Primary care - Three Visions: Dissolution, Restoration, or Transformation of Primary Care

I see three primary care visions.

- One is that primary care has “fallen off the cliff,” has hit bottom, will never recover, and will be replaced by armies of nurse doctors, nurse practitioners, physician assistants, and computer-aided consumers practicing self-care.

- Two is that primary physicians are in such demand that their salaries, benefits, and empowered organizations will restore them to primacy and will begin to attract medical students back into their ranks.

- Three is that primary care drive medical homes will transform medicine through renewed personal patient physician relationships leading to preventive care and coordinated, comprehensive care with a resulting renaissance of primary care.

Examples of Vision

What follows are examples of how these visions are being pursued by organizations and individuals.

• ProHealth Physicians, Inc, is a successful 232 member provider group (185 primary physicians, 5 or 6 specialists, and the rest NPs and Physicians Assistants). It is headquartered in Farmington, Connecticut. ProHealth is 10 years old. Primary care doctors are its owners. Over its ten year history, it has enhanced its owners’ incomes, set up diagnostic, imaging, laboratory, and other centers across Central Connecticut, and remained free from hospital control. It recently contracted with AllScripts to install EMRs in doctors’ offices. Its average market share is 18% in communities in which its practices are located. It seeks to restore primary care to its rightful role as a convenient access point for consumers, to set standards for its owners, who remain largely autonomous in their practices, and to improve care. It harbors no illusions that it will transform U, S health care into a primary care dominated system. But it thinks enhanced incomes and systematic pay-down of medical education loans will attract new primary care doctors. This type of organization could be said to belong to the Grow Big, or Die school, namely, that primary care doctors have to be in organizations with sufficient scale to have the capital, ideas, and infrastructure to make a difference and to thrive.

• The Physicians’ Foundation is a non-profit organization. It was formed in 2003 as the result of a class action settlement between state and local medical societies and major health plans. The health plans agreed to fund two physician foundations, which later merged into one foundation. The Foundation encourages physician practice improvement through grants and physician surveys. It has issued grants over $20 million to physician organizations to help them improve care, often through better use of EMRs and IT. Its IT experience has been most physician organizations lack the structure, skills, and incentives to adopt and to adapt to EMRs. Doctors are too swamped with heavy patient loads, insufficient reimbursements, growing overheads, and entangling and suffocating rules, regulations and managed care hassles. In a national survey of 270,000 primary care doctors and 50,000 specialists who often practice primary care, the Foundation learned that the primary care physician are in dire straits, with over 78% saying a primary care shortage exists, and as many as 50% thinking of retirement, alternative practices or careers, with significant numbers expressing disillusionment, demoralization; and most not recommending medicine as a career. The survey results were announced on November 18, 2008 and received wide media exposure. The Foundation hopes to sway public and policymakers’ opinions so that steps will be taken to restore primary care through various measures such as education support, forgiveness of loans, and revamped primary care reimbursement. Its view is that the time is growing late to save primary care, and steps must be taken now.

• The Patient-Centered Primary Care Collaborative - This organization is a mix of leading national primary care organizations, consumer groups, patient quality organizations, health plans, labor unions, hospitals, and others. It has 300 members. Its mission is to make primary care-led medical homes operating as teams the centerpiece of U.S. health care. These teams will stress prevention, electronic information linkage, and coordinated, comprehensive care. Paul Grundy, MD, director of health care transformation at IBM, serves as chairman. Through his leadership, national primary care organizations – the American Association of Family Physicians, American College of Physicians, American Pediatric Academy of Pediatrics, and the American Osteopathic Association – have developed joint principles for the Medical Home, which stresses a team-based approach to primary care with a personal physician at its core. Grundy envisions a series of medical homes across America. As in other countries, these homes or their equivalents will presumably lower costs, improve quality, and produce better outcomes with greater satisfaction among patients and doctors. Grundy’s model for care is Denmark, where

o primary care doctors are paid through a blended three part payment system – fee-for-service, a capitation fee for managing their panel of patients, and bonuses for responsive patient-centered services (same day appointments, and prompt responses to emails and phone calls),

o all doctors and hospitals can communicate through a physician-developed electronic medical record system, where all patients know the name of their personal physician,


o primary care doctors and salaried specialists have equivalent incomes and prestige and status.

