Whence, and whither, family medicine: will it have role in improving our nation’s health?: Part 3

The 25th J. Jerry Rodos Lecture, presented at the 30th Annual Conference of Primary Care Access, Kauai, April 8, 2019:

Part III: Whither Family Medicine and Our Health?

So, in the end, is it all about money? Is it about the primacy of profit? We have seen massive consolidation of health systems, all focused upon making money, even if not “for profit”. Doctors as employees, are “pawns in the game” (remember the Dylan song?). PAs and NPs added not because better but because cheaper. FPs are only good because they are cheaper. Do the key principles of family medicine really make a difference? Barbara Starfield said yes, but she is gone and so is the control FPs had of their practices. We are ambulists (some of us hospitalists), few of us deliver babies. How many even care for families?

Perhaps the variety is why we become family doctors. We have variety in our patients, not just limited to one kind of disease or organ system, and we have variety in our day. Well-child, older person with chronic diseases, sports injury, pregnant woman, substance user, minor surgery. Maybe it is this variety that keeps us going, and makes us different from the sub-sub-specialist who needs to know all there is to know about very little. It is challenging because it is more complex, much as that might grate on the specialist; what they do maybe difficult but it is the same thing over and over. A Graham Center one-pager (by me!) looked at complexity in terms of how many different diagnoses, ICD-9 codes, it took to account for 50% of all codes by specialty.  For family medicine, it took 23 codes, for IM 18, for pediatrics 11, for cardiology 6, and for psychiatry 3![i]

We often hear about family physicians being replaced by NPs and PAs, but what about other specialists? Their practices are often more routine, more all-the-same, and in fact easier for NPs or Clinical Nurse Specialists to replace, as we see daily in hospitals. The Clinical Nurse Specialist in Heart Failure knows all there is to know about a narrow practice. But they – both the physicians and non-physicians -- make more money than FPs or FNPs. Is that all it is about?

There are many other challenges that face us, and face other specialists as well. One of the things that my colleagues in other disciplines complain about, and I agree with, is the apparent attrition of critical thinking among many of our trainees. This probably has many intellectual, educational, and social causes, but a big one seems to be the electronic health record (EHR), and the fact that our employers, health systems, have designed them to maximize reimbursement, not truth (is it all about money?). Much of the EHR is about filling in boxes and checking the ones that make our employers the most money. It is about cutting and pasting rather than thinking. The patient had a chest x-ray? Just paste in the whole radiologist report. This creates a huge long note, is a bear to read, is available elsewhere in the record (under, like, ‘radiology reports’, where it was cut-and-pasted from!) and requires no judgement! A simple “normal chest x-ray” (or ‘chest x-ray with interstitial infiltrates, possible pneumonia vs congestive heart failure’) required at least some thinking and judgement. The old “SOAP” note is entirely unbalanced, with not too much in “S” (patient history), bloated “O”s (cut-and-paste) and then – Plan! Almost no “A”, no assessment, no taking the information provided above and reflecting on it and thinking about what it means, or might mean, or might be if it doesn’t mean the first thing. It may be this that is the greatest threat to the role of doctors, any doctors, except as technicians.

But it is not just residents and students and practicing doctors that are being co-opted into a world of rote. Our family medicine leaders – program directors and chairs -- must help contribute to the “needs” of their health system –that is to make as much money as possible. We may, as individuals, care very much for the individuals who are our patients and for good practice, and I think we do, but our institutional role can overwhelm that. For caring for selected populations, mainly those who we get reimbursed for. I remember in the early 1990s, in the days of the Clinton health plan, seeing a version of this cartoon: R. Dolan, MD. “Specializing in the diseases of the insured”.

Our organizational leaders should – and do not always -- guard against the seduction of being part of the “in group”, getting to go to meetings (especially if paid for) being named to policy-making committees and commissions, hobnobbing with other “leaders”. Or maybe I’m wrong, maybe it’s just me, maybe this is really the good part about being a leader, not providing effective advocacy for your faculty, residents, students, and most of all patients? One need not be José Baselga, the former head of Sloan-Kettering who lost his position over graft and lack of disclosure, to lose one’s way – but that is the end of gradual moral and ethical compromise.

Over a decade ago the discipline undertook a major study and marketing program, the Future of Family Medicine. What do you remember from it? I remember that 2/3 of those who thought they had a family doctor really did and 2/3 of those with a family doctor knew it. I remember that when presented with the idea of a doctor who had the characteristics we associate with a family physician – the “Starfield” characteristics of comprehensive, continuous, compassionate, and personal care in the context of family and community – there was terrific resonance among the American people. I remember that specialists valued family physicians almost more than we valued ourselves. But what came of this? Is our health system more oriented to those values and characteristics than it was?

