After graduating from Harvard Medical School, Dr. Tom Bodenheimer spent time as a Peace Corps physician in Costa Rica, where he learned about the political economy and health infrastructure of rural Latin America. This led him to wonder how the US might adapt successful public health models from the developing world, such as promotores, or community health promoters. Upon his return, he practiced primary care for 32 years in San Francisco’s Mission District, a primarily low-income, Latino community. He has written and co-authored several books on health policy, including Understanding Health Policy and Improving Primary Care. Dr. Bodenheimer has spent the past 11 years of his career in the University of California San Francisco’s (UCSF) Department of Family and Community Medicine, where with his colleagues, he works with primary care providers to improve health care service delivery.
Career in Profile
- 1961- Graduated from Harvard College
- 1965- Graduated from Harvard Medical School
- 1965-1966- Interned at Boston City Hospital, Harvard Medical Service
- 1966-1967- Worked as a Research Assistant in Neuro-Anatomy, National Institutes of Health
- 1967- Served as a Peace Corps Physician in Costa Rica
- 1967-1968– Consulted for US Department of Health Education and Welfare
- 1968-1969– Served as a Urban Coalition Fellow in Community Medicine at the San Francisco General Hospital
- 1969– Completed MPH at University of California, Berkeley
- 1969-1971– Resident in Internal Medicine at University of California, San Francisco
- 1972-1975– Physician at the South of Market Health Center
- 1974-1976– Researched at the Health Policy Advisory Center
- 1975–1979– Physician at Mission Neighborhood Health Center
- 1980–2002– Physician at BayWest Family Health Care
- 1991-1996- Associate Clinical Professor, Department of Family and Community Medicine, University of California, San Francisco
- 1995-96– Worked as the Hospital Utilization Manager at BayCare Medical Group
- 1996–2002- Clinical Professor, Department of Family and Community Medicine, University of California, San Francisco
- 1998–2000- National Correspondent, New England Journal of Medicine
- NOW – Adjunct Professor in the Department of Family and Community Medicine and Co, Director of the Center for Excellence in Primary Care, University of California, San Francisco
Can you talk about your decision to transition from practicing primary care to influencing health policy through your position at the University of California-San Francisco?
In primary care, there was this total divorce between primary care and populations. In primary care, we thought about who’s coming in today or tomorrow. People didn’t even know who their population was or who was on their panel of patients. Even though I have a Master’s in Public Health [MPH], I turned off that way of thinking for a long time due to the pressures of private practice, but now I’m getting interested in it again. I was always really interested in health policy, even during my 1-year MPH program at the University of California-Berkeley. Even while I worked as a primary care physician, I itched to keep my hand in health policy, so Kevin Grumbach and I co-wrote Understanding Health Policy. I did some writing as a physician, and I kept my interest in health policy throughout my career as a practicing physician, but didn’t have much opportunity to do much with it until I left the practice. I like to write. It’s fun.
My health policy work had to get pretty truncated while I worked in primary care, but being in a private practice really teaches you how the health system works, from the bottom up. Not from the very bottom, which sadly is where patients are, but primary care is close to the bottom. This was during the time when Health Maintenance Organizations [HMO] came into being, so we had HMO contracts and PPO Preferred Provider Organization [PPO] contracts and we were in different independent physician associations and we had to worry about different managed care issues … We learned a lot about health policy just by trying to keep our practice working in the crazy world of California in the 1980s and 1990s.
You’ve done a number of things in your career, so what are one or two highlights?
When people ask, what do you think you did with your life? I say, “I tried to take care of a lot of low-income, mostly Latina patients, and tried to do the best I could to make their lives better”. To me, that’s the best thing I’ve done.
In terms of highlights? When I left the practice, I had no idea what I was going to do. I realized, “I have to go…I’m too burned out to do this any longer”. I went to a conference up in Seattle that Ed Wagner’s group [GroupHealth Research Institute] was running, and I met people that I’d never met before – Ed Wagner, Kate Lorig – and I realized, “I want to work on patient self-management”. I know that if patients aren’t part of what happens, it’s not going to work.
