Explaining the critical gap of primary care physicians

There is a critical gap in the supply of primary care physicians in the U.S., and it should come as no surprise that our existing primary care delivery and payment models are at the heart of the issue.

The traditional primary care model — medical care provided by a physician and a small support staff, often without benefit of health information technology (HIT) — was developed at a time when the physician was focused on responding to “sick” patients with acute symptoms of illness.

Today, primary care providers are expected to focus on keeping patients “well.” This entails doing much more for each patient during a typical office visit — recommending and discussing a variety of age-appropriate preventive services, for instance, or monitoring and coordinating multiple chronic conditions for a growing number of aging patients.

Most of the existing primary care payment models are aligned with the traditional model, with fee-for-service representing more than 90% of practice revenue. But with steadily increasing demands on their time for prevention, screening, education, and complex care coordination, many primary care providers are no longer able to make a living from office visits.

As the pressures of work and financial stresses worsen for primary care providers, fewer medical students are choosing careers in the field, and existing practitioners are opting for early retirement or making career shifts.

In the health policy arena, there has been much discussion centered on increasing the number of primary care physicians and creating incentives to encourage them to embrace population-based primary care.

Effective population-based care — which is concerned with health outcomes of individuals in a group — includes interventions to reach, educate, and eliminate barriers to care. A key goal is to moderate the impact of factors such as lifestyle and behavior, socioeconomic circumstances, employment status, and the environment.

Population-based primary care is proactive and team-based. Moreover, it is the model for the “medical home” envisioned by those who crafted the national health reform legislation.

The patient-centered medical home (PCMH) is essentially delivery of holistic primary care based on ongoing, stable relationships between patients and their personal physicians. It is characterized by physician-directed integrated care teams, coordinated care, improved quality through the use of disease registries and health information technology, and enhanced access to care.

Importantly, the medical home model involves additional monthly payments to primary care physicians in exchange for which they lead prevention, disease management, and care coordination activities that reflect best practices.

The primary care medical home concept has captured the attention of providers, payers, purchasers, and policymakers alike. Demonstration programs across the nation show promising early outcomes, and the model is viewed as one means of reorganizing primary care under healthcare reform.

The working hypothesis is that primary care physicians will be motivated by population-based reimbursement incentives and be more inclined to join with other primary care providers and add additional support staff and technologies, which will enable them to broaden their scope of care and services.

This year’s health reform legislation also sets forth another interesting concept — the accountable care organization (ACO) — as a strategy to address the shortcomings of the U.S. healthcare system in general.

Although ACO payment models vary, the core principles remain the same:

  • Provider-led organizations with a strong primary care base, collectively accountable for quality and total per-capita costs across the full continuum of care for a specific patient population
  • Payments linked to quality improvement that also reduces overall costs
  • Reliable and progressively more sophisticated performance measurement

Clearly, primary care is essential to the success of ACOs because the model is firmly rooted in relationships that exist between primary care providers and their patients.

Implementing the medical home concept and ACO simultaneously could address budgetary concerns while providing more incentives for care coordination.

ACOs developed and tested in combination with PCMHs would constitute a substantial shift from volume-based payment to value-based payment.

Although healthcare reform legislation has created the perfect opportunity for redesigning primary care, achieving such major change will not be easy and will require more than legislative reforms.

It will take leadership from physicians and other healthcare providers and public and private payer support. And it will take changes to reimbursement that reduce the primary care specialty income gap and support investment in necessary practice improvements — e.g., additional support staff and health information technology.

Public policy interventions must be crafted with care in order to support opportunities such as:

  • Educating primary care providers
  • Funding pilot projects
  • Creating laws tying payment to solutions that deliver the greatest quality for the least cost
  • Fostering the creation of ACOs that unite traditional medical care with innovative primary healthcare delivery, especially those that incorporate population health solutions

In his recent commentary in Health Affairs, David M. Lawrence envisioned a “scalable, technology-based, disruptively reliable, affordable, direct-to-consumer primary health ‘front end’ consisting of state-of-the-art wellness programs that help consumers incorporate risk-reduction strategies through behavior change, preclinical disease screening and referral, chronic disease monitoring and self-management, triage, and navigation support when an individual requires sick-care.”

I remain optimistic that, with thoughtful public policy, adoption of the primary care medical home concept, appropriate payment reform, and development of accountable care organizations, our redesigned system will boost the health status of Americans and improve the quality of healthcare delivered by providers — all at lower cost!

David B. Nash is Founding Dean of the Jefferson School of Population Health at Thomas Jefferson University and blogs at Nash on Health Policy.

