Primary care trends in the health reform era

As a physician who is involved in educating medical students, I am often asked for career advice. Medical students are by nature smart and ask very good questions. “Will I be able to pay of my student loans if I choose primary care?” “Will I have a balanced lifestyle if I decide to go into primary care?”

I try to be both encouraging and realistic.  However, far too often I have found myself telling students that the future of medicine, primary care in particular is not clear.

That is no longer true.

The future of health care, and particularly primary care is now very clear.

Several recent events along with trends that have been in place for the last few years have clarified the future of health care over the next few years. The passage of the Affordable Care Act (ACA), the decision of the Supreme Court to uphold the constitutionality of the individual mandate, the re-election of President Obama, and the fiscal cliff/sequester have all set into motion changes to our health care system that are likely irreversible and clarify the future of health care. Essentially, there are two paths:

1. Health care in large integrated systems.  Health care costs are skyrocketing. The major fixes to the problem that are accepted on both sides of the aisle are an end to fee for service, bundled payments, and incentives for improving quality at lower costs. Accountable Care Organizations (ACOs) are one model being tested.  However, even if the ACO turns out to be HMO 2.0, and ultimately fails; health care will be delivered in large integrated systems. This trend is already occurring with hospitals, academic medical centers and other health care systems gobbling up (through incorporation or outright purchase) smaller private practices.

Because payment will be linked to performance, and performance must be measured and reported; the only way physicians will be able to make money is to not only have a large, robust electronic medical records, but also a staff that can help collect, process and report the important data. Even large private practices don’t have the economies of scale to make this happen. Thus, private practice as we know it will cease to exist.  This trend is already happening. According to a report by Accenture, over the past decade, the number of independent U.S. physicians has dropped dramatically, from 57 percent in 2000 to 39 percent in 2012.

The move to large, integrated is not necessarily a bad thing. Integrated systems allow for quality improvement. Large integrated systems like Mayo, Kaiser, and the VA have some of the best outcomes for health care in our country, usually at significantly lower costs. For physicians, being a salaried employee also has its benefits which include a guaranteed paycheck, reasonable hours, good benefits and no worries about running a practice. The current generation of medical students tend to value work life balance over the potential opportunities seen in private practice.

The down side of large integrated systems is less personalized attention. Rather than seeing your doctor when you are sick, a patient will likely wind up seeing a member of the doctor’s care team. Other modalities such as group appointments might be employed.

2. Health care outside the system. Some doctors (likely the ones currently in practice) will refuse to join these large integrated groups.  Some patients may decide that access to their own personal physician has some value. These patients are tired of waiting forever to get an appointment or a call back from their doctor, and want to see their doctor when they are sick, not a team member. They are even willing to pay beyond what their insurance premiums cover. These patients and providers will go outside the system.  Growth of retainer (often called concierge) practices, cash-only practice, or direct primary care demonstrate that going outside the system is already happening. This will likely be limited to primary care, as one might be able to pay cash for a doctor’s appointment, but not a colonoscopy or cardiac catheterization.

Health care delivery is already occurring in large integrated systems as well as outside the system. The aforementioned changes will cause these trends to continue, squeezing out the current physicians who are still in an insurance based private practice. These changes are certain.  What is unclear is the proportion of health care that will be delivered in either model. Will large integrated systems become so effective, that only the very wealthy will deem it worthwhile to get their care outside the system?  Or, will large integrated systems become so impersonal and inconvenient that only those with modest incomes will be forced to get their care in these systems? The truth is likely somewhere in between.

Regardless, medical students and residents who are trying to determine a career path should now have a clearer vision of the future health care. Patients who are currently receiving their care by a private practice physician who accepts their insurance should also realize that their current situation will likely not exist in the next few years.

Matthew Mintz is an internal medicine physician who blogs at Dr. Mintz’ Blog.

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  • http://www.facebook.com/profile.php?id=100000077801405 Jay B. Ham

    Historically, medicine has revolved around the micro-team. I suspect that the large, integrated systems will, in time, adapt to consumer pressure and move back towards a more personalized approach. There may be 50 doctors and 100 APPs (advanced practice providers) in a clinic, but they will be organized into smaller teams of perhaps 2 doctors, 4 APPs, 6 MAs and a health literacy coach. The numbers are arbitrary, but this could allow a small team to provide primary care for 10 – 15,000 patients, allow open-access scheduling, and increase the efficiency of care. Of course much more medicine will be done by email, phone, videochat, etc. Once billing schemes can support a non-office based system, (probably capitated in some fashion) then primary care will again be vibrant and attractive. I hope.

