Primary Care Transformation and the Coming Changes in Delivery


After interviewing 150 leaders in healthcare for his book, Stephen Schimpff found some common themes in the changes we can expect to see in primary care transformation, and the drivers of those changes. Here’s what he found.

Disruptive and transformational change is coming in healthcare delivery. And it’s not just because of healthcare reform but because of an aging population, obesity, physician shortage, and consumerism.

I interviewed in depth about 150 medical leaders from across the United States to collect information and distill it down to a few key observations for my book. Here is some of what we can expect to occur in the coming years.

First, many more patients will need substantial levels of medical care – not just any patients but two specific and rapidly growing groups. Americans are aging. Old parts wear out, creating impairments in vision, hearing, mobility, bone strength, dentition, and cognition. Add to that our many adverse lifestyles such as overeating non-nutritious food, being sedentary, being chronically stressed and, for 20% of Americans, smoking, all of which lead to chronic illnesses. So we can expect to see more chronic disease.

The especially sad part is that many of these individuals will be moderately young, and their disease states will be a result not of their age, but of their weight. One-third of Americans is overweight and another third is obese. And now that the AMA has specifically listed obesity as a disease rather than just a risk factor for disease, the number of Americans with chronic illnesses jumps dramatically.

Of course, care can increasingly take place outside the hospital. But with more patients in need of care for serious chronic illnesses, more will need high-tech hospital beds, ICUs, ORs, and interventional radiology. In recent decades we’ve heard that there are too many hospitals and too many beds, but now the opposite is true.

But building or renovating hospitals costs a lot of money. So does technology, such as electronic medical records, CT and MRI scanners, and OR and radiology equipment. To secure the funding, hospitals will need to access the capital markets. Smaller hospitals that can’t easily enter the credit markets will have to merge with larger systems to access capital. More and more smaller hospitals will merge with larger systems. Indeed, few stand alone community hospitals will remain in the coming years – a quite disruptive change.

Primary care transformation through interprofessional teams & direct primary care

Another change of which we can be sure is that the current primary care physician shortage will accelerate since few enter primary care after medical school. NPs and PAs will compensate for this in part. Notwithstanding the debate on the issue, NPs can be very effective and allow MDs to do what they do best. Together they can make an excellent team.

Without teams, primary care doctors practice in an unsustainable business model. Reimbursements from insurers have stayed level for years, but office and other expenses have gone up each year. So in order to keep their personal income at least flat, they need to make it up by shortening time spent with patients in order to see more of them. This also means no longer visiting patients in the hospital or the ER. Instead they wait for the hospitalist or ER doctor to call with reports.

But seeing this many patients means they cannot give comprehensive preventive care and cannot adequately coordinate the care of their patients with chronic illnesses – two of the key things a primary care clinician should be doing for optimum care. It is the absence of time – time to listen, time to prevent, time to coordinate, and time to think – that is critical.

Primary care physicians are taking at least two approaches to counter this dilemma. One is to no longer accept insurance and rather expect patients to pay a reasonable fee at each visit, which cuts out a lot of haggling with the insurer and means they can spend more time with the patient. Importantly, it recreates a normal, typical professional-client relationship since the patient, not the insurer, is paying the doctor directly. But this is certainly a disruptive change to not accept insurance.

Another approach gaining rapid popularity is retainer-based practices, sometimes called concierge or boutique practices. The basic concept is to limit one’s practice to 500 patients rather than the typical 2,000 or more, which means more time per patient. So in return for a fixed fee of about $1,500-2,000 per year, the doctor agrees to be available by cell phone and email 24/7 and will see you in the office within 24 hours of a call. You get as much time as needed for your problem. The doctor will also visit you in the hospital, the ER, or the nursing home – maybe even do a house call.

The result is better quality. But there is more. Since the doctor now has the time, the patient now gets much more preventive care. And if a patient has a chronic illness, the doctor will take the very real time needed to coordinate that care. This will mean much better care from the specialists and will avoid unnecessary tests, scans and procedures. Better care at less expense. One more very disruptive and, I would say, transformational change occurring in medical care delivery.

Stephen Schimpff, M.D.

Stephen C. Schimpff is a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center, and senior advisor to Sage Growth Partners. He is former CEO of University of Maryland Medical Center and the author of The Future of Medicine – Megatrends in Health Care and The Future of Health Care Delivery - Why It Must Change and How It Will Affect You.

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