Absolutely spot on. Compensation, when dictated by an outside agency, will always go down, whether it be for procedure or “relationship-based care” (terrible term, I thought it was medicine we practiced). The problem that so many PCPs have is that they cannot see any possibilities than their current environment. Yet in the current payment system, they are systematically devalued, despite providing a valuable service.

To save primary care, PCPs must have the courage to no longer take insurance, Medicare, and Medicaid, so long as such programs devalue their services. Rather, they must go to the people who do value their services, the patients. They need the courage to insist on proper compensation from their patients for the care provided, whether that be by the hour or by problem (like your mechanic). Take your case to the market: if you are valued, people will pay you. If not, then primary care deserves to die. Better to let the market decide your fate than some faceless bureaucrats.

Precedent? Well, look at those doctors who don’t take insurance, Medicare, or Medicaid. They seem a fairly happy lot to me.

By seeking the advice of a trusted physician before heading off to that specialist, the patient would increase the price of care. What would be more useful is a triage nurse or maybe a computer program that gathers information and directs the patient to the most economical and apporpriate provider.

Of course, it is implied that the specialist charges more for the office visit and will recommend a procedure that is unnecessary and the primary care physician will save the patient from all these unnecessary procedures.

How about this proposal: People buy insurance for catastrophic costs, say over 10,000, and save for the rest just as responsible people pay for a down payment for a house. The problem with health care cost is the same as the credit crises—too many decision makers with no money at stake.

The person will then want sound advice from a trusted personal physician before trotting off to every specialist in town for every procedure imaginable–because it is his savings at stake. The PCP’s will have the following incentive to advise accordingly: If they don’t, they will get a rep for being too expensive and their practice will suffer in the long run.

Sounds a lot like the days before 1965 when health care costs started skyrocketing doesn’t it?

Let’s face it, It is “good insurance” that really killed primary care just as cheap first dollar financing killed affordable housing.

“refusal to consider a payment model that makes the primary-care doctor share some responsibility for downstream costs is a nonstarter.”
Did the physician make the patient ill? How can the doctor predict what the downstream costs will be for a given patient? Should he simply ration out healthcare, and cut off access when you’re over your limit? Justify the implications of your statement, if you can.

The fact that we spend $2.4 trillion (for $1.4 trillion worth of care) is what's preposterous. Baby boomers start to retire in 2011, and we're in the biggest recession in 25 years. So something will have to give, and hospitals and physicians will be on the receiving end of the belt-tightening, as together we consume or control the majority of healthcare spending.

Primary care has done a decent job of promoting health and controlling spending in other developed countries, better than the fragmented system in the US. And those countries aren't exactly rushing to overturn their systems. On the other hand, Americans' desire for and habits of convenience and access to specialists are going to be hard to break.

When patients are told of the risks and benefits of tests and procedures they often choose less risk and lower costs. So if we can get people to have those conversations with a GP or a nurse practitioner, some of the waste would be saved. Or maybe fundamental payment reform (away for prospective payment & fee-for-service) would do the trick. Like packaging things together and paying for the entire episode of care regardless of the inputs in a particular case. Much like DRGs for hospitals. Of course, packaging ambulatory services would put enormous pressure on small practices to consolidate into multi-specialty groups. But those usually provide better care, so why not?

That was a bit of a ramble; I look forward to hearing what others have to say…..

To the generalist practitioners, it means more money for services and a means to reduce erosion of significance to the specialist communities. It has become a plan for survival.

To the insurers and government, it means cost savings by reducing referral to specialists. The same net effect that incentivized capitated care plans were supposed to have.

I am not sure how patients are to be sold on this. My guess is on fear not so much as opportunity. Insurance against lack of access, especially those without insurance or those on Medicare who are finding difficulty getting into a practice. For those who don’t have that kind of problem, I really can’t see any reason at all why they would care about “medical homes,” they pretty much have what they want.

And that last group is still really a lot of people, probably most of the people in the country. They really don’t have a reason to want a “medical home” anything more than what they have. If anything” medical home” carries the stigma of government care, seeing a mid-level at a big clinic rather that their own doctor. I see that as a very tough sell.

Despite the touting of the “medical home,” what has become a branding and promotional exercise by generalist societies and the interested third parties who envision costs savings by reduced specialist referrals (whiff of incentivized capitated care, here), I am not getting the impression that patients are all that sold on this idea. And I don’t think medical home will sell, unless it is pitched as a remedy to lack of access altogether or as some reassurance that it will prevent lack of access. I think, for most people who receive plenty of generalist and specialist care as they do now, modeling a generalist-hubbed access model, as in Canada or Europe, will not sell unless there were the threat of loss of access and the “home” model was somehow an insurance against that. Now that average patients have been sold on specialty care, it will be just about impossible to wean them off of that.