Thursday, July 29, 2010

What can a '68 Chevy Impala tell us about Primary Care?

When I was a much younger man, I had a 1968 Chevy Impala. I loved its V-8 engine and spaciousness, but I paid a steep price for it. It consumed gas like a drunk on a binge. It was prone to break downs, usually in the left lane of a busy highway. Even as it consumed my limited financial resources, I couldn't count on it to reliably get me to where I wanted to be. Yet I held onto it. One day, though, its transmission gave out, and I finally had to resign myself to buying a new, more reliable, more modern, and efficient vehicle. Yet to this day, I miss my clunker.

I am reminded of this when I think about the state of primary care today. Many of us are attached to a traditional primary care model that may no longer be economically viable - for physicians, for patients, and for purchasers.

We hold onto a model where primary care doctors are paid based on the volume of visits, not the quality and value of care rendered. We hold onto a model where patient records are maintained in paper charts in voluminous file folders, instead of digitalizing and connecting patient records. We hold onto a model that generates enormous overhead costs for struggling physician-owners but generates insufficient revenue. We hold onto a model that most young doctors won't buy, as they pursue more financially viable specialties and practices. Most of the time, traditional primary care still gets patients to where they want to be - high quality, accessible, and affordable care. But like my Impala, traditional primary care is at constant risk of breaking down, as established primary care doctors close their practices, leaving their patients without a regular and reliable source of care.

Most of us are unwilling to trade in the brand we know, even as we are told that there are better models of primary care in production.

Now, I know that some readers of this blog will be offended by my comparing traditional primary care to a gas-consuming clunker. Let me be absolutely clear: I have an enormous appreciation and respect for the work being done by the hundreds of thousands of primary care physicians in "traditional" practices. They work long and hard to provide their patients with the best care possible, even as the system seems stacked against them. But I believe that the traditional primary care is not sustainable, at least not for the long haul. We may be tempted to keep pouring more money into it, but at some point, we will need to face facts and trade it in for a better, more reliable, more modern and more efficient model of primary care delivery - the Patient-Centered Medical Home (PCMH).

The PCMH is no longer just a theoretical blueprint that is years from going into production. Instead, physicians and patients are taking it for a test drive in the dozens of communities across the country that have launched PCMH demos. Federal and state governments, private insurers, and businesses collectively are putting billions of dollars into developing and assessing the PCMH model. The early returns are promising, according to an analysis by the Patient-Centered Primary Care Collaborative. And the new health reform legislation includes funding for PCMHs under Medicare and Medicaid, for community-based programs to help primary care physicians restructure their practices as model homes, to develop PCMH curricula in medical education, and to encourage adoption by Medicare Advantage plans and by qualified private insurers.

Yesterday, the federal Agency for Healthcare Research and Quality (AHRQ) announced the launch of the Patient Centered Medical Home website "devoted to providing objective information to policymakers and researchers on the medical home, ... the site provides users with searchable access to a rich database of publications and other resources on the medical home and exclusive access to AHRQ-funded white papers focused on critical medical home issues."

Physicians now have an opportunity now to test drive the PCMH, by doing their own practice assessment, using ACP's Medical Home Builder; by participating in demonstration projects in their own communities, and by learning more about it from the PCPCC, AHRQ, and from ACP.

There comes a time when a beloved old stand-by must be replaced by a newer and better model. I still fondly remember my '68 Impala, but you couldn't get me behind the wheel of one now. Primary care needs to consider if now is the time for it to trade in traditional primary care for new ways of organizing, financing, and delivering patient-centered primary care around the PCMH model.

Today's question: Is it time to trade in traditional primary care for the PCMH?


Thinkingdoc said...

Love the car analogy -time to trade in for more fuel efficency.Hopefully the incentives,and not money alone,will be better aligned than now,so that primary care is an easier sell to med students &as PCPs we are not tearing our hair out.

PCP said...

