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Saturday, May 10, 2014

The Access Conundrum

There are many factors which clearly predict that we are facing a catastrophic access problem in the US healthcare system.  The Affordable Care Act has provided coverage for millions already, with millions more expected to follow.  Baby boomer physicians, who were prepared to retire 5 yrs ago, but whose retirement plans were delayed by the collapse of the economy, will likely be exiting the workforce in the near future.  In addition, many mid-to-late career physicians are leaving the practice of medicine to pursue other medicine related activities such as consulting, legal reviews, or chart reviews for insurance companies, providing them with the same or increased incomes without all the hassles that are inherent to working mainly for third party payors. The shortage of physicians by 2025 is predicted to be greater than 100,000.  The physician shortage that under-served areas have felt for years will become a reality for populated areas as well.   So "coverage without access", a term first coined by Dr Marcia Angell, former executive editor of the NEJM, will not be just a prediction for the post-ACA era, but a reality.

There are so many powerful stakeholders in the status quo that waiting for the healthcare system to reform its delivery model "from the top down" will not take place quickly enough to match demand.  The supply of new physicians to fill the gaps in access is likely to be inadequate when the dissatisfaction of physicians with current and evolving delivery models is so evident. I believe, and many others, including leaders within family medicine believe, that the direct patient care model is the best solution to the access problem in the long-term. The image of the family physician of the past, practicing personalized care to all members in multiple generations of families, will be further eroded in a model of care in which larger teams coordinate care "more efficiently" for larger panels of patients.  It is very difficult to practice truly patient-centered medicine in large teams, no matter how efficiently they function. So innovative delivery models like direct patient care need to quickly disrupt the healthcare system from the bottom up.  This can be done by demonstrating to employers, starting with the 50-200 employee companies and progressing to larger ones, that they can get significantly more value from their healthcare dollar by paying directly for their primary care.  Physicians will quickly realize that they can practice the type of medicine they always intended to practice when they spend the majority of their time directly in the care of their patients, and there will be a surge of medical students and residents interested in primary, direct care medicine.  Once there is a large enough “network” of direct care providers around the country that the largest of corporations in America can purchase care directly for their employees in all regions of the country, the direct care business model will no longer be a “movement” but the prevailing business model.
 
Clearly the movement towards smaller patient panels only benefits that small number of patients who are fortunate enough to receive care from the early adopters of DPC. The access to the system as a whole could be severely compromised in the short-term. There is only 1 rational conclusion to solving the access conundrum--solving the problem in the long-term without paralyzing the system in the short-term--and that is for primary care physicians and their peers with advanced nursing degrees to collaborate in meeting the primary health needs of ALL our citizens in unprecedented fashion.  The Federal Trade Commision recently issued a report that, in keeping with its mission, urged states to consider that scope of practice limitations may be detrimental to public safety, and anti-competitive in a way that prevents costs from declining.  The issue of public safety is key in this discussion because the purpose of professional licensure requirements and state scope of practice regulations are generally to protect the consumer. The Institute of Medicine, in its 2011 report on NP scope of practice, argued that easing limitations on scope of practice has no detrimental effect on consumer safety, and tighter limitations do not prevent harm.  When you consider the fact that NPs have been effectively caring for the primary health needs of the under-served in the country, it is hard to refute.  The FTC report also noted that requiring supervision of NPs by a physician inhibits the development of innovative delivery models that are so desperately needed to meet the rising demand for access. 
Many physicians experience fear and trepidation when the issue of NP scope of practice is even mentioned. More on this in a moment.  First, I am reminded of the climate in the late 1960s when Dr. Nicholas Pisacano established the American Board of Family Practice, a move which was controversial among his family practice colleagues.  The need for such stringent licensing requirements and certification, as well as examinations of competency every 7 years, was questioned. Dr. Pisacano moved forward and enacted these requirements against the popular opinion of his colleagues because it was "good for the health of the American people."  Today we are in a similar situation where the popular opinion of physicians must take the back seat to what is best for the health of the American people.  No one has more "skin in the game" than do our citizens.  But not to worry -- there is no reason whatsoever for providers of primary care services to fear competition in a direct patient care business model.  The fears of competition are rooted in the fee-for-service model in which the best negotiated rate for services is the primary focus. In the DPC model there is more turf than all the primary care providers in the world could hope to cultivate.  We are all on the same team and there will always be more patients than any of us could handle, especially when the new deal is for each of us to do a better job with fewer patients. 
So step back and view the access conundrum in the context of the DPC model.  All of us working together for a low, fixed monthly fee for our 600-800 patients (or 1200-1500 depending on personal preference) have no reason to do anything but collaborate. DPC physicians need to help NPs to adopt this business model for themselves.  Some NPs will be comfortable practicing on their own; others will still feel more comfortable collaborating directly with DPC physicians; but all should be free to practice within the scope of their training without unnecessary limitations on the scope of their practice.  Within each region of the country, DPC providers need to position themselves in clusters that can negotiate collaboratively with employers to provide direct care to their employees (as Qliance is doing effectively in Seattle, for example). Showing these businesses how well DPC providers meet quality measures with fewer ER visits, less missed days work, fewer high cost imaging studies, fewer referrals to subspecialists, fewer workman's compensation claims, and greater satisfaction for their employees, then the model will spread to larger companies. The health of the American people depends on it -- urgently. 

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