Originally published in MedPage Today. Visit MedPageToday.com for more health policy news.

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  • jsmithfan

    Wake up buddy. You’re living in la-la land. From my perspective as a general internist PCP, you would have to quadruple the revenue paid to PCPs to allow this to be a sustainable model. This would allow PCPs to double their current income and encourage trainees to actually start choosing primary care again. The other half of the pie would go to all of the administrative, IT, and staffing costs inherent in providing the round the clock accountable care you are touting. Dream on. I wish I shared your hope and optimism. But alas, I am an actual “provider” in this screwed up system and this PCMH/ACO model is even worse than the fee for service environment we currently practice in unless the payment reform is as drastic as I describe above (never going to happen.) We are quickly heading toward a world of ARNP run “Minute Clinics” and Concierge Medicine practices for the remainng MDs. I’m not sure that’s what the population wants, but that’s what they’re going to get.

    • r watkins

      Exactly.

      The OP writes:

      “the medical home model involves additional monthly payments to primary care physicians in exchange for which they lead prevention, disease management, and care coordination activities that reflect best practices”

      Translation: the only way PCPs will raise their pay is to, on top of what they’re already doing, take on lots more administrative and bureaucratic work of the type that docs despise.

      Who want to go through medical school and residency so they can become a “team director” and sit in front of a computer managing patient registries?

  • ninguem

    If primary care was really needed, people would pay for it.

    • jsmithfan

      Obviously I fundamentally disagree with this statement, but I’m a PCP and I’m biased. This is why I think concierge care medicine is the only way PCP MDs will survive. Our culture doesn’t value primary care and so it doesn’t pay for it. Our entitled culture does EXPECT premier primary care but it doesn’t truly value it or the compensation system would be different. For those select patients that have chronic disease or actually value longitudinal care with a doctor that knows them, they WILL pay for it. But the government and population as a whole WILL NOT. That’s why expensive subspecialty oriented assembly-line/cattle-call medicine will prevail for most. Ain’t America great!

      • ninguem

        I’m a primary care doc too.

        But hey, maybe I didn’t say it right, since you seem to agree. “Our culture doesn’t value primary care”.

        And I agree as well. “Concierge” care. Scare quotes only because that term seems to mean different things to different people, but I know what you mean. I’d add consumer-directed healthcare, where patients may come to value the savings of one comprehensive primary care visit, versus several specialty visits (and seeing the specialist’s midlevel practitioner).

  • http://www.BocaConciergeDoc.com Steven Reznick MD FACP

    Agree with JSmithFan but I am an internist geriatrician too. I do not want to manage care teams at the expense of spending time seeing and caring for patients. The patient centered medical home reminds me of attending rounds in training when the professor , three interns, one resident, three medical students, several nursing students and a medical social worker went from bedside to bedside. Summations of patient situations were presented by the housestaff to the attending who might ask a directed question of the patient or do a directed exam and then either agree with the care or suggest alternatives. There was certainly no budding doctor patient relationship or hint of longitudinal care.
    As for ACO’s, my local hospital has purchased physician practices, lost millions of dollars managing them poorly and given them back to the doctors to run several times already. Why would I want to be their employee and dependent on them to distribute funds received for patient care
    In todays world a PCP needs to earn $215-250 K in pretax dollars to be able to pay back their loans, support a family, buy a home and run a practice. They need to be able to make clinical decisions within the community standard without being second guessed and bypassed continually. When that occurs medical students will choose to go into primary care.

    • Fam Med Doc

      Dear Dr R,
      you wrote,
      “In todays world a PCP needs to earn $215-250 K in pretax dollars to be able to pay back their loans, support a family, buy a home and run a practice.”

      thank you for so clearly painting what i have known for awhile, that primary care doctors pay is too low for what is necessary to attract and keep docs in primary care. currently in primary care, im getting out soon because the pay is so low and and i see no change in the future. with over 140 K in student loans, i will never be able to get ahead but will scramble. unacceptable. so im getting out and leaving primary care. the sooner the better.

      which is sad because i have built up a great panel of patients who trust me and continue to come back year after year. and i love primary care.

      i just didnt know it would be so difficult in primary care when i selected that field in medical school.

      but the reality is society doesnt value our work. i just wish i had know that in medical school. in retrospect, i could have loved a speciality just as much as primary care.

