Gatekeepers vs. Quarterbacks: Primary Care Gets Back in the Game

09 Apr Gatekeepers vs. Quarterbacks: Primary Care Gets Back in the Game

Quarterback (kwôr‘tər-băk‘) n.


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.

5 Comments
  • Robert C. Bowman, M.D.
    Posted at 11:04h, 18 April Reply

    The simple explanation is that financial calculations allow $130,000 salaries to be multiplied times 2 for $260,000 debt that can be repaid. Granted this is difficult for those attempting to live in the highest cost of living locations in the nation that have the lowest primary care salaries. Moving away from such locations to better pay and lower cost of living is a great asset to the nation in many ways and is personally and professionally rewarding. This will not work of course for those who want their cake and eat it too.

    The more complex explanation:

    The nation will not change until arrogant people are forced to become aware of reality.

    After 32 years of experience involving medical school, residency, practice, family, and a life of learning I have found that I can teach just about anyone except the arrogant.

    Those who learn are those who desire to learn and who desire to learn in any dimension. The most important dimensions for human learning involve the human dimension. A failure to focus learning in the human dimension is a primary means to make society inefficient, ineffective, and arrogant. It is very easy to teach a society to be arrogant. One way is to make sure all have basic access to trinkets of little value, something that has worked to subjugate peoples for centuries. As long as the trinkets keep coming, few will be aware that their society is crumbling.

    It is relatively useless to attempt to convert the arrogant who often rise to influence medical schools, governments, health policy efforts, health care columns, media exposes, and more. However even they must eventually face the awareness that lower and middle income people are important and that physicians must first of all be able to related to people (all types of people as patients and as care deliverers). They must face the fact that the family practice, primary care, nursing, public servant, fire, police, military, and all basic human infrastructure careers that are more likely to arise from lower and middle income people and that are more likely to be found serving lower and middle income people

    ARE THE BEDROCK OF CIVILIZED SOCIETY

    There is no better explanation of the chaos currently found with multisystem dysfunction than an arrogant leadership that has grown to involve all states, all parties, and those who shape the nation in multiple dimensions.

    Once the basic foundations of civilized society are understood, then replenishing the service oriented pool (those that most believe in a nation when things are tough and those who sacrifice the most in such times) becomes a top priority and the answers to this are clear. There can be no higher priority that the birth to age 6 preparation of children for these serving occupations and careers, for no nation can remain stable without them.

    In health care as in all systems, the basic efficiency and effectiveness is first of all about the patient. There can be no higher priority for the best preparation for patients who can actually function adequately in health care situations. Physicians are actually involved in health care a small part of the time. Patients are always involved, regardless of who delivers the care. The patient factor is the most important factor with perhaps 50% or more of the health care cost and quality arising from the patient factor. Another 30% or more is likely to arise from the care delivery factor which is also the result of birth to health care encounter for each nurse, tech, administrator, receptionist, or assistant delivering care. Then there is the small physician component.

    The arrogance of health care studies that consider the physician to be most important is enormous and greatly disruptive to true attempts to improve health care cost, quality, and access, which are not about primary care, but about peoples who understand that better cost, quality, and access are about better children. Of course arrogant children may never understand this, nor will they reshape colleges, medical schools, training, or health policy in a way that makes the United States efficient, effective, and self-sufficient.

    By the way, the cure for arrogant children is to have lower and middle income children arise from humble origins and out think, out wit, and out perform children who have been raised insulated and isolated out of touch with the most important human relationships and values. There are two end results of arrogant children. In one situation arrogant children are more and more insulated and isolated and a nation is maximally disrupted. The other result is that parents learn not to raise their children arrogantly. The professional parents who often raise arrogant children are also able to learn very quickly, when colleges and professional schools no longer accept children who are arrogant.

    Arrogant lower and middle income children are usually poorly organized, unless organized and manipulated by arrogant children of higher status origins. The higher status arrogant children are far more organized and are able to do wonderful things such as organizing plane crashes into the World Trade Center and bringing nations into chaos and war, wars fought by lower and middle income children by the way.

