Three months ago a post argued that America’s primary care associations, societies and membership groups have splintered into narrowly-focused specialties. Individually and together, they have proved unable to resist decades of assault on primary care by other health care interests. The article concluded that primary care needs a new, more inclusive organization focused on accumulating and leveraging the power required to influence policy in favor of primary care.

The intention was to strengthen rather than displace the 6 different societies – The American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), the Society for General Internal Medicine (SGIM), the American Academy of Pediatrics (AAP), the American Osteopathic Association (AOA), the American Geriatrics Society (AGS) – that currently divide primary care’s physician membership and dilute its influence. Instead, a new organization would convene and galvanize primary care physicians in ways that enhance their power. It would also reach out and embrace other primary care groups – e.g., mid-level clinicians and primary care practice organizations – adding heft and resources, and reflecting the fact that primary care is increasingly a team-based endeavor.

We came to believe that a single organization would not be serviceable. Feedback on the article suggested that several entities were necessary to achieve a workable design.

So we propose here a new set of allied entities that, by convening clinical and non-clinical primary care stakeholders, will work to re-empower primary care’s role within the larger health care enterprise. In addition to aggregating and leveraging the strengths of existing primary care organizations, this new effort would collaborate with patients and health care purchasers to gather the influence required to effect positive change.

New Organizations

We envision four new organizations – an umbrella group and three professional entities – each independent and with its own governance structure. Membership in any organization would provide membership in the umbrella Congress. The names we have applied are suggestions only.

The Congress of Primary Care Professionals. This umbrella entity would bring all groups, including existing societies, together in a representative structure. The Congress would seek to galvanize and mobilize the power required to revitalize primary care, not only for primary care’s benefit but as a key remedy for America’s health care cost crisis. The effort must be about primary care, not a specific group within it.

The Section on Primary Care Physicians. Currently there is no physician organization that unites all primary care disciplines. Many physicians are adamant that they should have their own entity, and have expressed concern that physicians’ roles might be devalued inside a structure shared with mid-level practitioners.

The Section on Allied Primary Care Professionals. The accumulation of power requires inclusiveness. It makes sense to establish a separate section embracing nurse practitioners, registered nurses, respiratory therapists, radiation technologists, physical therapists and others participating in primary care.

The Section on Primary Care Organizations. A new society structure could mobilize influence by rolling up and leveraging the power of larger primary care practices. As one physician practice leader noted, “Market traction will come from organizations that facilitate more efficient and effective primary care.”

Where to Begin?

An undertaking like this begs several questions.

Will primary care physicians, other clinicians and organizations participate? We believe that primary care can be reinvigorated, but any campaign must first convince primary’s practitioners that a new effort is worthwhile.

Who can jumpstart this? Established primary care practices – particularly those that are sizable – have some resources and offer opportunities for collaboration and the development of a larger national campaign.

What’s in it for me? Why should I bother? Primary care practitioners have been diminished under old regimes that divide primary care by sub-specialty. Their other positive attributes notwithstanding, the standing societies have been unable to drive payment policy that meaningfully appreciates primary care’s measurable value. In turn, this failure has resulted in the diminishment of primary care’s current status and future prospects. A new effort would be dedicated to restoring an appreciation of primary care’s value in policy and the marketplace.

What will this Congress do (and not do)? We should emphasize that this effort does NOT aspire to assume most roles of existing societies (e.g., standards, continuing medical education). Instead, it will create structures that can more fully and fairly represent primary care’s interests. If the new primary care organizations focus on gathering strength that can create influence, then they must do several things.

- They must actively recruit members.

- They must develop approaches for easy, rapid communication with members (e.g., email bulletins, Webinars, semi-annual meetings). Taking advantage of more modern approaches like social media could streamline operations and costs as well as differentiate the new entity.

- They must analyze policy related to primary care.

- They must develop pragmatic alliances on policy advocacy with non-health care business.

- And they must drive advocacy that speaks for all primary care, and only for primary care.

Don’t existing primary care societies already do these things? Current primary care societies may respond that they already are engaged in these approaches. That said, despite their efforts, primary care as a whole is in desperate straits, and likely to remain so. Several societies maintain they can advocate for both primary care and sub-specialty interests. Comparatively low payment and stature has driven medical students away from this discipline. Most societies continue to participate in the AMA’s Relative Value Scale Update Committee (RUC), though its opaque and biased power structure has consistently undervalued primary care services. We believe a fresh approach is necessary.

Can primary care change health care? Not by itself. But primary care is the natural ally of health care purchasers, the one group with more size and influence than the rest of health care combined. Creating a unified primary care front is the first step in building an alliance that can reshape health care to be more reflective of broad primary care values and in the public interest.

