient record and when. I find it curious that Dr. Polack used the phrase “remain legally sound,” which somewhat suggests a paper chart cannot be altered. I’m pretty sure I’ve never seen an automated tracking system for paper charts, either.

Providers in Minnesota are now required by law to submit all insurance claims electronically, including those for private and governmental carriers. The state hopes to save about $60 million in administrative costs once all 60,000 providers have made the switch from paper. I’d actually like to see that math. I’m sure most larger clinics have already been submitting claims electronically for years. Is the $60 million a “real” number or just one that Minnesota legislators hope will impress their constituents?

EMR does not necessarily kill the use of pen and paper. So concludes a researcher from Roudebush VA Medical Center (IN). Clinicians often use sticky notes, index  cards, and notebooks to improve workflow efficiency, as well as for memory aids. Don’t dump that Bic stock just yet.

A Phoenix-area OB/Gyn practice bans e-mail on Fridays to encourage more interpersonal communications. The 16-doctor, 130-employee group now have “Conversation Fridays” to promote more personal interaction among employees.

A Kaiser pediatrician shares his thoughts on EHR in an LA Times opinion piece. He admits that EHR doesn’t save time or money, though it does allow him to work remotely from home after the kids go to bed. He’s also enthusiastic about the efficiency of e-mail consults, which can reduce errors and boost care. He concludes, “Ultimately, getting away from a pen and paper is better for my patients.”  Ahhh…so EHR isn’t just about stimulus money.

ENT and Allergy Associates (NY/NJ) announces they’ve expanded the use of their NextGen EMR system to 10 of its 30 practice sites. The practice includes about 90 physicians.

Fairfield County Community Health (OH) makes plans to purchase a PM/EMR solution after being awarded a $250,000 federal grant.

Parents claim that when their children’s care is coordinated through a medical home, their children have fewer hospitalizations and fewer school absences. Parents also worry less about their children’s health. The findings are based on a three-year New Hampshire survey that examined the effectiveness of using medical homes to coordinate pediatric care.

Disturbing: the Congressional Budget Office estimates that HR 3200 (America’s Affordable Health Choices Act 2009) would grow the deficit by a net $239 billion between 2010 and 2019.

The family of an elderly patient sues his dentist for allegedly dropping tools down the patient’s throat on two separate occasions. The  suit claims the dentist dropped an implant screwdriver tool in 2006 and a mini-wrench in 2007. The 90-year patient had several medical procedures to remove the tools but never recovered.

E-mail Inga

Intelligent Healthcare Information Integration 7/20/09

The Six Degrees of Integration

Tipping points and network theory. Malcolm Gladwell and Kevin Bacon. If short books and the Science Channel have taught me anything, it’s this: while I may not have all the answers, it is only a hop, skip, and a jump to where the answers lie and simple things may have the biggest impact (TV and the Web reaffirm this daily).

Have you noticed that no matter where you look, someone is promising the grand digitization of healthcare in the oh-so-near future. I’m starting to chafe from the tipping point upon which we’re supposedly perched. However, a look at the percentages of full-blown HIT users, either provider-side or consumer, doesn’t seem to tilt the impression that mass adoption is all that imminent.

Still, with Facebook at nearly a quarter of a billion users and Twitter plotting its plan to become the first Internet site to reach a billion users, it is apparent that providing people with a tool they: a) understand; b) find simple to use, and: c) find real, immediate use for has major power to quickly topple a tool over into mass adoption. If healthcare IT could get off its high horse and learn a lesson or three from these more “common” contrivances, maybe we could actually reach the Promised Land of Healthcare Information Integration.

Enter Kevin Bacon. HIT struggles virtually non-stop to understand how to integrate all the data we derive daily, be it patient care info, new medical knowledge, or business numbers management. And, from Kalamazoo to Cocoa Beach, everyone is trying to figure it out almost independently. Well, Kevin says we are all only separated by some six degrees or less. What if we take a part of Mr. Bacon’s recipe, sprinkle in some of Facebook’s Gladwellian success spices, stir it all up within the HIT pot, and then dump the whole stew out upside down?

Instead of Six Degrees of Separation, what if healthcare information integration chose to focus upon the reverse view that we are all within “Six Degrees of Integration”? We are not separated so much anymore as we are integrated. A quick breeze about the HIT blogs brings up some pretty interesting observations along these lines from both the more notorious as well as some lesser-known HIT brainstormers.

Many of them are now bandying about notions related to direct-to-consumer healthcare information integration management beyond PHRs and EHRs. After all, every person on the planet has health which needs care at some point or another, just as most everyone has social networks with whom they want to keep connected. If simple social networking tools are able to empower such rapid adoption and end user deployment, then haven’t they demonstrated the fast, focused force available for integration of healthcare info if we only harness similar motivating energies?

