20 Years of Transformation in Primary Care

Marcia Frellick

May 28, 2015

Before the explosion of managed care, electronic health records (EHRs), hospital mega-mergers, and just before the rise of hospitalists, primary care physicians had a very different role.

Leaders in the field who have practiced over several decades have different ideas about what has had the biggest effect in the last 20 years, but all agree they see their careers very differently than they did in 1995.

Mark E. Williams, MD, clinical professor of medicine, University of North Carolina School of Medicine, Wilmington, and emeritus professor of geriatric medicine, University of Virginia Health System, Charlottesville, is quick to state he still loves medicine after nearly 40 years.

He sees the promise of developments in recent years such as 3D printing, stem cell research, and sequencing of the human genome, but he worries about the monetization of healthcare and the way that tugs on physicians' moral compass.

"I am no longer a physician; I deliver healthcare for a large provider," he explained. "I don't care for a patient; I care for a covered life as part of an insurance plan."

Those cultural changes can lead to ethical compromises and conflicts of interest, Dr Williams said. Physicians cannot always foresee when they enter into an arrangement with a payer or drug company how the agreement might compromise the trustworthiness and independence of their treatment decision making.

In addition, checklists and codes have entered into a payment relationship that started out as something a family physician and patient worked out together, depending on the nuances of a patient's complaint.

Now, "physicians have to pigeonhole a patient's predicament into a very specific box," for which they must enter a Current Procedural Terminology code, he said.

As a geriatrician, Dr Williams worries that as medicine heads toward population-based approaches, physicians will lose sight of the fact that as individuals age, they also become more unique and less like one another. Although the system rewards physicians who persuade all of their patients to get mammograms or colonoscopies, checklists ignore the unique needs of each patient, he said.

"We have evidence-based protocols that say if everything else is equal, here's what you should do. The problem is, everything else is never, ever equal."

EHRs' Value for Physicians Not Yet Seen

Monetization of medicine and evolving use of electronic systems at the expense of nuanced patient care also worries Robert W. Morrow, MD. Dr Morrow, an independent family physician, is a clinical associate professor, Department of Family and Social Medicine and associate director, Center for Continuing Medical Education, Albert Einstein College of Medicine in the Bronx, New York.

"We're racing in a different direction to depersonalize the personal physician and turn healthcare into a very much monetized, fragmented system. This is very scary," Dr Morrow said.

He said EHRs have become an efficient tool for large health systems to help assign and track costs for procedures, but what they have not done well is prompt the development of patient registries with data on the preventive and chronic care services each patient has received.

The gobbling up of not-for-profit hospitals by health system giants has also made earning a living more difficult for independent family physicians, he said. That, in turn, has led fewer medical students to choose that path as they grapple with record medical education debt.

Growth of medical student debt has changed dramatically in the past 20 years, he pointed out. The American Association of Medical Colleges pegs median student loan debt at $180,000 for the class of 2014. That rate has increased 6.3% per year since 1992, compared with 2.5% for the Consumer Price Index. For the class of 1992, the median education debt was $50,000.

The race toward mergers and larger health systems makes much of what Dr Morrow finds so satisfying in family medicine more difficult. He spends much of his time trying to build bridges between community groups and public health and family physicians. Projects such as teaching grandmothers from public housing to help others control their diabetes are successful, he said, but getting the funding and replicating the programs is difficult with the large-scale emphasis of today's health system, which he thinks has led to monopolies.

Dr Morrow is thankful his mortgage is paid, his kids are out of college, and he owns his office building, because primary physicians' pay has been going down since the early 2000s, he said.

"In the '90s, I was paid adequately and got called to see patients in the hospital," he said. But that practice model changed dramatically with the rise of a new kind of physician — the hospitalist — a trend many say was first described by the New England Journal of Medicine in 1996.

Hospitalists Surged in the 2000s

Up until the late 1990s, primary care physicians would leave their clinics and head to a hospital before or after clinic hours, and sometimes in the middle of the day, to check on their patients.