Grundy’s view is that “comprehensivenists,” primary care doctors, deserve just as much income and status as “partialists,” i.e. specialists. He maintains that America already has a single payer system, consisting of CMS-RUC (Centers for Medicare and Medicaid Services + the specialty dominated Reimbursement Update Committee), and that this structure will have to be changed if an effective primary care transformation of American medicine is to occur. He says hospitals, specialists, and health plans recognize, or at least give lip service, to the need for this transformation, but it will take time, perhaps even decades, and robust federal and state support to resolve conflicts so that the transformation can happen.

Doctor shortage, physician shortage. locum tenens - Cut and Run: Temporary General Surgeons in Demand

According to the American College of Surgeons, the number of general surgeons has declined 25% in the last 25 years.

This fact has fostered a booming demand for travelling temporary surgeons. These surgeons criss-cross the country in response to requests by community hospitals for surgical coverage. Community hospitals require a general surgeon to provide such basic services as appendectomies, gall bladder removal, gastric hemorrhage control, bowel obstructions, gangrenous limb amputation, trauma repairs, and the list goes on.

Locumtenens.com, a hospital staffing agency, says its revenues have doubled to $2.1 billion over the last 5 years. The agency reports that 1 in 20 of America’s 17,000 general surgeons is on the road these days. Some surgeons say the can make as much as twice as much as locums as they can in private practice, and the business hassles and malpractice worries are much less.

Temporary surgeons are not an ideal fix for the general surgical shortage. Follow up care is sketchy, and continuity of care is less than ideal. And for hospitals, already stretched thin by declining Medicare revenues and mounting debts from covering the uninsured and the underinsured, a temporary surgeon may cost $1500 a day.

Interviews - Interview with Matthew Holt, Founder of The Health Care Blog and Health 2.0 Conferences

Political leaders who aspire to greatness first decide what needs to be done and then set about making it politically feasible. If the current health care reform initiative is limited to questions of coverage, without serious attention to cost control and coordination of care, the “crisis” in health care will continue to plague us for years to come.

Victor R. Fuchs, PhD, professor emeritus of economics, Stanford, “Health Care Reform – Why So Much Talk and So Little Action?” New England Journal of Medicine, January 15, 2009

The only truly promising way to save money is to change the way health care is delivered. In the United States, 85 percent of doctors work in small, fee-for-service practices. Many of these doctors are very good and hardworking. But they are autonomous, not members of teams. They do not systematically share information with one another. They are unable and unwilling to be held accountable for the quality and cost of care they delivery.

Alain Enthoven, professor of management, Stanford “Health Care with a Few Bucks Left Over,” New York Times, December 28, 2008

Prelude: It may seem odd to start on interview with Matthew Holt, a San Francisco-based policy wonk, blogger, and entrepreneur with quotes from two Stanford professors but not when you realize Matthew is a recovering health care Stanford academic. Holt’s professors at Stanford, Victor Fuchs and Alain Enthoven, still influence his thinking, but as you see, he is very much his own man.

Q: Let me begin by saying I enjoy your tart, irreverent, but always readable pieces in The Health Care Blog, which the Wall Street Journal has dubbed as the “granddaddy of all medical blogs,” no doubt because of 2003 start, which makes your blog ancient in the blogging world.

A: Thank you. I enjoy your stuff as well.

Q: How did you come to be such an astute observer of the U.S. health care scene?

A: It’s all part of a professor turning the wrong way in a class. I was a graduate student doing a term paper at Stanford. I was just going to be there for one year, and I was going back to the U.K. I was about to do a paper on the Japanese economy and its investment in the U.K. That subject was taken, so I turned around and asked, “What about the Japanese domestic economy? What about the Japanese health system? “A visitor from Japan showed up and wanted help comparing the Japanese Health System to the U.S. health system, and my interest in health care began. Alaine Enthoven was one of my teachers.

