Primary-Care Physician Shortage Solutions off Base

October 31, 2013

The newly insured under Obamacare needing primary care may be in the thousands or millions. Either way, primary care is the keystone solution to reduce spending.

In reading dozens of articles and op-eds proposing solutions for the upcoming primary-care physician "shortage," four things stand out:

1. Pundits, healthcare journalists, and physicians just don’t get it. No one needing care goes without. The challenge is transiting patients from the emergency department, the primary-care provider to the poor and uninsured, to the doctor’s office;

2. Their proposals are generally sound, but making more doctors in an environment where they go into practice buried in debt from student loans while being squeezed by reimbursements lowered to subsistence levels or below is why our best and brightest are running away from medicine, not toward it. These are smart kids, and they can do the math. Even if the student debt and reimbursement issues are addressed effectively, this proposed fix is a years-away proposition for a today challenge;

3. The real problem for primary-care providers with insurance reform, as envisioned in Obamacare, is not flooding the market with newly insured seeking services, as the general consensus seems to conclude, it is dumping the entire cost of primary care and much more onto the insured in the form of deductibles and copays. This makes insurance little more than an expensive discount program for the vast majority. Primary care represents six percent of the cost of healthcare and controls or directs 94 percent of the spending. Making primary care self-pay except for an annual exam - instead of an insurance benefit where the deductibles kick in beyond primary care, and short-term problems can be effectively and efficiently addressed and expensive long-term problems avoided or reversed - dooms the whole scheme; and,

4. Lastly, and most importantly, insurance reform is NOT healthcare reform. Insurance reform spreads the growing cost over a larger cohort. Healthcare reform reduces the cost while spreading it over a larger cohort, making it less expensive. One without the other is politics, not progress.

There are three obvious solutions for the short-, mid-, and long-term future:  

1. Short-term - increase capacity: Take a lesson from surgeons.Transform primary-care physicians from service providers into clinical managers, leaving the everyday care chores to advanced nurse practitioners and physician assistants, personally treating the most complex cases. Population management and risk- and disease-stratification systems that overlay EHRs and convert data to actionable information (like MDclick and others) facilitate this and much more, including taking the step from coordinating care to organizing it.

2. Mid-term - train more physicians and clinicians: Invest in them, because the return on investment in avoided costs, hospitalizations, and emergency department visits is huge:

Convert student loans to grants for primary care after ten years of practice, and suspend principal and interest during this period.

Invest in local residency programs. Training doctors and clinicians that go elsewhere for residency is senseless. Most by a large margin practice where they do their residency.

Invest in wellness and preventative care. Pay primary-care clinicians fairly, particularly with Medicaid, and take the burden of deductibles (not copays) for physician office visits off patients' backs to encourage their seeking care when things are simple, and early.

3. Long Term - invest in wellness and self-care: Chronic disease represents 80 percent of the overall healthcare spending and 96 percent of Medicare spending. Investment in stalling or reversing the pathway to complexity, and avoiding chronic conditions completely, will reduce unnecessary hospitalizations, emergency department visits, acute episodes, and readmissions by the hundreds of billions per year:

Reward primary-care providers who close gaps in care generously.

Reward patients who follow the rules, instructions, and healthy living practices with reduced or eliminated copays and deductibles.

Invest in patient personality typing to determine the best approach to gain patient compliance and cooperation.

And, a baker’s dozen more.

All Phases: Taking away the regulatory barriers that make organizing physicians into narrow, geographically contiguous medical neighborhoods that are connected to regional networks through a common population management, and risk and disease stratification platform, presents a legal nightmare that should be a legislative priority for state and federal government.

Common sense.