The evolving role of the primary care physician.

At the outset, let me state that my bias is clearly toward supporting the primary care physician (PCP). I was trained as a general internist and spent 12 years in an academic setting practicing medicine and training internal medicine residents. I am currently working for a unique managed care benefits plan, the Commonwealth Health Alliance, which promotes PCPs by supporting full reimbursement for primary care services, complete freedom for referrals, no gatekeeper role, and no locking in of patients to specific physicians. In the almost four years that I have worked with the plan, I have heard from hundreds of physicians all over the United States, including rural areas, about the problems with primary care practice. I see these physicians in two broad groups: in fee-for-service private practice and in organizational settings such as multispecialty group practices, HMOs, or hospitals. There is a trend for physicians to gravitate from the former to the latter, largely because of the increased hassle with reimbursement, paperwork, and uncertainty about the future. If frustration is driving this shift, I don't feel that the providers making the move will necessarily find the grass greener on the other side. There are some fundamental issues that need to be addressed.

Hammer and Champy, talk of three forces that are driving business today. customers, competition, and change.[2] Unless a business can respond positively to each of these forces, failure or demise will result. Is this what is happening to primary care providers? Let us look back at the "good old days" of primary care and see what is different today. Was there a failure of primary care physicians to respond to one or more of these forces?

The Past

For a look at the past, let's view the |50s and |60s. As I tried to research this, I ended up talking to an authority whom I know well - my father. Dad is a retired midwestern internist who started practice in the late |40s and retired So years ago. As someone who has seen a tremendous change in medicine, he made several points about patients (customers). First, they more readily accepted the word and instructions of the physician. Doctors had respect and standing in the community and were considered authorities in medical matters. Second, patients accepted their conditions. My father recalls that patients with rheumatic heart disease accepted their decline in function and looked upon death as an inevitable fate. There were few alternatives in medical care, and the family physician was the final word in many communities. Third, medical care was affordable. In the |50s, my father's office visits were $3-6 and it cost $16-18 per day to stay in the hospital. The rise of insurance coverage came with few controls once a patient was admitted, so there was a certain amount of gaming the system. For example, patients needing an upper GI series might be admitted because insurance would only pay for it on an inpatient basis. Then, the customer had few expectations and remained largely loyal to the primary care physician.

Competition in the past was limited as well. Perhaps the main competition came from families themselves. Dr. Christian Ramsey uses the term "family health expert" to denote the family member who directs health care.[3] Unless this person, often the mother or grandmother, deemed it necessary to see the doctor, other remedies would be forthcoming. Nonmedical practitioners, such as chiropractors, provided some competition but not in large numbers.

Change was not rapid in the past. The explosion of technology was just beginning. Practitioners could rely on their medical school education and limited internships to be able to practice medicine consistently and successfully for years. Continuing medical education was not perceived as necessary. Medical practice was unregulated, and life was good.

In his autobiography, Sam Walton[4] talks about how he came to be the head of the biggest discount chain in the world. He attributes much of his success to borrowing or copying as many good ideas from others (especially his competitors) as he could. Walton's precepts are relevant to primary care. Apropos of the good old days in primary care, Walton states, "But if you get too caught up in that good life, it's probably time to move on, simply because you lose touch with what your mind is supposed to be concentrating on. serving the customer."

The Present

The customer of the present has changed. In the United States, we have experienced an increasing emphasis on convenience. Witness the growth of fast food outlets and convenience shops. Customers of today expect to be served quickly and efficiently so that they can get on to other activities. In addition, the population is much more mobile. No longer is it the norm for someone to remain in the same community all of his or her life. Having a long-term relationship with the hometown family doctor is not realistic. Unless there is a compelling medical reason, customers of today are not going to seek out a primary care physician when they move into a new community. According to national statistics, less than half of Americans have an ongoing relationship with any physician.

People also have new expectations about what their health should be like. Whether it is due to the media or some other cause, there is a growing faith that technology will cure all that ills. Death is not seen as inevitable, there will be a cure just around the corner. These expectations have increased litigation., medical malpractice is much different from what it was in the past. Medical costs are, of course, much higher than in the past, and, although there is some concern about this, the customer wants the best that money can buy when dealing with a personal issue. Today's customers have a much higher set of expectations; they want a quick cure no matter what it costs. Relationships take a back seat to convenience. And, if their expectations aren't met, they are much more likely to litigate.

PCPs and other providers have another customer: the payer. In the past, the patient was the payer but insurance has changed that. Although physicians would like to say they remain loyal to the patient, it is the payer that is increasingly calling the tune. What does the payer expect? The major expectation has been low cost. Physicians have resisted responding to the cost issue, saying that quality will suffer under cost containment. What this response has really been is a failure to deal effectively with the needs of the customer. Although it has been shown that PCPs are low-cost providers, they have failed to market that distinction to payers and have ended up being lumped with all physicians subject to heavy discounts. Research by our company has shown that the primary care provider typically gets 6-8 percent of each dollar spent directly on health care. PCPs are not part of the cost problem; they could be part of the solution. However, until PCPs can work with the payers to demonstrate their value, this issue will remain.

What about competition? The rise of specialists has been the biggest threat to full-time primary care providers. Whereas, in the past, specialists would only see referrals, the growing number of physicians scrambling for patients has seen that unwritten rule go by the wayside. It is very common for subspecialists in internal medicine to combine their specialty interest with a percentage of primary care practice. Many gynecologists maintain that they are PCPs, although they do not provide the range of services that a family practitioner provides. Other competitors include hospitals with niche programs such as women's centers and sports rehabilitation clinics. Urgent care centers have capitalized on the convenience needs of the customer over providing long-term relationships. And nurse practitioners and physician assistants, who were originally developed and trained to help out the overworked PCP, are demanding the right to practice without supervision. Nonmedical providers such as chiropractors have remained on the scene but do not pose a greater threat than previously.

