Wednesday, September 21, 2011

Family Medicine: Impending Primary Care Melt-Down

I've been a Family Physician practicing since 1979 with over 150.000 patient encounters.  Patients are still fascinating and patient engagement is still satisfying every day for me and many Family Physicians. 

The business model in healthcare, however, is stifling and just wrong.  It seeks to identify "suckables" in every part of every patient to maximize the money sucked from their parts.  The more fragmentation, the better.  This now seems to be the status quo in non-primary care medical settings and is spilling into primary care settings owned by non-physicians.  Without a fundamental change in the mindset of practicing physicians, the best system we can envision will fail.  The vision just isn't yet aggressive enough to really help.

Physicians, however, are not a unified group of like-minded professionals.  In fact, it's sometimes difficult to notice whether we know what a profession is.  We are marginalized as a profession by the forces that are "sucking" the money and our own naivety.  We are also vulnerable enough to be accepting employment from entities that don't seem to have our patients best interest at heart.  The money and the patients are controlled by someone else.  There is not enough momentum in employers, the Patient Centered Medical Home (PCMH) and patients to make the changes needed for the current or the envisioned system to survive. 

I have concerns about who is going to do primary care.   Less than ten percent of senior medical students this year intend to do primary care practice.  All sorts of reports from medical schools "fib" by saying that more than 50% of their students selected primary care residencies when their alumni office knows full well what specialties and subspecialties their graduates are in.  The medical schools state that any senior student  selecting internal medicine for their residency training counts as primary care, and the government pays a bonus of Medicare dollars to the hospital that's training that resident, but both know that only 2% of them actually intend to become a primary care physician.  The primary care workforce is dying off.  Look carefully at the real numbers of practitioners.  Primary care physicians are leaving or not even starting down a much needed career path.  It's painful to see it from the inside and see the "fibs" that cover up the painful reality about front line healthcare in America.

Nurse Practitioners will play a large role in the future of primary care, but there will never be enough physicians to meet the need for primary care physicians.  Access to primary is deteriorating already.

The Dayton, Ohio market is down to two competing  private not-for profit hospital systems, both of which CLOSED the FAMILY MEDICINE residency training center at their flagship hospital in the last two years, converting most of the newly available training slots to cardiology fellowship training slots to help with their new heart hospitals.  Dayton also has a VA and Air Force Base health center.  The largest family medicine training center in Dayton closed with its entire hospital more than a decade ago.  The medical students were not knocking down the doors of the hospitals to fill the family medicine slots, since a lot fewer American graduates are choosing primary care.  The numbers are not good.

Investors have tried to make money from primary care before and failed.  I predict they'll develop another failed business model.  Profit margins are slim when dealing in an integrated way with the actual healthcare dollars of real people.  They don't actually need a lot of money sucked from their parts.

The patients and most employers don't know what is about to happen. What do you readers think?

A. Patrick Jonas, MD


  1. I've watched this issue with interest, since it greatly affects who will provide my health care in the future. My fear has been that my family doctor would eventually become a hospital employee and have to run his practice much differently.

    My doctor has been looking to hire other doctors to join his practice. I saw the ad a few years ago. No takers yet, it appears. What does it say about the number of primary care doctors when there's an attractive position available but no doctors to fill it?

    Last spring my doctor told me that there would be some changes coming in his office, and I held my breath, afraid of what he'd say. What a relief when he said he was not going to be a hospital employee! Just the opposite: a number of private practices in the area were banding together; they're still all private, but have some of the support/advantages of a group (and strength to resist the hospital take-over).

  2. Thanks for your comments, WS. I hope that your Family Physician is now stable d/t collaboration with others. It's encuraging to read about family physicians banding together to survive into the next era. The job listing lack of response isn't unusual. Lots of Family Physicians are finding it challenging to get another physician to expand or replace a physician who is leaving their practice. Stay tuned.

  3. Ultimately, the bottom line is that the American people, in spite of all the lip service to the contrary, simply do not value primary care physicians as much as they value other things. They'd rather put their money toward crap like cable television, overpriced sneakers, etc than toward comprehensive and preventive health care.

    When they have their heart attack and they are experiencing crushing chest pain and fear for their lives, then they greatly value the cardiologist.

    When their gallbladder is inflammed due to a blocked duct and they are in excruciating abdominal pain, then they greatly value the surgeon.

    They just never really feel the same compulsion to get all excited about their blood pressure number or their hemoglobin A1c, etc.

    If they felt as strongly about that stuff as the crushing chest pain makes them feel about the cardiologist, then they would fix the primary care payment system via vociferous calls to their congressmen, their insurance companies, etc. and the result would be that there would be no shortage of medical students looking for family medicine residency positions.