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Thursday, July 1, 2010

Primary Care--What are the Barriers?

Last week I was invited to join Hope Street Group 2.0 which is focused on economic opportunity for professionals and practitioners. It covers a variety of areas.  One of them is health care.

They posed this question:

Re: What do you think is the biggest barrier to innovation in primary care?

Aaron Doty and Sarah Steinhofer  enumerated the following: (Hope Street 2.0)

"It is possible to point to a  number of barriers that limit the spread of innovation in primary care  (see some examples below).

Examples  of barriers to innovation in primary care

  • Variations  across states in scope of practice regulations
  • Reimbursement  rules and lower earnings overall limit the attractiveness of primary  care specialties
  • Current training and practice in silos does not  support team-based work
  • Malpractice insurance rules discourage  part-time work, especially for retirees
  • Inadequate  access/utilization of health IT – telemedicine, electronic  communication, EHRs – restricts access in rural/underserved areas
  • Administrative  burden of care coordination
  • Design of new payment models is  complex
  • Payment models (such as pay-for-performance) may  incentivize shedding of sickest patients, or penalize those providers  with more chronic & complex patients
  • Lack of data analysis  capacity

Barriers  to the spread of particular models:
Retail clinics – concern  about fragmentation of care coordination, concern about loss of revenue  by other providers, lack of shared electronic record with PCPs
Accountable  Care Organizations – limited number of demonstration projects – new and  unproven payment mechanisms, lack of consistent specifications,  antitrust: perceived risk of collusion in the guise of care  coordination, loss of revenue from emergency presentations.
Patient  Centered Medical Homes – lack of clarity about essential features to  ensure quality outcomes, sustainability of savings unproven –  quality-funding link not built into the model, access to well-trained  care coordinators.""


I also suggest these additional issues:

In order to address the problem, one has to evaluate and anlyze what has caused the dramatic shift from general practice to specialty care, issues as great as reimbursement are only one part of the challenge..

Most analysts enumerate the disparity between specialty care and primary reimbursment, and  more administrative issues in primary care

I added these additional issues and challenges:

Several factors have been at work over the past fifty years.

1.The urbanization of America has caused a flight of young and old to the urban areas to seek out 'culture', diversity,access to health care and economic opportunity .  This has caused a well known  phenomenon of an economic shift from small towns to larger metropolitan areas.

2. Our challenges in primary care have followed this trend.

3..Some of these  problems involve the social and economic millieu in which highly educated professionals desire to work, live and recreate.

4. No one can challenge the fact that physicians are amongst the most highly educated members of society.  This is not just a technical skill, but by exposure to multicultural diversity, general fund of medical and social, political knowledge.  Physicians do want to serve, however are very reluctant to place their  families in areas that do not offer the best education or cultural opportunities.

4a.. Spouses generally drive where the physician choses to live in the long run. To do otherwise usually ends up in divorce.

5. Physician recruiting from rural and underserved areas is fraught with challenges, to attract bright inquisitve p eople who may be challenged by underachieving schools and other social and family barriers,both economic and other.  Many of these young potential physicians see education as a road out of their community, for many good reasons.It would be interesting to evaluate what percentage of physicians do return to their home to practice in their community in which they grew up.

6. Programs developed with economic incentives such as loan


forgiveness with contractual obligations provide some basis for supplying these areas, however what percentage of recipients remain when their time is up?

7..Although not as frequent in today's educational structure were those physicians who would practice general medicine for several years and then specialize.  The elimination of the  free standing internship with a possible break to work and perhaps look at a long term view of general practice has virtually destroyed this mechanism to produce general physicians

8. The well meaning elevation of family practice to a recognized specialty created the necessity to become board certified in family practice to be credentialled at hospitals and also insurance companies.Insurance companies are now 'driving this boat", Because specialty care pays so much better, one asks the question, why spend two to three years becoming eligible for a family practice credential, why not spend the same amount of time training to become 'specialty trained."

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