Now we have another project that cost the discipline $20 million, the Family Medicine for America’s Health (FMAHealth) project. Will it change the way the discipline practices and is structured, or will it be more of the same? How many of you have read the reports of the “tactic teams” in the recent February issue of Family Medicine? What do you think? As my friend John Saultz, editor of Family Medicine, notes that if FPs don’t define themselves, their roles, and their scope of practice, others will. It is happening and we as a whole are buying into it.

Is there hope? This is where I always say “a national health system”. I still say it. It is true that a national health system will not solve society’s problems – people will still need homes and food for health. It will not ensure quality of care. It will not mean that family medicine gets its due as the centerpiece of healthcare.

But it provides the context and mechanism for all of these. Most important, and of course this will be the challenge – it will change the focus of the health system from making money to be about delivering health care. It would provide a context for truly measuring quality. It would provide a reason to emphasize critical thinking. It would provide an impetus for health professionals to demand societal changes that will make a difference for people’s health. It would provide a way to make population health really be public health by not excluding anyone.

There will always be those who say we need to compromise, we cannot go too fast; it is something we are commonly hearing now as the campaign for the 2020 Democratic presidential nomination goes forward. But compromise is not always a good thing. Stephen Covey notes it is often lose-lose. We need win-win.

We need completely universal health care. 90% covered won’t do. “99-1/2 just won’t do” (Mavis Staples) because those are real people who are left out. Compromise means real people will not have health care. So the advocates of compromise need to specifically identify who those left out will be. I’m pretty certain they don’t think it will or should be themselves. Unless they are suggesting that we are going to leave them out, leave out the politician, pundit, wealthy, and their friends relatives and neighbors, then the people who need it most should get it most.

In the 1970s the British GP and epidemiologist Julian Tudor Hart put forward the “inverse care law”: the availability of care is inversely proportional to the need for it.[ii]

Let us correct that.

Health care for all!

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[i] Freeman J, Petterson S, Bazemore A, “Accounting for Complexity: Aligning Current Payment Models with the Breadth of Care by Different Specialties”, Am Fam Physician, 2014 Dec 1;90(11):790.

[ii] Hart JT, “The Inverse Care Law”, Lancet. 1971 Feb 27;1(7696):405-12.

Direct Primary Care, Scope of Practice, and the Health of the People

One of the relatively new and growing movements in family medicine is “direct primary care”, or DPC. The term seems to have a lot of different meanings, depending upon who is talking about it (or, often, it is talked about in very vague terms, as are many things we want to have only thought about in positive ways; if we get too specific people can criticize!). In general, however, it is about primary care doctors taking direct payment from patients for their services rather than getting reimbursed by insurers (including Medicare and Medicaid). This is touted to be a panacea for doctors tired of “bureaucracy” (often referring to the “government”, but certainly at least as painfully insurance companies); of too many forms to fill out and rules to follow and loss of autonomy. The primary care doctor provides the service that s/he is capable of and the patient pays, just like in the old days (maybe barter is included, but don’t know about paying in chickens – on visit to the vet the other day I saw an old sign on the wall advertising a vet’s services, indicating both cash and barter—but no poultry.)

There is a certain attraction to the simplicity of this arrangement. The doctor provides the services that s/he can provide (presumably not including most laboratory tests or medicines or immunizations) for a fee that is collected in cash. The patient can even apply to their insurance company for reimbursement. Voilà! Everyone is happy! The patient gets the service, the doctor does what s/he likes to do, and is freed from bureaucratic regulations and thus can operate his/her business more efficiently and with lower overhead, presumably (this is not always explicit) passing the savings on to the patient. But there are a few concerns.

The first, obviously, involves people who are too poor to pay. This may not concern some of the DPC doctors, but does others, and should concern our society as a whole. We know these people; we see them regularly in our student-run free clinic (except there they do not pay anything). I have pointed out that this need not be a problem; one of the advantages of not taking insurance is that the doctor is free to charge different people different amounts. The Center for Medicare and Medicaid Services (CMS) requires physicians accepting it to not charge anyone less than the amount they charge Medicare (not the amount Medicare actually pays). Not accepting Medicare means a doctor could charge a well-heeled person $100, and another poorer one $25 for the same service. Or $5. Or a chicken. Or nothing. And those people with Medicare (or another insurer) could still submit a request for reimbursement for what they actually paid. Don’t know if they would be reimbursed or not. And it might be tough for the senior who can barely accomplish their basic functions to submit directly to Medicare. It all depends, as I pointed out to a colleague considering such a practice, on how much you want to make. If you are willing to make less, you can charge people less. I have no idea how many of those physicians currently practicing or planning to practice DPC are charging such a sliding scale, or taking all comers, or are willing to earn less. But it is at least theoretically possible to do this.