So my main focus at UCSF has been patient self-management, mostly through health coaching. Health coaching works with people with chronic conditions to help them understand their disease, and gain the knowledge, skills, and confidence that they need to care for themselves as best they can. For example, if a patient with asthma doesn’t know how to use the inhaler, then the inhaler isn’t going to do any good. Using an inhaler is a skill. So a doctor gives patients a prescription for an inhaler and nobody will show them how to use it, they’ll use it incorrectly or they’ll use the wrong one, and it’s useless.
Virtually every chronic condition has some skills associated with managing it. Behavior change is a big component of chronic disease and preventive care, and we have a method for dealing with behavior change that is called ‘action plans’. Rather than saying: “you have to lose 10 pounds”, you ask: “What would you like to do to make your health better?” Let the patient give you their long-term goals. Then you say, “Well, how can we implement an action plan to get you there?” Baby step by baby step – that’s what the action plan is. The action plan might be: instead of eating a pint of ice cream each night, I’ll eat half a pint. Whatever they’re confident they can succeed in.
Medication adherence is a big issue in primary care, and health coaching helps patients overcome their numerous barriers to taking their meds, whether it’s cost barriers, not believing it’s important to take their meds, not remembering – whatever the barrier might be. So the summary of health coaching is helping people to be engaged in their own health.
There’s a part of public health that’s health education, and then there’s primary care, and health coaching is a space where the two meet. So it strikes me that health coaching is a way that health education can operate within primary care, by working with patients to manage their chronic conditions.
Let me push health coaching a little farther. A colleague of mine and I co-wrote a paper. We ask people to create action plans to change their behavior, but we don’t change the community in which they live. So a lot of times people live in a poor neighborhood where there are a lot of fast food outlets, and we ask them to create an action plan to improve their eating. Fast food is cheap! We haven’t done the “upstream” work so that our patients can achieve their action plans, because the environment around them doesn’t support their action plan.
We wrote a paper where we coined the phrase “evidence-based health.” Evidence-based health has 3 parts. First, evidence-based medicine – so the care team does all the things that have been shown to work. Second is health coaching, helping patients to incorporate the evidence into their lives. The third component of evidence-based health is community health, or all those upstream factors that make it difficult for patients to fulfill their action plans. This takes guideline-driven medicine, adds on the self-management piece to help people implement the guidelines themselves, but also recognizes the toxic environment in which many of us live. It’s like housing and asthma. You can do all the action planning you want with patients with asthma, but if you don’t deal with the mold in the walls, it’s not going to make much of a difference.
So it’s primary care engaging with the patient, and also looking at the broader context in which the patient lives or works?
Exactly. It’s where primary care and public health need to come together. And of course, that’s the big divide that nobody’s been able to figure out. Because primary care folks are too busy to deal with public health, and I think a lot of public health people care about primary care but they’re in a different world. The two worlds need to be in one world.
I often think of public health and primary care on a continuum, community to individual, but we’re often not talking to each other.
JAMA just had a 50-year issue on the progress on reducing smoking to improve population health. It was a wonderful issue, and they pointed out that most of the effective interventions have been public health interventions – the cigarette taxes that increase cost, smoke-free zones and mass media campaigns. Our counseling hasn’t made nearly as much of a difference as the public health measures. One author pointed out that most people who stopped smoking just did it by themselves. By now, thanks to public health messaging campaigns, almost everybody who smokes knows that it’s bad for them, it’s just hard to quit. So it’s pretty clear that with regards to smoking, which is still the biggest killer in the US, public health has been enormously successful, way more than medical care.
On that note, you also do work in health policy. Can you talk about that?
There’s the macrosystem and the microsystem. For example, how much primary care providers get paid. Because they get paid a lot less than specialists, most medical students don’t want to go into primary care and it’s harder work. So that’s a macrosystem health policy issue. The microsystem, in contrast, is what happens at the level of the individual practice or clinic.
