Sunday, January 23, 2011

Why the End of Internal Medicine As We Know It - Might Be A Good Thing!

A recent blog post in the Health Affairs blog proclaimed The End of Internal Medicine As We Know It.  What the article is really asking is the future of primary care in the world of health care reform and the creation of Accountable Care Organizations (ACOs).  While doctors should be naturally concerned about change, I don't completely agree with this article.

ACOs are organizations that are integrated and accountable for the health and well-being of a patient and also have joint responsibilities on how to thoughtfully use a patient's or employer's health insurance premium, something that is sorely lacking in the current health care structure.  These were recently created and defined in the health care reform bill.

Yet, the author seems to suggest that this is a step backwards.
modern industry abandoned command-and-control style vertical integration decades ago in favor of flatter, more nimble institutions
Not true.  Successful organizations are ones that are tightly integrated - Apple, Fedex, Wal-mart, Disney.

The author talks briefly about how Europe in general does better than the US in terms of outcomes and costs and has a decentralized system.  All true.  However, contrasting Europe and America isn't relevant.  After all, who isn't still using the metric system?  Therefore solutions found outside the US probably aren't applicable due to a variety of reasons.  Americans like to do things our way.

What I do agree on is that doctors need to be part of the solution and ensure that the disasters of decades ago, like labeling primary care doctors (internists and family physicians) as "gatekeepers" rather than what we really do, never happens.

I love primary care.  I've worked at Kaiser Permanente (KP) in Northern California since 2000.  I have long term relationships with my patients.  They see me when they are well.   They see me when they are sick.  They have me as their personal doctor.  There are no mid-level practitioners (nurse practitioners or physician assistants) in my unit.  I'm supported by information technology, staff to help those members with chronic conditions, and collegial specialist colleagues.

In other words, I'm doing what almost every primary care doctor wants: long-term meaningful relationships with patients, no hassles from insurance companies, the ability to retrieve information quickly and easily, and support for specialty colleagues who are equally focused on the well-being of the patient and who respect me as much as I respect them.

Perhaps the death of primary care as it currently exists with crushing administrative hassles, loss of work-life balance, increasingly short office visits, and paper charts which often has inadequate information or are unavailable isn't a bad idea after all.

Now I understand that KP looks very much like an ACO.   I also know it isn't for everyone, doctors or patients, and isn't the only solution for the country.  Certainly doctors should be wary of if every self-proclaimed "ACO" is really that or more of the same in the fee for service world but simply disguised in the ACO term.

However, for primary care doctors looking for a better way to care for patients, it is a very viable and sustainable solution.  If the future for primary care looks like what I see and do everyday, then I believe the future will be bright.

Primary care doctors looking for a better future in primary care and willing to move to Northern California should do more research here. 

Patients in the end may benefit from ACOs.  I know my patients do.


Anonymous said...

A couple points:

Government agencies and insurers see ACOs primarily as cost-saving vehicles, throwing in talk about better patient care only to make the pill more palatable. KP, to date, has not demonstrated any significant reduction in premiums compared to their competitors. If revenue at KP is reduced 10-15%, will it still be such a great place to practice?

If we tell primary care docs that they can only practice in ACOs, but if they sub-specialize, they can still own their own practices, office buildings, etc., if they wish, will that make primary care more or less attractice to med students?


Dave said...

Until I see more data, the jury is out on ACOs. I have to say the inefficiency I've seen in large health systems makes me leary but it's worth some pilot testing. In contrast, I'm much more convinced of the Patient Centered Medical Home. Organizations such as Qliance and Iora Health have demonstrated dramatic improvements in health outcomes at a significantly lower cost. Last week, I visited Qliance's Seattle clinic and was extremely impressed. It's worth noting that their financial backers are the founders of 4 extremely successful companies (Amazon, Expedia, aQuantive and Dell) that turned industries on their head.

This is part of the movement I call "Do it yourself health reform" that I wrote about on the Huffington Post - From my experience, I'd bet on entrepreneurs to find ways to deliver better service at lower cost. Gov't can help or inhibit. I get concerned when politicos that I call "Preservatives" try to preserve status quo rather than fostering innovation. Most "Preservatives" label themselves "Progressive" or "Conservative" but they are politically funded by companies focused on preserving status quo. Unfortunately, the innovators don't have the extra money sitting around to pay lobbyists and donate to political campaigns.


Every healthcare provider should switch to an EMR solution. Paper based records and prescriptions are a thing of the past now and it would be best for both doctors and patients to take advantage of their features and accessibility.

Medical Billing I Free EMR

KM, MSN, ANP said...

Please do not refer to us as "Mid-Level providers" and do not write as if people get better care by avoiding Nurse Practitioners, Physician Assistants, Nurse Midwives, etc. It is insulting, and I would have expected a higher level of discourse by an experienced healthcare provider such as yourself. And why don't you read this article by a physician....


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