How Obamacare will creatively destroy primary care as we know it

As Obamacare is winding its way through a hellish bureaucratic labyrinth of its own creation, accompanied by cheers and boos from the blood thirsty spectator crowds, confusion, fear, trepidation, despair and exhilaration, are gripping America’s doctors all at once, because whatever else is accomplished in the next decade, medicine will never be the same.

At the confluence of cutting edge technology, great poverty and unimaginable fortunes, a new vision for the practice of medicine is beginning to emerge. Medicine was formed during times when sickness was never far from death. It was devised by old men who went to bed every night thinking that they may never awaken, and it was institutionalized by women who shunned life’s earthly pleasures. They understood the fears of old age, the loneliness of disease, and the comfort and serenity that come with putting your life in the hands of God, when all was said and done. They built houses for the poor and sick and downtrodden, with larger than life doctors as God’s emissaries, and pious sisters as angels of mercy.

Over the last century, science and technology changed hospitals from places of suffering, grief and death, to places of hope and new beginnings; from dreary spartan wards for the dying, to plush private suites for the soon to be healthy; from whispered footsteps in the twilight, to shiny instruments of mechanical shops; from final moaning and groaning, to humming of machines and laughing soundtracks of sitcoms punctuated by shrill alarms and flashing lights.

Dying in a hospital is now considered a failure of sorts, a preventable and costly mistake. There is no place for God in a modern hospital, and there is no place for special emissaries or angels. And when God vacates the premises, big business comes in to take His place.

Today’s technology driven medicine is shaped by young and invincible entrepreneurs, in search of fame and fortune. Masters of their own fate, bursting with self-quantified health, brilliantly educated in the intricacies of computerized logic, armed with stacks of data points, and carefully clad in black turtlenecks, hoodies, tee shirts and designer jeans, these modern knights of the business round table are engaging in the timeless quest of vanquishing death, or at the very least making it less expensive for the rest of us.

So where does all this leave primary care? Primary care is now considered routine care; routine, like changing oil on an automobile. Sticking a needle in your arm so you never, ever die from a plague is no longer a miracle, just like switching the lights on, or flushing the toilet is no longer deserving of thought. Miracles only happen in hospitals now, and not very often either. Primary care doctors are increasingly banned from hospitals, and asked to stick with routine care and leave the complex stuff to their betters. And primary care doctors agreed to this arrangement, mostly voluntarily, and explained (mostly to themselves) that routine care nowadays is pretty complex on its own, and arguably even more complex than the narrowly specialized interventions occurring in hospital settings. Maybe so, but routine complexity is what technology entrepreneurs eat for breakfast. Terminology is important.

When health care reformers say that primary care is foundational to reform, they mean routine care. They mean vaccines given on schedule, screenings done on time, lifestyles assessed and documented, educational materials handed out, and referrals coordinated to completion. They mean managing populations, stratifying risk, conducting outreach, dotting every BP and crossing every A1c.

Welcome to Lake Wobegon primary care where all patients come in correctly diagnosed and ready to be tracked. These things can be automated with the right technology and properly trained teams of workers, supervised by medical professionals providing spot checks and quality assurance. High tech and high deductibles will combine forces to turn routine primary care into the first medical service to become a retail product, with its Med Emporium, Osler 5th Avenue, and eventually, Hello Kitty Diabetes toolkits sold at Amazon.com. The question is no longer how to stop the train; the question is where primary care goes from here.

Let it go!

When primary care physicians became overworked and underpaid, something had to give. Inpatient care, arguably the high end portion of practicing at the top of one’s medical license, was snatched away by hospitals oblivious to their mission statement, and a good portion of complex care had to be offloaded to secondary care, just so primary care can keep up with demand for routine care.

Primary care became literally broken, and with it, the entire system downstream was broken too. In a fool’s errand type of strategy, routine primary care now includes tasks aimed at gluing primary care together again (e.g. transitions of care management, exchange of clinical information across facilities). Furthermore, routine care is being expanded to include things previously in the purview of public health (e.g. health literacy, physical activity, safe sex), stuff that grandma used to do for us (e.g. eat your string beans, keep your hands out of the cookie jar) and new retail oriented things (e.g. online shopping, consumer experience, values and preferences).

Today, in a plot twist worthy of Beckett himself, tech entrepreneurs in concert with non-physician workers are vying for the business at the low end of primary care. The new routine care will be catalogued, standardized, sterilized, automated, delegated, computerized, transformed and reformed. If you hang on to it, it will drag you down to wherever it’s going. Let it go! Let it go to your “team” (read, staff), or (gasp) let it go to Med Emporium.

