The Primary Care Physician Needs to Take Center Stage in this New World of Healthcare

As we are transitioning to a world of risk/value-based healthcare and overall population health, the role of the primary care physician needs to take center stage. The role of the primary care physician should not be subservient to all of the other specialties. 

In fact, the role of the primary care physician should be more like the “conductor” of the orchestra. Conductors need not know how to play each instrument, but they know enough to bring them all together to make beautiful music. Likewise, the primary care physician can help orchestrate the care from the other providers to bring forth a better health status for the patient.

Also, just like the “conductor,” the primary care physician needs to have a holistic approach in that they are responsible for the entire ensemble or the overall health of the patient.

The primary care physician needs to be the trusted patient advocate

Primary care physicians are in a unique position to not only directly provide care to their patients, but they also have the “potential” to be a trusted healthcare advocate to their patients from a number of perspectives.

I state “potential” because not all primary care physicians play the role as patient advocate. In some cases, the primary care physician acts as more of an entry point for the patient to receive access to specialists and sub-specialists. In those cases, I believe that the primary care physician is doing a disservice to their patients, themselves and to society (there are cost and quality implications).

As a non-clinician, while I may not be an expert, I do know that I am made up of more than organs and body parts. I need a physician advocate who can look at me from a holistic perspective. I also know as a non-clinician, I need someone in my corner to guide me through the often confusing maze we call healthcare.

Finally, I also recognize that the best healthcare results when a patient is an active participant in their own healthcare decisions. Poor lifestyles and a lack of patient compliance will negate to different degrees the best and most expensive healthcare services provided. A trusted primary care physician advocate can play a key role in engaging patients in their own health.

Under-valuing primary care physicians

Sadly, while there has been a lot of rhetoric about the importance of primary care, the only “real” societal responses have been the increase in nurse practitioners (NP) and physician assistant (PA) programs and in the use of technology (virtual visits, etc.) to maximize the number of visits in a day.

I am an advocate of increasing the number of NP and PA programs, but it should not be a substitute for the needed growth in numbers of primary physicians.

In fact, as noted in a prior blog, State rules should allow for providers such as nurse practitioners and physician assistants to practice to the “top of their license”—i.e., to the full extent of their abilities, given their education, training, skills, and experience, consistent with the relevant standards of care.

I am also a believer in the increased use of technology to allow us to better leverage our primary care resources in an economical manner. But, this does not mean we reduce primary care to sound bite answers, with little or no personal interaction. Ultimately, the value of the primary care physician-patient relationship is based on trust.

If we as a society identify the expansion of NPs/PAs programs and the growth of virtual office visits as the answer to this physician shortage, then we are downgrading the potential value that primary care physicians can bring to the table.

As noted in a recent article in Health Affairs, “Data suggests that a small investment in primary care would yield a six-fold decrease in Medicare services and an overall 2 percent drop in total Medicare costs.”

As noted further in this Health Affairs article, “Primary care clinicians are uniquely trained to diagnose and treat the vast majority of medical ailments and chronic diseases, to reduce over-treatment, and to care for the whole patient. Primary care’s value in cutting costs, preventing disease, improving patient satisfaction, and enabling individualized care based on shared decision making has been well established.”

We as a society, need to unleash the true power of the primary care physician

We as a society need to look for ways to expand the role of primary care physicians and unleash their real power.

If our societal goal is value-based care and an overall healthier societal (also see blog titled, “Roadmap…”), then the role of the primary care physician needs to be enhanced.

If we are evolving to reimbursement methodologies that are more risk-based and rely on patient compliance, then the role of the primary care physician needs to be enhanced.

If we recognize the importance of integrated wellness and prevention in healthcare as well as nutrition, diabetes education and patient and caregiver engagement, then the role of the primary care physician needs to be enhanced.

If we recognize the importance of addressing the “social determinants of health” (see blog) along with the importance of linking patients with needed community services to remove gaps of care, then the role of the primary care physician needs to be enhanced.

If we recognize the importance of the linkages between clinical, behavioral/mental health and chronic disease management as well as the importance of a team-based approach in healthcare, then the role of the primary care physician needs to be enhanced.

Finally, if we are concerned about the escalating costs of healthcare from a societal perspective, then the role of the primary care physician needs to be enhanced.

Primary Care – The hub

As noted above, primary care needs to be the patient hub, and the primary care physician needs to be the “conductor.”

A key ingredient to achieving this objective, especially as it relates to unleashing the real power of the primary care physician, is timely and appropriate data.

The primary care physician cannot be a real advocate of the patient without the necessary data from the other caregivers.  

The primary care physician is also in the best position to play a key role in managing risk and the provision of value-based care throughout the continuum, but again they need timely data from all caregivers.

