The Real Primary Care

Will the real primary care please step out from behind Curtain #3?  In the past few years, primary care has come to much more public attention.  As millions more Americans gained coverage, the worry about a primary care shortage intensified.  Primary care incentive payments (a 10% increase in Medicare payment for primary care shortage over the past several years, scheduled to end next year) provided necessary but not sufficient relief to small independent practices like ours. Different and exclusive primary care models developed like cash-only and concierge medicine.  Other primary care doctors shifted to micro-practice, operating with few to no other staff-members and taking on administrative tasks well below their licenses for the trade-off of having lower overhead and smaller panels of patients. In the past few years, the Patient-Centered Medical Home model has gained both traction and criticism:  clearly a better way to take care of patients (as our own numbers prove) but at a high cost and not necessarily constraining the cost of healthcare.  With inadequate insurance company support for the model, it cannot be sustained.

In the face of the shortage of primary care doctors, other types of providers like PAs and nurse practitioners have arrived on the scenes.  In many states, nurse practitioners practice primary care without any accountability to physicians.  Now, nurse practitioners are posed to practice psychiatry independent of physician supervision in states like Nebraska.   Training for nurse practitioners in psychiatry is conducted online, in contrast to the three year in-person residency required to train a medical doctor in psychiatry.  It is hard to argue against nurse practitioners filling in care in Nebraska, as they are serving in outposts without other access to care.  Tele-medicine has been proposed as an alternative, but then supervising physicians would need to accept Medicare and other insurance payments which is all too rare among psychiatrists.

Even in Baltimore, it is hard to get our patients in to see psychiatrists who still accept insurance. The ones that do often work in hospital clinics where patients are charged up to $500/visit facility fees.  I would predict that psychiatrists will struggle to retain the value for their services if independent nurse practitioners are allowed to practice without them.  Such nurse practitioners could write prescriptions for anti-psychotics, treat bipolar disorder, and take on other aspects of psychiatry that even primary care physicians do not feel adequately equipped to manage.  Since psychiatrists have dropped Medicare and other insurance participation, they have lost substantial voice in the debate.  States and insurance companies may seize the opportunity to channel their customers toward care with nurse practitioners rather than paying them back at least partially when they see out-of-network psychiatrists.  Cash-only psychiatry to the tune of $350 or more per hour may bring in only the most affluent patients to see an MD psychiatrist, but even some affluent patients will choose to stay in-network and come under the care of a less-trained nurse practitioner.

The Veterans Administration has imagined settling their primary care shortage by allowing independent nurse practitioners to take on the care of veterans.  There is a bill in the Senate that would allow it.  These older, more complex patients frequently suffer from psychiatric and medical illnesses combined.  They would potentially have no doctor involved in their healthcare.  The lure of cost-containment seems irresistible in the present economy, but will this be one more way that veterans are short-changed?

Of course, then there is the computer.  Will computers take the place of primary care physicians?  It seems like we've been hearing less and less about avatars these days, but computer-driven triage nurses have been designed to take a medical history and send a patient in a certain direction.  Then there are websites such as wrongdiagnosis.com, or rightdiagnosis.com for that matter, helping web surfers decipher possible causes of their present illnesses often with little filter for probability.  55% of diabetic millenials who were surveyed said they would trust a health app more than a doctor. Robots are being designed to express empathy, so it may only be a matter of time before primary care physicians could be replaced by empathetic robotic diagnosticians.

But that's not all, now pharmacies and large companies are aiming to deliver the kind of "primary care" where and when patients want it.  Less than a week ago, CVS announced plans to acquire Target pharmacies' pharmacy and retail health care business.  This stunning report hit close to home as our star nurse practitioner left the practice at the end of last year to go and work for Target.  These pharmacy clinics that profit largely from retail business are able to offer deals that are hard to refuse to nurse practitioners who will earn more than my salary treating earaches, sore throats and sprained ankles.  The hard fact about this type of care is that it serves to fragment care.  A patient seen at a pharmacy here, a doctors office there, and goes to an ER has greater risk of incomplete information availability at each point of care.

The notion that primary care doctors are replaceable is most powerfully reinforced by the misperception that primary care is acute care, like the pharmacy clinic care I just described.  This misunderstanding has led some to anticipate an altogether end of primary care, as did Forbes contributer Dan Munro in his article in November of last year.   His article was laced with the phrase "low-acuity", repeated multiple times, like a stab to the stomach.  "Low acuity" might describe almost anything but the job I have.   As the leader of our independent practice medical home at Green Spring Internal Medicine, I have the responsibility for the care of over 2000 patients.  I employ a staff of 6 highly proficient team-members, working directly with the nurse practitioner who serves as care manager.  I regularly check in on four major medical journals and attend national conferences to train in my discipline about twice a year.  I also collaborate with hundreds of specialists and a host of hospitalists in the care of our patients.  I am also working with other primary care practices on performance improvement and more sustainable model changes.

In addition, I am responsible for the basic operations of our electronic medical record, working with our IT professionals to ensure systems are secure and working, and have responsibility for capturing and reporting clinical quality measures to Medicare and to the Maryland Multipayor PCMH Pilot program (MMPP).  Then, health insurance companies of their own are also requesting data reporting and actions on correspondence they send to us about our patient.  "Your patient, JB, was also prescribed _______ by Dr. Cardiologist."

The above is only the doctoring part of my job description, and I will stop short of describing my business and operations responsibilities.  Negotiating with insurance companies is one of my least favorite, which could get worse if they are allowed to consolidate.

How will we survive all of these threats to our value and to our stability as a business?  We have had to be strategic.  Our PCMH pilot is coming to an end, with the loss of a lot of funding of the model that came with it; however, now Medicare is paying for more elements of what we do.  The 10% primary care incentive may disappear, so we will have to make up the revenue elsewhere.  We have felt isolated in independent practice, and so we joined with Aledade to form an independent practice ACO.  The nurse practitioner moved on to work for Target, so we hired a new nurse practitioner who has two degrees from Johns Hopkins.  I have difficulty taking a real vacation, so I am working to hire a new physician.  

What is real primary care?  It is a physician-led team-based approach to coordinated, patient-centered healthcare using integrated health information technology to ensure safety, efficiency and the best health outcomes.  Real primary care is dependent upon physicians who are practicing at the top of the license alongside other health professionals like nurse practitioners and PAs, medical assistants and home health aides who are also all practicing at the top of their respective licenses. The primary care team, the patients, family members and caregivers all collaborate together.  This kind of teamwork is crucial for our most frail and complex patients, to be sure that all of their healthcare is what is best and centered upon their own values.  This kind of teamwork will always involve the human touch, with computers only a tool, and empathy that only comes from long relationships.  This kind of primary care is not on its way out anytime soon.