Wednesday, April 13, 2011

Family Medicine: At the Bottom of the Accountable Care Organization Funnel

Accountable Care Organization:  A Big Funnel of Health Care Phenomena into the top of which the tax payers (aka, the federal government) will drop one check as payment in full for all Medicare patients (at least 5,000) served by The Funnel. Initially, ACO's will be voluntary.  Government rules for ACO's seem to be evolving, but doctors and hospitals are preparing for them, expecting to be coerced into business and collaborative models that are unproven. Here are the rules:

Who/What is at the top of the funnel?  Who/What is at the bottom?  Is it a real/stable funnel, or something like Dorothy experienced in "The Wizard of OZ"?

I wrote this blog post in April, 2010: 

Family Medicine: A Human Relationship Specialty Being Crushed by the Medical Industrial Complex

Family Medicine is a relationship based specialty. The generalist nature of the family physician gives us a chance to become a systems management expert. Our patient may be a generalist or a parts oriented thinker. The confluence of our knowledge, beliefs and attitudes creates a space in which two humans may help each other. We are both humans, consumers and stewards of scarce, valuable resources. Each has an individual role of patient or physician, giving unique perspectives to their individual context. Inadequate emphasis has been given to the human, consumer and steward roles. These three factors may help to protect the patient- physician dyad from the intense pressures from time and money that are used to squeeze the quality and satisfaction from the relationship and the decisions made by the dyad. The demands of the medical industrial complex (MIC) are sucking the life out of family medicine. Can the unique aspects of the patient-physician relationship,shrouded with modern sociotechnical processes, save the day for family medicine?

Family Medicine is the specialty in breadth that combines the biological and social sciences to serve individuals, families and communities. Fewer and fewer medical students are selecting family medicine as their specialty. About eight percent of American medical school graduates now choose family medicine for their specialty training.

The American people need about thirty percent of physicians to be a primary care specialist to have an adequate primary care base as the anchor for the medical care system. Primary care pediatrics only gets about 2% of the medical students and primary care internal medicine gets 2% of medical students, since the advent of the hospitalist movement. The other often stated decision factor for specialty selection by medical students is debt versus earnings. The student graduates with about $150,000 in debt. Primary care generally pays the least of all the specialties (except psychiatry, which also has a shortage). It also is known as having a high hassle factor with paper work and forms that distract from patient care.

Emergency medicine was selected by more American medical school seniors in 2010 than family medicine. The pay is higher and the hassle factor is lower in emergency medicine. The hospitalist (an internist, pediatrician or even a family physician) may work seventeen or eighteen shifts per month and receive $30,000 to $50,000 more per year to start. The people need a lot more primary care physicians, the students aren't drawn to it. That's an expensive problem. Since the people don't have enough primary care, they go to emergency rooms and see narrow specialty physicians too often, driving up the cost of health care significantly.

What will protect and expand my specialty to serve the needs of the American people? Will it be technology? Social change? Guardian Angel? More later.

April 13, 2011:  OK, so now it's later:  The ACO's are upon us.  And the medical students are alleged to graduate with closer to $175,000 of debt.  The specialty selection gods and goddesses have spoken again last month. The rosiest interpretation of the match results for Family Medicine:
AAFP Notes Match Results

So we picked up a hundred more American medical school seniors to go into Family Medicine, an increase from 7.9 % to 8.4 % or so, and we need 30 % at least.  They will serve 1700-2200 patients in each of their practices, if full time (but 15-25 % won't be full time due to family needs or administrative responsibilities which are expanding with the advent of the PCMH and ACO's). That's 2,200,000, at most, of the 50-65 million or so people without primary care who will have access (depending on the business model of the Family Physicians).  Oops, I forgot the retirements of the Baby Boomer Family Physicians which will uncover more than 2.2 million patients yearly (and they would more likely have 2500-3000 patients each in their panel).

Actually, we're still going backward, but American ingenuity might figure out how to reverse the trend.  Remember, though, to keep looking at the numbers of patients served for a reality check.  We have a diminishing capacity to deliver primary care to Americans at the present time, if you like math, in spite of the PCMH, ACO, etc.  So the emergency rooms are building more additions for the increased need.  And the cost of care is still going up.

Will The ACO Funnel be the answer for America's Primary Care Shortage? If we get hit on the head by The Funnel and "Follow the Yellow Brick Road", maybe there's Hope.

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