A Primary Care Paradigm Shift

Dick Reece is a retired pathologist and a prolific health care commentator with an active following, particularly among physicians. An astute, incisive observer, he is the author of 10 books; the latest is Innovation-Driven Health Care: 34 Key Concepts for Transformation. He is regular columnist on HealthLeaders, and writes his daily posts at MedInnovation Blog. THCB welcomes him. — Brian Klepper

RreeceSomething profound is happening in buyers’ and the public’s attitudes towards primary care and the health system. With inexorable rises in costs and corresponding decreases in access to primary care doctors, buyers and the public are mad as hell, and they’re deciding they’re not going to take it anymore. Something is badly and sadly wrong, and corrective measures are being put in place.

Signs of Paradigm Shift

Signs of a paradigm shift – a change in assumptions about the system’s basic structure – are everywhere. No longer do we accept the notion every patient should have a specialist for every disease, every life-improvement procedure, every orifice, and every organ. Care, it’s now assumed, must be coordinated to prevent people from falling through the cracks. We must stop wasting time and resources for patients and the system as a whole.

The U.S. system lacks timely access to primary doctors who oversee care. And specialty services are overused. Yet the U.S. has fewer primary care physicians per capita than any other country in the developed world. On the other hand, we have more specialists per square mile than other countries.

What’s Driving the Paradigm Shift?

•    Major corporate buyers, led by IBM, which spends $1.7 billion on health care, have created an activist organization, The Patient-Centered Primary Care Collaborative. Paul Grundy, MD, MPH, IBM’s Director of Health Transformation, chairs the Collaborative. It is based partly on IBM’s experience in Denmark, where it owns a company, and where patient satisfaction with care is 97% versus 50% in the U.S. Grundy believes every citizen should have a personal physician, and every physician should be rewarded for offering same day access, managing a patient panel, and be compensated for telephone and email consultations.

•    A vibrant movement is underway to “disintermediate” health plans. “Disintermediation” occurs when access to information or services is given directly to consumers. In the process, “middlemen” in the form of health plans may be ended, or their services transformed. That’s what consumer-driven health care is about, that’s why their existence in their present form is threatened, and that’s why health plans are moving rapidly to high deductible plans linked to health savings accounts.

•    The “medical home” concept is gaining traction. This concept hinges on two ideas: 1) placing the primary care physician at the center of care by having him/her coordinate overall care; 2) giving primary care doctors “ownership” control of specialty care referrals. America wants a health system in which the primary physician uses a secure computer platform to coordinate efforts of specialists, pharmacists, therapists, and others. Increasingly patients don’t appreciate why they must fill out a new form at each doctor’s office, why doctors don’t communicate with each other, and why doctors duplicate tests and don’t know what other doctors do. A number of medical home pilot studies are now being conducted. To make medical homes happen, doctors will need financial incentives and support to introduce technology, and coordinate care. Payers will need to step up the payment plate to help medical homes become real.

•    New business models to reduce cost and offer convenience are fast evolving. These include retail clinics, medical offices at the worksite, specialty clinics, urgent care clinics, elective surgical centers, and ambulatory facilities offering imaging, multiple specialty services, and one-stop care. Most of these are outside expensive hospital settings. Some are currently beyond the control of primary care physicians. At last count, there were over 1000 retail clinics, 500 worksite clinics, and roughly 3,000 urgent care facilities.

•    The physician empowerment movement is growing. The Physicians’ Foundation for Health System Excellence, which represents state and local medical societies, has completed a survey of 300,000 primary care physicians to highlight their problems, to educate the public, and to persuade policy makers to take steps to enhance the supply of primary care doctors, to pay them better, and to give them tools to offer comprehensive coordinated care. Sermo, a physician social networking site, has 75,000 members and will soon issue an “Open Letter to the American Public,” signed by 10,000 doctors to reflect physician grievances and to indicate how the system can be improved. These efforts, coupled with the Patient-Centered Primary Care Collaborative, are designed to improve the lot of primary care physicians.

Conclusion: A new primary care paradigm is upon us and will fundamentally change how the U.S. delivers care.