Brian Klepper, PhD is an independent health care analyst and Chief Development Officer for WeCare TLC Onsite Clinics. His website, Replace the RUC, provides extensive background on the role that the AMA’s RVS Update Committee has had on America’s health care cost crisis.

This framework was developed with the participation and support of the following advisors:

William Bestermann, MD is an Internal Medicine Physician and Medical Director of Chronic Condition Management at the Holston Medical Group in Kingsport, TN.  Tom Emerick is a health care advisor to business, and the former VP of Global Benefits for Walmart.  Paul Fischer, MD is a Family Physician and Founder of the Center for Primary Care in Augusta, GA. He is the lead plaintiff in a lawsuit against HHS and CMS over their unaccountable relationship with the AMA’s RUC, in violation of the Federal Advisory Committee Act.  Tad Fisher is the former Executive Director of the Florida Academy of Family Physicians. He is now Executive Director of the Florida Physician Therapy Association.  Richard Glock, MD is a primary care internist and lead physician in the Internal Medical Group in Jacksonville, FL.  Paul Grundy, MD, MPH, FACOEM, FACPM is IBM’s Global Director of Healthcare Transformation and President of the Patient-Centered Primary Care Collaborative (PCPCC).  Jerry Miller, MD is a Family Physician and Founder of the Holston Medical Group in Kingsport, TN.  Patricia Salber MD, MBA is CEO of Health Tech Hatch. A former Internal Medicine physician at Kaiser Permanente, she later served as Medical Director for several large health plans.  Richard Young, MD is Associate Director of the Family Medicine Residency Program at John Peter Smith Health System. He has authored a book and blog, American Healthscare, and is in the initial class of CMS Innovation Advisors.

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48 Responses for “Strengthening Primary Care With A New Professional Congress”

  1. I am really glad you wrote this piece, Brian. I am not sure I agree with the method suggested here, but unless primary care stands up to be counted now, right now, it will most likely become something no one wants to practice and will disappear of its own accord with huge consequences to most patients.

    I am not certain that a blended entity is needed. I actually think that the current primary care societies should get together, just like they did in 2007 when they brought us the joint PCMH principles, which are changing the professional lives of their constituents (some supervision here is sorely needed), and pull their resources to truly represent primary care physicians.

    My feeling is that such combined effort should target the people of this country to clarify the role of primary care and how it is being currently diminished and what this means to individual patients. It should not be a lobby for increasing payments or fighting specialists. It should be an advocacy for patient care, because primary care is the only specialty that aligns naturally with patients (not necessarily purchasers of health care). And unlike other purchasers, patients will support their doctors if they understand the stakes.

    I appreciate your large tent approach, but I don’t believe this is how most physicians see their profession and, to my knowledge, most don’t believe that this is in the best interest of individual patients either. A professional association, or a consortium thereof, should represent its members, and we should step back, listen and accept the voice of the majority of physicians, even if it conflicts with current policy and other interests.

    Right now, doctors in general, and primary care in particular, are being railroaded by powerful financial interests, and I somehow don’t see them supporting a new entity to more efficiently decompose their profession.

  2. Margalit,

    Why do you suggest that this would be about “more efficiently decompos[ing] their profession?”

    For the past two decades reimbursement has been structured through the AMA’s RUC to dramatically favor specialists at the expense of primary care. In general, specialties are the gateways to revenues for the powerful financial interests you allude to. So long as primary care remains diffused and weak, it will die, and the real losers will be continue to be patients and purchasers.

    Maybe I misunderstood your phrasing, but I so strongly disagree with your statement that I was shocked. You assert “a professional association should represent its members, and we should step back, listen and accept the voice of the majority of physicians, even if it conflicts with current policy and other interests.”

    This is craziness. Health care has become about the interests of the industry over those of patients and purchasers. It must be the other way around, or we all ultimately lose. There is little evidence that what is good for the industry is by definition good for the rest of us.

    A couple statistics. RAND calculated last year that, currently, $4 out of $5 in household income growth now is siphoned off by health care. Only $1 of growth is available for other needs, like education and infrastructure replenishment. At the same time, US firms competing in the global marketplace are at a 9+% disadvantage on health care costs, relative to competitors in other industrialized nations.

    These figures are being driven by the regulatory capture of the specialties and other significant health care interests. Only an alliance of primary care and their most natural allies, non-health care business, can turn this around.

    How do you see physicians in general, being railroaded by powerful financial interests? I’m certainly in the middle of the marketplace and I don’t see it. Give us some examples.

    If you’ve got a better plan that I’ve presented to revitalize primary care, we’re all ears.

  3. Pam says:

    I know how to revitalize primary care—let the PA’s and NP’s do it. There solved.