To promote this reverse view of the Six Degrees for HIT, I propose a new organization: Pursuers of Integration’s Six Degrees, to be more affectionately known as PISD. If you don’t want to wait for the trickle down of big, siloed systems, consider becoming a PISD member. Help all of America, even all of the world, become PISD so we can get beyond the abrasive point upon which we tip.

The unwitting modern day Moses, Kevin Bacon, has shown us the Promised Land past the HIT Tipping Point. Now, if we could just pass over.

“If you’re not scared or angry at the thought of a human brain being controlled remotely, then it could be this prototype of mine is finally starting to work.” – John Alejandro King

Dr. Gregg Alexander is a grunt-in-the-trenches pediatrician and geek. His personal manifesto home page…er..blog…yeh, that’s it, his blog – and he – can be reached through http://madisonpediatric.com or doc@madisonpediatric.com.

News 07/16/09

iMedica changes its name to Aprima Medical  Software to avoid confusion with several other similarly-titled healthcare companies. The company also rolled out a new website, aprimaehr.com.

The HIMSS Electronic Health Records Association (EHRA) sends a letter to the ONC recommending, among other things, that CCHIT be “the single certifying entity to avoid duplication of effort, unnecessary expense and confusion in the market.” In case you need a refresher course on how these various entities are intertwined, here’s some background. CCHIT was spawned from HIMSS. The EHRA is comprised of EHR vendors, most of whom are CCHIT-certified. CCHIT’s operations are largely funded from the monies vendors must pay to apply for CCHIT certification. Certification fees are $28,000. So, it makes perfect sense that the EHRA members want to preserve their investment by supporting CCHIT. It certainly helps keep the riff-raff out of the game.

One vendor definitely not in favor of mandatory CCHIT certification is SRSsoft, who just announced Northern California Medical Associates as its latest client. The 21-location, 50-provider group displaced two CCHIT-certified EMRs in place of the SRS EMR product.

Doctors at Gaston Medical Group (NC) contact police claiming more than $333,000 has been embezzled from the practice. The six-doctor group claim the money was stolen using counterfeit payroll checks.

DocSite announces that six state medical associations are now offering its PQRI product to facilitate PQRI reporting. Medical societies in Colorado, Tennessee, Idaho, Nebraska, Iowa and New Hampshire are now offering the product to members.

e-MDs releases its 6.3.0 Solution SeriesTM solution, which incorporates such enhancements as a First DataBank’s drug database solution, upgrades to the Surescripts e-rx application, abd support for continuity of care documents.

It’s hard not to be sucked into the Michael Jackson medical drama since the media is constantly providing “breaking news!” with the latest scandalous details. Today’s headlines include word that at least nine doctors are under investigation for their role in providing Jackson prescription drugs.

Allscripts announces it is working with the AMA to offer an AMA-branded e-prescribing tool. The tool will be available at no cost to subscribers of a new online solution being developed by the AMA, with help from Covisint.

TetriDyn Solutions is now a certified VAR for McKesson’s Practice Partner EHR solution. TetriDyn also offers its own small-practice EHR solution, AeroMD, and is a Medisoft PM reseller.

XM Satellite Radio fans now have a new source for advice on improving physician practice management. Practice Success is a practice management radio show featured on ReachMD’s channel 160. Karen Zupko of KarenZupko & Associates is hosting the program, which will offer practical practice management advice for physicians and their staff.

The consumer price index for physician services rose 3.3% for the 12 months ending in June, which is a tad more than the 2.8% increase the previous year. Physician office prices rose .2% in June, compared to a .1% decline in May.

A Washington state oncologist files suit against Olympic Medical Center, charging the hospital’s hiring of employed physicians constitutes a monopoly. Dr. Robert Witham claims that the medical center’s direct hiring of doctors violates the law by creating unfair competition with private physicians. The case could be interesting to follow, especially with more and more practices selling themselves to hospital systems.

The HHS announces plans to develop an electronic family history tool that will help doctors identify women at risk for having preterm labor or delivering a child with a birth defect. The web-enabled My Family Health Portrait program will allow patients to enter data via computerized tablets, which would then be analyzed electronically.

Lori Heim, AAFP’s president-elect, tells Congress that healthcare reform will not succeed without an adequate supply of primary care physicians. The AAFP is calling for measures that would boost the number of primary care physicians to at least 45% of the healthcare workforce, and include an immediate increase in primary care physician payment.

E-mail Inga.