(The Sequel to "The End of Dr. Marcus Welby")
Today, health care in America is uneven. For some we provide too much and for others too little; for some we pay too much and for some we pay too little; some care is very efficient and other is wasteful and expensive. The assumption is that a Goldilocks approach must be found and such approach will not only feel right, but also have the right price tag. The reform bill, while providing definitive solutions to health insurance coverage, provides only guidance and an independent infrastructure for actual health care reform. It will be up to various committees and HHS, to try out proposed solutions and find the golden path. There are three broad themes standing out from the thousands of pages of newly minted legislation: change the care delivery model, change the provider reimbursement model and computerize health care. It is expected that each one of these efforts and all three combined will achieve better care for less money for more people. Let’s take a closer look at the emerging trends of thought.
The Delivery Model
Health care in America today is delivered mostly by small physician practices. 47% of doctors practice in groups of 5 or less and most are Primary Care physicians. These are the modern day descendants of Dr. Marcus Welby and the new theories of efficiency would soon drive them to extinction. The common wisdom is making the same argument that was made when Supermarkets and Mega Stores were created. The small practice is an inefficient business unit and consolidation will bring economies of scale and better ability to manage the business, from supply chain to FTEs, to ability to better serve customers. [Dr. Osler must be turning in his grave]
These proponents of consolidation are drawing from examples such as the Mayo Clinic in making the case for large groups of multi-specialty and salaried physicians, and against the current “cottage industry” model of delivering care. The Mayo model has been around since the nineteen century and while able to provide stellar health care for complex patients, it did not spread much during a century of existence. There are no Mayo clinics in Harlem or the Ozarks, just like there are no glitzy, well stocked, open 24 hours Supermarkets. I wonder why… Maybe for such areas, we should be happy with the 7-11 in a gas station version of health care convenience. They too can show economies of scale. The vast majority of cottage practices are serving both Medicare and Medicaid patients. Mayo seems to be unable to provide services for measly Medicare fees and some are wondering if large groups would constitute a better venue for extracting larger payments from private insurers. There may very well be economies of scale in consolidation, but it is unclear who will be benefiting from such economies. A pound of pink, waxy, fragrance free tomatoes at the Supermarket costs $2.99. A pound of red, sun-warm, freshly picked tomatoes at a farmer stand costs $0.99.
And then there is the Patient Centered Medical Home, a wonderful concept pioneered by pediatricians taking care of sick kids. The term is Medical Home, not Medical Complex, or even Medical House. The word Home has a very specific meaning to most people. It connotes intimacy, security, comfort, family and a safe haven where you can let your guard down and be yourself. The Medical Home calls for a personal physician, not a personal Department of General Practice augmented by the hospitalist du jour. Maybe they were referring to a personal Dr. Marcus Welby after all. We may never know.
The ranks of the Welbys are shrinking. Fewer and fewer medical students are choosing Primary Care. It seems everybody wants to be a sub-specialist. Specialists make a lot more money and the prestige of being a Cardio-Thoracic surgeon often trumps the "calling" of family medicine. Does filling out paperwork and referring patients to specialists (real doctors who actually treat patients) even qualify as Medicine, as Science? When you graduate at the top of your college class and have perfect MCAT scores to match your earlier perfect SAT scores, do you really seek a career as an underpaid hamster rushing through encounters at $35 apiece? Maybe educated physicians should just stick with the “hard” stuff and let someone else do all this Primary Care simple stuff. [By now, Dr. Osler should be clawing his way out of his grave]
Sure enough, the recent conversation is mentioning that NPs could very well lead Primary Care clinics with no physician supervision. They are very well educated, many have PhDs, and maybe their less scientifically rigorous and more humanities driven education would be a better fit for what Primary Care has deteriorated into. Not to mention that we should be saving a bundle if we delegate Primary Care to non-physicians. After all, NPs are providing good care to a wide range of patients in physician led clinics. Most folks are basically healthy and only a few have half a dozen comorbidities and twenty medications that need to be juggled. Three or four Internal Medicine specialists could easily take care of those complex cases. Did we just blow all that bundle of savings on Primary Care? Probably. A Boeing 747 requires a Captain and a co-pilot to fly the plane. The co-pilot is almost as good as the Captain and most of the time the plane is flown by the computer. We could probably save tons of money by getting rid of the Captain for the routine uneventful flights. Trouble is you never know when you’ll have to deplane via the Hudson River.
