Tuesday, November 26, 2013

What’s next for Primary Care?

As Obamacare is winding its way through a hellish bureaucratic labyrinth of its own creation, accompanied by cheers and boos from the blood thirsty spectator crowds, confusion, fear, trepidation, despair and exhilaration, are gripping America’s doctors all at once, because whatever else is accomplished in the next decade, medicine will never be the same. At the confluence of cutting edge technology, great poverty and unimaginable fortunes, a new vision for the practice of medicine is beginning to emerge. Medicine was formed during times when sickness was never far from death. It was devised by old men who went to bed every night thinking that they may never awaken, and it was institutionalized by women who shunned life’s earthly pleasures. They understood the fears of old age, the loneliness of disease, and the comfort and serenity that come with putting your life in the hands of God, when all was said and done. They built houses for the poor and sick and downtrodden, with larger than life Doctors as God’s emissaries, and pious Sisters as angels of mercy.

Over the last century, science and technology changed hospitals from places of suffering, grief and death, to places of hope and new beginnings; from dreary Spartan wards for the dying, to plush private suites for the soon to be healthy; from whispered footsteps in the twilight, to shiny instruments of mechanical shops; from final moaning and groaning, to humming of machines and laughing soundtracks of sitcoms punctuated by shrill alarms and flashing lights. Dying in a hospital is now considered a failure of sorts, a preventable and costly mistake. There is no place for God in a modern hospital, and there is no place for special emissaries or angels. And when God vacates the premises, big business comes in to take His place. Today’s technology driven medicine is shaped by young and invincible entrepreneurs, in search of fame and fortune. Masters of their own fate, bursting with self-quantified health, brilliantly educated in the intricacies of computerized logic, armed with stacks of data points, and carefully clad in black turtlenecks, hoodies, tee shirts and designer jeans, these modern knights of the business round table are engaging in the timeless quest of vanquishing death, or at the very least making it less expensive for the rest of us.

So where does all this leave primary care? Primary care is now considered routine care; routine, like changing oil on an automobile. Sticking a needle in your arm so you never, ever die from a plague is no longer a miracle, just like switching the lights on, or flushing the toilet is no longer deserving of thought. Miracles only happen in hospitals now, and not very often either. Primary care doctors are increasingly banned from hospitals, and asked to stick with routine care and leave the complex stuff to their betters. And primary care doctors agreed to this arrangement, mostly voluntarily, and explained (mostly to themselves) that routine care nowadays is pretty complex on its own, and arguably even more complex than the narrowly specialized interventions occurring in hospital settings. Maybe so, but routine complexity is what technology entrepreneurs eat for breakfast. Terminology is important.

When health care reformers say that primary care is foundational to reform, they mean routine care. They mean vaccines given on schedule, screenings done on time, lifestyles assessed and documented, educational materials handed out, and referrals coordinated to completion. They mean managing populations, stratifying risk, conducting outreach, dotting every BP and crossing every A1c. Welcome to Lake Wobegon primary care where all patients come in correctly diagnosed and ready to be tracked. These things can be automated with the right technology and properly trained teams of workers, supervised by medical professionals providing spot checks and quality assurance. High tech and high deductibles will combine forces to turn routine primary care into the first medical service to become a retail product, with its Med Emporium, Osler 5th Avenue, and eventually, Hello Kitty Diabetes toolkits sold at Amazon.com. The question is no longer how to stop the train; the question is where primary care goes from here.

Let It Go!

When primary care physicians became overworked and underpaid, something had to give. Inpatient care, arguably the high end portion of practicing at the top of one’s medical license, was snatched away by hospitals oblivious to their mission statement, and a good portion of complex care had to be offloaded to secondary care, just so primary care can keep up with demand for routine care.  Primary care became literally broken, and with it, the entire system downstream was broken too. In a fool’s errand type of strategy, routine primary care now includes tasks aimed at gluing primary care together again (e.g. transitions of care management, exchange of clinical information across facilities). Furthermore, routine care is being expanded to include things previously in the purview of public health (e.g. health literacy, physical activity, safe sex), stuff that grandma used to do for us (e.g. eat your string beans, keep your hands out of the cookie jar) and new retail oriented things (e.g. online shopping, consumer experience, values and preferences).

Today, in a plot twist worthy of Beckett himself, tech entrepreneurs in concert with non-physician workers are vying for the business at the low end of primary care. The new routine care will be catalogued, standardized, sterilized, automated, delegated, computerized, transformed and reformed. If you hang on to it, it will drag you down to wherever it’s going. Let it go! Let it go to your “team” (read, staff), or (gasp) let it go to Med Emporium.

Insurers, who could not be made to understand the importance of continuous, comprehensive primary care, seem perfectly willing to support the low skilled, electronic strings and duct tape of the new and expanded routine care. If you have an entrepreneurial gene in your DNA, hire staff, promote your office manager to Chief Quality/Compliance Officer, your receptionist to Care Coordination Manger, the triage nurse to Director of Resource Allocation, and delegate the bejeebers out of your daily work. Become the CEO, and get a secretary (a.k.a. scribe), so you never have to click another box, or type another embarrassingly misspelled sentence. Double your patient population, and let your NPs see the f/u for diaper rash, sports physicals, strains and sprains, the new wave of statin seekers, and everything that your Director of Resource Allocation deems routine.  Grab the fluctuating 25% or so of patients that are most complex and be their Comprehensivist.  Hospitals are routinely inventing specialties, from hospitalists to intensivists to nocturnists, to further fragment continuity of care and increase profits. It’s time to learn from the experts.

