Tuesday, August 24, 2010

Why the Solution to the Primary Care Crisis, the Patient Centered Medical Home, Will Fail

Everyone understands the need for a robust primary care workforce in making healthcare more affordable and accessible while keeping those in our care healthy.   With the aging of America and healthcare reform, even more Americans will need primary care doctors at precisely the same time doctors are leaving the specialty in droves and medical students shun the career choice.  So as a practicing primary care doctor, I've watched with great interest the solutions for the primary care crisis.

I've been utterly disappointed.

Patients so far don't like the patient-centered medical home (PCMH) as noted in Dr. Pauline Chen's New York Times column.  The changes recommended won't inspire the next generation of doctors to become internists and family doctors.  Experts understandably look at a dwindling workforce and unprecedented demand to come up with solutions like (from the May 2010 Health Affairs article - Transforming Primary Care: From Past Practice to The Practice of The Future):

  • "physicians can no longer enjoy trusting relationships with all of their patients.  Just as tasks must be shared among the primary care team, the joy of personal interactions with patients must also be shared."
  • "no contact at all with patients having uncomplicated needs.  The new primary care practitioner would function as a team leader and clinical teacher rather than as a healer to all who seek help."
  • "nurse practitioners and physician assistants could take responsibility for common acute and chronic care issues."
  • "small practices without a robust team would be limited in their capacity to institute such team-based care [for preventive and chronic conditions]".
  • "the primary care practice of the future must adapt to the reality of large panels - the number of patients under the care of a single doctor."
  • "models in the United Kingdom that have employed longer visit times with advanced-practice clinicians, patient satisfaction is high."

I wouldn't want to do primary care either as a practicing doctor or as a medical student contemplating a future career.  Having a larger panel size isn't attractive in a field lacking work-life balance. Putting aside the issues of reimbursement and medical school debt, which also need to be fixed, what experts have fundamentally failed to appreciate is that these solutions perpetuate the cottage industry that they so desperately need to transform.

First, Americans are not like people from Great Britain.  Americans are uniquely different. We have our own views.  Note how rapidly we've adopted the metric system.  Though the British may have high satisfaction with non-physician providers, given a choice and a level playing field of the same amount of time and access, I believe Americans will choose a doctor over a nurse practitioner (NP) or physician assistant (PA).  Telling future doctors that they can't see young and healthy individuals for acute problems not only makes them highly unlikely to choose primary care, it also will be quite upsetting for the general public.  As other articles have noted, NPs and PAs numbers are also insufficient to close the gap of an overwhelmed primary care workforce.

Second, stop rebuilding and perpetuating the cottage industry and reinforcing the fragmentation of primary care.  Except for very small medical practices like the ideal medical practice model where there is only one doctor with no staff, supported with technology, and extremely low overhead, having all primary care doctor offices create a team of staff to care for chronic conditions is absurd.    It isn't scalable.  Three quarters of primary care doctors are in either solo to five person practices.  Each doctor office shouldn't re-invent the wheel.  Instead, third party organizations should be accountable for managing chronic conditions and reporting to a patient's primary care doctor if the patient is not compliant with care or not following practice protocols.  Employer groups are leading this change as well.  This is a good thing. 

The article "Prospects For Rebuilding Primary Care Using The Patient-Centered Medical Home" notes that taking payments to invest in a "community-based organization provides infrastructure, such as care coordination services, that can be shared among several primary care offices" is already occurring in North Carolina and Vermont.  In addition, "local virtual organizations might consist of networks of small independent practices or of practicies affiliated with a hospital.  They could be linked through sharing of care management health IT or human resource for case management or care coordination."  These are ideas that must be pursued.  Few doctors want to be the doctor, the clinical chronic conditions leader, and the IT expert yet this is what most articles of the PCHM propose.