Q: And after Stanford?

After getting a couple of Masters Degrees at Stanford, I ended up at the Institute of the Future. My experience there exposed me to the thinking of the American private sector. I spent about 5 years at the Institute, and I did a lot of work on technology forecasting, particularly in health care. That accounts for my interest in combined health care policy and IT effects on that policy.

Q: What is your official title now?

A: I tend to say I am the founder and author of The Health Care Blog, and the co-founder of the Health 2. Conference. Most of my day to day stuff is running the operations of that Conference but I also write for the blog.

Q: When did you start the blog – now considered the granddaddy of all health care blogs?

A: I started it in 2003, and we recently celebrated its 5th anniversity. Other health blogs were started about the same time, and they didn’t get enough credit. At the time, all the blogs were pretty much writing for each other and most were narrowly focused. But as far as consistently writing about health policy, IT, and interconnections we’ve been around longer than anybody else. It’s nice to be considered a granddaddy when you’re only 5 years old.

Q: Would it be fair to say you’re a follower and admirer of Alain Enthoven – now considered the father of the managed competition approach to health care policy?

A: Yet, but I don’t agree with everything he says. I’m more of a lefty. I believe more in social insurance as the basis for managed competition. But I was definitely influenced by his lecturers and writings at Stanford. You can inject competition and innovation into health care, as long as you get the incentives right. If you inject competition into the system the wrong way, you get what we’ve got now. I think the management in more important than the competition, particularly in how you structure the incentives.

Q: And what about the influence of Fuchs?

A: He is a great economist, and he helped me understand the problem rather than what to do about it. Fuchs had a very clear understanding about the effect of supply driven health care, i.e, if you create more surgeons; you’re going to have more surgeries.

Q: How much do you think you’re influenced by your background as an Englishman?

A: Not that much. But I certainly do like to make international comparisons when I’m looking at how the world works.

Q: As one of the founders of the Health 2.0 conferences, you must think Health IT will go a long way towards fostering more rational and informed solutions to health system problems.

A: Health IT is only going to improve health care if you correct the underlying structure. You can put a lot of technologies in the wrong places and make the situation worse. Look at imaging, for example. We’ve spent a lot of money on imaging in the last 15 years, and it’s not entirely clear it’s done us much good.

Having said that, I think there is something that’s very important that's changed in the world of IT health care. Otherwise it's great. IT technologies have got to the point you can distribute IT tools very cheaply, and now you can insert communication tools into the revolution. These two things make it possible for a “team,” patients and doctors and all sorts of other people, to work with each other to get towards certain outcomes. I think one of the things we’re learning now is there are much more effective ways of sharing information that strictly relying on the physician-patient relationship.

A multifaceted environment is developing. That leads to a series of choice and conflicts. What types of tools should we be using? Who should be paying for them? What outcomes are we trying to get out of them? I’m optimistic we will resolve this issues, and we’ll be able apply computer power effectively to health care. But health IT will not be a panacea. It’s a good thing for health care and for the future of medicine. But it is not pain free.

Q: How important do you think the entry of Microsoft, Google, and other IT giants into the health marketplace are?

A: I think it’s important. It’s part of integration of health care into everyday life and everyday business. It shows that health care is not that different from other aspects of daily life, and it encourages smaller companies without big backing to enter the marketing arena. It gets consumers to understanding new opportunities.

Q: Your Health 2.0 conferences have been a smashing success and have been heavily attended by big and small players alike.

A: My partner and I work like dogs to put them on, and it’s good to see people like them. Most importantly, these conferences offer a forum for useful exchange of information. The conferences help get more information tools into the hands of consumers.

Q: I’ve been interviewing a lot of people about health reform, and the phrase I keep hearing is “We are cautiously optimistic.” Does that fit your view? Are you cautiously optimistic?