  4. Brian,
    First my apologies if I wasn’t clear on my intent. I am not arguing that specialties have not contributed their fair share to the woes of primary care through undue influence on the RUC (I do, however, blame CMS for allowing this to happen). Either way, considering the economic situation of most people today, I don’t believe that leading the primary care charge with demands for more money is good political strategy for whoever ends up representing these physicians.

    From what I see, there are concerted efforts from industry stakeholders to undermine the natural alignment between doctors and patients in general, and primary care in particular (i.e. railroading). This takes the form of continuously messaging the public on the “paternalistic” and materialistic conducts of doctors and the need to have them monitored and supervised by both consumers (not patients) and payers (public and private, including employers). It includes the revival of managed-care, where those managing the care are neither doctors, nor patients, the rise of technology algorithms (programmed by whom?), supposedly better suited than physicians to make decisions, and yes, the relentless advocacy to supplant primary care physicians with less expert resources, at least for the poorer folks. The 80-20 good enough rule may be OK for manufacturing, but I doubt it is ethically OK for medicine. To sum it all up, this is about reducing costs through redefinition of what quality of care means.
    And I think that in this country, quality of care means that every American should have unfettered access to a personal physician. And the primary care associations thought the same way back in 2007. What happened in 5 short years to change that conviction?

    This ties in nicely with my opinion that if we have to trust someone in health care, and we must, then my vote would be to trust physicians who have an ethical and moral obligation to do the right thing, and in particular, we should trust primary care doctors, who have practically no financial interest in all the things that make health care expensive, and the opposite may actually be true. This is why I suggested that we stand back and let the “members” of this fictitious organization lead the way. It’s their job to do so; it’s their professional responsibility which they accepted the day they chose to take that “old-fashioned” oath, and three quarters of them are telling us that what we are doing today (or proposing to do) is not likely conducive to better patient care (recent Medscape survey, amongst others). This should gives pause, if we cared for what we say we care.

    My advice to primary care physician has always been to go to the public and enlighten people about the likely effects of taking away medical decision making from physicians and patients, and placing it in the hands of entities that either have shareholders to answer to, or are mired in a perpetual elections cycle. Primary care doctors were, and are, and should be, perceived as the natural advocates for individual patients. Not for purchasers. Not for job creators or financiers. Not for voters and elected officials. Just people, one at a time, as the Harvard maxim says. People need to understand that reformations and transformations aimed at neutering the patient’s one remaining powerful advocate, while providing lip service to “patient empowerment”, is not in their best interest (and it won’t cut costs either). Get this message out, and you will have 300 million people (99%) behind you.

  5. This is a better explanation. Thanks.

    That said, especially given the egregious record of self-interested health care waste, I believe we all need to be accountable, even doctors, and even primary care doctors. And the worry that self-interest is guiding everything becomes significantly less if the payment structure is care-neutral, rather than designed to promote more services that accrue to the financial benefit of the provider.

  6. southern doc says:

    “payment structure is care-neutral, rather than designed to promote more services that accrue to the financial benefit of the provider.”

    What’s a care-neutral payment structure?

    With a growing shortage of primary care doctors, shouldn’t we be encouraging them, financially and otherwise, to provide more services (E&M codes) rather than fewer? That’s a miniscule drop in the bucket of health care spending.

  7. Southern Doc,

    Sorry for using a shorthand term. A “care neutral” reimbursement methodology is one that doesn’t create a financial incentive to deliver unnecessary care or deny necessary care. In my onsite primary care clinics, we pass through the operational costs – the costs of the clinicians, drugs, labs, office supplies, utilities, insurance – with no markup, and then we charge a per patient (or per employee) management fee for managing the process.

    I agree that we should be paying primary care physicians significantly more, so that the discipline becomes more attractive to students, and so that practices can invest in the tools/skills that will facilitate better identification and management of patients with risk.

    In my clinics, physicians (or NPs) have patient loads of 1,600, which translates to 20 minute office visits. Compare this to most practices that are seeing 2,500-3,200 patients, with 7.5-12.0 minute visits. Those practices typically refer 25%-35% of their patients to specialists – double the rate of a decade ago – while we’re referring 12%-18%, and we can demonstrate that we get better outcomes. The difference is in the percent of traditional primary care patients that have been jettisoned into becoming specialty cases, often at 15x-20x the cost, because the specialists are financially incented to do diagnostics and procedures.

    In other words, all reimbursement methodologies have tremendous impacts on care patterns. One that is neutral relative to the care provided is optimal

    Primary care physicians should be paid based on their measurable value in the system, which if considered properly, is much greater than currently understood. The value they create by good management is easily offset by reduced costs downstream.

    Hope this helps.

  8. Ron Hammerle says:

    The current system will change only if primary care professionals decide to quit mining the gold and getting left in the shaft. The referral-dependent Mayo brothers understood that a century ago.

