Tuesday, August 19, 2008

Primry care - Transitioning from a Specialty-Dominated to a Primary-Driven Health System

In an ideal world, how would America transition from the present specialist dominated to a primary-driven system?

Logic of a Primary-Driven System

Among primary care advocates, the logic goes like this.

Medicine is a science. Science relies on data. Data indicates funneling all patients though a primary care network with doctors armed with EMRs containing best practice data costs less and improves care. Data separates good doctors, those who cost less and have good results, from bad doctors who overcharge and have less good results.

Pay Only for Filtered Care

Consequently, to improve care, buyers should pay only for data-justified care filtered through primary care doctors. These doctors, using aggregated specialist data, will have sufficient knowledge to refer only to good specialists = those who deliver good results at low costs. Consumers who choose not to go through primary care physicians, and who instead go directly to specialists, will pay out-of-pocket.


This is imminently logical. The trouble is: it may not work. Why not? Medicine is an art, and many visits have little to do with science. Care involves handling a mixed bag of humanity = the seriously ill, the worried well, those who seek to prevent disease, those who simply want to consult with their doctor.

The American culture rests on individualism and freedom of choice. Forcing patients through primary care filters creates a level of bureaucracy. Consumers and specialists will object. A severe shortage of primary care physicians currently exists, and being forced to see them may require month-long waits.

Besides, what defines primary care physicians? Many gynecologists and internal medicine subspecialties serve as family physicians. Furthermore, American consumers think they are smart enough to go to obvious specialist for obvious problems. Americans expect direct and quick access to technologies, now in the hands of specialists. The political obstacles are formidable – specialty societies, high tech hospitals, and even consumer organizations. Many of these obstacles are psychological and have little to do with science and data.

Emerging Power of Primary Care

In my last blog, I described the emerging primary care paradigm. I noted its power to change the health system by placing patients and primary care physicians at the center of care...

The new paradigm differs from the managed care “gatekeeper model” because it rewards primary doctors for same-day appointments, telephone and email consultations, coordinating care, and giving doctors “ownership” of the process of selecting the proper specialists through e- knowledge of specialists’ “value”, i.e. their performance, price, and outcomes. Just paying primary care doctors for telephone consultations could make a tremendous difference, since these doctors may spend at much ½ to 1/3 of their working day on the phone.

The “medical home” and referral “ownership” concepts are based on computer information platforms that aggregate data on specialty performance and cost data. Carrying out these concepts and changing the current specialty paradigm will not be easy. Understanding and transforming the specialty paradigm is not a trivial matter since specialists comprise 2/3s of American physicians and dominate medicine.

The Specialty Paradigm

What is this paradigm? It’s a logical, predictable, entrenched, and taken-for-granted approach to health care. It’s performed by highly trained specialists who are board-certified experts in their fields. Specialists feel they should have authority and freedom to order procedures and tests they deem appropriate. However, buyers of care may think specialists abuse these privileges by doing unnecessary work for personal gain.

Americans Cater to Specialists

Americans may stand in awe of specialists who crack sternums, replace joints, open skulls, enter GI tracts, examine orifices, look inside bodies, and diagnose, treat, and cure rare and difficult disorders. .Specialists is admired as “doers” rather than strictly thinkers. Americans like those who do and are willing to pay for what they do...Doing is concrete and billable; thinking is abstract and hard to itemize.

Vertical vs. Lateral Thinkers

The specialist paradigm is a prime example of “vertical thinking,” a straight-forward, linear, and scientific approach to solving problems. Vertical thinking differs from “lateral thinking,” solving problems by unconventional, innovative, and creative means.

Edward de Bono, MD, founder of Thinking Institute in Malta and author of more than 60 books, invented the concept of lateral or creative thinking. In health care, de Bono once explained the differences in vertical and lateral thinking in this way.

Vertical thinkers dig deeper and deeper holes across the health care landscape. At the bottom of each hole, you will find a world class expert. The only problem is the various vertical holes don’t connect. One specialist may not know what the other specialist is doing and may have no means of communicating with him/her colleagues or hospitals.

