The End of the Primary Care Physician

The need for more primary care is quite apparent.  An effort to raise primary care provider reimbursement will be too little, too late.  And for a multitude of reasons—mostly the byproduct of crazy incentives over a number of years—the days of primary care physicians are numbered.

And I’m not so sure it’s a bad thing.

Last week the Wall Street Journal Health Blog asked a simple question, “What will primary care look like in twenty years?”

We know primary care’s messed up. Docs get paid a lot for doing procedures, but not much for sitting with patients, trying to figure out what’s wrong and what to do about it. So where do we go from here?

The post is in regard to a JAMA commentary that lays out several new primary care models that are currently being experimented with including the medical home, see a nurse first, and doctors on retainer.

Primary care’s next model, one that can be well staffed and more consistently reimbursed, will be most like the see a nurse first concept:

A service workers’ union in Las Vegas and Atlantic City is testing a tiered model where patients see more of “nonphysician clinicians and staff” (sounds to us like advanced practice nurses, physicians assistants and the like). The physicians manage the team and provide direct care for patients who have more complex medical problems, and oversee the nurses who treat the healthier patients. The authors note that basic prevention and screening visits may not be a cost-effective use of a physician’s time in many cases.

The shortage of primary care physicians has been well documentedAnother reference.  And for good measure.

Merrill Goozner of GoozNews writes about “Reform Woes,” and describes our problem of so few primary care physicians, “The U.S. doesn’t have too many doctors, it has too many specialists — about 70 percent of the total. In Europe, the ratio is almost exactly reversed — 70 percent primary care and 30 percent specialists.”

Jeff Goldsmith has a post at The Health Care Blog outlining the ramifications of an aging physician population (read: retirement) and a new breed of physician whose values are very different from the group proceeding them.

We know there is a problem.  The question, then, is what are we doing to do about it?  We should not pin our hopes on law makers realigning incentives to encourage more medical students to enter primary care practice.  So let’s work with what we’ve got, and maybe a few innovations that are in the currently in the pipeline, to solve our issues.

What do we need from primary care?

My simplistic answer is this: our primary care model should be one that treats the most common diagnoses, provides disease management services, and refers more difficult issues to specialists.  And we don’t necessarily need a doctor to perform these services.  Advanced practice nurses, physician assistants, and pharmacists are three groups of providers who can all perform these functions.

The Wall Street Journal recently had an article about nurses attaining their doctoral degrees.  These “Dr. Nurses” will be able to provide primary care:

More than 200 nursing schools have established or plan to launch doctorate of nursing practice programs to equip graduates with skills the schools say are equivalent to primary-care physicians. The two-year programs, including a one-year residency, create a “hybrid practitioner” with more skills, knowledge and training than a nurse practitioner with a master’s degree, says Mary Mundinger, dean of New York’s Columbia University School of Nursing. She says DNPs are being trained to have more focus than doctors on coordinating care among many specialists and health-care settings.

Yesterday, the WSJ Health Blog posted about pharmacists and primary care roles:

People have been toying with this model for years, and a new paper in the Archives of Internal Medicine is further evidence that the concept has legs. Regular consults with pharmacists significantly reduces hospitalization rates for people with heart failure, according to an analysis of 12 randomized trials.

Not to mention physician assistants who have been performing the primary care role for years.

Adding a number of primary care providers to the system should be sincerely welcomed.  It will allow and encourage providers to spend the appropriate amount of time with patients.  More providers will encourage innovation and experimentation with new delivery models, like this one: the reemergence of the house call will allow patients better access, as this Boston Globe op-ed describes:

Close your eyes and envision a physician carrying his or her black bag to make a house call on a frail elderly person, someone with a disability, or even an aging baby boomer. Does this image seem as outdated as multi-week hospital stays? Actually, house calls, with their potential to lower costs while improving healthcare quality, are more relevant than ever.

Today, a disproportionate percentage of rising healthcare costs are tied to the expense of caring for those with complex chronic illnesses and serious disabilities. This population cannot easily get to the doctor’s office or have their needs met in a 20-minute visit. In our approach to caring for these patients, there are many missed opportunities to prevent complications requiring costly hospitalizations and nursing home placements.

