The End of Primary Care As We Know It - Part IV - A New Paradigm

Is There A Way to Match Patient Needs with Provider Competence, Reduce Costs, Increase Compensation for Primary Care Physicians, and Expand Availability of Primary Care Resources?

For most primary care visits, it may be argued that the primary care physician is over- qualified. And since the payment system is geared to the services provided, not the level of skill or competency of the provider or the amount of time spent with a patient, it follows that the over-qualified primary care provider is compensated at a level well below his/her capability. The low level of compensation is a significant factor in the increasingly common decision of young doctors to not choose primary care as a profession, contributing to the primary care physician shortage.

This patient need/provider competency imbalance begs the question: How can we correct this imbalance expand the availability of primary care resources, reduce costs, and capitalize on the full extent of primary care physician’s expertise. These multifaceted, but interrelated goals require a new, somewhat radical health delivery paradigm.

A New Paradigm for Providing Primary Care

The proposed paradigm shift is built around the idea of "letting the solution fit the problem". As stated previously, for a significant number of primary care patient visits, the expertise of primary care physicians is more than required and the payment for these services is commensurate with the low complexity of the "problem". The key question is whether it is possible to train professionals to be Primary Care Providers (not Primary Care Physicians) who can properly manage many of the minor problems as well as preventative services now provided by primary care physicians? In some respects, the answer is evident, we already do. Both nurse practitioners and physician assistants fill this role in some practice settings.

The Primary Care Provider - A New Health Care Professional

The time and expense for someone to become a fully qualified and licensed nurse practitioner or physician assistant is substantially less than the time and cost for someone to become a medical doctor. Accordingly, NPs and PAs earn less than MDs, however the ratio of the training cost to annual compensation is substantially lower. The chart shows approximate comparisons. These calculations do not take into account the MD’s low compensation during a three year required residency, which would make the differential more pronounced.

Primary Care Medical Doctor

• Average Cost for Education $200,000 - $300,000
• Average Annual Compensation $140,000 - $150,000
• Ratio of Cost to Compensation 1.3 – 2.1

Nurse Practitioner/Assistant Physician

• Average Cost for Education $40,000 - $50,000
• Average Annual Compensation $75,000 - $100,000
• Ratio of Cost to Compensation 0.44 – 0.67
  
  
  The cost to compensation ratios for NPs and PAs are more in balance and, could encourage people to pursue this career.
  
  If NPs and PAs are to some degree already filling the role of "physician extenders" why do we need to create a new category of provider, the PCP (Primary Care Provider)? The answer is that the role of the new PCP is not that of physician extender, but rather a recognized independent health care provider on the health care delivery continuum who is licensed to practice primary care and is credentialed as such by third party payers. The title of "nurse" or "assistant" should not be used for the new PCP as those titles have historically indicated a lower level in the health care hierarchy. The PCPs should be considered and treated like mainline health care providers.
  
  Education and Training of the New Primary Care Provider
  
  A possible model for Primary Care Provider education and training may be a two year academic program with a one year internship. The academic program for PCPs could be a blend of the first two years of medical school, nurse practitioner, and physician assistant programs. A major emphasis would be on providing routine care with a very strong component of the training focused on when to refer a patient to a medical doctor for diagnosis and care. A clear set of protocols would need to be developed regarding when to refer patients to more experienced and deeply trained medical professionals.
  
  Future Role of the Internal Medicine and Family Practice M.D.
  
  Internal medicine and family practice physicians would become specialists who, like other specialists, would see patients referred to them, mostly from PCPs, who are in need of higher level diagnostic attention or medical treatment,. Under this system, the internal medicine and family practice trained physicians will be called upon to deal with patient related issues and problems that require their level of skill and training. In this manner there would be a more productive matching of patient need/provider competency.
  
  How Will This New Paradigm Evolve?
  
  At the present time, the Primary Care Provider as envisioned in the new paradigm does not exist and will take several years to create. However, the role of a Nurse Practitioner is very much evolving in this direction.
  
  Nurse Practitioners have been authorized to work fairly independently in mini-clinics housed in chain stores such as CVS. Further, recently passed health reform legislation in Massachusetts (Chapter 305 of the Acts of 2008) requires health insurance plans to recognize nurse practitioners as participating providers on a nondiscriminatory basis, for health maintenance, diagnosis and treatment. The legislation goes further, stating that "such coverage shall include benefits for primary care, intermediate care, and inpatient care, including care provided in a hospital, clinic, professional office, home care setting, long-term care setting, mental health or substance abuse programs, or other settings when rendered by a nurse practitioner who is a participating provider and is practicing within the scope of the nurse practitioner’s license to the extent that such policy or contract currently provides benefits for identical services rendered by a provider of health care licensed by the State."
  
