Can primary care work?

Of course it can. As with most things, all the hand wringing comes down to a few basics. No, it’s not trial lawyers, and it’s not insurance companies and it’s not managed care plans. These, and other distractions, divert our attention from focusing on a real problem that is emerging: how will we care for each other in the decades to come?

The term being bounced around now is “medical home”, but this is a revival of an old concept. The notion of looking to your primary care physician – of having a regular, primary care physician – is an old one. The early HMOs built their model around the PCP as the gatekeeper and coordinator for the entire spectrum of care. The idea was for this physician to be the one constant and the central point for your health care. This person would get to know you through routine preventive care and be the one to be the “captain”, navigating the patient through the health care system. Under capitation-based payment systems, physicians often are expected to provide this service. Under the procedure focused reimbursements system most commonly used, while there are CPT codes for these services, few, if any, carriers will pay for these services.

And here we are. We’ve been talking about fragmented care for decades now. Some insurance carriers would require the PCP to see a patient before referring to a specialist, but the patient bore the not-insignificant expense, and the time was often a waste for all concerned.

While is where some system for paying PCPs for coordinating care has a logic to it. Whether paid on an annual retainer basis, or on a fee for service basis, the whole question comes down to the fee. If it’s high enough, all is good. If not – not so good.

The other half of the model is to continue to increase the reliance on nurse practitioners to provide more routine and non- serious problems. There is a serious shortage of primary care physicians looming, and much of the future care needs are for chronic problems that could be handled well by non-physician clinicians. These non-physicians, used in many settings including the newly revived retail clinics, offer another professional and career route for bright people who don’t want to go into medicine (for any of a hundred reasons), but are attracted to the more regular hours, shorter (and less expensive) training, and higher incomes that this profession offers. Even with the new medical schools coming online, there are still only so many slots – supply and demand. As a society, we need a whole lot more supply.

The Wall Street Journal’s Health Blog took a brief look at this the other day, and this and the JAMA article are good background. For you – increasing capacity with non-physician clinicians can offer better care and buff up your practice income.