Flight of the Doctors
According to a Physician’s Foundation survey released on November 18, 2008, 49% of physician respondents plan to reduce the number of patients seen or stop practicing altogether in the next three years. 78% said medicine is either “no longer rewarding” or “less rewarding”; 60% would not recommend medicine as a career; and 45% would retire immediately if they had the financial means to do so. Primary care, in particular, is in deep trouble. In a survey of fourth-year students at 11 U.S. medical schools, only 24 of 1177 respondents planned to enter general internal medicine. The American Medical Association predicts a shortage of 35,000 to 40,000 primary care physicians by 2025.
None of this is really news – it’s a trend that has existed for over a decade. What’s truly disconcerting is the continuing lack of new solutions. The problem is that most proposed “fixes” are predicated on the belief that the business models of health care delivery will remain unchanged. In fact, there are a variety of health care providers and new models of care ready to fill the gap vacated by physicians – nurses, physician assistants, and other physician “extenders,” armed with disruptive technologies, are increasingly able to do more and more sophisticated things in convenient, low-cost settings. Even within the profession, osteopathic physicians and international medical graduates have been filling “undesirable” primary care positions for years. Rather than figuring out how to convince U.S. medical schools to train more primary care physicians, perhaps we should focus a large part of that energy on developing the growth of their disruptive counterparts.
Still, it’s hard to argue that white-coat flight is a positive sign, and the big question is how to make an occupation attractive again to professionals simultaneously threatened with disruption. The first possibility is to help primary care physicians move up-market themselves and disrupt costlier specialists. Just like nurses are working with simplifying diagnostic tools and algorithms, primary care physicians could manage more complex care by using expert systems software, point-of-care diagnostics, and simple-to-deploy devices. By moving up-market, generalists could chase the more attractive reimbursement rates more commonly offered to specialists and procedure-based care. This presents an enormous growth opportunity for clinical software, diagnostics, and therapeutics firms.
Second, we need to encourage business models that reduce paperwork and red tape, while rewarding lifelong wellness care – the core tenet of primary care medicine. Integrated, fixed-fee providers like Kaiser Permanente and Geisinger Health System are ideally situated to help lead the way in creating these new business models, because they can make the appropriate tradeoffs within their integrated systems. Large employers can take a more active role as well. Rather than cutting benefits and increasing employee co-pays to reduce costs, large employers can save money by involving themselves in primary care delivery – via on-site clinics operated by third-party entities like Whole Health Management (now a part of Walgreens) or owned by the employers themselves.
For physicians who cannot imagine being part of the “corporatization” of health care, there’s always concierge medicine. The problem is that this is clearly a sustaining business model – a way to chase higher revenues while still working within the system. It’s fine as a temporary solution for the individual physician, but it does little to resolve the big problems of the health care crisis. Other proposed fixes, such as adjusting reimbursement rates and tort reform, are well-intentioned, but they are short-term and overly simplistic solutions to deeply-rooted problems. Before we can even address issues like physician pay and malpractice concerns, we need to get the business models right first.
None of this is really news – it’s a trend that has existed for over a decade. What’s truly disconcerting is the continuing lack of new solutions. The problem is that most proposed “fixes” are predicated on the belief that the business models of health care delivery will remain unchanged. In fact, there are a variety of health care providers and new models of care ready to fill the gap vacated by physicians – nurses, physician assistants, and other physician “extenders,” armed with disruptive technologies, are increasingly able to do more and more sophisticated things in convenient, low-cost settings. Even within the profession, osteopathic physicians and international medical graduates have been filling “undesirable” primary care positions for years. Rather than figuring out how to convince U.S. medical schools to train more primary care physicians, perhaps we should focus a large part of that energy on developing the growth of their disruptive counterparts.
Still, it’s hard to argue that white-coat flight is a positive sign, and the big question is how to make an occupation attractive again to professionals simultaneously threatened with disruption. The first possibility is to help primary care physicians move up-market themselves and disrupt costlier specialists. Just like nurses are working with simplifying diagnostic tools and algorithms, primary care physicians could manage more complex care by using expert systems software, point-of-care diagnostics, and simple-to-deploy devices. By moving up-market, generalists could chase the more attractive reimbursement rates more commonly offered to specialists and procedure-based care. This presents an enormous growth opportunity for clinical software, diagnostics, and therapeutics firms.
