Thursday, December 10, 2009

Physician Business Ideas - Why Don't Intergrated Primary Care Based Models Catch Fire?

I’ve been writing about integrated health care for 35 years, first in Minnesota and later from a national perspective, focusing especially in California, the land of Kaiser. I’ve listened to the arguments about HMOs creating primary care gatekeepers, to managed care as a means of reducing specialty and hospital referrals, to paeans about cost-effective capitation would be, to Paul Elwood saying all the nation needed were ten megaclinics like Mayo and Kaiser blanketing the landscape, and to Steve Shortell proclaiming that integrated networks emanating out of hospitals were the future.

If these concepts are so compelling, why haven’t they swept across the land like a prairie fire? Why haven’t independent physicians bought in on a wholesale basis? And why have they resurfaced so forcefully as a main strut of Obamacare?

In the December 10 New England Journal of Medicine, Diane Rittenhouse, M.D. and Stephen Shortell, PhD, of the Department of Family and Community Medicine at the University of California, San Francisco, and Elliot Fisher,MD., of the Dartmouth Institute and Dartmouth Medical School, try again to push primary care and integrated models as the solution to our fragmented system.

All the U.S. needs, they argue, are patient-centered medical homes (PCMH) and accountable health organizations(ASO), which may take the form of large integrated delivery systems, physician-hospital organizations, mutipspecialty groups with or without hospital ownership, independent practice associations, or virtual-interdependent networks of physician organizations.

With medical homes as the base of accountable care organizations, they proclaim, the U.S. can have “ first-contact primary care that is continuous, comprehensive, and coordinated across the care continuum,” aided and abetted,of course, by “electronic medical records, population-based management of chronic diseases, and continuous quality improvement.”

Fine, even noble, words these. But it seems to me these thoughts are nothing more than gatekeeper, capitation, and integrated models in new clothing. Perhaps these two government supported and imposed models will work. Perhaps the multiple demonstration models envisioned for Medicare will save money and improve care.

But I am dubious. Why? For the following reasons.

Primary care doctors,

• are already in desperately short supply, and they do not have the will, or time, or resources to build the team or infrastructure to quickly build medical homes.

• don’t have the leverage to cut referrals or admissions to other providers who benefit from the status quo.

• can’t quickly address the cultural, legal, and resource barriers to create new organizations in most communities.

• would have to overcome already demonstrated patient resistance to being channeled to the specialists of their choice.

• might well resist being coerced by federal agencies to convert their current practices into medical homes and to be employees of powerful accountable care organizations.

Lastly there are issues of privacy, freedom of choice, and restrictions of individual liberties to overcome. There is also the problem of herding a million or more care providers, which operate in nearly 600,000 locations, into more centralized organizations. We should also keep in mind we live in an overwhelming bottom-up rather than a top-down society. Social prairie fires that must leap multiple cultural barriers tend to flame out from lack of oxygen.

Dr. Richard Reece is author, blogger, speaker, and innovation and reform commentator. Dr. Reece’s latest book, Obama, Doctors, and Health Reform ( is available at and other book websites. For information on speaking fees and arrangements, call 860-395-1501.

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