Hospitals face conflicting challenges as this alternative to traditional primary care gains momentum
The 45-year-old patient called New Pueblo Medicine, a Tucson, Ariz., primary care practice, on a Friday afternoon with complaints of dizziness. Later that night, he spent hours in Tucson Medical Center's emergency department before being sent home with a prescription for an anxiety medication and no other discernible medical problems.
Doctors at New Pueblo Medicine discussed the man's case at a physician practice board meeting about a week later as part of an ongoing effort to monitor ED usage. How did the physicians even know about the ED visit?
This spring, the practice began receiving weekly reports from UnitedHealthcare listing any of its patients who sought emergency department help‚ anywhere in the United States‚ during the prior week, says Mike Cracovaner, chief executive officer of the seven-physician practice. That immediate feedback allows clinicians to discuss cases, while everyone's memory is fresh. Prior to the weekly reports, he says, "A lot of times the trail was so cold‚ an elderly patient may not remember why they went to the emergency department."
New Pueblo is one of seven primary care practices in Arizona and more than three dozen nationally that are participating in UnitedHealthcare's pilot initiative to study the medical home concept, one of a number of efforts to boost the quality and the cost effectiveness of primary care treatment.
These days, primary care practices and the hospitals they are affiliated with, or owned by, are wrestling with several intertwining‚ and sometimes conflicting‚ challenges. The central dilemma: how to improve basic medical care within the current reimbursement structure as the supply of primary care specialists dwindles.
By 2025, the Association of American Medical Colleges projects a shortage of 124,000 physicians, 46,000 of them in primary care. In some cases, midlevel providers, such as nurse practitioners and physician assistants, are helping to alleviate the burden on overworked primary care doctors.
Potentially of more significance, the health care reform debate has intensified conversations about new payment structures that emphasize the quality of care rather than the quantity of services provided.
Numerous related concepts are involved, such as bundled payments and accountable care organizations. The underlying goal is to encourage doctors and hospitals to collaborate more closely, thus reducing unnecessary or redundant treatment. "If we simply pay fee for service, that rewards volume," says Rick Kellerman, M.D., chair of the Department of Family and Community Medicine at the University of Kansas School of Medicine in Wichita.
The free-flowing exchange of emergency department detail can pay off in several ways, Cracovaner says. Inappropriate ED use can be identified, educating patients and physicians alike. And patients who skipped follow-up care can be more rapidly tracked down. "If someone is sick enough for the emergency department, we want to get them into one of our providers right away," Cracovaner says. Hospital admission might be avoided in the process.
From a hospital administrator's perspective, that might seem counterintuitive, says Palmer Evans, M.D., senior vice president and chief medical officer at Tucson Medical Center. "When you look at all of these projects, the goal of a medical home and bundling is to keep people out of the hospital," he notes. But with public and private payers demanding better results, "we feel that being efficient and cost effective, down the road, will put us in a better marketing position." He notes that IBM is a partner in UnitedHealthcare's Arizona initiative.
The medical home model provides incentives for primary care doctors to coordinate with specialists and hospitals, ideally with the help of computerized medical records.
New Pueblo physicians are still paid per service provided, but they receive an additional fee per patient for broader case management and may earn extra compensation if they meet preset quality benchmarks.
Medicaid also has medical home pilots in at least 31 states, according to the Patient Centered Primary Care Collaborative, a coalition of employers, consumer groups and other supporters of the concept. A Medicare demonstration project is in the works, although federal officials have yet to announce the eight sites‚ states or portions of states, that will be involved. Once up and running, each site will include 50 primary care practices, with roughly 400 practices expected to participate.
Meanwhile, a state commission in Massachusetts in June recommended moving away from fee-for-service. Under its recommendations, doctors and hospitals would form networks and receive lump sums in an effort to boost quality and limit the costs that come with expanding health coverage.
To achieve anticipated quality goals, such as reducing readmissions, hospital administrators must take steps to forge even closer relationships with their local primary care doctors, says Terry McGeeney, M.D., chief executive officer of TransforMED. The for-profit subsidiary of the American Academy of Family Physicians is a consultant on the Arizona project.
"For hospitals, this is a critical, critical time," McGeeney says. "And they could come out winners or losers depending upon how they react and how they position themselves."
But there's a critical catch. More comprehensive care will likely require more physicians, at a time that some hospitals are already scrambling to fill gaps.
Hospital recruiting for primary care doctors increased 23 percent from April 2008 to March 2009 compared with the prior 12 months, according to an analysis by Merritt Hawkins & Associates. The current primary care recruiting rush looks much like the early days of managed care, says Travis Singleton, vice president of marketing at the physician recruiting firm. "It's hot right now," he says.
Hospitals in rural regions may find it particularly difficult to fill primary care needs. Gary Mitchell, CEO of Newman Memorial Hospital in Shattuck, Okla., says that whenever possible, the preference is to recruit local talent. The not-for-profit hospital operates 27 beds nearly three hours from Oklahoma City. "We've been really fortunate that local young people have wanted to come back," he says.
But sometimes a more significant investment is required. Mitchell says it took about 18 months and working with two recruiting firms to find a physician who will start this fall at the primary care practice closely affiliated with the hospital.
The medical school pipeline is not encouraging. Just 2 percent of students plan to become general internists, according to survey results published in 2008 in the Journal of the American Medical Association. Disincentives included the hectic lifestyle and relatively low salary. A primary care physician's median salary is $186,000 compared with nearly $340,000 for subspecialists, according to the 2008 compensation data from the Medical Group Management Association. Federal reform could expand insurance coverage, which will only worsen primary care access, if the 2006 expansion in Massachusetts is any indication. By 2008, 48 percent of internal medicine physicians were no longer accepting new patients compared with 31 percent in 2006, Massachusetts Medical Society data shows.
A generational shift now taking place seems to favor the medical home model.
"I can tell you that medical students like it‚Äîthey get it," Kellerman says. "They are more computer savvy. They don't want to practice hamster medicine, fee for service, which just rewards volume." In the last year, the University of Kansas School of Medicine established one of the country's first medical home residency programs, based in Salina, Kan.
But Mark Hochstetler, M.D., remains doubtful that many hospital leaders understand more than the broad brushstrokes of this emerging philosophy. "I think [the medical home] is a really new concept that's discussed a great deal in the primary care world," says Hochstetler, vice president of clinical affairs for VHA Inc.'s central region. "I don't think it's made it very high up in the world of hospital CEOs and their planning."
Cracovaner says hospital leaders have a reason to pay attention: the bottom line. He describes another New Pueblo patient, a 74-year-old woman who went to Tucson Medical Center's emergency department one Sunday evening complaining of numbness in her arm and pain in her shoulder and chest. The emergency physician didn't identify any heart problems with a CT scan, but wanted to admit her overnight for monitoring.
Then the physician spoke with the on-call New Pueblo physician, who pulled up the woman's records from home. As it happened, she was already being assessed for a possible herniated disc in the spine, the probable cause of her numbness and pain; imaging tests were scheduled for the following week.
The woman was able to sleep between her own sheets that night‚ and, says Cracovaner, "we avoided a one-day [hospital] admission to rule out myocardial infarction because of numbness in the arm."
Charlotte Huff is a medical writer in Fort Worth, Texas.
This article first appeared in the September 2009 issue of H&HN magazine.