President Obama’s efforts to reform the American healthcare system will be for naught unless the fundamental economics of the system undergo a sea change. That change relates directly to the way that physicians are compensated for the work they do and the responsibility they assume for the overall health of the populations of patients for which they provide care.
The revolution potential stems from the essential differences between the roles of the primary care provider and the specialist physician. These differences are the reason why the voices of the American Medical Association and state and county medical societies will be attenuated in the debate over healthcare reform. Their internal politics will make them ineffective spokesmen for a rational design…and fundamental change.
We all intuitively know that the ideal role of the primary care physician (PCP) is to provide first-line healthcare for patients, serving to triage their symptoms, diagnose and treat identified conditions within the scope of their specialty, and to manage their referrals when the patient’s condition(s) warrant referral to a specialist. The PCP’s role is to be the “quarterback of care” for the patients who have identified that physician as their primary care doctor.
The flaw in this economic model is that the PCP only receives compensation when he or she actually lay hands on the patient in the office. While there are some innovative healthplans that are beginning to recognize the value of e-mail and telephonic “visits,” for the most part a patient must be seen by their physician for that doctor to be paid.
When a patient’s stated symptoms obviously require a more thorough history and examination by the primary care doctor, or when there is any doubt, this fee-for-service compensation system is not per se flawed. But when a patient’s stated symptoms are so obviously beyond the scope of the PCP’s specialty training, the act of making a medical decision based on the patient’s stated symptoms and referring them to a trusted specialist deserves compensation for the actions taken and risks assumed, whether that decision is made as the result of an office visit or a telephonic or “e-visit.”
Once the specialist has evaluated the patient, correspondence regarding the patient’s condition and treatments performed or recommended is sent to the PCP. The PCP absorbs this new data and adjusts his or her own treatment plan for that patient, often without seeing the patient in the office again for another fee-for-service encounter. Again, decision-making is performed for the benefit of the patient without compensation to the primary care physician.
So what is the solution? How does the economic model of healthcare adjust itself to more appropriately reflect the contributions of its workforce, the primary and specialist physician?
One solution is to formalize the “medical home” concept, also known as the “patient-centered medical home,” or PCMH. In this model, the primary care doctor is recognized for accepting a certain base level of responsibility for the role they play in managing the overall health of the patients who identify them as their PCP. In exchange for accepting this responsibility, the primary care physician should receive a monthly stipend for every patient who has designated him or her as their PCP. The stipend can be small, $10 to $25 per patient, per month, but when multiplied times the typical patient base of a primary care doctor, the total affords the PCP a base income that should remove any economic barriers to that doctor accepting his or her role in managing the care of a population of patients.
This is where the potential of revolution enters the picture. Assuming that budget-neutral funding needs to be adopted to implement this new payment structure, from what source do these medical home payments come? If the primary care doctors “win,” who loses?
Perhaps no one loses. A bloodless revolution?
By formally placing the primary care physician at the forefront of the care model, and compensating them appropriately for the work that they do, whether seeing the patient in the office or coordinating their care when outside of the office, there will be immense savings to the overall healthcare system. By having access, even telephonic, to the advice of a qualified primary care physician, patients will most likely consume fewer specialist visits and go to the emergency room only when recommended by their PCP, or when that PCP was unavailable.
Moreover, because the base monthly payment is there to cushion the overhead of a primary care physician’s practice, he or she will be able to handle patients via telephone, freeing office time for truly sick patients or those requiring more hands-on management of their chronic conditions. And to prioritize annual preventive care visits so that patients’ long term health is optimized.
Why are the AMA and state societies compromised and unable to advocate for a payment system like this? The member base and inherent politics of these associations are a melange of both primary and specialty care physicians, in practices ranging from solo to large multispecialty groups. For entities with such diverse memberships, speaking with a unified voice to advocate for revolutionary change is impossible. If the primary care doctors win, the specialists may perceive that they lose, and that will cause a stalemate within the advocacy arms of these entities that will make Congressional gridlock events pale by comparison.
The primary care specialty associations are stepping up to advocate for the medical home concept to a degree, but the traditional fraternal nature of physician cooperation is resulting in them treading on cat’s feet on this shift, reluctant to advocate for a change that could be interpreted as advantaging primary care doctors over their specialist brethren. Such is the collegial nature of the medical profession…for better or for worse.
In the end, there will be other, equally favorable, consequences that can be imagined. With the basic economics of primary care recalibrated to encourage physicians to build a practice that welcomes hundreds, if not thousands, of patients, doctors in training will migrate back into choosing internal medicine, family medicine, or pediatrics for their residency. And access for the millions of uninsured will be eased as doctors have the fiscal wherewithal to hire midlevel providers such as physician assistants and nurse practitioners to add appointment slots for more patient visits.
For all the positives that this change would provide, it is not without its risks. The incentive for primary care physicians to build their patient panels to immense sizes while providing little to no direct patient care is present, but it should be self-correcting as patients who are not getting their needs met switch PCPs until they find one who provides the access that they need. And PCPs who exist merely to answer the telephone and refer out their patients will save the system no money; but a simple analysis of claims submitted versus panel size should provide information to detect such gaming of the system.
Unless the White House or Congress acts to adopt and impose this, or some other, innovative and revolutionary solution, the current system is going to equivocate itself into bankruptcy. Political courage and an independent perspective, two things that are not well known or practiced by front line physicians, must be expressed by forces that only the government can bring to bear to restructure the American healthcare system into something that makes sense.