09 Apr Gatekeepers vs. Quarterbacks: Primary Care Gets Back in the Game
1. The backfield player whose position is behind the line of scrimmage and who usually calls the signals for the plays.
2. To lead or direct the operations of an enterprise.
I have been reading with interest all the recent articles (here, here, here, and here) regarding the decline of primary care as a specialty and the rise of practice reform models, such as conceirge, retail clinics, and related variations. The common theme is that through the debauchery of managed care and RUC reimbursement schemes supported by the AMA (24 of 29 representatives represent specialties), we have created a completely skewed, unaccountable, and unsustainable financial model incenting the delivery system to provide a specific type of care. In essence, we are getting exactly what we paid for – dyscoordinated care, excessive procedures, and too many specialists (an excellent treatise on this is provided by Shannon Brownlee’s excellent book, Overtreated).
In reading non-physician commentary about this situation, I am intrigued with some of the insights but have to smile about most of the conclusions. Let me be candid with my experience regarding career choice options while I was in medical school. I attended the University of Utah, well known for its genetics and informatics programs, with a moderate slant toward rural care given the remote expanses which fed into the tertiary care centers of the University and Intermountain Health Care. There was a strong bias to recruit primary care physicians beginning with the free brown bag lunches that started during my first year. Incentive programs, like loan forgiveness or related financial incentives were tossed out as carrots, to attract potential primary care physicians. The problem for me, and most students, was that both the message and the messengers were unconvincing.
We all busted our tails to get into medical school, and despite whatever your higher motivation of choice you relayed during the interview process (I want to help people, I want to do well by doing good, etc), the rigors and demands of 7-12 years of post college training completely beat the altruism out of you. It came down to what specialty can provide the most value to me (outcome/price). This formula is important for non-physicians to understand. Some physicians in training are motivated purely by their love for some aspect of medicine – pediatrics, public health, AIDS, surgery, etc – but most settle on the practice type which helps them attain the outcomes they desire (quality of life, financial security, and career stability) at a price they are willing to pay (years of training, lifestyle, financial considerations, etc). When you sit down with a highly intelligent, highly motivated (remember these folks are gluttons for delayed gratification) person and present Hamburger A or Hamburger B, their decision making process becomes clear:
This data is taken from my personal thumbnail sketch and do not represent actual practice information.
So, please, tell me why as an aspiring medical student, feeling a little entitled by the prospect of the extra two initials looming, would ever go into Primary Care? You can drop the altruism right now because altruism does not put food on the table, children through school, or the finer things in life within reach. This is exacerbated when you have a plateful of specialty choices in front of you that offer everything you are dreaming about and in some cases much more. Remember, I am not disparaging my primary care brethren/sisters in anyway, they are fighting the “good fight” in the trenches and the evidence is clear that primary care is an integral part of improving health care and population health. I am merely acknowledging that the current financial system we have in place creates overwhelming incentives to go into a specialty, or even if you choose primary care (ie, internal medicine) you still choose to specialize (cardiology, pulmonology, infectious disease, etc).
As a result, I have become very interested in redefining health care financing to align incentives in order to obtain better health care outcomes. I believe that primary care needs to be paid in a way that recognizes the value that it creates for improving population health (just as I believe that teachers should be paid for the value they create for society). Notice that I did not say physicians – as I am of the persuasion that primary care physicians are being undone by their own lack of demonstrating value and moving appropriately up the health care delivery value chain. Primary care physicians ARE GOING TO GET REPLACED (appropriately so!) for all the simple stuff that is covered by retail clinics. Anything that can be reduced to a guideline, a template, or treatment algorithm should absolutely be given to someone else in the health care delivery chain. PCP’s should not fight this, they should embrace this, in order to move toward delivery of higher value oversight, complexity, and clinical conundrums where they can uniquely put those years of training and experience to work.
Paying primary care providers more has to be more than just a cost shifting scheme where more payment is given for the same method of delivery. I personally believe payors are willing to pay more for something new, better, and less costly. In order to facilitate this transition, primary care physicians need to move from the failed “Gate Keeper” concept (impotent guardians of health care expenditure) where they were perversely incented to do more and do less simultaneously to the much more enlightened “Quarterback” of a primary care delivery TEAM. Having been a quarterback myself both on the field and in the ER, I know what it is like to deliver great outcomes in a highly effective team environment. Primary Care Physicians should provide the clinical leadership, practice population oversight, care coordination, and overall direction for care teams (nurse practitioner, registered nurses, medical assistants, dietician, etc) that gets paid based on delivering outstanding results. This type of “Quarterback” model has some promise.
Its still pregame, in fact, the players are just wrapping up the final instructions prior to taking the field for final run throughs and warm-ups. However, the money boys are starting to place their bets. Everyone is looking for quarterbacks who can take lead the team.