    Adding four new organizations to six existing ones won’t do it, but Brian knows that the current six pack can’t and won’t achieve the objective..

    There are, however, lessons to be learned from the history of the AFL and CIO, stereotypes, professional egos and current market positions notwithstanding.

    Recognizing this could happen in healthcare, hospitals and insurers are rapidly buying up primary care practices and retail-affiliated clinics far more rapidly than primary care can get organized. Like family farmers of old, rugged individualism has its limitations..

    Ron Hammerle
    Tampa, Florida

  9. William Light M D says:

    Primary care is already dead. The future willbe teams of NP and PA’s working with an MD team leader . Maybe 2 to 4 per MD . It will take a ratio that high to provide the number of patient visits needed.

  10. Southern Doc:

    Yes, our docs are on salary. There are incentives for hitting quality targets and also for seeing a targeted percentage of patients within available appointment slots. But there is no incentive to simply see more patients. We believe that is a counter-productive approach.

  11. southern doc says:

    Hmm, I wonder about that.

    After four years of undergrad, four of med school, three of residency, is a salaried situation, with no chance of advancement, no possibility of ownership really going to attract the best and the brightest?

    What’s going to motivate the docs to stay late and see those three extra patients instead of sending them to the ER, to come in on Sunday PM and see someone, to take two hours on the phone getting the pre-auth done?

    Lawyers and accountants know that if they work harder they build their practices and get paid more. Do we really want to completely take away that from doctors?

    Wouldn’t work for me.

  12. Well, effectively, since they only carry about 2/3 of a typical patient load and have a 9 to 5 type of job, which from what I hear, people find attractive these days in medicine, Brian is paying docs almost double the per-visit market rates, assuming he is paying them a decent amount.

    If we applied a similar pay rate across the board in primary care, I have a feeling that you would get the same results (i.e. longer visits), plus the commitment inherent in an independent business owner scenario, plus real continuity of care.
    The “only” caveat would be that about 1/3 of people now having a doctor would find themselves doctorless. The solution may be to stop poaching internal medicine graduates for hospitalist jobs and have them go out and practice longitudinal care through the entire spectrum. Sort of like it used to be before some folks decided that breaking up continuity of care makes more money for hospitals.

  13. Physicians and NPs like working for us, and we have no problem at all recruiting top notch clinicians. We pay at the 90th percentile. Clinicians use 21st century clinical decision support tools. No money changes hands in the clinics, so it changes the “tone” of the practice, something the clinicians find very attractive. They have no administrative responsibilities. Physicians aren’t rushed, and so they can spend time with their patients. It’s much more like the medicine they imagined they’d practice in med school.

    That said, the purpose of my article wasn’t about describing how my clinics work, but to make the point that current primary care medical societies have squandered their ability to meaningfully influence policy in ways that benefit patients, purchasers and primary care physicians. A new Congress is necessary to unite and give more leverage to primary care.

    That would be the first step in real health reform. The next is to galvanize non-health care business, primary care’s natural ally. Together, these groups could begin to rationalize health care and bring it back into homeostasis.

  14. Very thoughtful and interesting. Over the years the sub-specialists used this strategy. They stayed separate but took control of the AMA and the RUC to advance their mutual interests.

    I think it is important to have each type of primary care professional be supported by their respective professional organization. Family Physicians, pediatricians and general internists overlap in their philosophy of care and scope of practice. But their differences are also important and need to be sustained – which their specialty organizations can handle.

    I think it is important to mention that the AOA is not a primary care organization but represents all Osteopathic specialties. Also the American Geriatric Society is composed almost, but not completely, of Family Physicians and Internists.

    The issue of what is and what is not primary care is a tricky one. There are a small but growing number of clinical pharmacists who argue that they should be recognized as primary care professionals. Their schools of pharmacy are upgrading their curriculum to prepare their graduates to practice as independent primary care clinicians.

    I applaud the idea of a common “political” front to represent primary care. At that same time I think there is need to clarify and respect the boundaries among the various professionals.

  15. Dr. Bauer:

    I believe the proposal presented here satisfies the criteria you lay out. As I describe above, existing primary care societies representing all disciplines would be preserved and convened through a larger house of delegates, which they would participate in but not control. This is important because, as you point out, several of the current societies – AAP and ACP, for example, represent both primary and specialty care physicians.

    In a sensible world, the clinical pharmacists you mention would be welcomed as primary care professionals.

    In other words, the Congress would unify and strengthen primary care as an overarching discipline, while maintaining the distinctive characteristics of each professional group within the House of Primary Care.