Joseph Ming Wah Li, MD, SFHM, associate professor of medicine at Harvard Medical School and chief of hospital medicine at Beth Israel Deaconess Medical Center, Boston, Massachusetts, was in his residency at the time that model started to change.

Some practices were starting to assign one physician to see all of the practice's hospitalized patients. That was the precursor to the movement to have inpatient physicians available in the hospital around the clock who would care for the sickest patients. As hospitals were under pressure to shorten length of stay, they were looking for an alternative to waiting for the primary care physician to come discharge their patient.

Also, about the same time, therapeutic agents became available for conditions such as deep vein thrombosis, which meant patients no longer had to be treated in the hospital, Dr Li said.

With the changes, family physicians began having to make a choice between inpatient and outpatient care.

"Some tried to do both, but it became an incredible challenge for them to do that and manage the balance between professional and personal lives," Dr Li said.

He recognizes the frustration of physicians who see the rise of hospitalists as a fragmentation of care. But he added that fragmentation has always been part of care, as one physician cannot care for a patient 7 days a week.

"You still had coverage on vacation, you didn't work every weekend. To think of the glory days when there weren't any handoffs is simply not true," he said.

The number of hospitalists has grown from a few hundred in the late 1990s to more than 45,000 today, by some estimates. They have been able to provide immediate care and add efficiency, but the patients, especially those with complex medical histories, can lose the benefit of history.

"As a hospital doctor, I have 4- to 5-day relationships with patients, I don't have 4- to 5-year relationships," Dr Li said. "On the other hand, what I can do is provide timely care for patients."

Enhanced Value of the PCP

The exodus of primary care physicians from hospitals also meant they were not rubbing elbows with their specialist colleagues, and they were leaving long-time patients to the care of others. Those changes led to some isolation in the field, said Larry Culpepper, MD, professor of medicine at Boston University in Massachusetts.

That came on top of a perception that had lingered since World War II, when scientific and technological advances pushed graduating physicians into specialties, he said. In the years after the war, "primary care was seen as something you did if you couldn't go into a specialty. It was not the top echelon of medicine," Dr Culpepper said.

However, a few things started to change the perception that primary care physicians were "gatekeepers" who referred patients to specialists. One was the recommendation in 2002 by the US Preventive Services Task Force to screen for depression, which was a reversal from its previous stance that screening does not improve outcomes. The World Health Organization had identified major depression as the fourth leading cause of worldwide disease in 1990, and sales of antidepressants were soaring.

Screening moved into the purview of the primary care physician, which began to make primary care the center for reintegrating mental health care with the rest of medicine. Screening for depression then spread to diagnosing conditions such as bipolar disorder, posttraumatic stress disorder, and anxiety. That, combined with the surge in demand for new antidepressants such as selective serotonin reuptake inhibitors, helped reintegrate mental health into the care of behavioral and physical needs and helped raise the profile of the primary care physician, Dr Culpepper said.

The connection between mental health and other health measures became more evident. For instance, "risk of stroke doubles with the depressed population," Dr Culpepper noted.

"We now realize if we don't come together, it's difficult to get good outcomes for cardiovascular disease or diabetes," he said.

As physicians are seeing more complex patients with several comorbidities who are often overweight, arthritic, and/or depressed, the status of the primary care physician is rising. Primary care physicians are now recognized as the professionals who can integrate the care and improve outcomes, he said.

Dr Culpepper sees the evidence-based, patient-centered medical home as the model that will truly realize the value of the family physician.

With patient-centered medical homes, "We finally got it right," he said, in terms of an organizational framework that supports primary care and makes the collaboration across disciplines much easier.

Now the question is whether pay will follow. Dr Culpepper said the answer to that lies in how quickly patient-centered medical homes can make their case.

"That's the question for the next 5 or 10 years: Can we demonstrate its value?"

Dr Williams, Dr Li, Dr Morrow, and Dr Culpepper are members of Medscape's advisory board. Dr Morrow writes a blog called The Transparent Practice for Medscape. The physicians have disclosed no other relevant financial relationships.


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