National Commentary

The Uncertain Future of Primary Care

Almost all knowledgeable observers of the American health care system are concerned about the decreasing numbers of our Medical School graduates who have chosen to enter primary care practice in the past two decades. There is a considerable amount of data that a health care system weak in primary care, is more expensive and, by many measurements, deficient in the overall quality of care delivered. The Affordable Care Act, many private insurers, and many academic observers of health care have taken or advised steps to turn this trend around. The major reorganization, stimulated by some variation in the way physicians are paid, is called the patient centered medical home (PCMH). In this reorganization primary care doctors—family practitioners, general internists, or, for children, general pediatricians— are practicing in larger, better organized, groups.

The practice has 24/7 phone or E-mail availability, is the point of entry into the health care system and coordinates care for all its patients. There are other health care providers, in addition to physicians, in each venue. These are most often licensed nurse practitioners, but may include physician’s assistants, other types of therapists, and possibly pharmacists who coordinate medication adherence and dosage. Almost all practices are required to acquire electronic health care records. There are changes in the payment system, in most still predominantly fee for service, but initiated to increase the overall income of the primary care physicians. These include “bundled payments” for certain chronic conditions, i.e. extra reimbursement for each diabetic, payment for formulation of “care plans” for the most complicated patients with multiple illnesses, and “payment for performance”. This latter, often called P4P, is the an increase for the entire practice’s insurance payments, if certain evidence based quality guidelines for a variety of common chronic conditions, and preventive health care measures for all patients, are met. This may be as much as a 12% increase in reimbursement. Most observers of the health care system, and the professional organizations representing primary care physicians have welcomed this entire reorganization.

In addition to the PCMH’s, there is another type of reorganization that is growing throughout the country. This often includes the primary care physicians’ practices, but joins them with hospitals, and often with groups of organized specialist physicians. These are called accountable care organizations, and their agreements with insurers further reduce costs and, by most measurements, improve quality Many of the physicians in these organizations are on salaries, rather than having their previous personal financial relationship with insurers.

All this sounds good for primary care physicians, but in actual day to day practice there are several potential down sides. In the PCMH much of the doctor’s time is spent in supervising the organization, not in face to face contact with the patient. Also, the adoption of electronic medical records, though usually producing a dramatically more readable and transferable record, definitely slows down and may at times depersonalize the physician patient interaction. This intrusion into the most important aspect of the doctor-patient relation, may ultimately come at a price. In my private practice, time with the patient was the most valued part of my practice. Also, there is a concern that the primary care doctor’s skills may be squeezed between those of the lesser trained nurse practitioners and the more technically trained specialists.

One other strategy to preserve or improve income by primary care physicians, particularly in high income communities, has been the formation of “concierge” practices, with substantial annual sign up fees, in addition to the usual primary care insurance reimbursement. With this significant additional income, the number of patients in each practice, as part of the deal, has dramatically reduced. Of course, this way to protect primary care will simply not work in rural areas, or in low income urban or suburban areas. This is not an answer in the vast majority of the country.

So, what is the answer? I think, as with most public policy dilemmas we must realize that there is a problem. We must also learn to place the well trained primary care physician at the proper spot in our value system. We can, and should, utilize his or her skills as an organizer, supervisor, and recorder of health care. But we must still recognize the primary care doctor’s face to face interaction with the patient, as the most valuable part of a high quality system, and be careful that the new organizations make time for this.