  An insurance carrier that requires the designation of a primary care provider shall provide its insured with an opportunity to select a participating provider nurse practitioner as a primary care provider or to change its primary care provider to a participating provider nurse practitioner at any time during their coverage period.
  
  It remains to be seen how this legislation will be implemented; however between the mini-clinic model and this legislation, the seeds have been sown to move in the direction of the new paradigm of primary care delivery.
  
  The pathway to create the new PCP may be through an enhanced nurse practitioner track or through a conversion of some medical school slots. Either way, a collaborative effort between medical societies, federal and state licensing and regulatory authorities, and third party payers is required.
  
  Conclusion
  
  The U.S. health care system is the most expensive in the world yet it is hardly the best. The Commonwealth Fund recently released its second national scorecard on health care showing that the U.S. spends more than twice as much per capita for health care as most other industrialized countries, but has fallen to last place among those countries in preventing deaths through use of timely and effective medical care. Perhaps the expansion of the primary care resource as envisioned above could provide one step in the right direction to increase access to care.

The End of Primary Care As We Know It - Part III

Are Fully Educated and Trained Medical Doctors Needed as Primary Care Providers?

All medical doctors go through the same four year medical school education, plus a minimum of three years of residency training. At the end of the seven years, the now educated and trained doctors have incurred similar costs and have earned roughly the same amount from their residency stipends. So, aside from those with independent means, upon graduation, all newly-minted doctors are in the same financial position, facing a staggering debt ranging from $150,000 to $500,000

From this point on, the economic and practice differences take shape. A fresh out of residency orthopedic surgeon will command compensation at least twice that of an experienced primary care physician. At the same time, the orthopedic surgeon will immediately be called upon to use his/her highly honed technical skills to treat orthopedic conditions, while the primary care physician may see a variety of patients, including healthy people coming for an annual physical exam, as well as others with minor, easily treated medical conditions. A small fraction may have a serious illness that requires significant medical intervention such as medication and or other non-invasive procedures.

The focused attention and time of the primary care physician is required no matter where on the complexity continuum the patient falls. However, insurance companies reimburse at a lower rate for less complex medical issues, based on the theory that such care does not require the full extent of the primary care physician’s skill, and is therefore worth less than if the patient presents with a high level of complexity.

Is there a way to match patient needs with provider competence, reduce costs, increase compensation for primary care physicians, and expand availability of primary care resources? The next blog post will address this question and propose a new paradigm for providing primary care.

The End of Primary Care As We Know It - Part II

What Do Primary Care Physicians Do and What is it Worth?

According to one of several definitions by the American Academy of Family Physicians, "Primary care is that care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern (the "undifferentiated" patient) not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis".Primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (e.g., office, inpatient, critical care, long-term care, home care, day care, etc.). Primary care is performed and managed by a personal physician often collaborating with other health professionals, and utilizing consultation or referral as appropriate.

For many years, comparative compensation surveys have shown the work of primary care physicians to be valued less than that of specialists. So why is primary care considered of lesser value than services by specialists? One possible reason is that specialists deal with "differentiated patients", i.e. those who have defined problems that require a high skill level to treat. Only sick people seek the services of specialists while a vast majority of patients seeking services from a primary care physician are not seriously ill or have only minor illnesses that can be readily diagnosed and treated. Third party payers do not pay a high fee for treating minor problems or no real medical problem at all. Advocates argue that the services of primary care physicians is undervalued stating that primary care physicians can resolve minor problems before they become major problems, and they may be able to influence patients to behave in a manner that promotes wellness. Obviously, neither of these arguments has influenced society to place a high economic value on primary care physicians’ services.

In fact nurse practitioners may be equally capable of providing a similar form of care. And regarding wellness promotion primary care physicians can only have limited influence on patients compared with other forces in the environment, especially given that relatively healthy patient may visit a primary care physician one or two times a year, and patients under thirty even less frequently.

This begs the question "Are Educated and Trained Medical Doctors Needed as Primary Care Providers?" This will be addressed in the next blog post.