  16. Gerard says:

    Team based practice under the direction of physicians is the inevitable future of our overburdened primary care system, but Mr. Klepper, I am surprised you don’t mention PA’s even once in your article or comments, considering the fact that PA’s are trained specifically for this purpose. Are you familiar with this profession? If not, you will be behind the curve when trying to navigate the future health care landscape. Med students today train alongside PA students and are more comfortable with the team based approach, delegating the more routine tasks to PA’s.

    PA’s and NP’s are both considered “mid-levels” (does that make RN’s low levels?) and often function interchangeably, but they are separate professions, with very different training and licensing requirements. PA’s have a master’s degree in medicine and are licensed to practice medicine by the state medical board, while NP’s have a master’s or doctorate in nursing and are licensed by the state BON to practice advanced nursing. PA’s are educated in a condensed allopathic school model centered around primary care, which prepares them to be generalists. NP’s are educated in one area of advanced nursing such as Family Medicine or Psychiatry. PA’s can never practice without supervision, while NP’s can in many states. Hope this helps!

  17. southern doc says:

    Ms. Gur-Arie says:

    “If we applied a similar pay rate across the board in primary care, I have a feeling that you would get the same results (i.e. longer visits), plus the commitment inherent in an independent business owner scenario, plus real continuity of care.”

    That makes sense to me.

    We know we can successfully design a fee for service system that increases the number of procedures and diagnostic test. Why not design a FFS sytem that increases the number of primary care E&M codes? The cost would be miniscule: too many primary care visits should be the least of our worries.

    As I said earlier, I don’t think a salaried position, with no productivity incentive, no partnership, no advancement is going to look like an attractive 35 year career for most med school grads.

    As far as I know, almost all the countries with better health care delivery than the US pay the docs who work harder and longer more, and let them own their own businesses. Why do we think we have to get rid of that here?

    • Because the real agenda here is not to truly provide better care at lower costs, although it makes very good copy for PR.
      The real agenda in a profit-driven system is to maximize profits, and other industry “stakeholders” would much rather take the profits now taken by independent small business doctors, no matter how minuscule these are.
      We all know what the solution is eventually going to have to be…. just taking the scenic route to our final destination, I guess. Hopefully we don’t end up belly up in an “unexpected” crevice….

  18. Southern Doc,

    While I understand that its the entrepreneur in you speaking, why should the rest of us want to perpetuate a system that incentivizes unnecessary services in any form?

    I don’t have any heartburn at all over enterprising docs who are willing to invest in the very formidable infrastructure required to properly manage care and cost in a 21st century context. Do I see many primary care docs thinking this way. No. Do the ones who work with us recognize the advantages of working in an environment that has made the investments. Absolutely.

  19. southern doc says:

    “why should the rest of us want to perpetuate a system that incentivizes unnecessary services in any form?”

    But that only applies to doctors, correct? Not to lawyers or accountants. Not to grocery store owners or landlords. Not to on-site clinic entrepreneurs, or computer company executives, or the other co-signees of your letter.

    All I can say is fee for service seems to work pretty well in a lot of other professions and a lot of other countries. The absolute last thing we need to be worried about here is too much primary care.

    I respect your work, but you’ve lost me on this one.

  20. southern doc says:

    Addendum: It seems like you’re saying it’s OK for you to be an entrepreneur in the health care system, but it’s really not acceptable for doctors? Correct me if I’m wrong.

    Thanks.

  21. Southern Doc,

    I’m not saying that at all. I’m all for docs being entrepreneurial, but I’m not for anyone, including me, doing so in a way that unnecessarily drives up cost without significantly improving quality. If you’ll look at our business, which as I mentioned is completely outside FFS, you’ll see that I practice what I preach.

    Being successful in this next generation of health care requires significant investments in analytics, clinical decision support, wellness/prevention/disease management programming, and a host of other business and clinical tools. So far, I’ve seen few organizations that are willing to put all that together.

    I disagree with Margalit that our agenda is to do anything else but provide the highest quality care while reducing overall cost. Our business model is predicated on the fact that health care utilization and unit pricing has become egregious, and that excess constitutes a market vacuum that is an opportunity for exploitation. We will win through economies of scale, not by being excessive.

    That said, Margalit’s comment is a precise description of the prevailing paradigm throughout health care, in every sector.

    The day I met the couple that would become my partners, we were walking down the sidewalk to get a sandwich. Lynn, the husband, turned to me and said, “When an employer sits at the table with all his health care relationships – the broker, health plan, hospital, doctor, drug and device firm – everyone int the room wants it to cost more and they’re all positioned to make that happen.”

    That was a true statement, and it became the impetus for what we do.

    To my mind, my willingness to speak so openly about that is straightforward evidence that I believe that you, Southern Doc, or anyone else are welcome to come down the same path. Just don’t think its going to be as easy as providing excessive services under FFS.