    Bob Bowman
    rcbowman@atsu.edu

  • scottshreeve
    Posted at 15:10h, 18 April Reply

    Bob,

    I have no idea what you said, but you seem pretty intense about the arrogance issue. I agree that their is a physician centric approach to alot of reform related issues. I continue to believe that we practice optimally in “care teams” and hence the Quarterback analogy rings truer than the isolated Gatekeeper analogy.

    We need to provide appropriate value to the activities that really matter. My school teacher example is instructive, because we don’t value them very much either. However, every study available shows the value of education.

    Primary care needs to have some physician leadership that can demonstrate the value. I think that there are many who are beginning to lead this charge, but the lead time for the message is long, the drum has to be consistently, and their needs to be a few guys who are really out there pushing the envelop within the existing political machinery.

    Hopefully you are planning to lead a revolution “of the people, by the people, for the people.” Any specific thoughts on how to put that 32 years to work to come up with some creative solutions?

  • Robert C. Bowman, M.D.
    Posted at 01:22h, 23 April Reply

    The nation fails in basic primary care understanding and in basic awareness of the most important priorities

    1. Basic definitions of Primary Care Training – Of the 5 so-called primary care training forms, only family practice remains with a majority of “primary care” graduates actually remaining in primary care. FP residency grads have 90% retention in primary care (losses to teaching, military, research, administration), pediatrics will soon dip below 50% of residency graduates remaining in generalist primary care, nurse practitioner levels are below a majority and are likely to be 35% or below in primary care (when comparing apples to apples translating AANP data), physician assistant data from AAPA indicates 35% in primary care. Internal medicine residency graduates in resident surveys (consistent with Masterfile changes over time) indicate 25% or lower remaining in generalist primary care (Garibaldi). Somehow all 5 forms manage to retain the primary care training nomenclature but only one form is permanent.

    2. Definitions of Primary Care Capacity – Physicians have 35 year careers with physician assistants likely to be about the same and nurse practitioner careers limited to 24 – 26 years, about the same as international medical graduates who also have delays in entry (international graduates also lose about 50% to failure in residency, return to home nations, departures for other nations, and chronic unemployment, in addition to being a good workforce addition to only 13 largely coastal states with the most GME positions).

    A standard of primary care capacity is needed. The best standard is the FP primary care year. FPs have 90% retention in primary care, 93% activity, and 100% of the volume of an FP. 35 x .9 x .93 x 1.0 = 29.3 primary care years. Other forms of primary care can be adjusted to this standard. NPs have the lowest primary care capacity contributions with 35% retention in primary care, 24 – 26 years, 0.5 – 0.6 volume compared to FP, and 0.7 – 0.75 for activity level. The NP graduate will only contribute 3 – 5 primary care years and perhaps 6 if you include geriatrics and women’s health as primary care. The levels have been declining steadily for the past decade. Pediatric levels are estimated at 15 primary care years for an average 2007 pediatric residency graduate. Internal medicine residency graduates and physician assistant program graduates entering the workforce will only deliver about 6 years each. IM, PD, PA rural levels have all been declining (also likely NP) and FP and PC forms have been declining, all indications of increasing concentrations in major medical center locations with each passing year and class year.

    3. Primary care and lower and middle income peoples are closely related to each other and to the short end of the stick in physicians, income, education, economics, shaping professionals, social organization, grant participation, the economics of health care, and more. Primary care is actually the dominant mode of care (highest percentages of physicians) for the majority of the population, but this fails to receive much attention. The media centers and the concentrations of people, income, economics, professionals, and physicians receive all the attention and the funding. Major medical centers with 75 or more physicians at a zip code contain 92% of researchers, 86% of GME positions, 75% of total active physicians, and 70% of internal medicine and pediatric generalists crowded in to 4% of the land area, clustered together, and with only 35% of the population, generally the top status populations of the nation, the ones with economics, income, and health care coverage. The nation rewards major medical center careers and locations with the most lines of revenue and the highest degree of reimbursement for each line of revenue. The major medical center locations are the only ones that have above average levels of physicians (300 per 100,000) with levels of 400 to 1500 per 100,000. These are also the only locations with levels of primary care above the 100 primary care physician per 100,000 average. Marginal urban locations have 150 per 100,000 or half of the national average and urban underserved locations (average 24% level of poverty at zip) are half again at 80 with levels of primary care at less than half of the recommended primary care levels. Marginal rural and rural underserved levels are much the same.

