By AL LEWIS

I would urge THCB-ers to read Reframing Healthcare by Dr. Zeev Neuwirth. While much of the territory he covers will be familiar to those of us with an interest in healthcare reform (meaning just about everyone reading this blog), Chapter 5 breaks new ground in the field of primary care.

Primary care is perhaps the sorest spot in healthcare, the sorest of industries. Primary care providers (PCPs) are underpaid, dissatisfied, and in short supply. (The supply issue could be solved in part if employers didn’t pay employees bonuses to get useless annual checkups or fine them if they don’t, of course.) 

They are also expected to stay up to date on a myriad of topics, but lack the time in which to do that and typically don’t get compensated for it. Plus, there are a million other “asks” that have nothing to do with seeing actual patients.

For instance, I’ve gone back and forth three times with my PCP as she tries to get Optum to cover 60 5-milligram zolpidems (Ambien) instead of 30 10-milligram pills. (I already cut the 5 mg. pills in half. Not fair or good medicine to ask patients to try to slice those tiny 10 mg pills into quarters. And not sure why Optum would incentivize patients to take more of this habit-forming medicine instead of less.)

This can’t be fun for her. No wonder PCPs burn out and leave the practice faster than other specialties. What some of my physician colleagues call the “joy of practice” is simply not there.

To steal the thunder from Dr. Neuwirth’s book, he observes that primary care is really five specialties rolled into one.  It was formerly six, I might add, but rounding has been almost totally taken over by hospitalists. Doctors with an interest in rounding can now become board-certified in doing that exclusively, while those who used to have to drive to multiple hospitals to see one or two patients, and then not be available to them the rest of the day, no longer have that burden.

Further, due largely to a free-market response to the shortage of PCPs available on short notice, one of Dr. Neuwirth’s other five subspecialties – on-demand care – has largely been segmented out already, into urgent care, Minute Clinics, call-a-doc services, on-site workplace clinics, and the like. These are generally efficient, fairly priced offerings, satisfying a demand for immediacy at the expense of continuity.

Few of these alternative care sites seem to alleviate the PCP workload, though. Rather, especially because they are subsidized by insurance, they simply encourage people to get care they otherwise wouldn’t have gotten and may very well not have needed.

This niche has been successful enough that at this point, surprisingly few people, including myself, would even think to call our PCPs for services, like a few stitches, that they need handled stat.

The remaining four segments are different enough from one another (though not as bright-line a distinction as hospitalists and on-demand care) that they could comprise four different subspecialties:

• Complex condition care (“quarterbacking” the many specialists and services required by a small number of patients)
• Condition-specific care (for example, helping diabetics maintain appropriate Hb A1c levels)
• Continuity care (a long-standing physician-patient relationship, often for a family as a whole)
• Wellness care (helping to keep generally healthy patients healthy, certainly the least demanding of these four subsegments)

For large multispecialty practices to ask PCPs to be both expert in and interested in all four of these categories is suboptimal in many ways. For instance, some physicians weight-shame patients, and/or get visibly frustrated with non-compliance. Clearly, they should focus their practice in one of the latter categories. Physicians who want a 9-to-5 existence should also focus on the last. Multispecialty practices should not denigrate their lifestyle choice, though perhaps change the pay scales to make them commensurate with workload. Patients who fit in this category will be among the most profitable in a risk-bearing environment.

Patients suffer if they happen to be matched with a PCP in the wrong segment because that particular PCP had availability on his or her panel when others don’t.  But more importantly in the long run, PCPs mismatched to their segments will leave the practice…and many patients may follow. Other patients may have already left because they were mismatched.

Further, if these large groups do nothing to segment themselves, they risk having increasing numbers of patients peeled away by some of these newer models. In the case of condition-specific care, they risk losing business to Silicon Valley-funded startups whose expertise in presenting outcomes may not be matched by the actual achievement of those outcomes.

The good news: This is doable and the outcomes are great

There is some good news, though. Providence Health Plan has been segmenting physicians for many years. As described in my book Why Nobody Believes the Numbers, Providence matches PCPs and patients looking for a PCP according to their respective interests and needs. Further, PHP has been doing this long enough that the real outcomes (as opposed to Livongo’s non-outcome outcomes) – reductions in overall inpatient admission rates related to chronic disease – have been tallied and validated by the Validation Institute for many years. Much of this is due to PHP physicians’ coordination with their internal disease management program as well, a left shoe-right shoe approach to chronic care.

Despite their largest account being health system employees (an occupation notorious for high utilization), PHP’s outcomes rank among the country’s best. For instance, their admission rate for all ischemic heart disease as a whole is only slightly higher than the country’s admission rate for heart attacks alone.

Next Steps

If you are a leader of a physician practice large enough to employ many PCPs, Chapter 5 of Reframing Healthcare could become your roadmap to the next generation of practice. Don’t take my word for it. Read the book…and then ask your physicians to read Chapter 5 and let you know what they think.

Yes, yet another ask of your PCPs. Maybe just summarize it for them.

Al Lewis, the originator of risk-based population health contracting and outcomes measurement, is founder and President of the Disease Management Purchasing Consortium International, Inc.