will primary care survive

[Guest guest]



RE can there be a model that works?

Will we ever find out?

1) Am a FM MD who sees about $15K of straight Medicare, with a functional EMR which gives my pts access and care, I am being "compelled" to institute an ePrescribing system or "loose" 2% of my pay.

2) Since 2% of my pay would equal about $300, and the ePrescribing system through my local hospital is barely functional for refills let alone point of care, I am encouraged NOT to participate unless I choose to give up my independence (and therefore ALL the continuity of care I've built up over the last 6 years of independent practice) in order to "qualify" for the nebulous "term" of PCMH.

3) Finally, not likely....

My predictions:

1) More and more primary care will be given over to "poorly trained EMT level" PAs and NPs; let's face it, these folks are well meaning but NOT trained enough to do complex medical management.

2) Ultimately a "2 tiered system" will exist -- most care will be in the "fast food clinics" as run by the PCMH certified hospital owned megaoffices, others seeing private practice primary care (like me who still take insurance) or cash only concierge membership practices will be the norm.

3) More and more testing will be done by more an more undereducated PCPs, and delay of care will be the "standard of care."

What to do:

1) Stand your ground if you can, and keep your independence, if you can.

2) For those who must, do your best but watch your back. Like most other "executives" be prepared to move every 5-7 years or you will have to give in to more and more nonsensical directives (patient who can't bear weight or move knee should be immobilized for 2-6 weeks until ortho appt is available; fill out 3 forms before you can refer pts to "speciality clinics" like the VA -- sorry, you cannot be seen until the cardiologists have an opening for your acute afib onset).

3) Realize that YOU as the FM/primary care physician are NOT the problem (and reasonably supervised NPs and PAs as well). Costs will continue to go UP and UP, and life expectancy will go DOWN AND DOWN in the aggregate.

For all of you that have ended up "in the system" (ie hospital owned/operated) it is just a matter of time before you will be asked to do something beyond your level of expertise -- you must decide what your response will be.

For now, I am pleased to say that I'm just out here as a solo. I finished my FP residency in 1988. I've worked for an HMO that tried all of these things from 1990-1996, and it didn't work then.

It will not work now.

The goals are different:

1) The docs want a decent quality of life and a decent standard of living; as a primary care doc, I like the continuity of care and the ability NOT to see pts that do not act responsibly.

2) The hospitals want as much business as they can possibly jam in the door and if you are an owned physician, as a primary doc you won't last more than 5-7 years in the system without replacement. As a "non" partnership entity, you have NO stability.

3) The insurers do NOT want to pay! Not at all. And they couldn't do the "quality/case management with their money" and now they don't have to, YOU do.

What to do?

1) Give access to your patients -- follow the rubrick of Advanced Open Access model per Murray and Tantua in Family Practice Management. Same day/next day appts for all cases, and weekends/nights depend on medical status.

2) If the "state" Medicaid doesn't pay -- you should stop taking it. My state pays all of $23/visit -- I gave up on this. The hospital owned practices are NONprofit clinics, they should take these pts.

3) Use technology ONLY when it HELPS YOU TO DO THE JOB! IMHO, the "teasers" of the advanced EMRs costing $20-40K per doc is OBSURD. Others such as Amazing Charts, SOAPware, and other portal models can work, and should be used.

From the wilds of Western PA

Matt, MD

IMP article in Medical EconomicsTo: Date: Sunday, February 27, 2011, 12:37 PM

Dreaming of the ideal practice - IMP article in Feb 10 Medical Economics http://bit.ly/hUawDzGordon