Physician shortage, primary care - Problems and Promises of Paradigm Shift to Primary Care

Yesterday, along with 17 other bloggers, I participated in an interactive IBM sponsored conference call, “The Patient-Centered Medical Home, What, Why, and How? A Blogger Briefing.”

IBM, the nation’s 4th largest employer, is an excellent example of how large employers are moving decisively to lower health costs.

I won’t go to into details of the hour-long briefing, which was a preview of a 4-author IBM study of prospects and strategies for building medical homes. Paul Grundy, MD., Global Director of Healthcare Transformation at IBM, spearheaded the IBM study and the blogger briefing.


One Conclusion

One conclusion of IBM’s presentation struck me,

It will not be easy to implement medical homes on a large scale even with the current momentum behind them, given challenges such as funding and level of change required.

Indeed, it will not be easy, for it entails a broad paradigm shift from a specialist-driven to a primary care-driven U.S. health system. Given the momentum already achieved through backing by the Obama administration, the AMA, the Association of Medical Colleges, all of the leading national primary associations, and many state legislatures and given the forces crying for fundamental health care reform change, medical homes will the part of the medical landscape in the near future, but there will be startup problems and problems of scale.

PROBLEMS OF THE MEDICAL HOME

1. Paradigm shift magnitude – Two thirds of U.S. physicians are specialists, and one-third practice primary care . It takes 10 years to produce a primary care doctor, longer to produce a specialist. Like it or not, true or not, consumers, hospitals, academic centers, and the public at large are conditioned to think specialty care is superior. Many medical and business organization, including specialist organization, profit from the status quo, and they will resist change.

2. Paucity of primary care physicians – The number of primary care physicians is shrinking rapidly, and less tha 10% of medical students are planning careers in primary care. This makes adoption of a primary-care centered model on a broad scale difficult, particularly in “sophisticated” medical markets long dominated by specialists and among hospitals, whose bottom-line depends predominantly on high tech specialty care rather than on generalist care.

3. Prestige of primary care physicians low - In academic teaching centers, hospitals, and the public at large, primary care prestige is low. This lack of prestige lessens the likelihood medical students will choose primary care careers. In teaching hospitals, you sometimes hear the term primary care doctors dismissively referred to as the LMD, or local medical doctor. Specialists dominate the faculties of leading academic centers and medical students soon learn spciality care is where the power. the glory, and the money resides.

4. Pay of primary care low – Reimbursement rates of primary care sanctioned by Medicare are 55% of what specialists are paid, and Medicaid rates are even lower. Health plans follow Medicare physician payment patterns. Medical students know this. Furthermore, primary practitioners typically work longer hours than specialists. It doesn’t take a rocket scientist to figure out why medical students shy away from primary care.

5. People confuse medical home “gateway” approach with the failed “gatekeeper” of managed care. – The gatekeeper model of managed care, whereby HMOs deemed primary care doctors at gatekeepers to specialists, failed, and in the process, antagonized patients, did not diminish flow of work to specialists, and “disintermediated” primary care practitioners. Explaining why the medical home concept is different, i.e why it empowers primary care practitioners, is difficult.

6. The paragons presented as models of medical homes, i.e, integrated group practices with salaried physicians, are not representative of mainstream physician practices. Certain organizations – Kaiser, Mayo, Geisinger – are often cited as examples of how medical homes could be organized. However, these and similar organizations models only care for 10% of Americans. Expanding these models or creating new ones, and shifting patients to these oragnizations on a large scale will be difficult or impractical.

7. The propensity of the current system geared to doing more generates more revenues. – Let’s face it. The current fee-for-service system rewards most major stakeholders – physicians, hospitals, health plans, suppliers, drug and device manufacturers – to do more and provide more services. It’s difficult to turn this paradigm around – to interpose primary care physicians as brakes and guides for the system. As yet, and despite the favorable rhetoric (who could be against compassionate primary care doctors providing coordinated and comprehensive care), the medical home has not gained widespread traction among most medical stakeholders.

PROMISE OF MEDICAL HOMES

8. Personal physicians produce better outcomes - Studies of health systems with a preponderance of primary care physicians with a broad personal knowledge of their patients, practical preventive measures, and close relationships with specialists consistently show better outcomes – lower mortality and morbidity, lower costs, fewer heart attacks, less smoking, better health habits, lower rates of obesity.

9. Patients respond positively to trusted physician advisors both in matters of health and in fiduciary matters - Reliance on primary care advisors is likely to grow as complexity, contradictions, and costs whelm patients and patients seek authoritative information based on physicians’ practical experience and ability to them navigate through the medical maze.

10. Practical models that truly empower primary care physicians and lower costs as demonstrated by irrefutable data will emerge and will move medical homes forward - It is one thing to tell warm and intimate anecdotes about the power of personal and productive interactive relationships of patients and primary care physicians in a medical home environment.

It is quite another to move health plans, the government, and the medical and technological establishment off the dime to fund medical homes models.

The latter sometimes take impending financial failure and data. Still, the realities that health plans have lost 13-14% of their membership over the last 3-4 years, that hospital admissions are stagnant, that the recession continues to deepen, that the business community has lost their global competitive edge due to exploding costs, that Medicare is on the verge of bankruptcy, may not be sufficient signals for the need of a paradigm shift to primary care.

Desperation and clear irrefutable data - from integrated multispecialty groups, multiple medical home demonstration groups, onsite clinics in corporate settings - showing signficant drops in costs, may be the impetus leading to a fundamental paradigm shift back to primary care.

The levers for this shift are likely to come from business organizations, who can move quickly to save their skins and satisfy shareholders, not from the political establishment, which by its very nature moves with glacial speed.