Insurers, who could not be made to understand the importance of continuous, comprehensive primary care, seem perfectly willing to support the low skilled, electronic strings and duct tape of the new and expanded routine care. If you have an entrepreneurial gene in your DNA, hire staff, promote your office manager to chief quality/compliance officer, your receptionist to care coordination manger, the triage nurse to director of resource allocation, and delegate the bejeebers out of your daily work. Become the CEO, and get a secretary (a.k.a. scribe), so you never have to click another box, or type another embarrassingly misspelled sentence. Double your patient population, and let your NPs see the f/u for diaper rash, sports physicals, strains and sprains, the new wave of statin seekers, and everything that your director of resource allocation deems routine.

Grab the fluctuating 25% or so of patients that are most complex and be their comprehensivist.  Hospitals are routinely inventing specialties, from hospitalists to intensivists to nocturnists, to further fragment continuity of care and increase profits. It’s time to learn from the experts.

Instead of waiting for the system’s other shoe to drop (on your head), proclaim yourself a specialist in the absolutely last remaining piece of what was once primary care. Grab it and hold onto it like dear life, because it will be nibbled on from below and from above incessantly. You will have to compete with the low prices of Med Emporium on one hand and with the natural expansionist tendencies of hospitals on the other. You will have to find a way to get paid for your new specialty services, and just like every other entrepreneur, you will have to take risk; the more complex the patients are, the bigger the risk and the larger the rewards.

Fortunately, the new health care law encourages precisely this type of advanced payment models. Go for it! Spend a leisurely hour with each patient needing comprehensive care, while your routine side of the business is humming along on its own.  With proper planning, you can collect the customary and usual fees for your greatly expanded panel, plus the special fees for comprehensive care, plus any shared savings you can generate from keeping these select folks out of hospitals and emergency rooms. You’ll have to do a bit of marketing and engage in some creative contract negotiations (get a lawyer), but the sky may very well be the limit.

Don’t let it go!

What if you have no entrepreneurial markers in your DNA? What if the previous few paragraphs made you sick, depressed or really angry? Fortunately, Obamacare is on your side.  For all the docs who argued that health insurance destroyed the doctor-patient relationship because it inserted itself in the payment process, and for all those who argued that insurance should not pay for routine oil changes, this is your lucky day, because it doesn’t anymore.

With the exception of the very poor and the very old, people will now need to pay for primary care out of their own pocket. That’s what high deductibles mean. A good portion of these people will become savvy shoppers and choose the technology enabled do-it-yourself method, or go to Med Emporium on an as-needed basis, but there will be more than enough patients (perhaps in higher income brackets), seeking quality over cheapness. The same folks that buy artisan bread and free range eggs from local farmers will bring their family to you, if you promise to provide hand-made wholesome and holistic primary care.

Direct primary care, whether concierge, or ideal or micro, or contracted by employers and even forward thinking insurers, will most likely explode in size during the next decade. There is a huge continuum of service definitions here, and you should be able to find your comfort zone. You can go back to being a country doctor in the midst of a bustling metropolis, and care for multiple generations at home, in clinic, at the hospital, nursing home and eventually hospice. You can dial back a little bit, or a lot, and contract with midsize employers to provide outpatient primary care. You can be a high-tech, electronic-everything doctor, or an old fashioned one, or perhaps a unique combination of both.  Here too, the sky seems to be the limit.

So what’s next for primary care? It seems that for physicians, the door is closing on the treadmill now known as primary care practice, but countless windows are being opened simultaneously. You just have to look up and find yours. Whether you choose to stay in the system, step half way in and half way out, or do it your way all the way, there will always be a need for good doctors. Whether you choose to run the patient mills at Med Emporium, or run your own exquisite Osler 5th Avenue, or start the Hello Kitty Diabetes Company, or care for people slowly and thoroughly, one at a time, from start to finish, primary care may just be the best place to be in right now.

Margalit Gur-Arie is founder, BizMed. She blogs at On Healthcare Technology.

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  • NPPCP

    Ahhhhhhhhhhhh!! Margarit!! You were doing so well!! An NP is not “your” NP. We practice under our own license. And you already know we see more than diaper rash. And we are not that willing as independently licensed providers to be on “your team” as a cash cow anymore. As you so skillfully mentioned, things are all changing. You will have to find another assistant to do the stuff you don’t want to. We are too busy providing complex primary care in our own clinics. Posted thoughtfully and respectfully.

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

      Well, the fact remains that an overwhelming majority of NPs are not practicing independently, and are employed by physicians or other health systems/businesses. This was a suggestion for how an employer may choose to deploy his/her resources.
      The fact that some NPs are choosing to practice independently has very little to do with that.

      • NPPCP

        I understand. You are right there. I guess the same is being said for physicians as well. They are employees, cogs, tools, as well. Guess we are all in the boat…. Thanks for responding. I enjoy reading your wisdom.

