Health CareOrganizing for innovation

Primary Care

Primary Care is key to the healthcare system. Yet, in spite of its importance, primary care is confronted with many challenges—and very different approaches are being used to address them.

  • At one end of the spectrum there is a movement that strives to put the physician back at the center of care, referred to as The Familiar Physician
  • At the other end there are Retail Clinics, which basically replace physicians with nurse practitioners and physician assistants in retail stores

The Familiar PhysicianWalmart Clinic

Highlighting the challenges

How can there be two such different solutions to the same set of challenges? Let’s start by looking at what is going on in primary care. Dr. Linden’s book The Rise & Fall of the American Medical Empire highlights 5 challenges:

1. Long work hours and growing workloads. There is an overabundance of patients, who are getting older and have more complex illnesses. The number of patients has increased because of population growth, but also because more are seeking primary care thanks to the Affordable Care Act.  At the same time, the workforce of primary care physicians is decreasing because fewer new physicians are being trained and many baby boomers are retiring.

2. Income, income gap and education debt. Medical education has never been more expensive than today. While many physician salaries have significantly increased over time, those of primary care physicians have remained the same or decreased.  Their starting salaries are low compared to other medical disciplines. When combined with the heavy workload mentioned above, primary care is no longer a very attractive field for new physicians.

3. Medical school and residency’s influence on career choice. Because of the reasons mentioned above, primary care is not the first choice of many medical students who can opt for a “better” field in medicine. The profession does not bring a lot of prestige either, as primary care research is unlikely to make The New York Times or Newsweek, nor get published in The New England Journal of Medicine.  So it is not surprising that many medical programs have responded by shifting their attention away from primary care to focus on the more prestigious and highly rewarding medical careers such as anesthesiology and radiology. The result is a sharp decline in residency positions offered in primary care.

4. Medical malpractice. Increasing workloads and the need to cover office expenses means that there is less time to spend with each patient. Patient-physician relationships grow strained, and a patient’s dissatisfaction easily translates into a malpractice claim, if medical treatment culminates in negative or less-than-stellar outcomes. In addition, with little time to diagnose early symptoms can be missed because of the breadth of the discipline, making physicians generally more prone to malpractice suits. As a result, medical malpractice insurance premiums for primary care physicians are among the highest and are reaching a point where they are no longer affordable.

5. Paperwork and the loss of autonomy, control and sense of satisfaction. Checklists are one way to increase safety and reduce liabilities, but they are time-consuming and can contain many irrelevant questions. Requiring checklists to be completed for each case transforms the practice of medicine into a bureaucratic, mind-numbing activity.  In addition, insurance codes (ICD-10) have become more detailed, to more accurately describe diagnoses and treatments. While the increased accuracy may be a good thing, the coding work itself adds to the administrative burden. Finally, insurance companies are reducing the number of treatment options they are willing to reimburse. It is left to the physician to explain to a patient why the best treatment from the patient’s perspective may not be the best treatment from the financial perspective of the patient’s insurance company.

Comparing the solutions

How do the two solutions mentioned above, The Familiar Physician and Retail Clinics address these challenges?

Primary Care Comparison Updated

The Familiar Physician approach addresses the challenges by putting the primary care provider back at the center and taking all non-clinical matters off their plates. This way more patients can be seen, leading to increased revenue streams. Patient satisfaction increases as well, as the patient can rely on being seen by his or her own physician. Another advantage of this approach is that the patient has a central medical provider to ensure that all medical treatments are aligned.

The Retail Clinics approach addresses the challenges by simplifying the care offerings and using cheaper labor to do the work.

The overview in the table above gives me the sense that Retail Clinics in the end will win over The Familiar Physician approach. Not because it is better for patients, but because it addresses the challenges in a more sustainable matter.

What the best approach for patients is, will depend on patient preferences. Taking a holistic approach and ensuring that all treatments are aligned is very important to some, especially those with complicated or chronic diseases.  Others claim that such an integrated approach by a single physician is outdated. They argue that with the arrival of the Electronic Medical Record, each physician has a full overview, and a physician new to a case may view things differently and provide new insights.

For healthy patients, both solutions probably work just fine. However, the chronically ill and those with rare conditions will suffer when in the future only the retail clinics are available to them.

Is there a possibility for physicians to offer an alternative that is the best of both worlds? Perhaps.  However, such a solution will likely require taking a significantly different approach to primary care. Patients are able to adapt to different models, as the success of retail clinics demonstrates. The question is, how flexible and innovative are primary care physicians? Will they be able to reinvent how they take care of patients to deal with their increasingly challenging environment?

Interested in learning how your practice can become more innovative and adaptable? Please contact us via e-mail at: info “at” organizing4innovation “dot” com, or visit our website www.organizing4innovation.com.

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References

Anderson, 2014, The Familiar Physician

Holly 2013, The Familiar Physician Contrasted with SETMA’s Experience Part I, The Examiner

Linden (2010) The Rise and Fall of the American Medical Empire

Mehrotra, Adams, Wang, Lave, Thygeson, Solberg, McGlynn 2009 Comparing costs and quality of care at retail clinics with that of other medical settings for 3 common illnesses