The health care reform bill has some provisions for modest increases in Primary Care reimbursement. More interesting are the authorized experimentations with alternative models of payment such as the Accountable Care Organizations (ACOs). Generally speaking these are large groupings of various types of providers organizing together to provide complete care for panels of patients. ACOs are rewarded if able to provide quality care for less than a regional benchmark. There are many questions to be answered and many details to be ironed out, but the most likely leaders of ACOs are either Hospitals or very large physician groups by virtue of their ability to provide proper management and financial coordination. In either case the Primary Care doctor will be further marginalized and relegated to the secondary role of providing care according to rules and regulations dictated by financial interests of a corporation who will be receiving and dispersing payments and quality bonuses. For years large provider organizations have been leveraging their sheer size to extract undue financial remuneration from private insurers. We are now proposing to place these same providers in control of reimbursements to loosely affiliated, or completely assimilated small practices. It is not clear where Medical Homes fit in with ACOs, but from both a patient perspective and a Primary Care doctor’s point of view, this could very well become HMO déjà vu. In any case these new reimbursement models do not make any changes to the basic fee for service model, or the bureaucracy associated with obtaining payments. If anything a brand new layer of ACO specific paperwork, measurements and reporting is likely to be put in place. Looks like Dr. Welby will still have to spend a large portion of his day filling out forms, fighting with payers and now also with the ACO powers to be.
Technology is everywhere in health care. Technology is one of the major health care cost drivers in the form of new equipment, new devices, new therapies and new drugs. Almost 100% of financial transactions in health care are electronic and so is patient registration and scheduling. One would be hard pressed to find a medical practice without a computer and a host of other electronic devices. The one glaring exception is of course the Electronic Health Record (EHR). EHRs are too expensive, too clunky, take too much time to implement, provide no real value, etc. However, EHRs are also the inevitable future of medicine and the entrance ticket to Medical Homes, ACOs and every other opportunity to keep up with where health care is headed. And right now, the Government is offering to pick up the tab. It won’t do so forever. EHRs and the promise of uninhibited electronic communications between doctors, patients and the entire spectrum of care providers are a prerequisite to saving Dr. Marcus Welby. Today’s generation of physicians is not interested in 80 hour work weeks. Personal values have changed and medicine has gotten complex and laden with bureaucracy. It is likely that what was accomplished by one doctor years ago, will require virtual collaboration of several small practices today. [Dr. Osler would probably try his hand at a patient centric EHR]
The Rescue Mission
There is enormous evidence suggesting that strong Primary Care is conducive to better population health and lower overall cost. Primary Care cannot be strong without fully qualified Primary Care physicians who can treat all conditions and effectively advocate for their patients when dealing with specialists and Hospitals. Strong and effective Primary Care must have roots in the community, and by community I do not mean the common usage of the term as “poverty stricken area”. Not everybody lives in Rochester, MN and most folks cannot afford Rochester prices. Most of us would be perfectly satisfied with a small and intimate Medical Home a few blocks down the street. Finally, Primary Care cannot be strong with no young people willing to follow a time honored tradition.
The AAFP estimates that we need about 2000 more Primary Care graduates every year. Let’s pay for their education and have them commit to practice in shortage areas for a certain number of years – that’s a well spent $300 million per year. Let’s decide to pay fair wages for honest labor and compensate Primary Care docs for their time and quality of work. Let’s empower Primary Care docs along with patients to make care decisions instead of subordinating them to Hospitals, specialist groups and other corporate interests. This is arguably the only stakeholder group that wasn’t feeding at the health industry trough for the last several decades. They were too busy seeing patients.
Dr. Marcus Welby’s fictional character embodies the means and the power to provide better care for less money to more people. He will have to trade in his black bag for an EHR, and his house calls for e-visits. He will have to have a supporting team and he will have to collaborate with a network of his peers, but we can save his integrity, compassion, professionalism and competency, if we can avoid temptation and muster the wisdom to forgo the big shiny things and the cheap little shortcuts, and instead restore Primary Care to what it was when we did not have a health care crisis in this country.
(Tonight is the big night for the Duke Blue Devils, so I thought of sharing my favorite Dukie's thoughts on Healthcare Reform, uncut and unedited)