Tuesday, May 4, 2010

What will it take to save primary care?

"Bold changes are needed in how the United States delivers and pays for primary care if the key goals of national health reform are to be achieved" according to the health policy journal Health Affairs, which today released a thematic issue devoted entirely to the crisis in primary care. (The complete articles are available only to subscribers, but Health Affairs' blog has a good summary.)

I have spent much of the day reading the journal - 47 articles, and a combined three hundred pages of text. My "take-home" messages from the articles:

1. There is a broad consensus that primary care is in crisis. (As an aside, I remember that some said that ACP was being alarmist when in 2006 we predicted that primary care was heading for collapse. Now it has become the conventional wisdom.)

2. The solution is not as simple as training more primary care physicians and paying them more, but to re-invent primary care itself. Susan Dentzer, the editor of Health Affairs, writes that "primary care is maddeningly struck in a by-gone era." Joel Howell reflects on the past and future of primary care, and that the question is not "Will primary care be re-invented" but rather, "How will primary be care be re-invented?"

3. The prescription to re-invent primary care recommended by most of the authors is team-based primary care, usually around a Patient-Centered Medical Home - although several of the articles discussed the need for more rigor in defining the necessary elements for PCMHs to be successful, the best mix of payment incentives needed to support them, the importance of putting more emphasis on features that matter to patients. Yet the articles recognize the potential of PCMHs to improve care and make primary care more attractive to clinicians. Two years after into adopting the PCMH model, the Seattle-based Group Health Cooperative reports on marked improvements in patients' experiences, quality and clinical burn-out.

4. Team-based care means much more than physicians. David Margolius, a medical student at Brown, and Thomas Bodenheimer, professor of family medicine at UCSF, write that "a transformed primary care practice must redefine the physician role such that the physician no longer sees all patients assigned to the practice but as a leader for a well-trained, highly functioning primary care team." Another article advocates for "unleashing" nurse-practitioners' potential to deliver primary care and lead teams - including eliminating state "barriers" to independent practice. Christine Sinsky, MD, FACP, writes about how her Iowa practice has developed a team-based model of care with community-based NPs. Lawrence Casalino argues that the typical workday of primary care physicians needs to be completely transformed, so that instead of seeing a high volume of patients, they would spend more time with those who actually need it.

5. Most of the articles agree that primary care physicians need more pay. One article suggests that narrowing the gap between primary care physicians and other specialties would require increases in primary care physicians' practice incomes, or substantial reductions in specialists' incomes, or both, of more than $100,000 per year. But others argued that primary care clinicians should be paid more only for doing things differently than they do today - that is, delivering patient-centered team-based care that achieves better outcomes.

The attention to the primary care crisis and potential solutions is a good thing. I wonder, though, whether primary care physicians "in the trenches" really want to have their practices re-invented. Most physicians, in my experience, are rugged individualists, and resist the idea of practicing as a member of a team. Moving away from what one article calls the "tyranny" of the 15 minute office visits sounds like a good idea - but figuring out how to get there, and sorting out the respective roles of every member of the team, is another thing. And no matter what, we need a viable payment model that supports, sustains, and nurtures the value of primary care internal medicine.

Today's question: Should primary care be re-invented? How?


PCP said...

Primary care is caught without an advocate. The only reason for this discussion is the crisis(no longer looming but arrived) in primary care.
Younger General Internists have been on a passive strike for the better part of a decade now. That passive strike being manifest in their decision to choose Fellowships, Hospitalist jobs, Concierge practices and basically anything but Primary care IM.
The youngest General IM in our town of 40K people is 47. We see younger sub specialists, and of course virtually the entire hospitalist programs in both hospitals are younger doctors under the age of 40.
Nothing in this legislation is about to change this evolving physician manpower allocation.

The answers to this are quite obvious, but those with the power the change it appear unwilling to do so. Who are these powerbrokers?