The End of Primary Care As We Know It - Part I

The signs of a pending crisis in primary care, the true front line of our healthcare system, are all about us, and not much is being done to deal with this potentially explosive problem. In this and future blog posts, I will present a diagnosis of the problem and propose a potentially radical solution. The discussion will be built around the following questions:

• What do primary care physicians do and what is it worth?
• Are medical doctors needed as primary care providers?
• Is there a way to match patient needs with provider competence, reduce costs, increase compensation for primary care physicians, and expand availability of primary care resources?

The shortage of primary care physicians has been well known for some time and the situation continues to worsen. The most recent survey of fourth-year medical students published in the Journal of the American Association reported that only 2% plan to work in primary care. This is down from 9% in 1990.

Google" "Primary Care" and dozens of articles appear regarding "the problem". In a nutshell, the shortage problem is attributed to two factors: compensation disparity between primary care physicians and specialty physicians; and lack of job satisfaction among primary care physicians.

Suggested solutions mostly deal with the compensation issue: putting more money in the pockets of primary care physicians will solve the problem. While compensation is an easy way to crystallize the issue, I believe it is only half of the problem. A complicated billing and coding system requires doctors to evaluate the value of each patient visit based on the complexity of the patient’s problem to justify the value of the visit for payment purposes, as opposed to the health care value of the consultation. One of doctors’ greatest fears is the audits and reviews by third party payers that often find that the doctor "over coded" claims and must refund money back to the insurance company. This creates an extremely unpleasant and often hostile environment for primary care and indeed all physicians.

Whatever the reason for the shortage, something must be done to change the system so that adequate primary care resources are available. In the next several blog posts, I will address the questions posed above and offer a possible solution.

Integrative Medicine Is Mainstream

The January 9, 2009 edition of the Wall Street Journal contained an opinion piece penned by Deepak Chopra, Dean Ornish, Rustum Roy, and Andrew Weil entitled "Alternative Medicine Is Mainstream". The authors are some of the biggest names in promoting alternative, complementary, and integrative medicine. The piece opened with the words: "The evidence is mounting that diet and lifestyle are the best cures for our worst afflictions."

President-Elect Barak Obama stated during his campaign: "This nation is facing a true epidemic of chronic disease. An increasing number of Americans are suffering and dying needlessly (italics mine) from diseases such as obesity, diabetes, heart disease, asthma and HIV/AIDS, all of which can be delayed in onset if not prevented entirely."

According to the authors of the Journal article, "The latest scientific studies show that our bodies have a remarkable capacity to begin healing, and much more quickly than we had once realized, if we address the lifestyle factors that often cause these chronic diseases. These studies show that integrative medicine can make a powerful difference in our health and well-being, how quickly these changes may occur, and how dynamic these mechanisms can be." Because of this statement and others, I am optimistic that the incoming administration recognizes that we must provide incentives for healthy ways of living rather than paying for only conventional drugs and surgery. In fact, in the long run, the only way we can make adequate health care available to the 45 million Americans who do not have health insurance is to focus on the fundamental factors that lead to both health and illness. Hopefully, this change in emphasis will be a key component of any forthcoming health reform legislation.

Another strong sign of the integrative medicine movement going mainstream is the recent opening of the Osher Clinical Center at Brigham and Women’s Hospital. The strong acceptance of the integrative approach by a mainline Harvard teaching hospital provides a ringing endorsement for integrative medicine. In fact, the cover story in the Fall 2008 edition of "The Magazine of Brigham and Women’s Hospital Boston" features the Osher Center. A key message in the story is the following: "Up until a few years ago, "alternative," or more commonly named " complementary" therapies were not provided at top academic medical centers such as BWH. But scientific research and clinical experience indicates that these treatments, some of which have their roots in Eastern medicine, do indeed offer viable and measurable medical benefits."

The Marino Center has been developing and providing integrative health care for over 15 years. It appears that these pioneering efforts are paying off through higher levels of utilization and public recognition of these treatment modalities’ efficacy.

On The Front Lines of Integrative Health

The purpose of this blog is to engage in a dialogue about improving our healthcare system from the perspective of keeping people well and treating illness in a manner that reduces the need for major and costly medical interventions. I will offer some of my own diagnosis and prescriptions for our ailing healthcare system and would welcome comments and feedback. I look forward to contributing to the coming transformation that must happen to save our healthcare system and the overall U.S. economy. To learn more about the Marino Center, visit our website: www.marinocenter.org.