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

          Thank you. The same steamroller for all, and it’s medicine’s turn now…

    • Bob

      I don’t see many NP’s at PCP offices, they gravitate to specialties just like physicians do for the same reasons. Given choice would patients see a NP or a MD? And I know that nurses, NP’s or not are the glue of healthcare, always have been and always will be.

  • May Wright

    “… and eventually, Hello Kitty Diabetes toolkits sold at Amazon.com.”

    I don’t know how to break this to you, Margalit. But…

    http://www.solaramedicalsupplies.com/hello-kitty-softy-flannel-insulin-pump-pack
    http://www.funkypumpers.com/shop/insulin-pump-waist-pouches/hello-kitty-splashproof/

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

      What can I say… I’m behind the times… :-)
      Perhaps a Walter White Cancer Self-Management Kit is still open for innovation :-)

      • May Wright

        Hah!

        On a more serious note though, I really enjoyed this post. Two of the positive paradigm shifts I can see coming as a result of the ACA are a move away from people being tied to their employers for health insurance, thanks to community rating/no knockbacks for pre-existing conditions (which has absolutely kept people in jobs they weren’t happy with, because they wouldn’t have been able to get health insurance on the open market); and the fact that it may spur more doctors and patients to get back to a real “primary care” experience without a lot of third parties in the room stinking things up, through the various direct pay models.

        • NPPCP

          All so very true.

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

          Agreed. The return of direct pay practices (and not just primary care) may be one of the most surprising “unintended consequences” of the ACA, which is pretty much postulating the demise of private practice.

          • doc99

            Until Participation in Medicaid, Medicare, and All ACA-Approved Plans Becomes a requirement for licensure …

          • Dr. Drake Ramoray
          • Bob

            Or fewer physicians accept it honestly as they are full up with “paying customers” that pays for their practices cost and allows profits.

          • Bob

            Primary care is a cul-de-sac, as low reimbursement will create incentive to pass along patients with multiple referrals to a more limited yet more highly paid group, often with no true cause, and most aged [Medicare] and poor [Medicaid] have multiple metabolic conditions causing a fission of visits as our healthcare goes nuclear!

      • Dr. Drake Ramoray

        Hey I proposed a Dr Drake Ramoray Im Thinking of Going Into Primary Care Lobotomy Kit on another thread. We can start a business together once my practice falls prey to one of the Megacorp hospitals in my area.

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

          Fantastic brand name…I’d be proud to serve…
          There should be a market for all sorts of DDR – I’m Thinking of Lobotomy Kits

          • Bob

            Great historian, but you forgot to mention charitable immunity died in hospital in 1954; as well as vision as in: vision is the ability to see what others can’t. And the change in medicine from what is today to the results of the now 10 year old Human Genome will leave ACA as a tombstone in history.

      • ninguem

        I’m sorry to say they closed the Hello Kitty S+M Bondage Love Hotel.

        http://www.kittyhell.com/2007/01/18/hello-kitty-love-hotel-bondage/

        Tokyo hasn’t been the same since.

        It’s safe for work, though people might avoid you in the lunchroom if they see it on your screen.

  • NPPCP

    From a specialty standpoint I agree with you. From a primary care standpoint, I do not. Less trained in sheer hours? Yes. Trained differently yes. Less skilled? Absolutely not. Did not mean to turn the conversation. Just wanted to mention the above to Margalit. Great article. Thank you both for responding.

    • Bob

      What is the average age of NP’s and their experience levels? And where are they working now and where are they most needed? Anyone ever think of all the military medics which are neither but saved many of the lives of our troops? Most of them are probably EMT’s with more experience than many nurses.

  • buzzkillerjsmith

    Wow. Margalit is, hands-down, the smartest person at this blog, and as an arrogant doctor it hurts me to write that. Later on this thread I will give my own thoughts on the future of PC, what should be and what will be, but for the moment I stand in awe.

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

      Thanks Buzz, but I am not, and you are no arrogant doctor either :-) Can’t wait to read your thoughts on the subject….

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

      Agree. Nice blog Margalit. always enjoy your insight….
      I have envisioned exactly the train barreling down the track that you described, but could never say it so eloquently. :)

      I see primary care in 3 different practices:
      1. McMedicine: doctor sits behind a desk while a team of 20 NP/PAs see patient….. not much different from Anesthesia these days (and as you predicted in your above blog.)

      2. Corporate Physicians: it will become increasingly evident to companies that for 200-400K (price of a modest executive) they can essentially pay for a doctor with an onsite clinic full time. win win for everyone involved.

      3. a new TRUE private practice. I think the term concierge medicine has become passe and we will now see direct financial relationship with patients as the “norm” and a true Private practice.

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

        Thanks, Dr. Stephens. I think you got the three types right, but I am wondering which one will be the most common, because that one will define the image of primary care, and will have consequences for medical students and the long term outlook for primary care (family medicine in particular).

