The Primary Care Dilemma
When I was a managed care medical director I used to tell my group when people were well they wanted Wal-Mart medical care—convenient and at everyday low prices. But when they got sick, they wanted Nieman-Marcus care—the “best,” spare no expense. As I saw it, our challenge was how to balance these two competing cultures. As we looked at what other groups were doing, we noted many of them decided to stress one style or the other. But we decided to try and straddle the divide and provide both kinds under one roof. Two recent articles have brought this to mind.
Kaiser Health News reported on 9 October 2018 that “Spurred by Convenience, Millennials Often Spurn the ‘Family Doctor’ Model. “…millennials, the 83 million Americans born between 1981 and 1996 who constitute the nation’s biggest generation. Their preferences—for convenience, fast service, connectivity, and price transparency—are upending the time-honored model of office-based primary care.” The cited a poll done in July 2018 by the Kaiser Family Foundation, which showed 26% of 1,200 randomly selected adults did not have a primary care provider, but 45% of those 18-29 year old people did not compared to 12% of those over age 65. The article then goes on to examine the rise of the urgent care market that caters to this desire.
In good journalistic fashion, though, they quote those who defend the old notion of a primary care physician who knows you. But, they point out, a national survey in 2017 showed the average wait for a new patient appointment in 15 large metropolitan areas was 24 days, up from 18.5 days in 2014. I suspect the problem is worse in rural areas like mine, where there are so few primary care physicians that many simply can’t take on new patients unless the older ones die. This is supported by the finding that of the 2,700 retail clinics in the United States, most are in the South and Mid-West, areas with large numbers of people not concentrated in metropolitan areas. The article quotes people who don’t want a primary care physician as well as those who regretted that they didn’t but does not draw any conclusions.
Not discussed in this article, but something that is becoming more and more common, though, is that primary care physicians do not go to their local hospital anymore, so he or she may not be available when knowing the patient would be valuable. The rise of hospitalist services has been touted as an answer to this problem, but with maturation of the model, it has become apparent that continuity of care is a major issue and a major driver of “unnecessary” care. Thus, it was interesting to read a preliminary report of a hospital that has tried to create a new model to provide that continuity for patients with complex medical illnesses.
Commonwealth Care Alliance and Boston Medical Center “created a hospitalist service staffed with physicians and mid-level providers who specialize in complex care…This complex care hospitalist model—which launched in July 2016—has four fundamental, replicable components.” These are communication, continuity of care, addressing social determinants of health, and using specialists in complex care. Communication consists of deliberately involving the primary care physician by having someone contact him/her upon the patient’s admission and especially when discharge planning is begun. Continuity of care means admitting the patient to the same unit every time so everyone, including nursing staff, get to know the patients and their families. Addressing the social determinants of health is recognition that a patient who can’t afford enough food or medicine is likely to be re-admitted, so addressing these needs is part of the continuity of care. Finally, they try to use physicians who are experienced in both acute and chronic care of patients with complex medical problems.
So, is it working? The author reports they have done only a limited number of chart reviews, but, so far, the program seems to be working in reducing 30-day readmission rates and 30-day ER visit rates. She thinks the limitations of the usual hospitalist model are so severe that the project is worth continuing.
“The challenges for value-based organizations will be how much control to exert over the inpatient hospital setting and how to triage patients to models of inpatient care best suited to their particular needs. But in an era where hospital costs and outcomes, particularly for high-cost, high-need patients, are more relevant than ever, the complex care hospitalist model offers an achievable and replicable option for value-based hospital medicine.”
I can’t help but reflect that when I went into private practice one of my first goals was to get the hospital to establish a ward where dialysis patients would be placed preferentially. I also saw myself as the internist for patients with kidney failure, particularly those on dialysis, so it was my job to coordinate their inpatient and outpatient care with the dialysis unit care. Recently I was visiting with a doctor who had newly finished fellowship. She noted their program director had specifically advised them NOT to take on the primary care role but retain the role of the specialist/consultant. And I don’t find many younger physicians in practice who feel comfortable taking on this role, either. So, where does that leave us?
Urgent minor care and a lot of simple chronic care has migrated to mid-level providers, leaving the physicians to take on more and more complex care coordination and goal setting. Yet the financial system does not reward this. CMS’ recent proposal to collapse the outpatient visit codes into one with a price that was in the middle range of current prices penalizes those who undertake care of complex illness. But the growth of retail markets has put a cap on opportunities to do low intensity, high volume care profitably. In some urban markets there may be enough primary care internists and family physicians to make the current system work, but in many locations, there are insufficient numbers. The preferences of younger consumers mean the shortages will likely become worse.
I also see problems with current training methods for younger doctors. If everyone is a specialist in one organ or one kind of problem, who is going to “own” the responsibility for guiding care of the patient? Clearly it will be different people at different stages of a patient’s life, but what does that mean for the role of the physician? I can foresee where a generalist is the driver when there are three or more chronic problems that need treatment, but a specialist may be the driver when one problem, such as cancer or dialysis, drives the bulk of the care. This is one of those cases where there are lots of questions, but, as of now, few good answers. In any event, Dr. Marcus Welby died many years ago and that model of care seems unlikely to return, even though it is one many physicians, including me, yearn for.
14 October 2018
 Boodman, Sandra G. Spurred by Convenience, Millennials Often Spurn the ‘Family Doctor’ Model. Kaiser Health News, 9 October 2018. https://khn.org/news/spurred-by-convenience-millennials-often-spurn-the-family-doctor-model.html.
 Berchuck, Caroline M. A New Hospitalist Model for Managing High-Cost, High-Need Patients. Harvard Business Review, 9 October 2018. https://hbr.org/2018/10/a-neew-hospitalist-model-for-managing-high-cost-high-need-patients.html.
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