  22. southern doc says:

    Thanks for the reply. Enjoyed the discussion.

  23. pcb says:

    Brian,

    You mention MDs and NPs working as your “clinicians” in your model. Do they do different things? Are they, for the most part, interchangeable for you? Do they each manage their own 1600 patient loads?

    If so, I’m wondering what you think the role of the MD will be over time.

    Because if NPs/PAs are doing most of the same work as the MDs, and easier to churn out and cheaper to employ, then we can all read the writing on the wall. If this is the case, I’m not sure about the long term MD role in this “primary care congressional congress”.

    • Gerard says:

      pcb,

      Please see my above comment about midlevels. PA’s and NP’s are not the same.

      PA’s are a creation of the AMA and they are lisenced only to practice medicine under the supervision of an MD or DO. They are trained solely to be extenders, as such, they are not in direct competition with doctors. In fact, they help increase doctors efficiency and profitability by handling the more routine aspects of patient care. NP’s can practice independently, bill independently, and soon all their programs are transitioning to doctorate degrees.

      • Actually PAs can and do lead FQHCs and RHCs on their own.

        • Gerard says:

          True, PA’s can own or become partners of a practice in some states, but the laws are such that MD’s & DO’s have the final word on any and all medical decisions. PA practice laws must be upheld, of course, and these do vary by state.

          You can read about PA owned practices here:

          http://bit.ly/T63Kcd

      • SJ Motew, MD says:

        Gerard, I do not agree with your interpretation of PA services. The scope of practice of NPs and PAs, their ability to work independently and bill are equivalent in most states. CMS narrowly differentiates that PAs must be under “the general supervision” (though not necessarily on site) of a physician, while a NP must work “in collaboration” with a physician.

  24. Brian,
    Since this post started with advocacy for primary care, and evolved into a debate on fee-for-service, I think there is a fine point here that southern doc was trying to make which often gets lost in the shuffle:

    Primary care physicians derive negligible financial benefits from “more” services, except “more” primary care E&M services, which are both relatively inexpensive and, as I’m sure you’d agree, serve as a deterrent to other more expensive services.

    In the case of primary care, more and more thorough, is actually better, so why do we need to put these guys on a salary?
    From all the experiments out there, it seems to me that docs with significantly smaller panels, are able to provide much better and more efficient care.
    Any way you slice and dice this, and assuming that the take-home pay is not widely variable, it translates into paying more for each visit. If you are concerned that physicians will churn through 5 minutes visits even if you paid double (and I don’t think this will happen), then by all means, have CMS and all other insurers, set the fees by time spent instead of by documentation generated.

    As to infrastructure and analytics and risk management, you need those things if you deal with populations. If you deal with a few hundred patients, as most concierge docs do (and as all docs should do if they were paid appropriately), the need for fancy tools is less obvious, since you go to the hospital when the patient goes and you actually talk to the specialists and patients themselves as needed.

    I guess it’s the difference between hand-made and mass produced. I think in health care most folks are more comfortable with hand-made at this point. And to just close the loop on the primary care advocacy piece, I think most docs don’t believe that what they offer can be, or should be, mass produced at the current state of scientific development.

  25. pcb,

    I most assuredly do NOT think that physicians and nurse practitioners are interchangeable. There’s a wealth of literature suggesting that NPs can often provide routine care as, or even sometimes more, effectively than MDs, but by definition they typically cannot identify or manage complexity nearly as well. To be crass about it, those cases are where the money is. To me, any other strategy is penny wise but dollar foolish.

    Please note that I wrote a strong response to the AAFP’s most recent exercise in poor judgment – http://thehealthcareblog.com/blog/2012/09/20/the-business-case-for-nurse-practitioners/ – when they recently went out of their way to point out that NPs shouldn’t lead practices, as though anyone needed to say so. (To my mind, family medicine doesn’t have so many allies that it should take liberties poke one of them in the eye.)

    So no. I don’t think the handwriting is on the wall. I do believe that competent NPs can do a lot of primary care work, but they are not physicians and will never be.

    Margalit, I’m not saying that physicians need to be kept down, and I’m completely comfortable offering incentives for hitting quality targets. That said, I don’t think any of us benefit from the continuation of a cottage industry where everyone makes up their own rules as they go along. I’m a believer in science, evidence and performance. That applies where my loved one’s are concerned, and to everyone else as well.

    To your point about mass produced vs. handmade, medicine is, alas, still a handmade science and art, even at the level of care that my Elaine is getting, with the best genomic science currently available.

    Until we can break through that bar, I’d suggest that we need to trust professionals who can think through problems at the molecular level. We need to change the system to give them an advantage, and the smart money is on the long term play toward appropriateness, and away from excess.