Instead of waiting for the System’s other shoe to drop (on your head), proclaim yourself a specialist in the absolutely last remaining piece of what was once primary care. Grab it and hold onto it like dear life, because it will be nibbled on from below and from above incessantly. You will have to compete with the low prices of Med Emporium on one hand and with the natural expansionist tendencies of hospitals on the other. You will have to find a way to get paid for your new specialty services, and just like every other entrepreneur, you will have to take risk; the more complex the patients are, the bigger the risk and the larger the rewards. Fortunately, the new health care law encourages precisely this type of advanced payment models. Go for it! Spend a leisurely hour with each patient needing comprehensive care, while your routine side of the business is humming along on its own.  With proper planning, you can collect the customary and usual fees for your greatly expanded panel, plus the special fees for Comprehensive care, plus any shared savings you can generate from keeping these select folks out of hospitals and emergency rooms. You’ll have to do a bit of marketing and engage in some creative contract negotiations (get a lawyer), but the sky may very well be the limit.

Don’t Let Go!

What if you have no entrepreneurial markers in your DNA? What if the previous few paragraphs made you sick, depressed or really angry? Fortunately, Obamacare is on your side.  For all the docs who argued that health insurance destroyed the doctor-patient relationship because it inserted itself in the payment process, and for all those who argued that insurance should not pay for routine oil changes, this is your lucky day, because it doesn’t anymore. With the exception of the very poor and the very old, people will now need to pay for primary care out of their own pocket. That’s what high deductibles mean. A good portion of these people will become savvy shoppers and choose the technology enabled do-it-yourself method, or go to Med Emporium on an as-needed basis, but there will be more than enough patients (perhaps in higher income brackets), seeking quality over cheapness. The same folks that buy artisan bread and free range eggs from local farmers will bring their family to you, if you promise to provide hand-made wholesome and holistic primary care.

Direct primary care, whether concierge, or ideal or micro, or contracted by employers and even forward thinking insurers, will most likely explode in size during the next decade. There is a huge continuum of service definitions here, and you should be able to find your comfort zone. You can go back to being a country doctor in the midst of a bustling metropolis, and care for multiple generations at home, in clinic, at the hospital, nursing home and eventually hospice. You can dial back a little bit, or a lot, and contract with midsize employers to provide outpatient primary care. You can be a high-tech, electronic-everything doctor, or an old fashioned one, or perhaps a unique combination of both.  Here too, the sky seems to be the limit.

So what’s next for primary care? It seems that for physicians, the door is closing on the treadmill now known as primary care practice, but countless windows are being opened simultaneously. You just have to look up and find yours. Whether you choose to stay in the system, step half way in and half way out, or do it your way all the way, there will always be a need for good doctors. Whether you choose to run the patient mills at Med Emporium, or run your own exquisite Osler 5th Avenue, or start the Hello Kitty Diabetes Company, or care for people slowly and thoroughly, one at a time, from start to finish, primary care may just be the best place to be in right now. You should be thankful this week, because the best is yet to come…


  1. Brilliant, eloquent! Comprehensivist entrepreneurs = The New Primary Care. You absolutely describe the characteristics of the many medical practices I have seen that are thriving today as well as being well poised for the changes coming.

    1. Thank you! Now, let's convince them to listen, and most important, stop sitting there like so many ducks....

    2. Could it be ?

      President Obama really does not want the Affordable Care Act to suceed. Obama's ideology does not match the system of the Affordable Care Act. The ACA is a mix of governmental regulation, socialistic ideology and capitalistic free market competition. Obama's mantra is 'hope and change'....a change in direction for the United States. This includes redistribution of wealth. The Affordable Care Act is a guise for this goal. It is blatant, and thinly disguised. Those who believe the ACA will provide health care to the uninsured are misguided. The preventive measures guarranteed by Obamacare could have been delivered without revising health insurance. Expanding Medi-caid (a failed system in many states) is a poor option for the poor and uninsured. A better choice would have been to design a new agency to administer subsidized Obamacare. The entrenched administrators of Medi-caid will not have fresh ideas having been bogged down for decades in public social services which also is in charge of cash aid,, and the SNP Food stamp programs. Let's put some of the 'poor' to work administering their own ACA benefit.It is going to take tens of thousands of people to administer the program. The secondary benefit will be fewer unemployed, and perhaps they will be able to pay an insurance premium. They already know what is at stake, having been 'victims' of the present system for decades. Are these people going to have to stand in line with a pile of paperwork to enroll in Medi-caid....or is the HBX going to bypass this process? We have not heard any answers to these questions.

      Ultimately the impending confusion and chaos will make the public demand universal payer or some type of total governmental health system. The current system is unsustainable regardless, and the ACA is no better. In terms of the initial success or failure of Healthcare.gov the ultimate result will be who has an insurance card on January 1, 2014. Obama and his administration's announcements how successful the HBX now is, and how many people have enrolled, there remains a large gap between enrolling on an unproven and a demonstrated unproven IT system.

      - See more at: http://healthtrain.blogspot.com/#sthash.JEMOX8EN.dpuf

  2. Another one of M's brilliant, eloquent, articulate articles on PCP and medicine in general. Harnessed and empowered further by the ACA.

    1. Thanks, Dr. Levin. I enjoy your writing as well, not always agree, but diversity of opinion is what makes us grow....

  3. This is the best thing written about primary care and current trends in medicine I've read in a long time.

    Keep it up, MG-A


    1. Thank you, pcb, and thanks for reading. Means a lot...