The future of primary care in an ACO model

Primary care is a unique field of medicine.

Primary care physicians (PCPs) are the gatekeepers to specialized care, provide preventative care, and most importantly, they have the ability to manage patients with multiple chronic conditions. Thus, primary care physicians are in prime position to become the point men in the accountable care organizations (ACOs).

Accordingly, the value of PCPs will increase, and their salaries will rise. Moreover, the goal of establishing patient center medical homes seems obtainable. The key tenets of medical homes, which include long-term personal care, integrated team-based care, and increased access to health care, will improve patient health.

But a medical home without foundation is not a home at all. Currently, there are not enough PCPs in the U.S to address the increase of the U.S population, the retiring of the baby boomers, and the increasing number of patients with chronic conditions. So despite a likely increase in prominence, one must wonder if health care reform, particularly the ACO model, can help revamp the field of primary care.

The solution is clear either increase the number of PCPs by increasing the number of foreign PCPs or increase the number of U.S medical graduates going into primary care. But are there enough incentives to instigate the change necessary to meet the increase of people entering the health care system? Simply, the answer is no. Sadly, for many medical students, good intentions are not enough. This is an issue beyond financial considerations. Rather, it is a matter of lifestyle. For many students, primary care is not “sexy.” Ear infections, back pain, diabetes, and hypertension just are not as interesting at coronary catherization and advanced MRI studies. But the lifestyle concern expands beyond the day-to-day care provided; it is about the lives of physicians once the white coat comes off. The grueling demands of medical education and a generational shift towards prioritizing a more controllable lifestyle has resulted in medical students seeking specialties with a better work-life balance.

It is questionable whether primary care can provide this lifestyle. By 2025, the workload for PCPs is expected to increase by nearly 30% relative to the workload in 2005. Being the prime players in ACOs could possibly further increase the workload of PCPs. However, if team-based care really does take hold in ACOs, the workload for PCPs may decrease. Currently, if one used the ACO model, there would have to be more assistance from mid-level providers and/or from specialties to help relieve the burden on PCPs. Of course, the affect of ACOs on PCP workload will depend on if ACOs have an economic of scale to adequately distribute and/or decrease the amount of work-per-provider.

The current trend of an increasing number of medical students going into primary care allows for cautious optimism. Nevertheless, the past trend of a shrinking number of PCPs will leave its mark. That is to say, any increase in the number of medical students going into primary care will not offset the dearth of PCPs necessary to address the health care dilemma. In addition, if the ACO model does not decrease the workload of PCPs, then medical students may shun away from going into primary care. Based on past patterns, current PCPs may move to other fields of medicine. Finally, with the recent shortening of work hours for resident physicians, the medical culture of endless devotion and extremely long hours will take another step towards oblivion.

It is hard to predict the story will unfold, but if ACOs come to fruition, primary care as we know it will never be the same.

Kunmi Sobowale is a medical student.

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  • Steven Reznick MD

    The real question is what will primary care physicians actually be doing in a patient centered medical home. Will they be providing hands on longitudinal care over the years developing meaningful relationships with patients, or will they be like attending physicians on teaching rounds listening to case presentations from ARNPs and PA’s and just signing the chart off ? Will the PCP become todays hospital based nurse manager who provides very little hands on care but manages lesser paid aides?
    Most of our small mom and pop primary care offices can not afford the care team specified in the ACP and medical centered home model. Most of our local hospitals are looking to purchase and employ existing PCP’s to be part of their hospital ACO system. When you accept a paycheck from the hospital part of the checks and balances that protect your patients from profit motivated behavior is lost. It is an inherent conflict of interest that hospital systems and employed physicians refuse to recognize.

  • doc99
  • Margalit Gur-Arie

    If ACOs come to fruition as designed, primary care will become a managerial job. It is possible that more medical students will be attracted to this line of work, since there will be no boring ear infections and back pain to deal with, and ACOs will probably attach “executive” titles to this position, so the prestige will be restored along with good working hours. Many of the currently practicing PCPs and many of the prospective medical students who actually want to practice medicine and heal people, will not consider this type of career very desirable, leaving you mostly with candidates and graduates that should have really gone to business school.
    Eventually, patients who can afford it will vote with their feet and choose to receive primary care elsewhere. Since ACOs are currently defined as voluntary for patients, I expect this to happen very quickly. If they remove the voluntary clause, we are back to HMOs on steroids, and we all know how that experiment fared.

    IMHO, if primary care is to deliver on the promise of quality and efficiency for patients, it must remain independent, and it must be actual patient “care”. Perhaps we need to screen med school candidates a bit differently for this specialty.

    • pcp

      “Since ACOs are currently defined as voluntary for patients”

      If ACO patients are free to use non-ACO docs, where does the cost control come in?

      “Perhaps we need to screen med school candidates a bit differently for this specialty.”

      A tremendous number of students enter medical school wanting to do primary care and are dissuaded by the grim financial reality. The ONLY way to save primary care is to boost income dramatically. Everybody knows that, and no one is doing anything about it.

      • Margalit Gur-Arie

        “If ACO patients are free to use non-ACO docs, where does the cost control come in?”
        That’s a big problem, but Medicare said that folks can go wherever they want to go with no penalty. I guess they don’t want to face the HMO backlash.
        Realistically, though, don’t most patients just go to the specialist that you recommend?

        • pcp

          “don’t most patients just go to the specialist that you recommend?”

          Yes, but . . .

          Am I really supposed to say to my patients:

          “I want you to see this cardiologist (or, even worse, I want to to switch from the cardiologist you’ve been seeing for years to this new one). I know he’s far from the best in town, but, according to this print-out from my ACO, he’s definitely the cheapest, and I’ll get to pocket some of the money saved on your health care.”

          Has anyone even considered the ethical implications of these arrangements? How does this differ from an old-fashioned kickback?

          • gzuckier

            i think the idea is to tell your patients, “i’m giving you the name of a specialist who’s contracted with your insurer, because i know you couldn’t possibly afford to go to anyone else”
            kind of like it works now.
            a couple of years ago, after an extensive bunch of workups, just when we were about to get to the actual treatment part of the diagnosis, came the letter from the insurer, that both my neurologist and my orthopedist were no longer participating. so, back to square one with two new guys. (they were just as good as the previous guys, at least for my non-zebra problem)

  • Marc Gorayeb, MD

    The conflict of interest is real. Hospital-based physicians – emergency physicians and hospitalists for example – have every right to order outpatient tests and make referrals to the providers of their choice, but rarely if ever do. It may or may not be more convenient to send the patient to your own hospital-based lab, X-ray or other provider, but it is most certainly greasing the palm that feeds you. Hospitals are financially associating with physicians to corner the market for services that those physicians have the inherent power to control.

    You may have noticed that Shields MRI, for example, is advertising and competing on price. That kind of market-based cost control is about to be squelched. The proposition that government encouragement of hospital-physician associations will save money is simply ludicrous, but not surprising. This putative command economy is not going to control costs, because it never has; but it will most certainly work to control the practice of medicine. If you want more bureaucrats telling you what to do, then you’ll love ACO’s.

    • ninguem

      “Accountable Care Organizations for Reform Now”


      They’re back.

    • gzuckier

      are acos going to result in more referrals to in house imaging, for instance, or to the cheaper imaging places that are popping up around major medical centers? we’re certainly seeing a lot more of the latter type steering right now.

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