  26. Margalit,

    A quick note. The fact that PAs and NPs are less expensive than physicians and that certain organizations – including FQHCs, convenience care clinics and many worksite clinic vendors – use them to advantage does not mean that, as I noted earlier, they can spot or manage complexity when it presents. This is a market-based choice, of course, but one that clearly has quality ramifications that are, to my mind, corrosive, filled with moral hazard and inexcusable. It is bad medicine, not necessarily when the mid-levels are doing routine care, but when they miss a sign or symptom that is suggestive of something more serious, which is inevitable.

    I should acknowledge that this same thing also happens with physicians, but their significantly more in-depth training is a buffer against poor decisions, and presumably improves the odds of a better outcome. That’s why we have doctors in the first place.

    • Gerard says:

      “It is bad medicine, not necessarily when the mid-levels are doing routine care, but when they miss a sign or symptom that is suggestive of something more serious, which is inevitable.”

      If there was so much bad medicine being practiced by midlevels, don’t you think the trial lawyers figured that out by now? Patients can pretty reliably be stratified by complexity and severity and referred to the appropriate clinician. If you think this can’t be done by well trained and experienced midlevels then you have missed the boat. That issue has already been settled.

  27. One more thought. My previous comment is NOT meant to demean the care that NPs and PAs deliver. Mid-levels play an increasingly important role in a primary care system gutted by the politics of money and influence. But it is critical that we avoid the last logical step of suggesting that they are “just as good as but cheaper than docs.” They aren’t.

  28. Brian,
    It’s difficult to make politically correct statements when it comes to the non-physician scope of practice conundrum. I believe these folks are a vital part of health care delivery, as they always have been and most likely always will be.

    However, I also find the statements that doctors should be there to only deal with complex situations a bit disconcerting, because in addition to extensive education, expertise is built by day-in and day-out practice (this is true for everything, not just medicine). One is properly equipped to become an expert upon completing various graduate programs, but the road to expertise is just beginning at that point.
    If we don’t allow doctors to actively practice, and instead place them in overseer of analytics positions, much of that education will be squandered and I don’t know where the expertise to step in at the right time will come from.

    BTW, a similar thing occurred with software engineering, which based on Mr. Friedman’s misguided book(s), and capital’s interests to cut costs, allowed “drudge” work to be outsourced in the hopes that US engineers will become the architects and master designers overseeing armies of cheap programming labor. It didn’t work out quite that way.

    Americans see doctors less than people in most developed countries, and the numbers keep dropping. I don’t know what the deal is with the obsession of replacing doctors with either mid-level providers or machines or phones. There is not much money for the public to save with these tactics and there is plenty for us to lose, and frankly, I don’t think the need for entrepreneurs or corporations to make money by replacing doctors constitutes an overriding public interest.
    As I said above, there is really full alignment of interests between physicians and people/patients, we just need to quit worrying about other “stakeholders” who are in this solely for the cash.

    • southern doc says:

      “If we don’t allow doctors to actively practice, and instead place them in overseer of analytics positions, much of that education will be squandered”

      That’s exactly what the PCMH gurus are proposing. But who would go through the rigors of med school and residency to do that kind of work?

      They tell us that the NPs/PAs should see the “simple” patients and the docs the “complex” ones. What they don’t tell us is who assigns the patients to those categories: is it the high school grad receptionist? the patient themselves? Are simple patients ever allowed to become complex, or are they stuck with that label until death do us part? One thing I’ve learned in my career is that I never know if a visit will be simple or complex until I’m alone with the patient behind a closed door.

      It’s another one of those gimmicky ideas that sounds good until you actually start to think about what it means. The real reason they’re pushing it is that the finances of the PCMH are so bad that the doc has to have a team of mid-levels to even have a chance of breaking even.

      • pcb says:

        “They tell us that the NPs/PAs should see the “simple” patients and the docs the “complex” ones. What they don’t tell us is who assigns the patients to those categories: is it the high school grad receptionist? the patient themselves? Are simple patients ever allowed to become complex, or are they stuck with that label until death do us part? One thing I’ve learned in my career is that I never know if a visit will be simple or complex until I’m alone with the patient behind a closed door.”

        This is worth repeating because it’s rarely articulated this clearly.

  29. pcb says:

    Re: mid-levels.

    I see a disconnect between their role in theory vs. what ofthen happens in the real world.

    “Supervision” or “collaboration” is often minimal, if at all. The supervision/collaborating physician is seeing their own full load of patients, if even on site. Literally hundreds of day to day treatment and diagnosis decisons are made without any supervision or collaboration, and the decision when something needs to be discussed is entirely up to the mid-level. This is why many NPs and PAs are advocates for independent practices that wouldn’t require any supervision. They’re pretty much practicing independently already.