One of the interesting aspects of a redefined primary care model is the change in employment structure of the primary care provider: moving from the doctor who is self-employed to the providers (nurses, pharmacists, PAs) who will be employed by hospitals and clinics.  While organizations will take on more risk associated with malpractice, the benefits could help reform our delivery of care.

The World Health Care Blog has a related post.  This excerpt highlights the challenge of moving away from the primary care physician to the more broadly defined primary care provider:

More recently, the medical profession has taken on developments such as retail clinics which use nurses or physicians’ assistants, rather than physicians, on grounds of quality concerns.  The fact that these clinic offer more convenient care at lower prices, hence take away lucrative patients and visits from physicians is by no means ignored, though never mentioned by physicians, themselves, as a reason for their objections.

If physicians don’t want (or are unable) to practice primary care, why fight it?  We have very capable individuals who could step into the roles of primary care that are most needed and do a wonderful job.  Redefining primary care functions, and those who serve in the roles, is a needed change in our system.

5 thoughts on “The End of the Primary Care Physician

  1. I couldn’t agree more. The use of mid-level providers is an excellent cost effective method of improving the primary care provider issue. It opens up doors for advanced practice nurses and physician assistants which is good. It improves access as well. The big problem here which will be the typical response from the AMA will be that of patient safety and the lack of training that mid-level providers have compared to MDs. These narcissistic turf wars have little tangibility in terms of a good argument against using mid-levels and demonstrates the continued lack of collaboration that the AMA (many not all) is so well known for. Even Suzanne Gordon writes about this nonsense in her book Nursing Against the Odds.

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  2. I disagree. My hospital is trying to get APNs into the system to undercut the primary care physicians and strongarm us into accepting our diminutive salaries, while inexplicably supporting seven-figure salaries for some of our subspecialists.

    Why should I accept liability for someone else’s work? Sounds like I’ll be transitioning into “concierge” medicine where patients who want to see a doctor will have to pay for that privilege.

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  3. I also couldn’t agree more… Most Primary Care docs are concentrated on preventing the impending Mcare cut. This is just a drop in the bucket when contemplating how to keep our primary care docs busy, useful and reasonably well compensated.

    The theory behind their practice methodology needs to change. They should not fight the move to redi clinics in pharmacies…they should embrace it as it offloads simple tasks that can be repeated all day long by extenders following simple treatment schemes or algorithms.
    Primary care docs must embrace the Quaterback theory which has been bantered about for a while now.

    Primary Care physicians should provide the clinical leadership, practice population oversight, care coordination, and overall direction for care teams The resulting reimbursement should then be based on the results of their care coordination abilities and the proof of their efforts. The payors and Mcare are beginning to consider how to reimburse these care coordinators and I think we should support this wholeheartedly. Fighting to prevent another medicare cut is just an annnual right of passage to continuing practice medicine in its current dysfunctional form.

    http://www.howardluksmd.com/journal/

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  4. This is so so so wrong. If your definition of primary care is to follow simple protocols, do preventive medicine and dispense simple medications for colds, flu and UTIs it’s fine to use midlevel providers. But most people are looking for a doctor that can diagnose complex problems, manage co-morbidities and understand the complex organism we call humans. This takes rigorous training and a comprehensive knowledge of physiology, psychology, pharmacology and anatomy. You do not get this training in a 2 year PA course or chiropractic course or nursing school. Every successful health care system in the world is based on robust primary care and that field is honored and valued. If you want to see health care costs go through the roof (more than they already have), just do away with primary care or hand it over to nursing. Everyone will flock to specialists for every headache or stomach ache and the fragmentation will be just what we deserve for this short-sighted view.

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  5. I would personally like to say Nursing school is a POWER house of anatomy and physiology. Nurses are well trained in the physiologic nature of the human body as well as the holistic approach of assessment (more than a 5 minute visit, as you would want if you were the patient DOC.) Please do not assume. We have clinical experience throughout our four year program in medical/surgical/pediatrics/gerontology/primary care/and so on. before medical students get to touch a patient and are still tied up in their organic chemistry courses. (Sucksss) Nursing is the not the practice of following the physician anymore. It’s 2009, and autonomy is extremely prominent in nursing and well deserved at that. This whole argument is proof of the existence of “doing it for the money” and the immature attitudes that befall them when it isn’t what they thought. Tsk tsk. C. Sherid-Peds Surgi ICU RN. ( I did it for the heart.)

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