A: I’m more optimistic now than I was six months ago. The key issue is the United States is that nobody is really concerned about reform unless it adversely effects their own arrangement. We needed a big recession to drive reform – and we have now have it. If the U.S. middle class thinks it’s going to become the U.S. lower class, and they will be unable to pay the bill when they go to the emergency room, then something might happen. We’re not going to see coverage of the uninsured unless the recession gets really bad. And you need about 15 to 20 other things to fall into place.

Q; I recall Fuchs saying it would take a World War, an economic depression, an unprecedented natural disaster, or something of similar magnitude to bring about universal coverage.

A: I spoke to Fuchs recently, and he said we’re not quite there yet. We may be 40% of the way there. My major concern is that we’ll get a small chunk of people covered that are now uninsured, and we’ll think things are better, and ten years later well wake up and find things are as bad as ever.

Incremental changes should not cause us to declare victory. I’m a huge believer if you don’t get everybody in the system and every dollar accounted for, then the health care system will find a way to keep pricing up and costs up. Which means eventually some will get tossed off the lifeboat, like the uninsured have been for the last 50 yers. You have to make the whole system more cost effective – a huge task because you’re going to gore someone else’s ox.

Q: But what if we don't have enough doctors to cover the uninsured when they're covered? What about the primary care shortage? What good is coverage if you don't have access to doctors?

A: The shortage is important, but primary care will end up by being replaced by things that don’t look like primary care. I think we’ll end up with lower level people providing care. Much of these tasks will be taken over by computer-aided non-physician personnel.

I don’t see how we can develop a core of 300,000 primary care doctors. We’re not going to have the same proportion of primary care doctors that other countries enjoy. I don’t think it’s even sustainable in those other countries. People are going to have to take better care of their own health, and health care it will have to be put in a lower-cost environment.

Q: You’ve been heavily exposed to the West Coast medical environment with the Kaisers and other giant multispecialty clinics. Do you think that model represents the wave of the future?

A: I don’t think so. I think if you change the way you pay for health care, reward FPs for doing the right thing, paying for preventive care, managing chronic disease, not doing unnecessary things, you will see other arrangements coming together. Until you get those incentives in place, it doesn’t make a lot of sense to try to export Kaiser to other regions of the country. The start-up and infrastructure costs are huge, and physician resistance is high.

Q: Any concluding remarks?

A: I’ll continue to do The Health Care Blog and the Health 2.0 conferences, and I hope you will continue to do your stuff. Let’s keep the pot boiling.

Alternative therapy - Alternative Medicine Goes Mainstream

Like most physicians who cut their teeth on “scientific medicine”, double blind controlled studies, and “curative medicine,” I’ve been skeptical of alternative medicine because it often has no “scientific” basis, and its outcomes do not stand up under controlled conditions.

My mindset may be wrong. The American public has certainly embraced plant-based diets, meditation, yoga, acupuncture, and herbal remedies. And in January 9 WSJ piece, “ ‘Alternative’ Medicine is Mainstream, “ four passionate alternative medicine advocates – Deepak Chopra, MD, Dean Ornish, MD, Rustum Roy, and Andrew Weil, MD, forcefully argue the heyday of alternative medicine has arrived.
As evidence, they cite a conference “Summit on Integrative Medicine and the Health of the Public,” to be held in mid-February and to sponsored by the National Academy of Sciences and the Bravewell Collaborative.

The spokesmen, who have academic connections at Harvard, U. of California, Pennsylvania State University, and the University of Arizona, argue that those ignoring life style and diet is causing millions of Americans to die needlessly from obesity, diabetes, heart disease, asthma, and HIV/AIDS. These diseases, with the help of alternative medicine techniques, they claim, could be prevented and even reversed by diet, exercise, behavior change, alternative medicine approaches. They assert what we eat, how we respond to stress, how much exercise we get, and the quality of our relationships and social support can be just as powerful as high tech interventions, drugs, and urgery. Furthermore, they point out 95% of every dollar spent on health care is spent after the disease has already occurred.