    Studies of primary care are flawed in many ways because they consider primary care types to be the same. This is not true.

    Only family physicians escape major medical center concentrations with 53% of graduates (60% for osteopathic FP) and this is a much better match to the 65% of the population outside. There are two reasons for this. The first is that family physicians arise from “outside”. Family physicians are the only physicians arising from the widest range of populations at the same rate of 1 per 100,000 per class year. All other physician specialties increase with increasing income and population density. The second is that family physicians do well with funding from outside including community health centers, rural health clinics, better salaries away from major centers, and locations where they can use the health care reimbursement structure (and the better training programs) to their advantage with ER, hospital, procedure, and delivery charges in addition to (and in support of) their primary care dedication. Of course with 100% of medical students trained in major medical centers, they rarely see family physicians or primary care physicians treated well.

    The other major source of physicians for locations outside is those born “outside” in marginal urban, urban underserved, marginal rural, and rural underserved populations. Sadly they have 20 – 50% of the probability of admission and are the most likely to distribute as well as choose family practice and primary care when they do gain admission. About 65% of the population depends upon admissions of those from outside (supplies specialists to outside and internal medicine and pediatric physicians to outside), family practice career choice (doubles urban distribution outside, triples rural distribution outside of major medical centers).

    Logistic regression for urban location outside for 280,000 recent graduates
    FP choice 2.15
    Older than 29 at MS grad 1.16
    Foreign born 0.9
    Osteopathic 1.44

    Other variables
    Historically Black graduate 1.55
    Top MCAT school 0.73
    Office IM – 1.26
    Office PD – 1.3
    Younger than 26 at MS Grad 0.77

    Rural locations outside of major medical centers
    FP – 3.35
    Rural birth 2.6
    Older – 1.4
    Osteopathic 1.5

    Only office IM contributes at 1.2
    Top 20% MCAT school – 0.5
    Bottom 20% MCAT – 1.5
    younger – 0.88
    foreign born 0.94

    The direction for the US is more upper status, more with higher MCAT, more foreign born, fewer rural birth, fewer lower income birth, fewer FP, and fewer in office primary care

    Note that the problems are not rural or underserved or tiny fragments of the population that are often disregarded in workforce planning. The problems involve 65% of the population in 96% of the land area. For a variety of reasons the various leaders involved either fail to grasp the magnitude of the problem or minimize it. Another possibility is that the United States has been admitting those least aware for many decades and training them in the locations least aware, resulting in the current policies and advice to government.

    Applications – More primary care trainees in flexible forms of primary care will not work for basic health access. Decreases in the percentages remaining in primary care result in losses in all class years. In NPs and PAs each year thousands are leaving primary care each year and fewer of the new graduates begin in primary care.

    Applications – Expansions of physicians will not work for increase primary care and health access, unless the expansions specifically involve family physicians or expansions of lower and middle income children in medical school admissions. Pediatric expansions would appear to work, but according to the Committee on Pediatric Workforce, pediatric markets are saturated with all types of primary care competing for fewer children while residency positions remain the same.

    The 1970s and 1990s policies worked well because
    1. the nation rebuilt basic health infrastructure
    2. the nation redistributed health support to lower and middle income people of the time, (although the elderly do not fit this category as well any more)
    3. the nation created family practice, the one primary care form that still fulfills its promise
    4. the nation doubled medical school class size at the optimal time for expansion, during optimal primary care health policy
    5. state and federal government shaped physician workforce with funding that emphasized primary care and family practice in medical education, resulting in a quadrupling of primary care in a decade
    6. medical schools did not mind doing primary care when they were funded to do it, very different than the 1990s when the optimal policy for primary care was mandated and primary care rebound resulted from guilt by association
    7. the nation of the 1970s was very different with fewer divisions and rising opportunity because of the 1950s GI Bill and the 1960s and 1970s reinvestments in education, providing better prepared medical students of wider range of origins, those most likely to choose family practice and primary care and locations outside
    8. Medicare and Medicaid of the 1970s had not been divided up and changed compared to Medicare and Medicaid of today where primary care has been squeezed out of the picture and is poorly supportive to those outside of the elderly and the most destitute.