  • Matthew Mintz

    @Jay B. Ham, your vision of small integrated teams is appealing. Whether or not this comes to fruition is unclear. What I did not include in my post was that though there is certainty that health care will be delivered in large integrated systems or outside the system and it is only just the proportion that isn’t; the proportion is likely fluid. In other words, if ACO’s get off to a rocky start (recent data suggests this is likely), more patients may gravitate to getting their care outside the system. However, if “large, integrated systems will, in time, adapt to consumer pressure and move back towards a more personalized approach,” which you suggest, patients will follow and go back into the system.

  • Homeless

    My children don’t know what it’s like to have a personal doctor. When they are starving college students, they won’t know what it’s like to have a personal doctor. When they are struggling to start a career and a family, they won’t know what it’s like to have a personal doctor. When they develop chronic health problems, they won’t pay extra to have a personal doctor.

    The Marcus Welby MD generation may still be willing to pay for personal care but the next generation will be content in the large integrated systems.

  • Varun Kejriwal

    The evolution and use of technology is another important factor that will affect primary care “outside of the large systems.” Providers used to measure a patient’s blood pressure. Now it can be done by an automated machine.

    WebMD and even Google search results have allowed “self-diagnosis” to be a preferred method of healthcare for many. Teladoc and Ringadoc allow people to “phone a physician” 24 hours a day, with a pay-per-call structure. PCPs can become solely employed by these companies or even split their time between a physical clinic and these services. I’m not necessarily advocating for these methods, but rather demonstrating that more patients are beginning to take these alternative technologies as an avenue for receiving care.

    In other words, the use of technology as a source of care has and will continue to manipulate the relationship between the PCP and patient. On a more personal note, as someone who is considering primary care as a profession, I look forward to integrating technology into my care without sacrificing that essential, personalized, and trust-based connection – regardless of which other professionals are involved in each patient’s care.

    Varun

    • Suzi Q 38

      I think that these changes have been interesting.
      I wonder if doctors will be able to change and integrate technology into their treatment modalities. Physicians have had to make many changes over the years, but generally they are a tough group to win over.
      Eric Topol, MD has an interesting book out about medicine and the iphone. Patients like myself can check our vital signs and more on our iphones. Digital medicine.

      This iphone can collect personal data and warn me of an impending heart attack, prevent major side effects of medications, etc. These devices can be used to help prevent disease.

      • Varun Kejriwal

        I also find the inevitability of change to be an important consideration. Not only should patients get comfortable with this idea, but PCPs should as well. I know that this can be a sore subject for many healthcare professionals, and reasonably so. The stress of providing care in a system that is tightening its grip on those that are dedicated to helping patients makes it difficult to keep up with all of the changes. But with that said, there are many past changes and changes on the cusp that will influence primary care in the positive direction.

  • http://twitter.com/FerkhamPasha Ferkham pasha

    Why is healthcare so confusing?

  • buzzkillerjsmith

    Personal note: large integrated systems did not work for me. I’m much prefer my current small unintegrated practice. But that’s me. My question for you, Dr Mintz, is whether you think the young docs coming up will like corpmed over the long term.

  • Matthew Mintz

    @Varun- Glad you are considering Primary Care. I agree that technology will enhance the patient provider relationship. Our current payment system and malpractice system are the biggest barriers at the moment. You correctly point out that people are already taking advantage of these “outside the system.”

    @buzzkillerjsmith- Not sure if “young docs coming up will like corpmed over the long term.” What I can tell you is that 1) more inclined that previous generations to be employee than employer and 2) definitely don’t like the insurance based primary care model they are exposed to in medical school. They see primary care docs who are burned out and struggling to make ends meet and quickly decide “this is not for me.” If large integrated systems deliver high quality care in a supportive work environment and appropriately compensate primary care physicians, then students will be attracted to this. This remains to be seen. There is not question that students are (currently) more attracted to docs who have gone “outside the system,” because they are generally practicing high quality care in a low stress environment, and are more appropriately compensated. The good news is that regardless which pathway dominates the future of healthcare, things are looking up for primary care physicians and students interested in this field should be very encouraged

    • buzzkillerjsmith

      Going outside the system is limited to certain areas. Here in rural America, where we are most needed, we would be ostracized as money-grubbers and, perhaps rightly so.

      I agree that the current is broken but should the young docs entrust their professional futures to the tender mercies of Corpmed? Corpmed never rests, you know that. Innovation must occur, and innovation in Corpmed and in services in general often means squeezing more out of each worker. Talked to any ER docs recently? That might very well be the future of employed family medicine and internal medicine.
      The guys who run Corpmed often dislike docs (and I can’t really say I blame them) and would replace prickly PCPs with more compliant midlevels if they could. Right now they have little leverage given the shortage. That could very well change.