8 replies »

  1. Thank you both! You guys will be sorry to hear that I will not have time to do the weekly updates anymore. I’ll make a blog post about it on Monday. Sorry, but there’s just a lack of spare time in my life right now, and I’d rather get back to the tutorials.
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  2. I want to thank the AMA and the proceduralists on the RUC for putting into place an environment in which, after a three year residency, I can earn more than most of them for a fraction of the work and risk.
    Differential pay rates and a clear disrespect for what I bring to the table has resulted in a breathtaking shortage of generalist MDs in a free market with a preponderance of aging baby bomers who have health concerns and money to burn.
    Of course, I only care for about 300 relatively healthy patients instead of the 3200 I used to…… but heck, isn’t that what the RUC says NPs and Doctors of Nursing are for?
    Read this blog’s comments on previous posts “NPs are just as well trained as Danish FPs” “anyone who says generalists have not had a pay raise is being disingenuous, after all Medicare has cut their pay less than Radiologists” “Most FPs are just not well trained. No one I know would take their family to one”
    Hey, keep posting comments like these, as long as the supply of new FPs suppressed, I can charge whatever I like.
    There is an enormous pool of folks who look around and see they need a quarterback who provides access to healthcare and has enough professional confidence to know when not to move the ball forward and how to push for action when it does. I get more satisfaction from the time I spend at a free clinic and my few scholarship patients, but hey, if I am not wanted at the party, I am not gonna come.
    Meanwhile my price for healthcare outside the system just keeps going up and up and so does the cost of care within a cost based system that obviously has no use for me.
    If CMS would just stop seeking the advice of the RUC, much would be mended.

  3. Big Insurance is the largest part of the problem. Yet look at any major city skyline (Boston for instance) and what do you see…the Prudential, John Hancock , etc. These businesses are the Exxon (and Enron) of American Health Care and they will not go quietly into the night. It’s going to take a technological hack of the order of Microsoft or Google to take them down. But not likely in the Boomer’s lifetime. We are likely saddled with our so called capitalistic system til the end of time…
    /not bitter much
    //30 year combat veteran

  4. I am afraid that there is some wishful thinking going on here.
    I experience 2 kind of patients, one kind that – explicitely or between the lines – demands: Do everything you can, even that diagnostic test that you tell me has a low chance of revealing anything. And maybe you can refer me to that subspecialist I heard about (or maybe I go there without your referral) etc.
    The other kind of patient does consider that healthcare does cost money, and if it’s not your personal money, the costs are somehow socialized/distributed. When a diagnostic test is diagnostic only (i.e. it may be helpful arriving at a diagnosis, but that diagnosis won’t change the management).
    Many patients fall somewhere in between or are fluctuating between the 2 attitudes.
    But as long as you have that kind of thinking in a major part of the population, and a reimbursement system that heavily tilts towards procedures, plus a malpractice system that may punish you for not doing what the “reasonable physician” of your specialty may do (i.e. a lot of testing), things will not change a lot, I am afraid (even though I wish it was different).

  5. I would advance the idea that Americans, particularly those with health coverage (!) are a “keep up with the Jones” oriented bunch.
    A shortage of primary care physicians creates a situation where people begin to think they’re worth something — enhancing their position.
    If everybody has a Cardiologist, but only the chosen few have an Internist then what do you think your average American will think they need?
    Anybody that thinks that Americans of a certain age and class don’t compare notes about their health care and who has had what done is never going out to dinner with their friends! They do and it’s quite possible the tide is turning.

  6. “New business models to reduce cost and offer convenience”
    Funny, but the health services research that is emerging shows the procedures performed in physician-owned ASCs are usually more expensive/as expensive than in hospitals and that the quality levels aren’t better either.
    Yet, I am sure when Waxman or others in Congress who have tried to halt the rise of physician-owned ASCs (and imaging centers) will be attacked by the physician lobby in DC.

  7. Important players in health care delivery and advocacy in the USA are increasingly aware of the distortions in the American health care workforce.
    We have over developed a specialty and subspecialty and technology based health care system.
    Given the composition of our physician and allied primary care workforce, it will take thirty years to correct our primary care deficit imbalance IF we begin today. That is the career span of a physician. Today’s young subspecialists will be around for another thirty years or so.
    Immediate action towards primary care is not likely to happen. Consensus will take at least a decade.
    There will have to be a fundamental revolution in the financing of our medical education system (both medical school and graduate) and a fundamental revolution in our organization of academic medical centers and teaching hospitals for any change in workforce policy to take place.
    The forces of resistance to these changes in American medicine will not disappear.
    Unfortunately, things will have to get worse before they get better. The retirement of the baby boomers may help tip the balance in favor of primary care. But that too will take a decade or more.
    Bohdan A. Oryshkevich, MD, MPH
    New York City

  8. Apropos of nothing: Why do you refer to “primary care physicians per capita” and “specialists per square mile”?