Sunday, August 10, 2008

Primary Care, Variations off the Main Theme

The Foundation for Health System Excellence, representing physicians in state and local medical societies, has just completed a national survey of all U.S. primary care physicians, the results of which are being tabulated, to be released when ready.

I would like to examine variations off the main theme, the main theme being primary care clinicians practicing by themselves and under the thumb of managed care insurers. There are roughly 300,000 primary care physicians – family physicians, general internists, pediatricians, most of whom treat insured, Medicare, or Medicaid patients

Physician Assistants and Nurse Practitioners

Primary care doctors are in short supply, maybe on the verge of extinction; even though policy experts assert these doctors form the backbone of national health systems. Many primary care doctors seek to survive by hiring and working with physician assistants (PAs) and nurse practitioners (NPs). Since 2001, PA numbers have grown from 43,000 to 68,000, and NPs from 82,000 to 125,000.

PA and NP salaries are in the $85,000 to $90,000 range, a pretty penny for many struggling primary care practices. Their roles differ. PAs must practice under a physician’s supervision. NPs may practice independently, though most do not. PAs tend to work for generalists, NPs for specialists. In the last 5 years, NPs have rapidly risen to prominence for staffing retail clinics, now numbering about 1000.

Nurse Doctors, Another Variation Off the Theme

In 2004, the American Association of Colleges of Nurses recommended new NPs, who now have masters degrees, earn a doctor of nursing by 2015. The Columbia School of Nursing offered the degree in 2005. Now 74 nursing schools do, and 63 more have programs in the works. Doctor nurses may practice independently, prescribe, treat patients on their own, and join medical staffs. They are intended to supplement, even replace, primary care practitioners.

Prepaid and Cash Only Primary Care

Yet another variation off the traditional theme are generalist doctors who drop out of Medicare, insurance plans, and third party programs. These clinicians, who many in the elite medical establishment consider mavericks, treat patients on the basis of a prepaid retainers, generally $1000 to $2000 annually, which may be paid in quarterly installments, or on the basis of discounted “cash-only” fees, often 50% less than current fees.

Critics may label prepaid primary care as luxury, concierge, platinum, boutique, VIP, or two-tier care, the implication being practices cater only to the wealthy. “Cash-only” practitioners call their services direct, patient-financed, simple, innovative, or payment at the point of service. These practices serve all comers, including the uninsured, underserved, or those unhappy with the present system.

Common Distaste

Pre-paid primary care retainer practices and the cash only crowd share a distaste for practices beholden to insurers, practice restrictions, staff and other overhead required to process claims, low and delayed reimbursements, entangling bureaucracies, and for the assembly-line care they must provide to break even.

Marcus Welby Reincarnate

Both may say their care represents a re-incarnation of Marcus Welby, with more time, greater access, and closer patient relationships. Prepaid practitioners limit their base to 350 to 500 patients, down from current loads of 2000 to 2500 patients. Cash-only clinicians do not restrict numbers of patients, some of whom may be transient. Services for retainer practices may include unlimited doctor access,24 hours a day, 365 days a year; unlimited telephone and e-mail access, uninterrupted time with physicians, annual lab work,EKG and hearing evaluation, coordinating care,
navigating patients through the medical maze, and referral to top specialists. Cash-only doctors generally offer across-the board discounts for most services.

How Many Prepaid or “Cash-Only” Practices Are There?

It’s hard to tell. The practices go by different names, and they may or may not belong to associations. Their practices may be controversial, and they often assume a low profile posture.. Retainer practices limit rather than expand practices, so no need exists to to market. The Society of Innovative Medical Practice Design ( an umbrella term that generally implies concierge practices, says its members practice in about 30 states and covers over 100,000 patients. SimpleCare, Inc, in Renton, Washington, which has a fee-for-service fee schedule for short, medium, and long visits, claims it has a national network of 1600 physicians.

In my book, Innovation-Driven Health Care(Jones and Bartlett, 2007), I observed,

” The number primary care physicians leaving traditional practice is a precious few. I estimate their numbers at less than 1% of practicing physicians, although I can find no single source to document their actual numbers. The success of these practices depends on the willingness of patients to pay out of pocket for more personal, more convenient care.”

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