I have no argument with these self-evident assertions, in theory. But I do have practical questions. Given our freewheeling culture, can integrative medicine reverse or alleviate these diseases, which account for 75% of costs. in sufficient numbers to make a difference in costs? Will the public, conditioned to live and behave as they please, respond to pleas to behave? Will Americans, en masse, turn to alternative medicine, as a means of reducing health costs?

I have my doubts. Still, alternative medicine is worth a try. “It is time,” our alternative medicine spokespeople say, “to move past the debate on alternative vs. traditional medicine, and to focus on what works, what doesn’t, for whom, and under what circumstances. It will take serious government funding to find out.”

Now all we need to do is persuade Congress to spend the money and patients to take personal responsibility, eat and exercise right, try herbal remedies, use yoga, meditate, and use acupuncture for pain. It might work. All we need is a change in mindsets.

Interviews , blogging, general - Interview with Kevin Pho, MD, of KevinMD.comm fame

Prelude: Kevin Pho, MD, is a leading solo physician blogger in the United States. He has been blogging since 2004 and has a wide readership among the public, fellow physicians, and the media. Doctor Pho, a general internist, practices in a five person group in Nashua, New Hampshire.

Q: First of all, congratulations on being selected – along with Clinical Cases and Images, founded by Ves Dimov, M.D., Clinical Correlations from the NYU Medical School, The Health Care Blog, a granddaddy among blogs, and the WSJ Health Blog – as one of the five finalists for the best Medical Weblogs for 2008. You’re in august company.

A: Thank you. By the way, I read your blog often, and I appreciate this chance to explain my blog to a fellow blogger.

Q: How long have you been blogging, and what motivated you to blog in the first place?

A: I’ve been blogging since May 2004. Initially I started because I wanted to give a physician’s take on the medical news that was being reported. I sought to give a physician’s perspective. I had read other doctor blogs, and I figured I could do it too. I think the blog has evolved, and it is now regarded as the physicians’ voice, especially because of uncertainties surrounding health reform. One of the motivations of the blog was to fill the void created by lack of the physicians’ voices.

Q: You also seem to want to inform your audience what goes on behind the doors of physicians’ offices.

A: Exactly. I want to give patients insight into what they might not know.

Q: You have quite a following. You’re often quoted in the major media, including the Wall Street Journal.

A: Thank you. It’s definitely one of the more visible physician blogs, and I appreciate my readership and those who cite and follow my blog.

Q: I notice you have “subscribers,” of which I am one. How did that come about, and how many subscribers do you have?

A: I am always searching for new ways for people to engage my blog. One of the ways is delivering my contents via e-mail. Not everyone has the time to visit my site, so I deliver it to them. I currently have over 18,000 subscribers.

To help others engage my blog, I also have business arrangements with other blogs, so I can reach a wider audience. This allows me to expose my blog through their networks, and I benefit them by exposing my content to their readership.

Q: I notice you ofte solicit opinions among your readers.

A: Yes, it’s simply another way to engage my readers. It’s always interesting to have others express their opinions. I want to create a forum where others can have a relatively large readership. It’s a good way for doctors to practice writing opinion pieces. We need to get our voice out there. Otherwise those not practicing medicine are going to make our decisions for us.

Q: I notice sermo.com and the Physicians Foundation, which represents doctors in state and local medical societies, are getting the physicians’ voices out there through blogs and surveys. So you’re part of a growing movement of social networking among physicians and informing the media and policymakers that there’ something serious wrong with our system.

A: I agree. Sermo is a great site, but it’s a closed network, and the public can’t read doctors’ opinions. One reason people like my blog are its open to everyone.
Q: What is the proportion of physician versus public response?

A: I don’t have exact demographics, but I think it’s about 60/40.

Q: Perhaps it’s because I’m not a twit, but could you explain to me the “twitter” phenomenon, which has surfaced in the last year or so as a new communication tool.

A: Twitter is the so-called micro-blog. It simply asks the question, “What are you doing right now?” Users are invited to participate in 140 characters or less. It’s a way to write short concise posts. It’s called micro-blogging because of the limit on character size. I have my posts regularly posted on twitter, and people engage me that way. You have to experiment with other media to maximize the potential of your blog.