The lateral thinker, on other hand, roams the countryside looking for connections, seeking ways to put things together into an integrated whole, searching for a system blending relationships and eliminating care gaps, and hunting for self-organizing information platforms and disruptive innovations that lower costs and that work outside traditional specialty silos.

There are, of course, examples on integrated systems – Kaiser, Mayo, the VA, the Cleveland Clinic, and academic institutions. Most hire salaried physicians with a common institutional mission and with primary care physicians and specialists working in tandem.

These systems are admirable, but most independent practitioners don’t have the resources or infrastructure to implement what integrated systems do. These institutions are the exception rather the rule for U.S. health care. They care for perhaps 10% to 12% of patients. Consequently, many patients must wend their way through the maze, sometimes falling through the cracks, sometimes seeing care duplicated, and sometimes undergoing needless procedures.


The typical Medicare patient with chronic disease sees six different specialists, some of whom are unaware of the other. Individualism is often the modus operandi among doctors and patients. Many patients believe they have enough sense to make their own decisions and choose their own specialists. Besides, they may enjoy the freedom of picking dermatologists for skin problems, ophthalmologists for eye disorders, bar iatric surgeons for obesity, orthopedists for joint conditions, and so forth, commonly on the basis of word of mouth from relatives, friends, or neighbors.

Hospitals Promote Specialists

Hospitals recruit and promote high tech specialists, who contribute 80% to 90% of their bottom lines. Hospital marketing departments unabashedly promote expertise of doctors armed with the latest robotic surgical device, computer imaging device, or heart disease detection equipment. These activities are typical of hospital high tech marketing wars, designed to show who is on the cutting edge.

Reimbursement Favors Specialists

In the meantime, some primary care doctors may suffer economically because specialists essentially control the coding rates through the AMA’s RBVS Update Committee (RUC). RUC rewards specialists more handsomely than primary care physicians (see www.medinnovationblog.blogspot.com, “The RUC (“RBVS Update Committee ) Ruckus,” December 11, 2007, and are reluctant to give up any of their revenues to primary care physicians in a revenue neutral environment.

Quality’s Multiple Dimensions

Meanwhile arguments rage on what constitutes “quality,” how to prove it,” and how to improve it. Quality often resides in the eye of the beholder. Some say it rests on data, others on convenience and satisfaction. In reality, quality is combination of patient satisfaction and anxiety, physician personality, convenient and timely access, and performance and outcome measures. These factors aren’t easily be teased from one another.

Sensible business buyers tend to define quality as physicians or systems that satisfy employees while following “best practices.” The Patient-Centered Primary Care Collaborative believes the greatest satisfaction, lowest costs, and best care, collectively constitute “quality,” and its achievement lies in comprehensive primary care. Specialty societies may think otherwise, i.e., in procedures done well by “best” or “top” doctors, whether performed independently, in isolation, or as part of a larger institutional system. .

Consumers tend to equate quality with being seen promptly and efficiently by primary care physicians close to home and being seen, operated upon, or having procedures by top-grade specialists in the immediate region. Reputation is paramount in consumers’ eyes. This is one reason hospital marketing is so effective. Consumers don’t pay much attention to Internet rating systems. Payers may equate quality with patient satisfaction; others with price, outcome, and adherence to best-practice metrics.

To paraphrase President Bill Clinton, quality depends on what “is” is. Quality, like sex, is a slippery subject. Quality depends partly on the participants’ satisfaction, partly on personal desires, partly on metrics, and partly on the aftermath.

Conclusion: Changing the specialist paradigm may be more difficult than transforming the primary care paradigm. The real world is a messy place. Doctors don’t always fall neatly into categories. Some primary care doctors specialize. Some specialists do primary care. Some thinkers do. Some doers think. Most do what needs to be done in spite of their category. Those who think otherwise may be suffering from hardening of the categories. Nevertheless, because of relentlessly rising buyer costs, ever growing consumer dissatisfaction, and uneven quality, the primary care paradigm has reached a tipping point, and ultimately, specialists may follow

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