For starters lets look at organised medicine. The AMA and its RUC, continue the charade of pretension around the RVU system and continue to denigrate my time while valuing the proceduralists time at in many instances, an order of magnitude higher than mine. Time is my commodity in medicine and this sets the tone.
Hospitals compound this issue because they are paid at vastly higher rates than physician services. Hence they do their calculations and feel having Physicians on salary is to their benefit and as specialty services may best we see the investments in those areas, their thinking goes, if they can capture more patients for more lucrative services, then they are more profitable.
Insurers compound this by squeezing where they can squeeze, as there are more Primary care "providers" than specialists, the negotiating power is less and the private for profit insurance industry squeezes costs and institutes mandates where they can and sucks it up where they can't. If you are the only orthopedic group in town, I imagine you have more leverage than being one of 25 primary care practices (which can't collectively negotiate).

PCP said...

The quite simply ridiculous reality of being one form of "primary care provider" without any clear dileanation of professional roles does nothing to improve the self esteem of young doctors considering primary care. Why is it that we can't even seem to say that every patient must have a physician of record, whereas we seem unwilling to say we should allow NPs to be trained to do most routine procedures.
When every NP lobby, says, "We are just as good as you and in some ways better than you" and your training does not matter and politicians pander to that ridiculous argument. Worse yet when our professional representatives take a conciliatory approach to that lobby and agree with them being allowed to head up Advanced medical homes instead of being members of the team led by a Doctor. We have an issue. Young doctors are not stupid, they see the writing on the wall. They know their roles will evolve. It is up to society and politicians as their representatives to figure out whether they value the concept of a personal physician overseeing their OP care or not. If that is not so, then the Generalists role will evolve, perhaps in a limited concierge role or that may be as a hospitalist to put humpty dumpty back together effectively saying, "When you are sick come see me in the hospital otherwise go see your nurse".
We can't have it both ways. It is time settle this issue. When we choose some will feel hard done, but it is precisely this type of political correctness that has us where we are. Instead of moving forward with team based care.
Finally the dumping of various chores on PCPs by everyone from Insurers to Gov't to medical boards to countless other agencies needs to be curtailed and the best way to do so is to allow for physician billing for those services. If an insurer wants me to review medication for cheaper alternatives, pay me, if gov't wants me to supervise home care, pay me, if they want me to be available 24/7 then pay me, if they want e mail/phone then again nothing is for free. We also need to have a full recognition of the breath and scope of services offered by Generalists. Specialists need to understand that they can't and probably don't want to do what I do, so that should be reflected in health carer policy and advocacy.
Finally I have found team based care to be very effective when done with the right clinicians. Those include psychologists, certified diabetes educators, podiatrists, optometrists and many such professionals. We need RNs and mid-levels too, but each in that team must understand their roles. The patient must know who is ultimately responsible. Every team structure will not be the same. When a team works well everyone benefits. I may wish to structure my team differently to another, but in the end, I should be measured against some benchmark or some combination of them.
I doubt we will come to this wisdom, there are far too many special interests to get there. We are more likely to keep arguing while Rome burns. The best gig is the one that deals with the ramifications of this problem ie ER and Hospitalist jobs. That is why the young doctors are going there.

Steve Lucas said...

From a business stand point the team approach makes the most sense. The problem is this elevates the doctor from a care giver to a manager. From a persona standpoint I find many doctors have difficulty with this concept.

One, they are not trained to manage, they are trained to do.

Second, we have this whole perceived liability issue. Many doctors feel that if they do not personally review every patient they will be sued. While this possibility exists, and I for one want tort reform, the numbers show very few doctors actually are sued.

From my perspective as a patient; I don’t care who delivers my health care, sorry guys. The person standing in front of me in the white coat is the person I am dealing with, not their title.

I often find I enjoy dealing with a nurse more than a doctor. The 15 minute office visit, the drive to up code, the resulting HIT issues, and the general issues of trying to run a profitable business makes many doctors focus someplace other than the patient.