Our group at UCSF is called the Center for Excellence in Primary Care. Most of the work we’ve done is microsystem work. We try to figure out how can we help practices work better. How can we help them use data to drive quality improvement? How can we help primary care teams work together? See more patients? Primary care doesn’t have enough capacity to see all the patients who need primary care. We’ve also developed models for providing intensive health coaching for complex patients – the 10% of patients who incur 70% of costs. All of those things are microsystem improvements that desperately need to be done, because a lot of primary care clinics don’t work well at all.
This relates back to the macrosystem, because if medical students train in primary care clinics that don’t work well, or all the doctors are unhappy and burned out, then the students say, “I don’t want to go into this!” So the two are related.
Can you illustrate what that looks like?
One of the practices we’re working with is a pediatric practice. One of their goals was to improve cycle time. Low-income families come in, it’s a teaching clinic, so they see a resident. The resident then goes to the attending to get precepted, the patient’s sitting there with kids bouncing off the wall. Finally the resident comes back, maybe with the preceptor. Then the kids haven’t gotten their immunizations yet because the preceptor has to approve the immunization order, so then the families have to wait even longer for the LVN [licensed vocational nurse] to get everything ready. So families are waiting a long time, and it’s really hard for patients with small kids to wait so long. Our analyses showed that roughly 50% of the cycle time – which was 2 hours – was waste and 50% was value-added.
We had to figure out how to reduce the waste, and a lot of it had to do with the workflow for immunizations. If we could get the immunizations approved earlier and done while parents were waiting for residents to come back, we could maybe reduce the cycle time by half an hour. That’s an example of the kinds of things we try to do with clinics. Sometimes we fail and sometimes we succeed.
When you think about public health or primary care, what do you see as a persistent challenge?
I think it’s where the dollars go. It’s something like 3% of the total health budget, which is about $2.25 trillion, goes into public health, and about 6% goes to primary care. A lot of it goes to specialists and hospitals and to interventions that aren’t evidence-based and that patients don’t even need or want. Some of it is end-of-life, unnecessary surgeries, unnecessary tests. There’s a whole movement called “Avoiding Avoidable Care”. To avoid care that’s unnecessary, and thus drive down costs.
We need to completely redistribute the health budget so that way more goes into public health and primary care. There is plenty of money in the healthcare system, and it is maddening to see the priorities of where that money is spent. It’s the paradox of excess and deprivation.
There are so many people who have so much care that they don’t even want, and a lot of this is driven by fee-for-service payment. And then there are a lot of people at the other end – the uninsured, minorities, vulnerable populations – who don’t get care. It’s a huge challenge and it won’t be easily solved. So much money goes into the far downstream care of people who didn’t get the upstream prevention and primary care that they need.
What might it take to solve this problem?
Well, I know what the healthcare budget would look like – channel the money that’s being wasted on unnecessary care in specialty and unneeded hospital admissions, etc., and redirect it into primary care and public health. How to get there is political.
The will to do the right thing in this country seems to have waned in the last 50 years, and I don’t know if we’ll get it back. So people can see what the solution should look like, but I cannot see how we’re going to get there. I can give you a bunch of platitudes about how we have to elect Don Berwick as Massachusetts’ governor (former head of the Centers for Medicare and Medicaid Services, and former President and CEO of the Institute for Health Improvement) – but it’s much deeper than that. It’s a deep-seated problem and I don’t know how we’re going to solve it. Other countries have solved it because they have political systems that are more rational, I think, and also more humane.
10% of a person’s health is determined by healthcare, and 60% is determined by self-management issues, community issues, education, class, race, anything but healthcare. There’s so much potential for people to live long, wonderful, healthy lives in the 21st Century. People should have the opportunity to do it and the opportunity should be evenly distributed among society, and it’s not. It’s sad to see that the potential of humanity is so variable depending on where you come from, your income, what family you were born into, issues like that. I think that’s, to me, the biggest issue. People call it “disparities.” I think it’s about allowing everybody to have the opportunity to have a long, healthy, happy life, as much as it’s possible.
