Thursday, May 21, 2009

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.


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.


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.


Paul said...

Thanks Dr Reece,

We are also starting to get some information on the financial Impact of practice transformation. (This from transforMED)

Publication of results from TransforMED's National Demonstration Project (NDP) began last week with the article, "Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home" in the May/June issue of Annals of Family Medicine.TransforMED launched its two-year National Demonstration Project in 2006 and included primary care practices from around the country, studying the process of transforming to a Patient-Centered Medial Home. Additional articles on the outcome of this one-of-a-kind national study will continue to be published, including an extensive supplement to AFM scheduled for publication later this year. Congruent with the efforts of the NDP evaluation team, TransforMED has studied targeted financial data gathered from the NDP practices. The data demonstrate some critical findings about the impacts of practice transformation.

“There has been debate about whether small to medium sized practices can transform to a patient centered model of care. The answer from the NDP is a resounding "Yes!"”

There has been debate about whether small to medium sized practices can transform to a patient centered model of care. The answer from the NDP is a resounding "Yes!" There has also been an ongoing question about whether small to medium sized practices can implement an Electronic Health Record system effectively and efficiently. Again the evidence from the NDP is a resonating "Yes!"

Another national discussion is whether primary care practices can afford to transform; calling into question the financial impact on practices. The Evaluation Team's analysis of the NDP indicates that primary care practices can make substantial progress toward implementing components of the Patient-Centered Medical Home model. TransforMED's analysis of financial data gathered throughout the study reveal that they can do so while improving the finances of the practice as well as physician salaries. It is worth noting that about 70% of practices had an implemented EMR at the beginning of the project, and as a result many of the practices were also implementing EMR systems during the NDP. The analysis of financial data from the NDP demonstrates that practices do not have to experience a reduction in practice revenue as a result of meaningful practice transformation. In fact, the average NDP facilitated practice revenue increased 10.49% and 2.43% in the self-directed practices. Furthermore, physician salaries increased nearly 14% in facilitated practices and 13% in the self-directed practices. It can be deduced that the revenue and salary increases reflect increased efficiency because physician salaries actually rose at a greater percentage than the practice's increase in revenue.

These data demonstrate that primary care practices can accomplish meaningful, extensive practice transformation. Adequate attention to the "business of medicine" and effective practice management can lead to improved revenue and increased efficiency thus allowing the practice to absorb the cost of change and technology while improving the bottom line. Future data will most likely continue to demonstrate improved practice revenue and physician income as practices move past the challenges of transformation while providing solutions to the challenges facing the US Healthcare system.

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