The point has been made for some time we need to change the job. Long hours, stress, and outside forces have all made front line medicine a meat grinder.

I am a big fan of the cash or retainer model. Let me pay you for your professional services. I don’t like the concept of the insurance company cutting my visit short, or driving test as a means to boost income.

I know doctors who see 50 patients a day. Most of my healthy friends are on 90 day cycles. All in the name of good medicine and driving practice income.

We are at the breaking point. Doctors are on a treadmill they cannot get off. Patients are spending more and more time dealing with referrals and test so that someone, somewhere can make more money.

We have to create a saner system where the truly ill receive timely care and the relatively healthy are not pushed trough the system for financial gain. This is how we bend the cost curve.

Steve Lucas

Rich Neubauer MD said...

It has been interesting to watch the evolution of ACPs involvement in transforming primary care. What started as an effort to re-invigorate primary care internal medicine evolved into the current focus on the patient-centered medical home model. Correspondingly, other organizations representing various constituencies in "organized medicine" have likewise gathered around the notion of the patient-centered medical home. As the PCMH concept disseminates, it is maturing albeit at a pace that may seem far too slow to many who seek change to our current dysfunctional systems of care delivery.

Transformation is not easy, especially when we continue to have misaligned incentives, training that does not address managerial skills that might be needed and other easier and more lifestyle friendly paths that attract the best and brightest out of training programs.

And yet, transform we must. I agree that this effort is far too important to fail. But the effort will require commitments both from society and the medical profession. I agree with the notion in the Health Affairs issue that the health care reform bill was the end of the beginning.

The bad news for those currently involved in primary care is that major change is difficult and sometimes wrenching. The good news is that while difficult and sometimes wrenching, it can be incredibly satisfying. Meanwhile, ACP needs to continue to find ways to support internal medicine, its subspecialties, and the patients we serve as the world changes around us.

Robert J. Sobel, M.D. said...

Let me be succinct. It is maddening to me to be accused of being caught in a "by-gone area." We apply state of the art knowledge in a setting of the long-standing traditions of modern medicine. We work diligently to carry out the multiple tasks that are necessary to comprehensively address the modern American. If the future must entail reporting to the administrator on every aspect of our care, I would argue that the medical-industrial complex that thrives on more diffusion of responsibility will only be serving itself.

I'm not much impressed with the team rhetoric, when it has to work so hard to define who does what. On the other hand, the role of dieticians and psychologists and many other disciplines can be intergral to patient needs. The introduction of unnecessary complexity and more bureaucracy is not an innocuous enemy.

I propose the bold change of actually addressing simple payment reforms, not further eroding the role of the personal physician. Apparently, personalized medicine is now a term for genetic testing to guide pharmacotherapy. The hype machine drones on.

Jay Larson MD said...

The term “primary care” should be re-invented first, at least for internists. The name just does not seem to capture what a general internist does today. The name brings up images of a GP treating a cough, cold, or ankle sprain. Internists manage complicated patients with chronic disease.

After reading Richard Baron’s article about the tasks internists do without reimbursement, I started to exam my own practice. Average patient age 58. Average number of medications prescribed per patient 5-6. Average number of chronic medical problems 14. 180 patients with diabetes (125 type 2, 55 type 1 – 35 of which are on insulin pumps). Average number of prescriptions written per week 150. Average number of patients seen per day 14. Average number of medical problems addressed in patients with appointments 70 per day. BTW seeing 70 patients with 1 medical problem will generate a much higher level of revenue than seeing 14 patients with 5 medical problems to deal with.

Should my practice be “re-invented”? Heck no. My practice is very efficient and I can show good quality measure results for diabetes management (diabetes quality care monitoring system is used). Why would I want that screwed up?

Chronic disease management is a long term process and requires a good relationship between the physician and the patient. There should be trust and good communication. Like any relationship, it takes time to develop through personal contact.

