The primary care opposition to transition care

The lack of access to primary care physicians is a well known problem impacting our healthcare system. The problem sends all sorts of negative ripples through the system, not the least of which is increasingly crowded emergency rooms packed with patients whose conditions could have been addressed earlier and cheaper had primary care been available.

What is less talked about is the mixed reaction of primary care physicians to the kinds of strategies that seek to make up for this lack of access. When primary care isn’t available, or isn’t available fast enough, it is ironically the primary care physicians themselves who sometimes seek to head off another care provider stepping in to fill the void.

The growth of transition care programs is a prime example (and earlier PCP opposition to hospitalist services is another). In the shift to prevent 30 day readmissions, transition care programs that send healthcare providers directly into patients’ homes are running up against PCPs who either don’t want another care provider stepping in, or don’t understand the value. This isn’t surprising. After all, PCPs should have a sort of proprietary oversight over their patients’ health and well-being.

The problem is that we’re not there yet. In a perfect world, everyone would have access to a great PCP, and everyone would take full advantage of that access. Unfortunately, the world we live in is one in which $17 billion a year is spent on readmissions just for Medicare patients, and one in which 75% of those readmissions are considered preventable. Of all the Medicare patients who are readmitted to the hospital within 30 days, 50 percent will not have seen a primary care physician in that time.

To solve this enormous problem, transition care programs need to work closely with PCPs. But right now, a large number of patients who could benefit most from transition care are weeded out of the programs because of PCP opposition. In one recent pilot program at a hospital in Maryland, roughly a third of all patients who otherwise qualified for transition care were weeded out because of their primary care doctor’s opposition.

Rather than perpetuate a turf war over patients, any program that sends healthcare providers directly into patients’ homes needs to reach out to the community of providers that is already looking after those patients, beginning with the primary care docs. Transition care programs need to include PCPs in care management and make them aware that these programs aren’t looking to steal away their patients. On the contrary, the goal is to get patients back to their PCP as soon as possible and at the same time prevent a hospital readmission.

Meanwhile, primary care docs need to recognize that having a second provider in their patient’s home can fill a gap in care when the patient is at their most vulnerable. Additionally, sharing information and working together on both sides will lead to better outcomes for patients, more satisfaction, and less utilization overall — the triple aim.

Michael Cetta is an emergency physician who blogs at the the Outpatient Care & Emergency Medicine Blog.

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  • southerndoc1

    Maybe the fact that primary care doctors are getting a little weary of dealing with the paperwork, doing the supervision, and assuming the liability all for free has something to do with it?

    • fatherhash

      hit the nail on the head!

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

    Are we sure that “75% of those readmissions are considered preventable”? I thought there were several studies (literature review) that reached a different conclusion regarding preventability (e.g. http://www.nejm.org/doi/full/10.1056/NEJMp1201598 )

    On a different note, I am not sure the problem is “PCP opposition” or some desire for “proprietary oversight” over patients. What happens after that one visit to prevent readmission within 30 days?
    Doesn’t it make more sense to notify the PCP, send a discharge summary and let the PCP manage the care? Doesn’t it make even more sense to have the PCP admit the patient and manage the care throughout? Perhaps if the care is inherently continuous, we won’t have so many broken transitions…. just a thought…

  • Steven Reznick

    You use the term healthcare provider very loosely. Who exactly is being sent into the home and what exactly are they doing.? In our community private home health services provide care in the home post hospitalization and unless their task is really specific such as wound care or infusion care, the work they do is basically worthless. Billing for transition of care especially to CMS is impossible as well. To have to bill on the 30th day is near impossible.
    The system works best when your primary care providers provide continuity of care in the inpatient setting and in the post hospital setting. I am not saying that generalists in family practice or general internal medicine are better than hospitalists. I am saying that knowing your infirm patient makes care and life much easier for the patient.

  • Michael Wasserman

    Transitional care should be the work of primary care physicians. It can be done, and in fact my practice did this successfully for a number of years.