    Currently the nation fails in birth to admission and admission with a narrow range of top status (65% from the top 20% income level, 85 – 90% for the top ranking MCAT schools), most urban, children of professionals admitted (3 – 10 times the probability of admission, who have higher scores, but no indication of being better physicians) who often have little awareness of lower and middle income people. (3 AAMC Minorities in Medicine studies) The nation trains physicians and health professionals in top concentrations. The nation concentrates physicians with health policy.

    Nurse practitioner, physician assistant, and physician primary care levels are all likely to result in about 25 – 30% found in primary care and all are moving steadily toward major medical center careers and locations, except for those born outside (fewer admitted each year) and family physicians (fewer due to difficulty with medical students trusting the current remaining permanent form due to health policy and little or no exposure to the FPs doing well).

    See presentation 11. “Categorizing Physician Locations by Physician Concentrations” for more on the coding system by Robert C. Bowman MD at http://familymed.uthscsa.edu/research/conferences/2007presentations.html

    Robert C. Bowman, M.D.
    rcbowman@atsu.edu

  • SOAP: Apply, Rinse, and Repeat « Crossover Healthcare
    Posted at 05:43h, 06 May Reply

    […] residents, cool patients, amazing medical science, powerless medical science, trying to figure out what specialty to go into (what respectable student would “settle” for primary care), spending 5 weeks […]

  • Dan
    Posted at 03:17h, 22 July Reply

    So, You Want To Be A Doctor……

    Lately in the media, others have said and appear to express concern about the apparent shortage of primary care doctors in particular. Typically, the main reason believed and speculated by others for this decline of this health care profession specialty that historically has been the apex of our health care system is lack of pay of this specialty when compared with other specialties chosen by potential physicians while in training, as the annual salary of a PCP is around 130 thousand a year on average, others have concluded may be the national average and factors in payers both of a private and public nature.
    Yet considering the additional attention of shortages of students in some medical schools as well, as conceived by others, one could posit hat this professional vocation that has been one viewed in the not so distant past in the U.S. as one with great esteem and respect may not be desired as a vocation by many, that requires commitment and dedication, as reflected in their training regimen in the U.S. that consumes about a third of thier lifespan. Such reasons for this paradigm shift may include:
    Primary Care Doctors perhaps more than other physician specialties seem to be choosing to practice medicine under the direction and financial security of one of the many and newly created health care systems These regional and nationally created systems are typically composed of numerous hospitals and clinics under combined ownership- frequently of a private nature that is not dependent upon their beliefs as it is perhaps on their profit motives and intentions. Yet their approach and etiology of their views regarding the restoration of the health of others are usually similar with such mergers of multiple medical facilities, which are presently preferred to save costs, it has been said, and therefore these systems have not been protested by a largely uninformed public.
    Conversely and in addition, this system of increasing popularity is not necessarily a desired method to practice medicine as a primary care physician, often stated by them as members of their employer that has the power to limit and dictate how they practice medicine. This is because, among other reasons, such doctors have largely unexpected and unanticipated limitations regarding their patients’ heath provided by them. This is further aggravated by possible and unreasonable expectations of their employer, such as mandating that doctors they employ are required to see as many patients as theycan in a day, and there have been cases of physicians being fired by a health care system- along with financial rewards for seeing more patients a day than what is determined as average visits by others. Such requirements likely and potentially affect or alter the clinical judgment determined by physicians employed in what may be viewed as authoritarian employers, which would limit the medical care they provide to their patients, as well as the quality of this care. Also, such health care systems may have their own managed health care system that may be determined by factors not in the best interest of the patients of doctors employed by the health care system.
    The primary etiology and stimulus for a doctor to practice medicine in this way is due to their frequent inability to provide and employ ancillary staff, combined with the increasing premiums for their mandatory malpractice insurance, which may make doctors financially unable to work independently.
    Malpractice laws and premiums, which is determined in large part on a state level, are an issue with those required to have this adverse aspect of their professions. Also, these premiums become more expensive for doctors, depending on the perceived risk of their chosen specialty. For example, the premiums of an OB/GYN doctor are usually higher than one of a specialty viewed less risky for lawsuits, such as Dermatology, perhaps. Plantiffs win about 25 percent of the time on average a half a million dollars. 95 percent of these cases are settled out of court.
    In addition, the issue of medical malpractice is also frequently a catalyst for a doctor to practice what has been called defensive medicine, which basically means that the health care provider is prohibited from relying upon their subjective factors in their assessment of their patients, which in itself raises the question of what the point was of all of their training in the first place. Because if a doctor practices medicine in such a way, it typically involves what may be considered as unnecessary diagnostic testing for their patients to rule out what may be unlikely disease states of their patients’ medical conditions. This waste of medical resources is further validated by the legality reflected in the tone of the notes a doctor usually annotates or dictates with their patients.
    Such restrictions and limitations imposed on today’s primary health care provider are usually not fully illustrated during their training for this profession, which is one that has been viewed as one that is quite noble and of great responsibility on a societal level. It seems that this perception and vocation that now is greatly misperceived due possibly to being deformed by others who may have profit as their motive for the health care they may dictate to doctors they may employ in some way, which often and likely is in conflict with their motives as doctors and how they wish to deliver needed health care to others. This may be why this medical profession may no longer be viewed as distinct from other vocations, in large part, as it seems that presently the profession of a doctor has been reduced to one dependent on the financial stability and growth of its employer, which may alter how the doctors perceive what is expected of them as well, which may affect the importance of how they view their profession, as it has been said that overall, doctors are somewhat understandably more cynical and demoralized, which may be replacing the pride they historically have viewed their callings as doctors, as well as the perceptions of patients in the U.S. Health Care System.
    Further complicating and vexing to these restrictions is the usual financial state of the individual physician, as theynormally have to pay off the debt acquired from attending medical school and training, which averages well over 100,000 dollars today after their training is completed, it has been estimated, along with this debt amount presently is about 5 times higher than it was only a few decades ago.
    Conversely, there are some who believe that doctors in the U.S. are over-paid and are compared with some corporate monster, who behaves based upon the premise of greed. In spite of how they are judged, physicians are likely not absent of financial concerns- which may be of more of an issue than many other professions, comparatively speaking, in addition of taking on more responsibility that is of greater importance compared with other vocations. Such realistic variables should be factored in when one chooses to judge the profession of a physician. On the other hand, no physician should view their jobs as no different from any other venture capitalist when rationalizing their income and motives related to this exceptional vocation as a physician, as others are more dependent on their judgment.