A second concern is “what is the scope of care provided by the DPC provider?” Sometimes discussions of DPC seem to focus on treating colds, high blood pressure, sprains, etc., all the things that are currently taken care of by the increasingly common Urgent Care Centers in drug stores and big box stores. Many of these things are problems that do not need to see a provider (your mother can tell you to drink plenty of fluids, rest, and eat chicken soup – perhaps a better use for that chicken than paying the doctor!). Otherwise, it is not clear what advantages DPC offers over Urgent Care Centers, except that the latter are often staffed by Nurse Practitioners, not physicians. If you care. If the services being offered are within the scope of practice of the provider, what difference does it make? And the Urgent Care Center will take your insurance, not a small matter when it comes to the cost of immunizations, for example.

Clearly, this DPC model cannot work for problems that need to be cared for in the hospital, or require facilities. The doctor cannot choose to be DPC only for their outpatient practice but be on insurance for inpatient care, so won’t do it. Or probably deliver babies. Or provide any beyond the simplest of office-based procedures. Including the critical ones of providing long-acting reversible contraception (LARC), IUDs and implants, which have very high up-front costs, except for quite well-to-do patients. Again, it is getting hard to see the benefit of DPC over Urgent Care, except, possibly, the provision of continuity of care with the same provider. Unless, of course, you need something that cannot be done in the office. Metaphors abound; one DPC provider is quoted as saying “you don’t use auto insurance to buy your gas; why should you use health insurance to buy primary care?” I leave this question up to you, including whether the metaphor is apt. However, it clearly minimizes the scope of what primary care doctors can do.

This is a potential challenge for family medicine and other primary care providers, especially as family medicine moves into its “Health is Primary: Family Medicine for America’s Health”[1] campaign. For a long time, other specialists have derided PC for only taking care of simple problems. Many, including me, have argued the contrary, that primary care is difficult and complex (see, for example, my 2009 blog post “Uncomplicated Primary Care”, and my recent Graham Center One-Pager “Accounting for Complexity: Aligning Current Payment Models with the Breadth of Care by Different Specialties”[2]), but quotes like the one above seem to indicate a retrenchment, away from “full-scope” practice. Obviously, like DPC, “full-scope” can be defined in various ways, but usually means things like caring for people in the hospital (another thing I have argued is a strength of US family medicine), delivering babies, caring for children, doing a variety of procedures, and even caring for people in intensive care. At the recent North American Primary Care Group (NAPCRG) meeting, several papers from the American Board of Family Medicine (ABFM) and Graham Center indicated that in most cases greater scope of practice of family physicians led to lower cost. The ABFM developed a 0-30 scale for scope of practice, and found significantly lower costs for patients cared for by FPs with 15-16 scores than those of 12-13 (a relatively small difference in scores). Presumably this is because those with lower scope of practice are referring more to higher-cost specialists. The interesting exception was integrated practices (like Kaiser) where the scores for FPs were low (~11.5) but costs were low, as a result of the other surrounding services available to patients from those integrated systems. These would not be characteristic of small DPC practices.

Finally, there is the concern about “who is health care for?” Much of the interest in DPC among residents, it seems, is to make their own lives less stressed, less busy, less frustrating. Not bad things. But the ultimate and only real measure of whether our society should embrace such a trend is whether it enhances the health of our people. All our people. Rich and poor. Rural and urban. White, Black, Asian, Hispanic. Over 150 years ago, Rudolf Virchow (the Father of Social Medicine) wrote “Medical education does not exist to provide students with a way of making a living, but to ensure the health of the community.… If medicine is really to accomplish its great task, it must intervene in political and social life.”

I hope that we still believe this to be true.

Happy New Year!

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[1] Phillips RL, et al., “Health is Primary: Family Medicine for America’s Health”, Ann Fam Med October 2014 vol. 12 no. Suppl 1 S1-S12.

[2] Freeman J, Petterson S, Bazemore A, “Accounting for Complexity: Aligning current payment models with the breadth of care by different specialties”, Am Fam Physician. 2014 Dec 1;90(11):790.