Having infrastructure that is scalable and seemless via health IT will off load both chronic conditions and preventive care to these other organizations which can assist doctors in providing the right care.  As a result, a doctor with an average panel size of 2000 is free of the 17.4 hours per day needed to do it alone.  This time is now available to do what primary care doctors were trained to do, to evaluate patients with problems that don't quite fit standardization or protocols.   Opportunities to see those who are young and healthy if they wish to be seen even if a protocol could treat a bladder infection over the phone or email are possible.  Patients and doctors would find this encounters far more satisfying.  One thing these third party groups must do is to agree to common reporting standards rather than proprietary ones to make the evaluation of clinical data quick and easy. 

An area which is already being carved out of a primary care office is the acute care provided by retail clinics like Minute Clinic as well as start-ups like Zipnosis.  Focused on a subset of problems where protocols are developed delivers care more rapidly and at less cost.  Primary care doctor offices can either try to replicate this as well or perhaps better would be having the healthcare system virtual integrate these providers offering precision medicine (protocols) with primary care doctor offices who do intuitive medicine (cognitive / clinical decision making).

So what does this all mean?  Avoiding the discussion of the federal government's role of community clinics, the future of primary care will thrive in three areas: large integrated healthcare systems like Kaiser Permanente, individual doctor offices virtually integrated by third party vendors as well as other non-physician providers like retail clinics, and the solo practitioner doing the ideal medical practice.

My fear, however, is that this won't happen.  Instead, medical students will be more appalled with the future vision of primary care, fewer doctors will be in the workforce, patients continue to bypass primary care doctors, and the unthinkable crisis that experts are trying to avoid in fact occur more rapidly.

I hope I'm wrong.


Anonymous said...

Sigh. I hope you are wrong too. But there are some disturbing trends here. I have been in practice 10 years, general Internal Medicine (hi Davis, long time, no see!). I am not certain I will be doing this in another 10 years... student loans are paid off... no life balance ... we can all do the math here ...
I am dedicated, but endless self-sacrifice, aggravation and harassment, with only intermittent satisfaction is not enough.....
-- Lisa, UCONN 1997

Juliet Kottak Mavromatis, MD said...

David, I enjoyed reading your blog. I am curious about your vision: "instead, third party organizations should be accountable for managing chronic conditions and reporting to a patient's primary care doctor if the patient is not compliant with care or not following practice protocols." My view is that third party management (insurance company generated feedback reports) is not very effective in terms of inspiring quality improvement. Most doctors tend to ignore these types of reports unless they themselves generate the reports, or their own health care organization generates them.

I guess that I am less pessimistic than you about the future ability of small practices to use electronic records and interconnect in a meaningful way to larger referral centers and specialists. I think that this will come eventually with meaningful use. I think the current challenge for small practices is how to afford the transition. Some of the less favorable data on the medical home pilot projects has to do with the lack of support during this time of transition. Clearly a medical team in a small practice will look very different than a medical team in a integrated health system. Some patients may continue to prefer the intimacy of this type of practice setting.

Davis Liu, MD said...

Lisa, appreciate your comments and all of the hard work you are doing. Always good to hear from an alumna!

Dr. Mavromatis - I think third party doesn't mean insurers. It can be employer groups who contract services with other organizations to deliver chronic care as noted in recent NY Times - http://www.nytimes.com/2010/07/24/business/24patient.html?pagewanted=2

I'm not against small practices. The challenge is that there is no standard where a practice can virtually integrate with larger referral centers / specialists. Right now there are different vendors jockeying for position. This is not unlike the dot.com boom. Until this settles, I fear that small practices will be left behind.

Anonymous said...

Americans were stupid in not converting to metric.

MC said...

Dr. Liu. I wish to offer some refuting information in regards to your statement "Though the British may have high satisfaction with non-physician providers, given a choice and a level playing field of the same amount of time and access, I believe Americans will choose a doctor over a nurse practitioner (NP) or physician assistant (PA)."

My wife has worked for the last 15 years as a Gerontological Nurse Practitioner exclusively in the long term care setting. According to the nursing home staff and administration at more than one facility, many of her patients prefer being seen by her to being seen by the physician.

Some Americans can and do accept alternatives to the traditional care model.


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