Q: How long have you been twittering, and what has been the response?

A; I’ve been twittering for 4 or 5 months now, and I have about 2300 followers. It’s been an opportunity to expose my blog to another segment of the population.

Q: What do you consider the major problems of physicians at this stage of health reform?

A: There are so many, but I would say if I had to name one - the physician payment system. We have a fee-for-service system, and doctors are encouraged to do more to generate more revenue. This has a whole host of unintended consequences. More medicine isn’t necessarily better for the patient. Fee-for-services causes doctors to rush through patients, rather than spending more time with them.

Q: Do you think the “medical home” is a potentially promising solution to the payment problem and to spending more thoughtful time guiding and understanding patients?

A: Yes, I do. The patient-centered medical home proposal reimburses for time and coordination of care. If financial incentives are re-aligned for issues that benefit the patient, it’s a good step in the right direction.

Q: What are your expectations for health reform under the new presidential administration?

A: I am cautiously optimistic. In his piece in the New England Journal of Medicine, it was clear he understands the issues facing primary care. But Obama is a politician, and politicians can’t always deliver on health reform. The devil, as always, is in the details, but with the high level of dissatisfaction with the health system, there’s a good opportunity for reform. If something is going to get done, it will get done in the next five to seven years.

Q: A final question. Do you think it’s too late to “save” primary care?

A: It can go either way. One opinion is that primary care has hit bottom, and with the tremendous shortage of these doctors, the market can only get better. According to physician recruiters, primary care is in great demand, salaries are rising, and graduating primary care doctors have their pick of jobs. It’s really a buyer’s market. So primary care may be on the upswing if Obama can follow through on his promises. Although the situation is dire, I predict a better future.

Physician business ideas - Job Ratings - The Good News and Bad News for Physicians

CareerCast.com, a job search portal, is out with its ratings of the 200 “best” and “worst” jobs based on 5 criteria – stress, work environment, physical demands, and income.

• The good news that the income for physicians (psychiatrists $108,000, family physicians $167,000, and surgeons $369,000) far surpasses the average of best ten jobs ($73,500) and ten worst jobs ($33,200).

• The bad news is that combination of high stress, negative work environment, greater physical demands makes physician jobs relatively undesirable in the eyes of the job search firm. Psychiatrists are ranked 100, family physicians 142, and surgeons 156 out of the 200 rated jobs.

Here are the 10 “best” jobs.

Ranking

1-10 – Mathematician, Actuary,
Statistician, Biologist, Software
Engineer, Computer System
Analyst, Historian, Sociologist,
Industrial Designer, Accountant.

And here are the 10 “worst” jobs.

Ranking 190-200

Construction worker, Iron
Worker, Roustabout,
Garbage Collector, Roofer,
Emergency Medical Technician,
Seaman, Tax Driver, Diary
Farmer, Lumberjack

And here are the rankings of three physician specialities.

100. Psychiatrist
142. Physician (Primary Care)
156. Surgeon

The only surprise here is that physician specialties are ranked relatively low in the eyes of job search firms, even though a shortage of physicians exists and health care is among the few growth sectors in the U.S. economy.

Otherwise, I see no surprises.

• The “best jobs” go to knowledge workers, many of whom deal with finances and IT jobs, others with professions, like history and sociology. Most are desk jobs. These jobs have desirable working environments, low physical demands, low stress, decent incomes, and work weeks averaging about 30% less than physicians.

• The “worst jobs” have tough , often dangerous, work environments, high physical demands, slightly greater stress than health professional jobs, but with lower incomes, and shorter work weeks . The “worst jobs” tend to go to mostly non-college graduates who work with their hands, often in stressful environments and who earn much less than physicians.

Not Too Fine A Point

I do not want to put too fine a point on all of this Most of what is presented by the search firm is self-evident and shows the value of an education, and, among health professionals, the long hours, adverse working conditions, and stress under which its practitioners work.