Second, we need to encourage business models that reduce paperwork and red tape, while rewarding lifelong wellness care – the core tenet of primary care medicine. Integrated, fixed-fee providers like Kaiser Permanente and Geisinger Health System are ideally situated to help lead the way in creating these new business models, because they can make the appropriate tradeoffs within their integrated systems. Large employers can take a more active role as well. Rather than cutting benefits and increasing employee co-pays to reduce costs, large employers can save money by involving themselves in primary care delivery – via on-site clinics operated by third-party entities like Whole Health Management (now a part of Walgreens) or owned by the employers themselves.
For physicians who cannot imagine being part of the “corporatization” of health care, there’s always concierge medicine. The problem is that this is clearly a sustaining business model – a way to chase higher revenues while still working within the system. It’s fine as a temporary solution for the individual physician, but it does little to resolve the big problems of the health care crisis. Other proposed fixes, such as adjusting reimbursement rates and tort reform, are well-intentioned, but they are short-term and overly simplistic solutions to deeply-rooted problems. Before we can even address issues like physician pay and malpractice concerns, we need to get the business models right first.
Comment
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Comment by David A. Lynch, MD on January 7, 2009 at 12:44pm -
I agree with Julio Bonis and Eirin above, and I was interested to see that I was quoted above in a comment. The problems documented here are all too true.
There is some GOOD news, however, and that is that innovative work done by my independant family practice medical group, Family Care Network, shows that it is possible to design a simple paradigm with insurance payers that supports the personal medical home. The idea is insurance companies actually pay for the management and professional activities that primary care doctors need to perform for their patients. What a concept! Pay for the desired behavior, and align incentives. Instead of treating primary care as an accident using the insurance model, we see it as a public utility that everyone needs. As a result, more new doctors now want to join our practice, and our quality is observably better while costs are low!
My health care reform blog contains more details about our Medicare personal medical home project, and the services that we provide: http://drdavelynch.blogspot.com/2006/12/what-care-enhancement-services-are.html
This is the kind of result that you will not see from medical care corporate silos, but it can be the model for change that we need.
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Comment by Eirin on January 7, 2009 at 6:31am -
This is a very interesting discussion! Julio, you comment ont he baby boomers entering the age of needing a primary care doctor, but you forget that most of the primary care doctors are babyboomers themselves. When they start to retire, en masse, there will be a major disruption to an already barely functioning system.
I read on Dr. Dave Lynch's blog about testimony provided to the Senate on Feb. 12th of last year that our nation's health care system continues to undervalue primary care services, and that this is leading to a skewed physician payment structure that is rapidly creating a shortage of primary care physicians throughout the nation. Do you agree with this author's response to this data?
http://drdavelynch.blogspot.com/2008/02/senate-hearing-links-physician-payment.html
I think it would be very interesting to know how the Innovator's prescription would apply to the advances in having "Patient Medical Homes" http://drdavelynch.blogspot.com/2007/02/joint-principles-of-patient-centered.html
Thanks for the very informative articles!
The Family Health Care Network in Bellingham,WA is leading the charge for quality health care change in the Northwest region.
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Comment by Julio Bonis on January 6, 2009 at 9:02am -
> I place the blame squarely on a faulty reimbursement system that fails to value intangible work.
I agree with you. Maybe all those babyboomers entering in "the age of needing a primary care doctor" and plenty of political and economical power would be the fuel to that change.
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Comment by Jason Hwang on January 5, 2009 at 8:25am -
I think foreign doctors and nurses are motivated by the same forces as here in the U.S. -- primarily higher incomes for specialty and procedure-intensive work. However, if I can restate my point... if nurses and foreign doctors aren't willing to fill the gap (because they too are moving upmarket), then there is a big financial incentive for someone else to step in. This is a growth opportunity for schools to train these new professionals, for diagnostic firms to develop the technology to assist them, and for the health systems who hire them.
I agree with your last point about how we need to raise the profile of primary care given its centrality to most patients' interaction with the health care system. I place the blame squarely on a faulty reimbursement system that fails to value intangible work. If we figured out a way to put patients, perhaps armed with Health Savings Accounts, in greater control of their health expenditures, the financial rewards for primary care physicians might begin to match the value we believe they provide. Is the concierge medicine movement proof of that?
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Comment by Julio Bonis on January 5, 2009 at 5:19am
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> In fact, there are a variety of health care providers and new models of care ready to fill the gap vacated by physicians
Not so sure about that. At least in Spain most nurses want to work in specialized (hospital) environments that found more interesting for their careers.
The same for foreign docs (mainly from latinoamerica in Spain). They could accept to work in primary care when they arrive but their objective in the long term is to become a specialist.
The question is not about how to replace family doctors but thinking about why primary care is so less attractive from a professional, social and personal perspective being at the same time so important from a real ill patient's perspective.
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