  • maribel

    I don’t think primary care should be covered by insurance. Doctors then could be free of the headaches caused by medicare and private insurance (which should be reserved for procedures) and could practice medicine the way they want to. If someone doesn’t pay you, drop him as a patient – we need you more than you need us. If people don’t value their health enough to budget money for it that would be their choice – just like it’s their choice to never exercise and to consume 3x’s the number of calories they need each day.

  • Dr.Z

    @Dr. Nash …

    “David B. Nash MD, MBA
    The Dr. Raymond C and Doris N. Professor and Chair of the Department of Health Policy
    Jefferson Medical College
    Thomas Jefferson University
    Philadelphia, Pa, USA”

    So you aren’t practicing medicine in a traditional PCP capacity I gather?

  • Primary Care Internist

    If they just took all the salaries from every academic and pseudo-academic nonpracticing MD sitting in front of a computer 39 hrs/week and supervisising residents / med.students on rounds for 1 hr/wk, and combined all of that money, then distributed it among the shrinking cadre of actually PRACTICING DOCTORS, that’d be a start to cutting “waste, fraud, and abuse” that Obama keeps spewing about.

    After all, teaching hospitals are substantially supported by the gov’t in payment for residency training spots, non-profit status, etc.

  • Primary Care Internist

    Also, as far as the increasingly popular “team approach”, what i foresee is that the only “team” member reachable on evenings or overnight or weekends is the DOCTOR.

    After all, try contacting a social worker, NP/PA, physical therapist, or administrator after hours these days. That’s right – nobody is available, call back during regular business hours, if emergent call 911 or your doctor immediately. With expansion of such a team, this will only get more UNcoordinated. This simple truth is so obvious to anyone who has run a small business but seemingly so foreign to our policy-makers and academic “doctors”.

    • HJ

      “After all, try contacting a social worker, NP/PA, physical therapist, or administrator after hours these days.”

      I have my therapist’s home phone, cell phone, office phone, and e-mail. She also answers e-mail when on vacation. My physical therapist gave me her home phone and her e-mail during a difficult period. With both providers, I can get a same day appointment if needed.

      With my doctor, there are no urgent appointments, no direct phone conversations.

  • http://thehappyhospitalist.blogspot.com The Happy Hospitalist

    I can’t wait until the day comes where I can hook video cameras to the lapels of hoards of APRNs coming our way and then I can just sit at home with multiple LCD monitors while watching my patients as supervisor of the APRNs rounding on them from 8:00 – 4:30, with a 30 minute lunch break.

    The future of hospitalist medicine is going to be great. I think we could probably extrapolate this model to outpatient clinic. Why are you guys all worried?

    I’m excited about hope and change coming our way

    • HJ

      My spouse was hospitalized and was seen by a string of physician assistants while the doctor in charge of his care sat in the background. They didn’t wear cameras.

      • http://thehappyhospitalist.blogspot.com The Happy Hospitalist

        I want my APRNs to wear cameras, so if I run into the patient that I’ve never met, at the grocery store, I could ask them how they’re doing.

  • Dr.Z

    In the UK … PCP is king. PCPs are in private practice w/specialists for the most part employees of the NHS hospitals. PCPs have capitation contracts with the local/regional primary care trust. Patients have 24 hour PCP coverage … not through ED. “Out of hours” surgeries established to provide the service or else the primary PCP has to provide 24/7 service. Making patient records available to your after hours partner is the reason that in UK nearly total adoption of EHRs by PCPs… w/out any NHS incentive money.

    PCPs do very well in the UK … no gerimandered FFS reimbursement nonsense … just simple capitation contract by patient name.

    Hospitals are problem implementing EHR though … despite having NHS as the single national general hospital operator.

  • Anon-MD

    I am probably a lone voice in the wilderness here, but this whole “focus on wellness” is a joke. It is a misdirect. It is also a waste of physician training.

    EVERYONE is going to get sick. Not only do we have limited data on preventive care, there is no evidence it saves money or saves lives. But even if it did … I go back to my original statement … everyone is going to get sick, and at some point terribly ill. And it is not going to happen to most of us in our 90s.

    Doctors take care of sick people. They are trained to make them well and, if patients want, to keep them well. And we need that. We need good, motivated doctors to take care of sick people. In fact, if there is a shortage of physicians, as suggested, the last thing we need to do is divert this valuable resource from the sick, to care for the well.

