Strategic Questions for Physicians Part 1
Recently I have been discussing strategic questions for hospitals but in this article, I want to look at the challenges facing physicians. More than 25 years ago I was writing an article for my group about the challenges posed by managed care. I started by stating my conclusion: “Marcus Welby is dead.” The response was interesting. The older physicians laughed and the younger ones asked me who he was. I have noted since that many old TV series are available on cable, but not, apparently, “Marcus Welby, M. D.” Yet I suspect many physicians still think their primary job is taking care of one patient at a time. If they do it well, all will be well. But this formula has not been working well for the past decade or so, as evidenced by widespread dissatisfaction amongst physicians and now the need to accept direct government assistance as business has collapsed for some in the face of the pandemic.
Consider a recent report from Kaiser Health News. Rovner identifies three trends likely to persist after the current crisis: telehealth for all, a dwindling supply of primary care doctors, and a declining emphasis on hospital care.
“Telehealth is not new; medical professionals have used it to reach patients in rural or remote settings since the late 1980’s. But while technology has made video visits easier, it has failed to reach critical mass, largely because of political fights…The other obstacle, not surprisingly, is payment…It’s easy to see why many patients like video visits—there’s no parking to find and pay for, and it takes far less time out of the workday than going to an office. Doctors and other practitioners seem more ambivalent.”
While I was on active duty in the U. S. Army, one of my colleagues developed what was called an “AMIC Clinic.” AMIC stood for acute minor illness. He and his team developed simple algorithms so corpsmen, who were trained about like civilian LPN’s, could triage and treat the ailments people presented with. Now you might argue he had an advantage, since most of the people presenting were on active duty and were pre-screened to have been healthy, but the system meant that only about 1% of patients had to been seen by the physician assistant or nurse practitioner who was the next level of backup and very few of their patients had to be seen by the supervising physician. From a community health perspective, a lot of patients present with acute minor illnesses. These patients were easy to treat—they were likely to get well with no treatment—and profitable. But telehealth will increase competition for this volume even more than is now the case.
Practices that depend on this volume are in trouble already. A recent study showed primary care visits by insured patients declined by 24.2% from 2008 to 2016 and the proportion of adults with no PCP visits in a given year rose from 38.1% to 46.4%. The decline in low acuity visits was 47.7% and visits to urgent care increased by 46.9%. The pandemic has only accelerated the trend. Rovner reported:
“The American Academy of Family Physicians reports that 70% of primary care physicians are reporting declines of patient volume of 50% or more since March, and 40% have laid off or furloughed staff. The AAFP has joined other primary care and insurance groups in asking HHS for an infusion of cash…One easy way to keep primary care doctors afloat would be to pay them…capitation…Still, many physicians, particularly those in solo or small practices, worry about the potential financial risk—particularly the possibility of getting paid less if they don’t meet certain benchmarks that the doctors may not be able to directly control.”
What about Medicare payments? After all, CMS has instituted a number of “capitation” style payments to encourage primary care. But an analysis of the impact at the practice level suggests little will change and the economic disincentives for primary care will continue.
All of this suggests physicians need to ask themselves the following questions. First, am I going to retire or adapt? Second, if I am not going to retire, how do I regain some joy in my practice so I have the energy to adapt? Selling your practice and becoming an employee will not answer these questions. I suspect the biggest challenge for all physicians is to embrace the notion it is possible to provide quality patient care indirectly. The apprenticeship system for graduate medical education has not worked to create that understanding nor has it given physicians the knowledge and skill sets to be successful in achieving quality care through others. Yet regaining some sense of control of the process is one of the keys to restoring satisfaction to the practice of medicine.
NEJM Catalyst recently published a booklet arguing that physicians need to assert their voice to transform care and drive innovation. Some of the people quoted report their own institutions are not doing a good job listening, but some of those in small practices talk about how they have been able to capture quality payments by thinking clearly about their care processes and automating some features. I recommend the document to give further ideas.
Can primary care be saved? Marcus Welby really is dead, but a primary care physician or group that uses mid-level providers and office staff effectively and uses the doctor to take care of the patients who are “off protocol” can increase both doctor satisfaction and capture more revenue. The easy money of insured patients with low acuity issues is gone—survival means figuring out how to work smarter, not harder, to take care of the patients who still need a concerned, knowledgeable primary care physician.
19 July 2020
 Rovner J. Rapid Changes to Health System Spurred by COVID Might Be Here to Stay. Kaiser Health News, 8 June 2020. Accessed 9 June 2020 at https://khn.org/news/rapid-changes-to-health-system-sprurred-by-COVID-might-be-here-to-stay.
 Ganguli I, Shi Z, Orav EJ, Rao A, Ray KN, Mehrotra A. Declining Use of Primary Care Among Commercially Insured Adults in the United States, 2008-2016. Ann Intern Med 2020;172:240-247. doi:10.7326/M19-1834.
 Sessum LL, Basu S, Landon BE. Primary Care First—Is it a Step Back? N Engl J Med 2019;381(10):898-901. doi:10.1056/NEJMp1906593.
 NEJM Catalyst. The Clinician Role in Health Care Delivery and Innovation. Accessed 1 July 2020 at https://catalyst.nejm.org/
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