      • psychomd

        Well put. I think Osler would be rolling over in his grave at what has happened to medicine.

    • buzzkillerjsmith

      Margalit lays out some of the possible futures of primary care medicine.

      One is to be the operator of a patient mill with lots of help from NPs, PAs and various other folks. This is the model advocated by the family doctors’ and internists’ professional societies, and it might work for some doctors.

      Will it work for pts? Hard to say, but they might not have much choice. Primary care docs are and will be as rare as hen’s teeth.

      Another problem for us docs with the pt mill model: Why are we needed? Routine care is routine. You don’t need an MD to practice it, at least according to health insurers and the government. We all know this model is nonsense, that very sick people are admixed with routine cases, but decision makers don’t care about this, at least not at this time. CorpMed would gladly replace us docs in primary care with someone else if it could save a little money. Med students are right to worry about poor income, poor working conditions, and every increasing deprofessionalization. I ask you all: Would you sign up for that?

      Yet another problem with docs in the pt mill: Who the hell wants to do that all day? Most of us are interested in diagnosis and treatment, much more so than routine prevention. Margalit correctly notes that you don’t need an MD to tell people to eat less and exercise more. And yet…. One old sickie after another all day every day is a fork in the eye. To some extent primary care medicine is destined to be a lousy job.

      Direct pay might be better. A smaller panel of pts, better income. Of course from a societal standpoint this is a catastrophe as ever more millions will be left as medical orphans. Also a lot of people will be unwilling or unable to pay. Docs overestimate their chances of being able to swing direct pay.

      There is currently no way out of this box, no way at all. A way out would require this society to guarantee primary docs that their 11 years of education and training after high school would
      be trashed for business expediency. This guarantee is not coming.

      Any med student who goes into primary care is a damn fool. I say let the chips fall where they may. You made this devil’s sandwich, America. You eat it.

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

        You bring up an aspect that I was frankly trying to avoid: the kids. One cannot in good faith advise a young student to take a leap of faith and go into primary care right now. Things are too fluid. That said, I think there will still be med students choosing primary care in the near future. Maybe fewer, and maybe they will need to be “incentivized”, and maybe they will be different than those practicing today.

        As to direct pay, I was extremely suspicious of this for a very long time, but if we are all going to have those horrific high deductibles, then wouldn’t everybody be practically forced to pay for the primary care portion that is not preventive (and thus “covered”)? And if we have to pay for it, why wouldn’t we pick a nice little practice that is closer to home, cheaper than the big hospital and cozier than Walmart? I may be wrong…. I hope I’m not.
        As to the social aspect, I agree, the folks with no real deductibles and no money (the poor and elderly poor) will not fare well, at least for a while, until we wake up and throw that sandwich in the trash, if we ever do….

        • Luis Collar, M.D.

          Great piece! My only question is as follows… Though some of the plans on Healthcare.gov are indeed high-deductible plans, many others are HMO-type plans… To the extent that HMO-type plans are still being offered in the exchanges, is there any reason to believe that direct-pay solutions will be quite that widespread? That is, enough to reach the critical mass necessary to guarantee a paradigm shift? Aside from that, pretty much agree 100% with the premise and conclusions. Again, great piece… (P.S. Sincere question from another “arrogant doctor” that isn’t that bright outside of diagnosing GI tubular adenomas… lol… Terrific article…)

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

            That’s a good question, because many of those plans are HMOs. However they still have those high deductibles. So, yes, it seems like you’d have to see the plan PCP if you want the referral to be covered. The other construct that may attempt to deter people from using direct pay is the ACO.

            So honestly, direct pay from patient to doctor may very well be limited to the well to do patients, at least initially. Another “direct pay” possibility, which I think is being used by some today, is to contract with employers who fund those HRA accounts, effectively becoming a little HMO, or at least partial HMO.

            I don’t know if this is enough for a paradigm shift, and I don’t know if this entire situation will be tenable for any length of time before it blows up and we are forced to move in another direction….

            Thanks for the kind words. I wouldn’t know what a tubular adenoma is if it hit me on the head, or maybe that’s what it’s supposed to do… :-)

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

    Sorry for taking so long to reply. I do agree with you that a two-tiered (or more) system is emerging, and perhaps that is the answer to that 25% of truly sick patients. The compromise of good primary care for all is a given in this arrangement. There will still be good primary care for those who can, and and are willing to, pay for it, just like any other retail product.
    There may also be some selfless ideology based good primary care in community health centers for the poor, but I have a hunch that the safety net will be co-opted. I don’t know if that’s true in other states, but in my state all community health centers are “in network” for exchange plans, while the academic center doctors, less so. I am wondering about the implications for Medicaid patients….