Sunday, September 22, 2013

There's little doubt that a sea change is under way in how primary care medicine is organized and practiced in this country.

That doesn't necessarily mean there is a change in the quality of care - some even say the new collaborative model is better.

But the days of the sole practitioner following a patient through most of an adult lifetime and making rounds in the hospital are fading.

The factors are well-documented. A more mobile society puts a lower value on cradle-to-grave care by the same family doctor. Technology has gotten more costly, as has malpractice insurance, but incomes have not risen proportionally. Insurance payments reward volume, not spending more time with fewer patients. And the costs and red tape of dealing with the welter of plans and pre-authorizations take away from the time a family physician can spend with patients taking case histories and reviewing the effectiveness of various medicines and therapies.

Also, as Medicaid expanded access by poor people to preventive care, clinics like Kaiser Permanente in California sprang up to supplant the care the poor had been relying on from county public health departments. Kaiser also took on company group plans under an HMO model and added nutrition, weight-control, smoking cessation and a host of other wellness programs to help patients stay healthier in between visits to the doctor.


Now, as the Affordable Care Act expands health coverage to millions of working poor and people with prior medical conditions who previously have been denied policies, the pressure to improve the efficiency of primary care will increase. The gap in primary care providers is already wide in many rural areas and poor neighborhoods, and experts see it only getting wider after Obamacare begins Jan. 1.

The law does provide incentives to train not only more primary care physicians but also nurse practitioners and physicians' assistants, but ramping up will take time.

The Flagstaff region, according to a federal study, is not one of those areas underserved by primary care practitioners. Although private family practices are dwindling, the gap is being filled in part by North Country Healthcare, which operates a large Flagstaff clinic and more than a dozen others throughout northern Arizona. The physicians who work there are part of a nationwide trend that has seen the percentage of doctors working for clinics and hospitals go from 43 percent in 2000 to 61 percent today.

But the patient mix at North Country is now 25 percent uninsured after cutbacks in state health insurance for poor, single adults. That has strained North Country's finances, and even when uninsured patients are billed for primary care on a sliding payment scale, there are few specialty procedures that they can afford if they need a referral.


It's why many wind up going to an emergency room - the hospital is bound by law to treat their acute appendicitis or stress fracture, even if the care goes unpaid for. North Country will see not only more Medicaid patients under Obamacare but also more insured patients, and the challenge will be to respond to higher patient loads with more staffing as more revenues come in. So this fall, North Country is focusing on signing up the uninsured - both from among its patient base and others - for Obamacare, which administrators support as a way to improve overall community health, despite the inevitable start-up glitches.

A new arrangement in family medicine has hospitals setting up primary care practices of their own in advance of Obamacare as a way to give newly insured patients a health care "home."

Flagstaff Medical Center has begun Team Health with three physicians and four nurse practitioners. The hospital already employs physicians - known as hospitalists - to care for patients, leaving Team Health to focus on office visits and coordinate referrals to specialists and hospital admissions and discharges through so-called "navigators," who also coordinate care with the hospital's outpatient programs.

That kind of vertical integration makes sense as the insured patient volume at the primary care level - the so-called "gatekeeper" function in Obamacare - gets set to rise dramatically. It also makes sense financially as Obamacare sets penalties for hospital readmissions that review teams find are not justified - primary care that is focused on prevention is a key way to keep patients out of hospitals.


But hospital-employed physicians also can bill Medicare at higher rates than private physicians to account for higher overhead, a trend that one congressional study estimates costs an extra billion dollars a year.

And as the New York Times has reported, private physicians in some cities like Boise, Idaho, have seen the hospital-owned primary practices become so dominant that they control referrals to specialists and diagnostic procedures and give patients fewer choices. Team Health administrators say their family practice is aimed primarily at better coordination of FMC services for patients of all types, not making a profit for the hospital.

We will take them at their word but urge them to be aware that FMC is already the only choice in the region for many ill patients and to protect a niche in the community for private family doctors, too.

Source: Azdailysun

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