What about the third force, change? Certainly the pace of change has increased, particularly in the area of technology. Medical advances have made it a challenge for specialists, much less generalists, to keep up. Information technology has also exploded. The PCP has been one of the last to benefit from these advances. The world is moving fast, and primary care has not adapted quickly enough. Instead of adapting, many are opting to leave practice, and certainly there are few incentives for medical students to enter a dying profession.

Pinn, in a letter to the editor of American Medical News,[5] notes that the current state of primary care could be expressed as a formula. "Highest Risk + Most Work + Most Responsibility = Lowest Reimbursement." Culley states, "The primary care business is not the hospital business nor is it the fried chicken business."[6] Although he is trying to make the point that PCPs should be partners in health care ventures, he doesn't recognize what benefits the convenience industry might offer for health care practice.

Pinn's formula may be accurate and Culley may have a point, but I maintain that neither provides a solution or vision for solving the problem. In my view, there are competitors using aspects of the fried chicken business to meet both patients, and payers, needs, and they are getting more business. In the meantime, PCPs in private practice who are not changing are proving the validity of Pinn's equation. Regardless of the group in which PCPs are placed, they are professionals who need a degree of autonomy in their practice of medicine. Unless this is addressed, I believe that the supply of PCPs will dry up and they will be replaced by other providers.

In the private practice of medicine, the PCP's destiny is in his or her own hands. It is clear that, in order to survive, primary care medicine can no longer act like a cottage industry with solo, two, or three physician groups practicing independently in a community. A growing trend is for PCPs to form networks to be able to take advantage of a number of efficiencies. In a network group, PCPs can lower their overhead Cone of the highest in medicine) by group purchasing of supplies, equipment, and insurance (including malpractice). Administrative costs can be shared. And, perhaps most important, the group can have a more powerful relationship with payers so that important issues, such as reimbursement, can be negotiated. In some instances, primary care networks are sharing the risk and becoming more like insurers.

However, a number of networks are being set up only to negotiate with payers. This is a short-sighted approach, as it ignores the other customer, the patient. Primary care practices must be competitive not only in cost (thus the importance of lowering overhead) but also in convenience and quality. Physician networking can address these issues through the use of better time management and information technology.

On the time management issue, larger numbers of physicians can mean better call schedules and linkages with urgent care facilities where patients can be treated nights and weekend and referred back to the PCP of record. By owning and operating the urgent care facilities, the network can achieve goals of convenience and long-term relationships.

The adoption of information technology is paramount for PCPs. Both management books cited above[2,4] list the use of information technology as a high priority for success. The administrative benefit has long been recognized, in the reduction of paperwork and billing hassles. However, the role and the benefits on the clinical side have lagged. This is the area of opportunity as I see it. Primary care's strong suits have been continuity of care, with long-term follow-up and prevention. Information technology used with medical records can reduce the amount of paperwork, increase the ease of data retrieval, and ease the transmission of data to and from other providers. High-quality care could be demonstrated in PCPs, practices through the monitoring of preventive care. For example, physicians could monitor their Pap smear rates and blood pressure checks to demonstrate to patients and payers their commitment to high-quality preventive care.

All of the above steps require a high degree of organization and leadership. I believe that this is an opportunity for physician executives to provide support to these physicians. Already the American College of Physician Executives is working with the American Academy of Family Physicians on some joint educational ventures, and I envision its working with some of the other primary care membership organizations as well.

What about the other group, PCPs who are employed? As many managed care organizations will attest, not only are PCPs in short supply but also those coming directly from residency training are not equipped with the skills necessary to take efficient care of patients in these settings. Turnover is a problem, as many PCPs get frustrated working day in and day out as unappreciated caregivers and gatekeepers. Often, PCPs are outnumbered by specialists and have little or no say in how the organization is run.

The major problem that I see in the employed setting, then, is how PCPs can be given a stake in the system rather than just being another cog. Walton acknowledges that one of his greatest successes was to make his employees associates, to give them a say and a stake in the business. That is a good idea to steal and apply to health care organizations. Physician executives can play a major role in supporting their colleagues in primary care by inviting partnership and participation.

What is the future for the PCP? I don't believe that it will be decided by government mandate. Rather, I feel that the responsibility should be shouldered by PCPs them, selves. They need to reexamine their practices and their role in the health care system. Networking is vital, not only in communities but also among membership organizations such as the American Academy of Pediatrics, the American Academy of Family Practice, and the American College of Physicians. The American College of Physician Executives and its membership can lend support, but fundamental change needs to come from within.

References

[1.] Koop, E. "Revitalizing Primary Care: A 10-Point Proposal." Hospital Practice 28(10):87-90,94, Oct. 15, 1993.

[2.] Hammer, M., and Champy, J. Reengineering the Corporation: A Manifesto for Business Revolution. New York, N.Y.: HarperCollins, 1993.

[3.] Ramsey, C. Personal communication.

[4.] Walton, S. Sam Walton, Made in America: My Story. New York, N.Y.: Doubleday, 1992.

[5.] Pinn, M. "Capitation Formula Doesn't Make Sense for Family Physicians." American Medical News, Dec. 6, 1993.

[6.] Culley, G. "Fried Chicken Medicine - The Business of Primary Care." Journal of Family Practice 38(1):69-73, Jan. 1994.

Robert Hodge, MD, FACP, FACPE, is Vice President, Commonwealth Health Alliance, Inc., Charlottesville, Va. He is a Past President of the American College of Physician Executives and Chair of its Group on Primary Care. He is a member of the College's Society on Academic Health Care and of its Forums on International Health and Medicine and on Medical Informatics.