    It has been determined by others, and suggested often and lately, that many of today’s physicians practicing medicine in the United State do not recommend or speak favorably of their professions compared with their typical views of their profession in the not so distant past. While this self-perception physicians may have of a negative nature may be somewhat understandable it is also and potentially unfortunate for the health of the public in the future, and the nature normally associated with the medical profession which could deter ideal medical care for others
    There have been cases where doctors do in fact change careers, and get into vocational fields such as medical communications or corporate medical companies. Also, expert witnessing is another consideration for those who choose to leave their profession. Finally, other choices considered include consulting and research. The training of doctors fortunately leaves them with options not involved directly with the flaws of medical care, but this is bad for us as citizens, overall. The etiology of their departure from their designed profession is largely due to the negative state perceived by themselves as well as others of their profession as medical doctors.
    Then again, not all doctors are deities. Like others, some are greedy and corrupt, which complicates others in this profession in relation to how their vocation is viewed by others and based on limited judgment and analysis. Yet citizens overall should determine what sort of health care they desire, and it seems that often they fail to voice this right as a citizen.
    For perhaps Primary Care Physicians in particular, the medical profession and those who provide medical care clearly needed by others to some degree appears to be absent as a desired path of today’s careerist. The authentic reasons for what many believe to be a negative perception of possibly the entire health care system may never be known, yet many would agree that most U.S. citizens are understandably concerned with the state of this system of great importance to society. Yet need to be active more in assuring this necessity is more aseptic.
    “In nothing do men more nearly approach the Gods then in giving health to men.” — Cicero
    Dan Abshear
    Author’s note: What has been written has been based upon information and belief of a layperson, yet also the assessments of a patient.

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