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    Primary care has lost its quarterback position in patient care

    Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Stephen C. Schimpff, MD, a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center, and author. This blog is also coauthored by Harry Oken, MD, a practicing primary care physician and professor of medicine. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.

     

    There is a crisis in primary care and it’s now flowing over into the hospital when a primary care physician’s (PCP) patient is admitted.

     No longer cared for by the PCP, the role has largely fallen to the hospitalist. There has been a loss of the long time primary care physician-patient relationship and the trust that comes with time. There has been a frequent loss of satisfactory communication when the patient is admitted and again when discharged. At a time when the patient most wants and needs the comfort of a long-time trusted professional friend, the patient instead is confronted with a stranger at the helm. What has happened to create this state of affairs?

     

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    PCPs have seen their overhead costs rise dramatically along with insurer-mandated paperwork and government-mandated electronic health record (EHR) time requirements. This means the PCP must see more and more patients for shorter and shorter periods to cover overhead and still reserve time for the nonclinical requirements. The average visit time is now 15 minutes with only 8 to 10 minutes of face time. It also means that most—but definitely not all—PCPs no longer attend their patients in the hospital, leaving that function to the hospitalist.

    Hospitalists are trained in caring for patients in the hospital. Since that is all they do, they become very experienced in dealing with the types of medical issues that require hospitalization. Working full-time in the hospital means that they know how to get things done in that setting and do so fairly efficiently.

    The growth of the hospitalist movement over the past 20 years has been truly phenomenal—at 50,000 physicians, it is the largest medical subspecialty (cardiology is next at 22,000), surpassed as a specialty only by general internal medicine at 109,000 and family medicine at 107,000.[i]

    Early studies suggest that quality was improved and costs reduced with the advent of hospitalist care. This was especially true for complicated patients who required multiple physician visits and interactions each day, something difficult for the community-based physician to achieve. With the need to see multiple patients each day in the office to cover overhead, many PCPs willingly ceded hospital care to the hospitalist. 

    In our experience, hospitalists are a heterogeneous group, many are just out of an internal medicine residency; some are working part-time because of childcare obligations. Many are contemplating a fellowship, but want to catch up on loan obligations. Some hospitalists anticipate at a future point to become PCPs. Still others intend to make a career as a fulltime hospitalist.

     

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    Frequently employed by the hospital, they still must meet productivity standards in order to earn their salary. Often this means caring for a large number of patients, most of them quite ill. Although they are expert in what they do, they do not have the years of interaction with the patient that the PCP has. They did not know the patient before the hospital event and are not likely to know him or her after. Each patient is an individual with his or her unique family, social, economic, and of course, medical background.