    One of the hardest skills (arguably the most important skill) in primary care is recognizing when something isn’t routine or treatable with an algorithm, i.e. looking for the needle in the haystack of common, self limited conditions. If MDs aren’t doing the hands-on front-line care, then we’re leaving the needle finding to those who aren’t trained to do it as well.
    Additionally, developing long lasting relationships with patients, interacting with them in person, following them over time, and establishing a therapeutic relationship is one of the biggest reasons MDs choose primary care in the first place. Most don’t want to track population data and provide managerial oversight to NPs and PAs.

  30. This strikes me as a bogeyman discussion.

    First, in a proper medical home – not the pretenders that have bought NCQA level 3 credentiallng but don’t do anything differently – a lot of patient data – med/surg claims, Rx claims, DM/UM data, HRA and biometric data – is constantly tracked and analyzed so we already have a good idea of which patients have risk when they walk in the first time. Those indications are validated or refined as patients are seen by the staff. Traditional practices typically don’t have anything comparable.

    All our practices are led by physicians, meaning that we begin with a doc, then add up to two NPs before adding another doc. Mid-levels have significant autonomy as pcb described, but all patients charts are reviewed with the team. Mid-levels who suspect that a patient has complex issues calls in the doc.

    It is not a perfect system. It appears to be far better, though, than what we can see in conventional primary care practices. The docs who come to work with us strongly agree.

    • southern doc says:

      But it’s not a bogeyman.

      The only medical home that the AAFP acknowledges is the NCQA PCMH, and they are trying to make sure that that’s the only one insurers will pay for. Read the articles on the Transformed site: it’s very openly about complex patients turn right and see a doctor, simple patients turn left and see some member of the team, continuity of care be damned.

      But now that the members of the PCPCC have realized that the NCQA PCMH is just a glorified triage station and CAN be run by an NP or PA, the AAFP has really got its panties in a wad, as we recently saw.

      Why does it make me think of Frankenstein’s monster?

  31. Southern Doc:

    Well I’m certainly with you on that point! See my cover article in last month’s Medical Home News here (http://brianklepper.info/2012/09/11/demanding-more-from-medical-homes/).

    My argument here is that, despite all efforts to stop it, a health care market is emerging. Value – measurably driving down cost while improving quality – will take precedence, particularly among employers and, even possibly, health plans, and so the ability to perform will become much more prized than it has been.

    Or at least that’s my story and I’m sticking to it.

  32. Brian,
    I have a couple of questions. I’m not sure if you calculated the exact numbers, but a ballpark will do.
    How many patients are one doc and two NPs carrying altogether?
    How much are we saving, in dollars per visit or PMPY or PMPM, by having one doc and two NPs instead of 3 docs?

  33. Margalit:

    Total patient load of 1 MD/DO + 2 NPs is around 4,800.

    I’d have to double check to make sure, but its probably a difference of $160K-$200K per year.

    • So that’s about $50 per patient per year, or less than $5 per month. I am just theoretically wondering if patients, or even employers, wouldn’t be willing to pay that for the assurance of having a “personal physician” as the PCMH principles originally intended…

      Just thinking out loud here, Brian. May be a differentiator for a bunch of entrepreneurial docs getting together and offering a service like this… I can think of some really nice marketing messages… :-)

  34. pcb says:

    “Mid-levels have significant autonomy as pcb described, but all patients charts are reviewed with the team. Mid-levels who suspect that a patient has complex issues calls in the doc.”

    Reviewing patient charts, especially “all patients” takes a lot of time, at least if it’s more than a worthless cursory review. Reviewed once a year? Reviewed for every visit or phone call or decision? Who decides what’s worthy of reviewing if it’s not everything?

    Additionally, “Suspecting complex issues” is the difficult job we’re talking about. If you’re calling in the doc everytime something might be complex, what’s the benefit of the midlevel?

    Brian, as you know, everyone’s busy, and the midlevels end up making a lot of autonomous decisions. If the MDs were really supervising thoroughly, they woudn’t be making enough money themselves , and the financial benefits of the arrangement dissolve. The dirty little secret those on the front lines know is the money doesn’t work if the doc has to back off on his/her productivity significantly to supervise/collaborate.

  35. pcb,

    As I mentioned, our FT docs and NPs have caseloads of about 1,600, which affords a 20 minute standard office visit. We’re a lot less concerned about “productivity” and more concerned that our patients get good quality care in the clinic and downstream, throughout the continuum. Our employer clients know going in exactly what the investment in the clinicians is going to take, and they understand that they’re investing in the clinic to get the money back at a high multiple on reductions in health plan excesses.

    All clinicians have every chart reviewed during their first 3 months of work with us, and then periodically after that. We have a team that does that across our clinics.

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