Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

Why Aren't More Physicians Choosing Family Practice?

6/9/2015 12:55:53 PM | 2 comments

Recently, I set out to recruit several new physicians for our urgent care practice — and in the course of my interviews noticed some disquieting trends.
 
In general, the physicians I interviewed were enthusiastic about urgent care. But the moment I mentioned that primary care was also part of the job, the mood changed. Even for physicians coming out of a family medicine residency, primary care seemed to be a deal breaker.
 
When I called residency program directors to check references, I asked if they had noticed this trend.
 
"Yes, it's true," came the typical reply. "A lot of them want to do urgent care. A lot of them want to be hospitalists. But primary care? It feels like too much responsibility."
 
I thought this was an extraordinary revelation given the dire shortage of primary care providers. It also didn't bode well for the fact that our healthcare system is shifting toward a value-based model in which primary care providers play a crucial role.
 
Then again, as a primary care provider myself, I can relate. In this post, I'll describe some of the growing pressures on family physicians, the consequences for patients and what healthcare leaders can do to help.
 

A Combination Practice at Work

 
The urgent care center (UCC) where I practice is unique in that it has been delivering primary care since the early 1980s. When managed care began to take hold in California, the parent system formed an independent practice association (IPA) with the UCC physicians also serving as primary care providers. (This approach was rare at the time, but has since grown in popularity. Today, about 15–20 percent of UCCs offer formal primary care services.)
 
Today, our UCCs meet all the standards for urgent care, including extended hours, onsite procedures and acceptance of walk-in patients. However primary care visits make up 40 percent of our practice. Many of our primary care patients are assigned to us by managed care organizations. Others have chosen us based on physician preference or convenience.
 
Running a combination practice presents unique challenges. While we try our best to encourage primary care patients to make appointments (which are scheduled)  patients often walk in expecting to be able to address all of their chronic health concerns. And due to rising out-of-pocket costs, patients who come in with a cold or laceration often end up talking about their diabetes in the same visit. (Who can blame them for wanting to stretch their hefty co-pays?) All of this translates into longer wait times.
 
On the plus side, I think our primary care patients really benefit from the flexibility of our practice model. They're a lot more likely to adhere to treatment and seek preventative care when they can do so on evenings and weekends. And while the dual nature of our practice can be confusing, we're usually pretty accommodating when it comes to handling as many of our patients concerns as we can even when they walk in.
 

Rising Administrative Burdens

 
While primary care can be very rewarding, there's no arguing that it's a lot of work. This is especially true in the context of managed care, where the primary care physician bears considerable responsibility for the health of assigned patients. And while I'm all for improving healthcare quality, I'm concerned that some of the programs that have been advanced place a disproportionate administrative burden on primary care providers.
 
In real life, this translates into complex data mining and a huge volume of paperwork. Each day, our mail contains a big stack of papers letting us know which of our diabetic patients is overdue for hemoglobin A1C or fasting blood sugar testing. It's our job to track these patients down and convince them to come in (which isn't always easy).
 
Being a combination urgent-primary care practice adds a layer of complexity. We often get paperwork for patients who aren't actually assigned to us. (Maybe they've been to our center four times, but haven't seen their assigned provider at all.) And sometimes the insurance company just flat-out makes mistakes (e.g., asking for tests that have already been done).
 
Another reality of being a primary care doctor is that under the current model, we’re one hundred percent responsible for care coordination. Many spend hours each day (after their regular appointments finish) calling patients to report test results, arrange home health visits, make referrals and so on.
 
There's no question that care coordination benefits patients, and that our current system is in desperate need of integration. But given the disproportionate pressures on primary care physicians, it's no wonder that urgent care and hospital medicine are attracting family practice residents.
 

Barriers to Independent Practice

 
In addition to impacting their career decisions, administrative burden may also be influencing physicians' employment options.
 
When physicians work for themselves, their earnings are more or less commensurate with their efforts. When the practice thrives, they reap more benefits. But given the growing demands and uncertainty around primary care practice, it's perhaps no wonder these physicians are seeking the security of employment.
 
The competition to hire primary care physicians is pretty fierce. In my area, employers (in particular, hospital-based foundations) are offering physicians very generous salaries and benefits to work bankers' hours. This arrangement is much more attractive than working at a facility like mine that's open on evenings and weekends.
 
On the other hand, I question whether these high foundation salaries are going to be sustainable over the long term. These benefits are usually guaranteed for two years and after that period will be tied to strict performance and productivity criteria. Meanwhile, I know at least one foundation-employed physician who's currently seeing only 10 patients a day after a year with the group because the practice isn't growing nearly as quickly as expected.
 
It's also worth mentioning that the anecdotal evidence around physician employment suggests it doesn't yield high productivity or quality over the long run. While I think it's definitely too early to write off the employment model, it will be interesting to see if the huge investments hospitals and health systems are making in physician groups pay off down the road.
 

Future Considerations

 
So given the forces working against primary care providers, where will patients get their care as the shortage deepens? Our group's CEO believes that the job will eventually fall to EDs, and he's preparing the practice accordingly.
 
As much as I tend to agree, I really hope it doesn't come to that. Reliance on the ED doesn't allow for good follow-up care when someone's newly diagnosed with diabetes or hypertension. Patients in that situation need someone who can provide a sustained, rational approach to managing the problem. It takes time to get chronic conditions under control and provide education. I can't see that happening in an episodic setting.
 
So what's the answer? I wish I had a magic bullet. But I think one takeaway is that it's absolutely imperative for providers to play an active role in redesigning the healthcare system.
 
I also think that while quality is an eminently worthy goal, we need to weigh what's convenient against what's practical and equitable. From where I'm sitting, our primary care workforce is looking more and more fragile. With all this talk about being good stewards of our healthcare resources, shouldn't sustaining and nurturing it be a high priority?


Comments
Lawrence Earl, MD
Agree there is no magic bullet. We've discussed a number of options to handle primary care issues while maintaining urgent care throughput and productivity. One is a modified RME process (Rapid Medical Evaluation or RMA - Rapid Medical Assessment) for only those patients that have straightforward urgent care problems to be cared for quickly without a lot (or any) "oh-by-the-way-doc's" (this has to be made clear from the entry into this queue). Another is increased recruitment of PAs and NPs to provide both urgent care and primary care - even retail clinics are following evidenced based protocols for NPs to care for chronic "primary care" conditions. Finally, using technology to track and remind patients of their needed follow ups, lab work, refills, etc instead of bogging down the providers to do it manually is a must. If not directly through the EMR, then with a number of available apps to help in this regard.
6/15/2015 12:30:22 PM

Scott Baron PA
DR Silver, you hit the nail directly and firmly on the head. Thank you for that cogent and succinct review of our present model.
6/14/2015 10:01:45 AM