Forgive me for being cynical, however, it seems laughable at best to believe that the same payers/policy makers that drove the traditional Primary care model into the ground, have somehow miraculously become so enlightened that they are lining up to reward Internists for setting up the PCMHs. This is yet another fallacious argument from our supposed advocates. Just like they do not see the SGR induced cut sticking us in the back later this year, after the mid terms, once the left leaning politicians have got what they want with us, and will leave us in the lurch and blame it on the right. This is yet another example of the self sacrificing behavior that our representatives are taking us through at a time when our very survival is at stake.
What the PCMH does is add in yet more layers of bureaucracy and control of the profession to the payers and policy makers and administrators. Alas it is sold to us as a breath of fresh air by none but our alleged representatives.
It freely promotes the role of ANPs soon to be DNPs in that capacity, and it promises little in return to our embattled profession. I read of a medicaid plan once paying a grand total of 2$ per member per month for the PCMH, surely that will lead to Primary care's rebirth. Quite laughable actually that the ACP believes that this will attract young physicians. It just demonstrates how out of touch they have become.
So yes, I too did trade in my clunker this last year, I gave up my Primary care practice of 7 years. I also decided to give up another clunker, my ACP memebership. The nostalgia is there, but the hassle and cost was frankly not worth it. Options will open up, but I suspect that unless society, payers, and the all powerful AMA sponsored RUC decide that the Physician led PCMH is worth paying for, I am afraid we will not see any renaissance of physician led primary care. It too shall go the way of the Dodo bird. ACP policies, I am afraid will ensure that it remains about as dead as King Tutt.

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

The appropriate analogy to a medical home would be a real home. We plan 10-30 year or longer intervals and we are willing to take out a debt to obtain this right. I believe the bureaucratic co-marketing of the medical home and the electronic medical record is a direct attack on independent practices. I do not appreciate the bias it introduces into the political rhetoric that pervades. It does not consider the long-term and it substitutes bureaucracy for a personalized market where patients decide. It reflects an undue belief in the value added of bureaucratic mandates.

Quality is not our problem. If you measured calcium supplements as a quality intervention, you better regrade everybody (emerging data reflecting vascular risk). You only find out where you stand with brand medications at the end of their patent life. The old drugs remain shrouded in mystery from the current standard. We reward short-term over long-term.

I don't see what ingredient is missing in my current independent practice. The sharing of information is not an irrefutable value added and does not justify the further shunning of independent medicine.

My wife's paternal grandparents together in Manhattan, my grandfather as an ENT in mid-20th century Chicago, my father for 50 years, the latter 15 with me. Did we not provide medical homes?

Focus on the hassles of our daily life. Take the road of true representation. Fight the onslaught of corporate America into a local, family-based business. Please fix the brand-generic dichotomy that threatens our budgets, our professional autonomy, and patient safety. Leave the rest alone.

Steve Lucas said...

Just make sure that when you trade in that Impala you don’t end up with a newer, more fuel efficient, Vega.

Steve Lucas

W. Bond said...

"The curious task of economics is to demonstrate to men how little they really know about what they imagine they can design."

Any easy challenge: name one service delivered more efficiently by enlightened central planning.

Arvind said...

Is it too much to ask that society simply restore the value it had for primary care, or that price-fixing on an arbitrary basis end ASAP or that consumers be allowed the freedom to choose their PCP without constraints of Medicare participation?

I find the Impala comparison rather flawed. Traditional primary care did not survive the onslaught of government and private payer collusion because PCP's relied and continue to rely, on their so-called representative organizations, such as the ACP, AAFP and AMA to look out for them. Alas, this is how it feels when you are stabbed in the back by someone you trust. Unfortunately, most PCP's will never learn because their minds are so clouded in this fantasy that somehow somebody else will come to their rescue.

I have to agree with PCP and Robert here.

Jay Larson MD said...

My aunt had a 1968 impala with a 396, man that thing had some juice.

If primary care is to be held to a different standard than the rest of the medical community, there is no hope for its survival. Procedure reimbursement is based on volume of visits, not the quality or value of care rendered. Paper charts are just as commonly used by procedure based specialties as primary care. The notion that a small medical “office generates enormous overhead costs for struggling physician-owners but generates insufficient revenue” only holds true for inefficient systems. Young doctors are not flocking to primary care because the grass truly is greener on the other side of the fence. Primary care requires a significant amount of non-reimbursed grunt work, much of which has to involve physician decision making. No matter how the work is distributed amongst physicians and staff, the grunt work has to be done.

Patient-Centered Medical Home (PCMH) is just another name for what many of us do already. My practice already serves as a PCMH. I don’t need to label my practice differently just because it is the vogue thing to do. For the past 20 years, I have been and will still be a general internist. Being called a primary care physician does not change the fact that for my patients, I always had been the first contact, serve as the main physician in their healthcare and help them find care not provided in my office. My medical records are 100% electronic. My overhead costs are substantially lower than a larger medical clinic (no administrators to pay!). My patients have access to all specialties, just not under one roof.

Why do we have to reinvent these round things called wheels all the time? Why not look at the wheels that already spin freely without squeaking and using the design that already work?

Going back to the car analogy, you don't have to go out and buy a new one if the old one is well taken care of and kept in tune.