The Year of Living Apprehensively: A PCP Roundtable on 2011

Robert M. Centor, MD; Larry Culpepper, MD, MPH; Bradley P. Fox, MD; Robert W. Morrow, MD; Daniel Z. Sands, DM; Dennis Salisbury, MD; Mark E. Williams, MD


January 05, 2012

What Nonclinical Events Do You Think Had The Greatest Impact on Primary Care Practice in 2011?

Robert W. Morrow, MD (Family Medicine)

Three events mark 2011 for me, none of which seem to be the "swerve" that would change medical civilization as we know it -- but very well might do so.

The first is the opening of the Patient Centered Outcomes Institute (PCORI), whose move away from organ-centric research and toward the use of stakeholders (take that, vampires!) to develop research that might matter might very well change the world of academic research. I say this not only with a fierce desire that it be true but because I've met with research graybeards who acknowledge that something's happening here, although they don't quite know what it is.

The second pivot is the launch of Amagine™ and the plausible next wave of patient-centered eHIT. Now, I'm not the only one who thinks that electronic records can be cheap, be helpful, be interoperable, and be coded to support the chronic care needs of patients.

The third is not the publishing of my little editorial in Academic Medicine[1] but the tipping of the political landscape towards primary care, as evidenced by the continuing focused attention to our needs by the Centers for Medicaid and Medicare Services. As usual these days, this support for primary care is counterbalanced by the need of the commercial health plans to drive up the cost of healthcare by driving away primary care, preferably in a hearse. After all, if one's company answers only to stockholders (the 1% in today's jargon), and if the company takes about a fixed 20% of the premiums to run their business, there is no "business plan" to drive down costs but rather to drive them up. If that sounds paranoid, let me hear another reason for the rapid drop in commercial fees to primary care docs, who save money like crazy for the plans.

This churning political motion might collapse into an uncertain waveform, refuting standing quantum mechanics on its head, or more likely will grow like a soliton* to support the surge of medical students into the foundational primary care practices of modern medical care. We might seize the intellectual high ground after all, if it is a wave!

*A soliton, in dynamical systems, is a spontaneous waveform that can dwarf the basal activity; a quantum or quasiparticle propagated as a traveling nondissipative wave that is neither preceded nor followed by another such disturbance; a rogue wave.

Wishing you all an immersed next year.

Robert M. Centor, MD (Internal Medicine)

  1. The tide is turning against pay for performance (P4P). This year has 2 major clues: the Cochrane Collaboration paper showing no benefit from P4P[2]  and the end of the 6-hour pneumonia rule.[3]

  2. Reason for hope: Comprehensive Primary Care Initiative

Larry Culpepper, MD (Family Medicine)

Stepping out of my area of expertise, the following are game changers this year:

As a homo sapiens alive in the world today, it's global warming and the United States having an absolute banner year in 2011, dramatically increasing our carbon output over previous years.

As a citizen of the Northern hemisphere, it's the popular recognition and politicization of the economic divide, discussed in economic circles and by health disparities folks for years and by the other 99% for months: the bottom 40% of the United States' society has 0.3% of the wealth.

As for primary care, it's the recognition that individual disease management programs are dead on several counts.

  • First, livers aren't very responsive to case managers; people are if they feel they are being treated individually and in a "patient-centered" manner.

  • Second, evidence is emerging that the modest improvements available through disease management are vastly improved if the multiple problems/risks that a patient has are managed in a comprehensive manner. See, for example, the work at Group Health showing the significantly better results from such an approach.[4]

  • Third, care management is most effective when imbedded in the primary care setting rather than through a 1-800 resource.

  • Fourth, the feds have emphatically charged all units of the US Department of Health and Human Services (HHS) to make significant shifts in approach in Multiple Chronic Conditions: A Strategic Framework.[5] To quote from its forward:

"The intention for this framework is to catalyze change within the context of how chronic illnesses are addressed in the United States -- from an approach focused on individual chronic diseases to one that uses a multiple chronic conditions approach. It is this culture change, or paradigm shift, and the subsequent implementation of these strategies that will provide a foundation for realizing the vision of optimum health and quality of life for individuals with multiple chronic conditions."

Bradley P. Fox, MD (Family Medicine)

For me, the biggest game changer in the past year has been connectivity. I have gone from a Blackberry to an iPhone and, within the next month, also an iPad, with access to my charts 24 hours a day no matter where I am -- in a car in a parking lot at the mall or in a restaurant, in a comedy club or in the bathroom. I have found that communication with patients has become completely wide open. I get phone calls and texts and emails and notes via social media, whether it be Twitter or Facebook or Linkedin. I now am getting texts with a direct link that I can I hit to call the patient back. The buffer has been removed and it is actually making things worse. No one is happy at home with how available I am to patients and how they take advantage of that accessibility. It is a difficult barrier. Up until now I would tell them that I would take care of things on my computer when I got home. Now I have everything within reach of my hand and I hate to lie and tell patients that I don't have access. But I need to learn that my life is sometimes as important as the patient's.

Daniel Z. Sands, MD (Internal Medicine)

  1. Meaningful use

  2. Patient engagement as it relates to meaningful use

  3. New reimbursement models (patient-centered medical home, accountable care organizations)

Dennis Salisbury, MD (Family Medicine)

Wow -- so many good points. Game changers for me:

Many of the points raised so far (including Brad's about connectivity -- a very big deal).

Challenge to the individual mandate for health insurance in the Patient Protection and Affordable Care Act (PPACA). The mandate has thus far survived 2 courts but is certainly headed for the Supreme Court. This has huge impact on what happens, both from a population status as well as from an individual practitioner perspective, as the ability to have healthy patients with minor illnesses (as well as the occasional major ones) with a form of payment besides their nonexistent cash reserves would be predicted to dilute the difficult chronic illness patients and help subsidize the great work family physicians (and other primary care clinicians) do every day.

Increase in primary care matching for residency programs this year. Family medicine residencies experienced the first upsurge in medical students choosing that career in many years. This is likely attributable to many factors, but the influence of PPACA and the emphasis on increasing primary care payment and status/importance cannot be discounted. Halleluiah! Maybe there is hope for our country's healthcare nonsystem!

That's it. Hopefully the game changers have changed the game in the direction of patients and our society actually winning said game. (Knock on wood, throw salt over the shoulder, pray, genuflect, venerate your caduceus, meditate, etc.) My Medicare discounted, 27.4% reduced, 80% of allowable two bits.

Mark E. Williams, MD (Internal Medicine)

I agree with others that the major changes in the American economy have been and will be "game changers" for primary care. Not in the sense that care itself will dramatically change but that the demographics and conditions will shift, possibly radically. There is considerable data to show that health deteriorates significantly in populations when personal economic security is threatened. Older workers are disproportionally affected because they contributed to the work force when there was a meritocracy. That is gone and the security of healthcare and a stable pension is in jeopardy (or nonexistent). All this coupled with the daily global economic uncertainties are real life stressors that affect health far more than one's cholesterol level or body mass index. Access to high quality primary health will be a significant issue as the numbers of economically disadvantaged persons increase.