      Things looking up for PCPs? Don’t be fooled by short-term trends. No one has a crystal ball, decision under uncertainty as the economists say. Experts are no better at predicting the future than are laymen who pay attention, as Tetlock at Berkeley has shown. There is every chance of continued de-differentiation of the primary care practice environment. A practice model that we don’t foresee may come to dominate.
      I make no comment on the world that the subspecialists live in. Do you know how they’re getting along?

      • Matthew Mintz

        While I agree that going outside the system in rural America is certainly a challenge, it is not impossible. There are several examples of doctors providing direct primary care to patients who are uninsured or who have Medicaid but no access. (I am aware of examples on the west coast and in Florida).
        My take that things are looking up for Primary Care is that in either system Corpmed (as you call it) or outside the system, PCP’s will likely be compensated better and have less stress. Which path young docs should take is a bit more tricky. Corpmed may be the safer bet initially, but your cautions are very real concerns. Going outside the system may be harder to do initially and is certainly riskier, but rewards are greater and you have more control.

        • buzzkillerjsmith

          Your views are reasonable but reasonable views are often wrong in social matters because they neglect the whole set of other reasonable views. We all like to predict. It’s a very human thing to do.

          Here are some other possible scenarios. I attach no number to their likelihood:
          1. Corpmed with fall in love with midlevels, accelerating our degradation.
          2 Corpmed will die, as did HMOs before it and be replaced by single payer.

          3. Single payer will result in improvement in our working conditions.

          4. Single payer, in thrall to subspecialists, will accelerate our degradation.
          5. Things will carry on as they have, with our slow-motion degradation.
          6. Corpmed will come to realize our value.

          I’m sure we can all think of others. The point is this: Your crystal ball is cloudy. No shame in that. But don’t believe your own predictions.

          • Matthew Mintz

            Of your six scenarios, 2/6 are good for primary care. However, all of these scenarios fall under the large integrated system pathway. Assuming the more negative scenarios come to fruition, the more likely the primary care can thrive outside the system. In other words, if your scenario #1 occurs and Corpmed decides to delegate as much primary care work as it can to mid-levels, there will likely be a subset of patients that become frustrated with this system because they want to see a doctor, preferably “their” doctor.
            The point of the post is that the pathway for primary care is now pretty clear. It will either live inside a big integrated system (your Corpmed) or live outside the system in cash only, retainer, or other models. In fact, both are and will likely continue to happen. While I can’t predict the proportion of primary care practice in each model or how successful each model will be, these two pathways are clear.
            For students interested in primary care, insurance based private practice is not appealing. When counselling students about career choice, it had been harder and harder to put a positive spin (i.e. yes, you’ll make less, but differential diagnosis is really hard and when done right very satisfying). Now, I think I can say to students that the primary care they are seeing in outpatient clinics today will be very different when they have completed their training. It will either be in large integrated systems, or small (even solo) practices outside the system. This gives me confidence that primary care with thrive in one of these systems (perhaps both). It’s which one that’s not clear.

          • buzzkillerjsmith

            Pathway is clear. Primary care will thrive. I wish I had your confidence in my own predictive abilities. The good news for you, Dr. M. is that when the future does come to pass, predictions about it, even inaccurate ones, will have been forgotten.

          • Matthew Mintz

            I am less predicting the future, but rather describing trends that are currently underway and at a pointwhere it doesn’t seem likely that they will reverse. Over the past few years, fewer docs have been going into private practice. At the same time, more and more docs (at least in primary care) are starting to practice outside the system. While I don’t see that retainer medicine, cash based medicine, direct primary care or the variety of other outside the system practices will one day dominate the health care system; I do see this trend contiuning to grow. The more young doctors and patients are dissatisfied with Corpmed, the more likely these practices will grow. Thus, I think that I can tell a medical student now who is considering primary care as a career with pretty reasonable confidence that:
            1. It is unlikely that you will be able to sustain a solo or small group private practice that accepts insurance.
            2. Opportunities to be an employed PCP will be available.
            3. Opportunities to be a private practice, outside the system PCP will be increasingly more available.
            4. Salaries might increase in the large integrated systems model. Salaries are definitely better in the outside the system model.

          • buzzkillerjsmith

            If you re not predicting the future, then you and I have no disagreement.

          • drd

            “6. Corpmed will come to realize our value.”

