(From Hospitals and Health Networks Online, July 9, 2008)
Hospitals need primary care physicians. They should hire physicians, they should buy physician practices, and they should join the retail clinic movement.
At the core of any real health care reform, as well as at the core of institutional survival, we find one key problem: the relationship between primary physicians and hospitals.
Hospitals are not rationally deployed where the need is. As in any ecological system, they are deployed where they can survive. To the closest approximation, that survival is predicated on one factor: the flow of patients from physicians. Some of those patients flow from specialists, some stagger in or are carried in through the ER doors; but the core flow is from primary care doctors, either directly to the hospital or through referrals to the specialists. And primary care is suffering, so hospitals are suffering.
Go to Massachusetts and talk to some of the 340,000 citizens newly insured under the state’s pioneering near, almost, not quite, close-but-no-cigar “universal” health insurance plan. For them at least, problem solved, right? Now they can get those baseline physicals, get tested for diabetes, get that troublesome lump looked at, right? Not quite. First they have to find a doctor, and about half of the primary care practices in the state aren’t taking any new patients. And once you get in, you’ll find that wait times for an appointment can easily be six weeks, and if you want some of that good preventive stuff, like a full baseline physical, you may have to wait a year or more.
Or go to San Francisco, to the vast, charming, edgy, multicultural stew that is the city’s Mission District, with its bodegas and pupuserias and capoeira studios and Candomble practitioners, and you’ll see only two hospitals. San Francisco General is straining under the load and trying to expand. St. Luke’s is done with straining under the load. Its managers at California Pacific Medical Center (and their owners at Sutter Health System) are planning to stanch the budgetary bleeding by closing St. Luke’s as an acute hospital.
Or go to St. Louis, where the good sisters at SSM Health Care could find no way to keep St. Francis Hospital open in Blue Island, like San Francisco’s Mission District a lower-income part of town. An up-to-date facility with new operating rooms, a new same-day surgery center, upgraded mostly private rooms and a top-quality cardiology program, St. Francis has nonetheless lost $40 million since 2002 and is expected to lose another $20 million this year alone. SSM tried to sell the facility to some 30 other systems, Catholic or not, for-profit or not, and found no takers. They tried to give the hospital away (one imagines the item on Craigslist, “Free hospital, must take as is”) and found no takers, the phone loudly silent. After the press ran the story nationwide, Falcon Investors, a for-profit New York–based investment group, and its subsidiary, Transition Healthcare, finally came up with the financing for an undisclosed deal to keep the hospital open as MetroSouth Medical Center.
But peel away the top layers of these stories and it turns out they are not so much “failing hospital” stories as much as they are “failing primary care” stories. You can look at their patient mix and see that they were much too over-burdened with non-paying customers, mostly coming in through the ED. But that is the same as saying that they are not getting enough paying customers. Why?
The Disappearing Primary Care Doc
Being a primary care physician is an increasingly tough business these days, and running that business in not the best part of town is getting pretty near impossible. Increasingly, primary care physicians in the not-so-swell parts of town are pulling up stakes and taking their practices elsewhere, or closing them and becoming hospitalists, or advisers to insurance companies, or something else that pays a salary and has regular hours. These physicians find other ways to turn the crank. They leave, and break the connection between the patients and the hospital.
And they are not being replaced. In 1949, 59 percent of all physicians were in primary care. By 1970, that had dropped to 43 percent, by 1995 to 37 percent. And the slide is continuing: In 2000, only 14 percent of all med school grads were headed for family practice. By 2005 it was down to 8 percent, and more than half of all family practice residencies were going unfilled.
And why should young doctors go into family practice, when it pays so much less, and has so much less prestige, for so much harder work, than specialties?
Yet primary care physicians are a key driver of value in health care, whether from the individual patient’s point of view or from a population health point of view. Repeated, well-constructed studies comparing national systems and comparing areas within the United States show that systems with universal, convenient, affordable access to primary care do better in every measure. A higher ratio of primary care physicians to specialists translates into less overtreatment, less undertreatment, lower mortality and lower cost. What’s not to like?
The future offers little solace. The biggest chunk of primary care physicians (like the biggest chunk of any field) are boomers, set to retire soon—and their difficult working conditions are encouraging them to retire sooner. According to the American College of Physicians (which represents internists) and the American Academy of Family Physicians, the combination of these retirements and the increased need from the aging of the population means that we will need 40 percent more primary care physicians by 2020, yet we are actually getting fewer every year.
The explosive growth of retail clinics in Wal-Mart, Walgreen’s, CVS, Rite-Aid and other big boxes in the coughs-colds-and-cut-fingers market will exacerbate the problem, massively substituting nurses and nurse practitioners (themselves already in short supply) for physicians, in a structure that is isolated from “real” health care.
At the same time the basic contract between hospitals and doctors is becoming a palimpsest, indecipherable, written over again and again. The deal was, “We’ll give you a free place to work, and all the support stuff and staff that you need. All you have to do is bring your patients here, serve on medical staff and take call.” Under the increasing time pressures of managed care, encouraged by new technologies, and now further by the advent of hospitalists, doctors are increasingly seeing less need to admit, and little need to visit their patients in the hospital, much less take call and serve as staff.
The Fragile Patient Supply
The most important input that a hospital needs to survive is not capital, but patients—especially patients with insurance or Medicare. For most hospitals the patient supply chain is tenuous at best, the merest gossamer, concocted of equal parts plate-spinning and prayer.
We have to do better than this, for the people we serve and for the survival and health of our institutions. There is little question that hospitals must take increasing control of the primary care that supplies them with patients. They must buy practices, hire primary care doctors and establish clinics rationally to represent the community need, spreading the economic risk across their whole catch basin.
At the same time, hospitals must go into strong “coopetition” in both retail and urgent care, setting up competing practices when they can, and where they can’t, cooperating with existing and new practitioners, giving them backup, coordinating IT, providing them lab and imaging services at high quality and competitive rates, and setting up an easy pipeline for referrals.
In a world that is both data-driven and customer-driven, the value of primary care actually rises, because IT allows the primary care physician to deliver far more real care, and because the value of prevention and case management rises.
In a world of “value-driven” health care, the primary care practice takes on two roles. The first is as a “health management practice unit,” with its own measures and guidelines. The second is as the front and back end of condition-centered “practice units”—teams that deal with, for instance, pregnancy and birth, diabetes management, chronic kidney disease, asthma, cancer o
r cardiovascular disease.
You don’t win the World Cup, the Ryder Cup, or the Stanley Cup with a pick-up team. You don’t become Wal-Mart by taking goods from whoever shows up. FedEx’s drivers are not freelancers. Hospitals have long operated on a loosey-goosey business model with no control over its principal players, its principal drivers of cost and quality, its principal suppliers of income—its physicians. The 21st century has little tolerance for that kind of free play in any system. In primary care and in key specialties, hospitals must change the business model.