Too many times, and we all know as consumers of healthcare services, our primary care physician does not have access to this timely data.

Electronic Medical Record (EMR) connectivity is critical to the hub and the multiple roles of the primary care physician.

The EMR, ideally, also needs to have critical social determinants factors identified that are integral to the patient’s health status.  

We need to strengthen interoperability of the EMR through enhanced data management and collaboration with provider and health plan and community partners.

The Problem

We have just spent a bit of time articulating the benefits of the primary care physician and the importance of expanding their role in our society.

All of this great, but we have just one “little problem.”  

We do not have enough primary care physicians to meet today’s needs, let alone our future needs. We will need many more primary care physicians, given their increased role in our new risk/value-based world, that is focused on improving the health status of our population.

Approximately 35 percent of all clinicians, including nurse practitioners and physician assistants, currently provide primary care services, a number that stands in stark contrast to other high-income countries, where the ratio of primary care providers to specialists is generally 70:30.

As noted in the second part of the series on primary care physicians in the 2018 Health Affairs article, “The Association of American Medical Colleges (AAMC) estimates that by 2030, the US will face a shortage of as many as 49,000 primary care physicians. Given that it takes nearly a decade to train a physician (less time is needed to train a physician assistant or nurse practitioner), we need to start now if we want to have enough primary care providers in the future.”

Why do we have this problem? (We have found the enemy and it us)

The following is a brief overview of the reasons why we have such a small percentage of our physicians going into primary care:

·      Prior to the introduction of Medicare and Medicaid in 1965, there was a greater percentage of physicians in primary care. The establishment of Medicare and Medicaid resulted in an increased demand for more physicians, but it was mostly fueled by the demand for specialists by hospitals. 

Between 1965 and 1980 federal aid increased the number of medical schools from 88 to 126 and the number of graduates from 7,409 to 15,135. Most of the increase in physician graduates were in the specialties and sub-specialties which were more highly compensated vs. primary care.

For further insight, from a historical perspective, of the evolution of the U.S. healthcare system, check out my blog titled, “Healthcare’s Memory Lane.”

·      Primary care vs. specialty residency slots may also present some problems in different geographic areas, but the key issue is still tied to physician compensation. Even if more residency slots were to open, medical students would still shy away from applying to them, in large part because primary care physicians are the lowest paid among their peers.

·      While primary care physicians’ income is increasing at a slightly higher percent vs. specialists, as noted in the 2018 Medical Group Management Association annual compensation survey, specialists’ salaries still average $167,000 higher than primary care physicians. Obviously, for some specialties, that dollar spread is much higher.

The good news, as noted in the Forbes 2018 article, is that there is increasingly a recognition by both governmental and commercial payers that primary care needs to be paid more.

·      Adding to the financial challenges of primary care physicians, most independent primary care practices must pay for expensive electronic medical record systems and tech support, staff to contend with increased regulations and fee collection, and sometimes scribes and nurses to satisfy regulatory demands.

·      Also, the large amount of debt that medical students incur often dissuades them from entering primary care (I saw this firsthand when I was the Associate Dean of Ohio University Heritage College of Osteopathic Medicine in the late 1990s).

·      Finally, the diminished role of the primary care physician in our “sick-care” system that exists today (but is hopefully changing) has discouraged medical students from selecting primary care.

CONCLUDING COMMENTS

I will deep dive a little further into potential fixes for this shortage of primary care physicians in my next blog. 

I also want to state that, even though I am an advocate of increasing the role of primary care physicians, I am not under-valuing the role of specialists and sub-specialty physicians. I am definitely not suggesting that a primary care physician has the expertise of these specialists, nor would any primary care physician make such an assertion.

Patient care should be a team approach, and the primary care physician does play a necessary and increasingly important role in our new world of healthcare.

Finally, all of this also does not mean that the primary care physician is ready for this expanded and necessary role. As clearly noted in this blog, to achieve this new enhanced role, primary care physicians will need to develop leadership skills that do not always come easy for physicians.

The primary care physicians needs to be both a team player and a team leader. See blog titled, Physicians, where are you? We need your leadership in healthcare.”

While these leadership skills may not come easy, I also see as a professor and the Director of our Health Care MBA program that is can be accomplished. Our program is heavily weighted towards leadership development and our physician students evolve over the course of the program to be true leaders inside and outside of the classroom.

Thomas Campanella is the director of the Health Care MBA and an associate professor of health economics at Baldwin Wallace University near Cleveland, Ohio.

If you are interested in receiving a monthly summary of all of my healthcare blogs, you can respond to me on LinkedIn or e-mail Tom Campanella ([email protected] ) with your contact information.

Source of pictures: pixabay.com & pexels.com