            # 6 quite humorous. I think they already see our value–as dollar signs to them.

          • buzzkillerjsmith

            Agreed. Probably is close to nil.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    I don’t know that this is an unalterable future at this point. Yes, this seems to be the trend right now, but I think this ultimately depends on the students. If they are OK with taking the same route that pharmacists did and work retail, because very few will be practicing at Mayo, then I guess that’s what the “system” will look like.
    Besides, Mayo is not cheaper than a little private practice, and when it comes to primary care, I am not certain it is better either, so it is possible that whoever finances health care will eventually wake up to this simple math. I am also not sure about economies of scale, since if there were any, a visit to a “system” doctor would be cheaper and that’s not the case either. And those big EMRs that people supposedly need right now will become obsolete before your students graduate.

    I think this consolidation is throwing us all off into thinking that it is actually solving something, when its entire purpose is to increase market share and margins. At some point there will be numbers available and we will need to decide if it’s OK to pay even higher prices for a watered down version of what we now call medicine, and compensate with mass produced Walmart BP cuffs and such (and may be a PCP shift supervisor) for most of the country. Somehow, I don’t think this will fly…. and nobody else is going this route either, not even the socialist countries – http://onhealthtech.blogspot.com/2013/03/around-primary-care-world-in-80-seconds.html

  • http://www.facebook.com/kcscooterdude John Holloway

    I am curious how you see the role of the nurse practitioner changing in this new environment. I am a nursing student and I see a potential opportunity here for those of us who track toward becoming a practitioner. I am diabetic and three times a year I see my NP and the fourth time I see my endocrinologist. I receive excellent care from the NP (and the doctor) and don’t usually have issues that require the doctor’s attention.

  • Matthew Mintz

    @Margalit Gur-Arie I am not stating that the consolidation is a solution or desirable (time will tell), but things will continue to move in this direction. However, it is beyond profit margins. What is changing and will continue to change rapidly is the way payors (government, private insurance) pay for health care. Currently, most payment is fee for service. The more you do the more you get. The future is pay for performance or P4P. The better you do on certain measures (diabetes control, re-hospitalization, heart attacks, patient satisfaction, etc.) the more money you will get. Again, whether or not this will achieve higher quality at a lower cost is unclear, but organized US health care has already started moving in this direction. Thus, EMR’s will not be obsolete for many years to come, because the only way to measure the outcomes you will get paid on is through an EMR.

    @John Holloway If P4P is going to work, it will require teams of health care professionals from multiple domains- MD generalists (PCP’s), MD specialists, NP’s, PA’s, nurses, pharmacists, social workers, etc. Thus, I believe the role for NP’s will continue to grow.

    • southerndoc1

      “The more you do the more you get.”
      That’s kind of the way every profession, business, industry in the history of the world has worked. And it seems to work pretty well for medicine in other countries. I wonder why American health care is so different?
      I thought we had already learned from the HMO experiment that “the less you do the more you get” doesn’t work.

      • Matthew Mintz

        Not entirely correct. Yes, if you are Apple, the more iPhones and iPads you sell the more you make. However, medicine is more of a service model. So the more time a plumber spends fixing your plumbing and the more parts she uses, the more the plubmber will get. If you are paying the plumber, you will want them to do what needs to be done (and want it done well). However, if they start doing extra stuff or take too long, then you would likely get concerned. In health care, we have 3rd party system in where (if you have insurance) what ever the doctor orders usually gets paid for. It is easy to see why health care is so expensive.
        However, you correctly point out that the opposite approach (the HMO getting more for doing less) is also not ideal because though less costly, it may lead to tests or treatments not getting done. The solution may be somewhere in between, which is where P4P comes in. Again, I am not saything this will work either, but this is how payment will be delivered over the next few years.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          Actually, in our system, it takes a lot of doing for doctors to have insurers pay for what they order, more so than in any other country.

          As to the plumber, chances are that you won’t use the cheating/loitering plumber again and won’t recommend him to your friends. However, if your plumbing is old and in bad shape, there is very little chance that a plumber will accept P4P to fix your kitchen sink.

          Either way, since we are talking about primary care here, I just don’t see the “do more” aspect being too terribly applicable. Maybe if primary care did a lot more, and got paid a lot more, there would be less need for doing more downstream where things get expensive in a hurry. Unless P4P pays enough to reduce panel size to around 500 per physician, I don’t see how it can help primary care be better.

          I do however agree with you that this is how things will be over the next few years (for some people), and barring opposition from physicians and patients, this is how things will be for a very long time.

  • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

    We have been headed for a dual healthcare system for some time. Obamacare did not cause this, but it certainly has accelerated it greatly.

    in short it will be:
    Government subsidized mediocre care on one side and Private “get what you pay for” care on the other.

    we would have been better off to have just made a universal healthcare system and allowed doctors and patients (who so choose) to contract privately outside of the system as free market allows.
    It would have been the same and the universal system would have been MUCH more effective and less convoluted.

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