Primary care physicians (PCPs), or family physicians, are becoming increasingly frustrated with the way today’s health-care system requires them to practice medicine. As a result, experts say their ranks are thinning as PCPs retire and only about 3% of current medical school graduates enter the field.
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At the current rate, by 2025 the U.S. will be short 40,000 PCPs, according to Dr. Glen Stream, president of the American Academy of Family Physicians (AAFP).
Concentra CEO Jim Greenwood claims PCPs are being forced to step back from what they first set out to do: manage the health of their adult patients, their kids and their kids’ kids in a holistic, patient-centered way, deterring more individuals to enter this field of medicine.
“This is the joy of family medicine,” says Stream, and the model for managing the care of the undifferentiated patient. “The dynamic engages the patient and builds lifelong trust.”
The lack of new primary care physicians and problems plaguing the field can have a significant negative impact on patient care. Some employers are creating business models that work with health-care organizations to help PCP’s regain their status as the gatekeeper in a patient care and reduce their own health-care costs.
Fee-for-service: exacerbating the problem
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Insufficient insurance reimbursement that results from the fee-for-service structure now being used in the field is putting primary care and family practitioners under fire, despite scientific evidence showing patients want a family doctor who knows them, their family and takes care of them over time.
The current evaluation and management codes which govern billing and fee-for-service reimbursement do not accurately account for the cognitive expertise of PCPs but rather value procedures, which are largely the province of specialists.
The structure sets up a dynamic that requires PCPs to take on more patients, and limits patient-time-per- visit; it also encourages them to farm out their patients to specialists who run diagnostic tests and complete procedures.
Oftentimes patient data is not adequately shared among physicians, resulting in fragmentation which frustrates physicians and compromises care, says Dr. Tom Fogarty, chief medical officer at Concentra.
The significant gap in the compensation of PCPs and their specialist counterparts is also an outgrowth of the fee-for-service structure and similarly disheartens primary care and family practitioners.
“Some specialties earn two, three or four times the salary of the family physician,” Stream claims. "That’s a harsh financial reality when a young physician faces $200,000 of medical school debt even with the loan repayment programs that the AAFP has established.”
In fact, in November, the AAFP told the Senate Health, Education, Labor and Pensions Committee (HELP) that depending only on a fee-for-service system to pay for health care undermines congressional efforts to improve care quality and constrain cost. “Such a system discourages the very primary care services on which transformation of the U.S health care system depends,” the AAFP says.
Prevention, risk management and patient engagement
Some employers are creating business models that work with health-care organizations to help PCP’s regain their status as custodians in patient care.
And, says Greenwood, employers are investing money to bring family practice health care to the workplace to reduce patient health-care costs.
Employers are incenting employees to see these physicians for preventive care, managing risk factors and chronic conditions and overall wellness. By establishing a team approach incorporating health coaches and other medical professionals like nurse practitioners, nutritionists and other specialists, the system encourages a more efficient use of resources and works to prevent disease before it happens. Experts say the model bends the cost curve and saves money for individuals, businesses and the health-care system.
In some employer settings, the physician actually becomes the employees’ PCP. In others, the physician functions in an urgent care role, but shares information about the onsite patient encounter with the employees’ outside PCP.
Changing the reimbursement model
Onsite PCPs are paid a salary as opposed to a fee-for-service, and the employer assumes risk, according to Greenwood. The PCP’s focus becomes managing the health of patients, and salary is based on performance.
In 2009, Perdue gave its work-site doctors a 20% raise dependent on the physicians signing a pledge confirming that they would retain more patient management and make fewer specialist referrals to “truly lead patient care,” says Dr. Roger Merrill, Perdue’s chief medical officer.
Perdue launched its worksite system about seven years ago with its Health Improvement Program, in which about 85% of employees participate.
Repeatedly, Perdue’s statistics exceed national standards in controlling chronic conditions, and health costs have been limited to an only 2% increase which is significantly less than the national 10% to 12%average—results that Merrill attributes to the company’s system of high-touch care.
“A placebo effect kicks in,” Merrill says. “The patient trusts the PCP, feels more confident about his or her health and generally consumes less health care dollars,”
“The objective is gaining the most health per dollar spent; not widgets or procedures. There’s no question that’s where the value is.”
The patient-centered medical home
These private strategies have become models for the Comprehensive Primary Care Initiative (CPCI) undertaken by the Centers for Medicare & Medicaid Services (CMS) to help Medicare patients as a component of the Patient Protection and Affordable Care Act (PPACA)
The plan identifies five to seven regional markets and 75 practices within each market. Its reimbursement structure supports the patient-centered medical home (PCMH) model, and will continue some fee-for-service care management per-member-per-month.
Primary care practices that choose to participate will receive pay-for-performance tied to quality outcomes after two years of participation and will be given better primary care support for their Medicare patients.
Despite these innovations, Merrill remains “somewhat cynical and predicts “we will experience higher cost and inferior results if we continue on the current path.”
Still he sees employers who apply the same business rules and philosophy to health care as they do to their own businesses as having the potential to right the system, at least in the short term. “Only when we hurt enough” will we improve health and lower costs.