    Next: Discouraging findings

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    • UBM User
      As a EM physician that has practiced in suburban and rural hospitals, I have witnessed the dimunition of pcps in our medical system as well. It is rare for pcps to admit their patients as that responsibility has essentially been usurped by hospitalist. It is understandable with the mounting demands necessary to run an outpatient practice. The unfortunate reality is there will be no return to the good ol' days when pcps had the time to tend to patients in the office, care for them in the hospital, and continue care in post-acute settings. What is needed, on the other hand, is a more seamless way for pcps, EM docs, and hospitalists to better coordinate patient care. We need to find novel solutions to this issue for the health of our medical system.
    • [email protected]
      I think it is a pity that primary care physicians have relinquished their role in managing their hospitalized patients. We have spent time earning the trust of our patients and families in caring for routine problems. Then when the patient is more seriously ill, when they need us the most, their inpatient care is managed by a total stranger who often lacks critical patient background information. It should also be noted that the vast majority of our residency training involved inpatient management. What we are now left with is the more routine and frankly less challenging problems. We are now responsible for an increasing burden of administrative and time consuming tasks. Furthermore, much of what we do is now being performed by urgent care centers and large national chain pharmacies(where one gets treated by a "doc in the box", often a PA or ANP). If we do not do something soon to reclaim our role in the total care of our patients the future will be bleak. It would difficult to imagine why medical students would chose a career in primary care medicine instead of, for instance, surgery or dermatology.
    • [email protected]
      The Scripps Retired Physicians Discussion Group has addressed medical funding and we have come up with a proposal that might add to a more positive doctor-patient relationship and help to resolve the "quarterback" issue. The essence of the proposal is to create patient savings accounts (PSA) similar to HSA’s. The difference is that the PSA would be used only for physician payments and that the government would deposit the first $3000 of federal tax into a taxpayer’s personal PSA account. The financial impact would be the same as HSA’s tax credit, but should Congress enact tax reform, any elimination of tax credits would not affect this model. The group strongly felt that ALL members of society should have access to quality care. However, for reimbursement purposes, there would be two tiers of payment. Tier I would be for those who pay no federal tax and they would be provided a safety net. Tier I physician and hospital reimbursement would be by the government much like Medicaid and care would be primarily at Community Clinics that have a proven record of delivering cost-efficient quality care. Tier II physician payments would be from PSA’s while the Tier II hospital reimbursement would be from insurance products limited to hospital care. Should PSA funds be depleted, patients would be moved to Tier I for their care unless patients elected to pay physicians out of their own funds. Tier II patients could opt for Tier I care at any time by simply forfeiting their PSA funds back to the government. Any PSA funds not used would accumulate. It is anticipated that many would prefer Tier II due to conveniences such as more immediate care for non-urgent problems. Though physicians make up a limited part of medical costs, they drive the system. The primary advantage of this structure is that patients would be taking money from their own personal PSA to pay the physician. This would decrease over-utilization. There would be no gatekeepers. Pre-existing condition exclusion would not be relevant to physician access since there would be no insurance for physician payments. The 20% insurance profit would be turned into savings. Immediate physician reimbursement from PSA’s could reduce physician staffing. Physicians may have an incentive for reduced or free care to retain patients until funds are replaced the following year. As current young people approach age 65, they might elect to forgo Medicare if their PSA is substantial, perhaps saving Medicare. The immediate costs would be up to $3000 for each taxpayer. Calculating the number of tax filers paying federal tax, less those on Medicare might yield about 50 million PSA’s for a cost of $150 billion per year. The government could break even by collecting $150 billion in taxes from those benefitting and still leave the public with any savings above that figure. In summary, we believe this proposal will guarantee medical access for all, save money by decreasing over-utilization, avoid the pre-existing condition exclusion problem and most important return the control of medicine to the patient. This plan was endorsed by Drs. Carson, Roseman, Pund, Saliba, and Gormican. As a group we would appreciate any feedback.
    • UBM User
      Yes, all true I would question the statement "Early studies suggest that quality was improved and costs reduced with the advent of hospitalist care. " as being one of those "literally true" but not "practically true" statements. Another very reasonable interpretation of the literature would be that hospital costs varied little between hospitalists and PCP's and mortality not all in most studies. Furthermore, assuming hospitalists represent an "extra" cost to the medical system, one could easily argue that the overall cost to the medical system is greater with hospitalists. Hospitalists were promoted originally as being able to spend more time with patients, but as noted above , they have become just as overwhelmed as PCP's. And I agree they routinely repeat tests that have been performed outpatient, and seem to consult excessively (does every "pneumonia" need an ID consult?). I still see my own inpatients, enjoy hospital medicine, embraced the hospital EMR more than any other MD, and do feel that my patients appreciate greatly my seeing them in the hospital.
    • [email protected]
      As a 35 year old Family Medicine community physician it is difficult to spend all day and evenings seeing patients and doing paperwork. That being said, I practice in the outpatient office 5 days per week and see 3-7 of my patients in the hospital every morning and it is the most rewarding job I have ever had. I was blessed (or is it #blessed?) to have found a practice out of residency with an older family physician who practiced traditional inpatient/outpatient family practice. His mentorship along with my residency education gave me the foundation to practice in/outpatient medicine. All my patients are very happy to see me when I visit them in the hospital. I agree, hospitalists are necessary, and we use their services for admission History and Physicals as well as ACLS/code blue when I'm on call. That takes some of the burden off me. Without their help, it would be a very tough to juggle work and family life. But I agree with the author that my in/outpatient care helps to minimize the costs of the hospital stay. It saddens me to think that hospital administrators want to keep PCPs out of the hospital setting. Makes me wonder if they have ulterior motives (i.e. hospitals keep salaried hospitalists charges but not PCP charges). I do see that the younger generation of docs want more of a leisurely lifestyle, but isn't it more important to get satisfaction from your occupation? Plus, the extra earnings from hospital visits goes to paying off my student loans faster!
    • [email protected]
      Insightful and thoughtful writing. I agree with all of Dr Schimpff's conclusions. I would love to see a deep commitment to patients return to be the "norm", but a combination of financial, generational, and societal pressures all seem to be simultaneously pushing to compartmentalized jobs, with punch in and punch out expectations. I personally fear for the experience ahead of me when I (inevitably) become frail or in need of continuous medical service. Does anyone see a point of leverage to change the current trends?
    • [email protected]
      Use the hospitals and insurance companies to leverage primary care doctors to practice inpatient/outpatient care. One way you can do that is make student loans disappear for each year of service in traditional inpatient/outpatient primary care. Make it $10,000 stipend for each year of inpatient care in addition to the doc charging for his/her visits. After the physician has been doing inpatient care for the 10-20 years it takes to pay off the student loans, s/he won't want to give up the inpatient care.

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