Putting another person in between the patient with chronic disease and the physician only complicates complex decision making. Obtaining the right kind of information from patients and to get at the true underlying reason for the visit is truly an art. Body language can not be relayed by a written or verbal report, yet is an important part of assessment. The person making the decisions has to incorporate this information into the decision process.

What should be done instead of “re-invention” is “re-assessment” of the value system with greater emphasis on cognitive skills rather than procedural skills.

In regards to Patient-Centered Medical Homes, this makes sense for urban areas where there are plenty of medical resources. Patient-Centered Medical Homes may not work well in more rural areas with limited resources. In rural areas, we call it private practice where everything is patient centered or you go out of business.

Harrison said...

Without primary care every abdominal pain sees a surgeon. When will surgeons have time to operate when they are busy doing exams and ordering CT's?
Chest pains all see cardiologists. A-fib is completely managed by cardiology.
Oncologists will have less time for chemo regimens, and will have to over see palliative care and will also have to spend more time seeing patients who are febrile and have weight loss and feel that they have cancer. Whether they do or not.
All sinus problems will be managed by allergists and ENT physicians.
Acne will all go to dermatologists.

And the specialists will order lots more expensive treatments for people who don't need it because they are trained to do so.

We need primary care physicians to do what they do now.
It would be good for them to work with teams. Nurses and NP's can help manage chronically ill people, and can spend more time for less cost and help to avoid unnecessary hospital stays and tests.

And we need to train more primary care physicians.
And fewer specialists.

But I don't think we can have a vision for an ideal primary care practice and continue with this over regulated market environment.
We are not encouraged to experiment.
We are told what to try and if it looks like we might save the system money then some insurer will find a way to throw us something extra as a way of saying thanks.

That is why concierge medicine exists and is growing.
It is a free market.
It allows freedom of framing and pricing products that we don't otherwise have.

We can't do this with teams because those teams are aimed to take care of chronically ill people. They are not wealthy. They are numerous and they are needy and they do not have resources. Indeed it is their lack of resources that creates the need for us to develop team approaches. We need to have teams to overcome the lack of resources that get in the way of medical care.

We can only afford those teams collectively, but the payers decide on what the teams should look like and what the outcomes should be.

Change will be slow. Very slow.


Unknown said...

Whatever it takes to save primary care, it won't be cheap. Comments anyone? Rationalization from the ACP?


Bruce Smith said...

I agree that comprehensive reform is needed. After 20 years in private practice I joined Group Health 3+ years ago. We're one of the groups that wrote up our experience with the PCMH in Health Affairs. It's not all beer and skittles, but it really does seem to be a good alternative. We're a 900 doc group mostly in the Puget Sound metropolitan area, but many clinics in the 'burbs and some in almost rural areas.

When we decided to go "all in" with the transition to PCMH we had to hire a bunch of PCP MD's. As most will know, that isn't always easy. Happily, the word is out among new grads and we are averaging 15-20 qualified candidates for each PCP position. We employ more specialists than PCPs overall, and recuriting for specialists is good, too.

We're a pre-paid staff model HMO (think Kaiser). All docs here are on a salary, but it's far better $ than most of my private practice friends are getting. We have a collective interest in doing the right thing for patients, not just more things for patients. We have an extensive EMR that patients can access, too. We give docs recognition for emailing or phoning patients. Patients rated us first in the nation for patient satisfaction in Consumer Reports and we won the JD Powers consumer award for the last 2 years. And we score highest on many quality of care measures compared to all other practices in the state.

We're not perfect by a long shot, but it's one model to consider.

The elephant in the room of the national conversation about insane healthcare costs is our reliance on fee-for-service medicine. I believe Mr. Doherty was so bold recently to predict its eventual demise. I believe we're headed there, too. How do we structure that transition to allow patients and docs to continue to care for one another?