    More important, we need to NOT divert scant resources from the sick to the well. For one thing, where is the money going to be when people get sick? Sorry, Mr Smith, healthcare is only for the well. If you are sick, you have only a limited number of options. Good luck

    I know there is criticism that the medical industry is keeping people sick. It is just not so. Sometimes I wonder if Pharma can be criticized in that regard … where are the cures? Obviously, our system generously rewards them to discover drugs that maintain chronic illness. But what I see day to day is doctors trying to get patients well, and patients wanting, for the most part, to get over an acute illness and get back to status quo

    Now, there IS a role for preventive care and health maintenance. But it is not the role of doctors. We definitely need to motivate Americans to choose more healthy behaviors. But that is not the primary role for doctors

    • jsmith

      You’re right. Wellness is vastly over-rated. A naked emperor, but people aren’t ready to hear it.

  • Sandra

    We don’t need MORE staff in primary care, we just need to shift the traditional paradigm about how we think about and deploy that staff and have skilled/quality staff members and not just ANY RN or MA. Primary care MDs need to step back from the forest and see the trees — that about half of the time when a patient makes an appt with their PCP, the need can actually be fully addressed by a non-MD (RN w/ meds from MD if needed, physical therapist as front line, or NP/PA to see the simple sniffle-related stuff and a few other things). Accepting this concept doesn’t at all diminish the role of the MD — it just frees the MD to take care of true MD-level needs of which there are plenty, makes MD access better, MD worklife sustainable, and even allows the MD to be responsible for a much larger number of pts. doesn’t work with FFS though — only in a capitated or HMO environment. I’ve been doing this for the past 3-4 years, seeing about 8-10 pts per day with lots of email w/pts too, with an IM panel size of 1400 at “a large HMO” in the NW. To do it, you need Direct PT and a few SKILLED RNs (not just any RN) to make it fly.

    • http://thehappyhospitalist.blogspot.com The Happy Hospitalist

      We don’t need MORE staff in subspecialist and surgical care, we just need to shift the traditional paradigm about how we think about and deploy that staff and have skilled/quality staff members and not just ANY RN or MA. Subspecialists and surgeon MDs need to step back from the forest and see the trees — that about half of the time when a patient makes an appt with their subspecialist or surgeon, the need can actually be fully addressed by a non-MD (RN w/ meds from MD if needed, physical therapist as front line, or NP/PA to see the simple stuff and a few other things). Accepting this concept doesn’t at all diminish the role of the MD — it just frees the MD to take care of true MD-level needs of which there are plenty, makes MD access better, MD worklife sustainable, and even allows the MD to be responsible for a much larger number of pts. doesn’t work with FFS though — only in a capitated or HMO environment. I’ve been doing this for the past 3-4 years, seeing about 8-10 pts per day with lots of email w/pts too, with an IM panel size of 1400 at “a large HMO” in the NW. To do it, you need Direct PT and a few SKILLED RNs (not just any RN) to make it fly.

    • HJ

      This actually sounds like a great model for outsourcing primary care.

    • Fam Med Doc

      may i ask, are you an RN, NP, or MD?

  • IndiepsychNP

    As a psych ARNP in private practice with no office staff except for a bookkeeper for reconciliation, I am on call 24/7. When I was in a multi-specialty practice I shared the night and weekend pager with the one psychiatrist. None of the PhD psychologists carried it in case an actual medical emergency arose. I can tell you why you can’t reach your “mid-levels” after hours: It is implied by the fact that you call
    them mid-levels. If you treat them like profit generators for your organization or financial stop
    loss tools, they are not incentivized to take call. Also, if don’t trust their judgment to handle after hours calls, then you should definitely make them wear cameras while they treat patients, review their charts and then you would probably have to give out some raises and (maybe let a weak link go?) and have some people to share call with….

  • imdoc

    The author of this article could not possibly have been practicing in a capitated HMO of years gone by. That model had all the same promises and I recall being told to “get on th e bus” because this is the new way. History tells the tale: the whole thing was an utter failure. As soon as primary care actually started preventing expensive care episodes and managing costs, the insurance companies soaked up the proceeds

  • jsmith

    I read this post and shake my head sadly.
    Option 1: Be an incentived PCP, managing the population and keeping them in tip-top shape, Big Macs and smokes nothwithstanding; managing your ever-changing cadre of nurses and MAs; going back and forth with your suit-wearing fiscal overlords, two years out of a bachelors program in Health Care Management; jockeying the ever-crashing EHR so as to make sure the paps all get done so you don’t lose your 0.5% quality-of-care bonus; butting heads with the subspecialists over money at the weekly (and after hours) ACO meeting; and, oh, by the way, providing expert diagnosis and treatment, all for a coupla extra bucks per month per patient.
    Option 2: radiology at three times the salary
    Tell me, young med student, which do you choose?

    Med students are not education majors. They have options.

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