She sent me a link to her newest piece for the California Healthcare Foundation ( @chcfnews ), linked to above, which I of course read from cover to cover. And the result was that….I was made to think.
In the piece, Jane goes over the sobering data about the future of primary care, as well as a series of innovations underway and facilitators/hurdles that could improve the situation.
The first thing Jane made me find out about is the state of primary care choices by medical students. To be honest, I haven’t researched this directly, by myself (until now, can you believe it), so I went to find out for myself. If you base “going into primary care” on “match into residency,” there is better news in 2011 than in previous years, see the tables I clipped out of the latest NRMP report, as well as this press release, which indicates that more students are choosing family medicine, up 11% this year. If you look at the companion table regarding osteopathic residents (DO’s), you can see that they have a much stronger orientation toward pediatrics and family medicine relative to their allopathic peers (that’s us, the MD’s, the ones descended from the barbers).
After I got that clear in my head (thanks, Jane!), I reviewed the key innovations that Jane investigated. To my eyes, there’s an interesting trend best summarized with this quote:
“more” (family medicine, bigger teams, small panels) equals “less” (costs)
This means that several of the innovations are about physicians having less rather than more patients to manage, and more assistance to manage them, in the interest of reduced downstream work and costs. It is important to see this development laid out here, because some future models of primary care propose that physicians have more “weak ties” to patients through larger than smaller panels. (A note on costs – when I think “costs” I always think “costs to the patient and family” which includes time lost, unnecessary suffering, etc, as opposed to just costs of health care – patient centered perspective!)
Also, there seems to be a healthy amount of alternative modes of access cropping up using technology, with, as Jane mentions, some risk of fragmentation, because all of these new models (from retail clinics to telehealth) may not connect back to THE relationship a person has with their personal physician. Take a look and see what conclusions you draw about the overall impact on well being for patients – on the one hand raising awareness of healthy activities in life outside of the medical office, on the other hand creating more potentially confusing choices.
One add from me: Specialty care
One thing that was not addressed in the paper is a discussion of specialty care. I say this as I openly reveal my bias as a family physician within a multi specialty medical group who has experienced the benefits of excellent cross-specialty collaboration :).
As I’ve discussed on this blog, leading edge health systems are incorporating specialists into primary care more, with great benefit.
As Jane indicates in the piece, 50% of ambulatory care visits were made to primary care physicians in office-based practices in 2007. That means that 50 % of visits were not made there. Why not leverage this very important other 50% to support primary care, too? If you take a look at this post I wrote in June (“IInnovating in communication in health care, from “outcome measures” to “saving lives”) and the video contained in it, you’ll see that specialists are extremely valuable in a health system engaged in saving lives. Because of excellent health information technology systems and good leadership, this transformation is happening, which is really good news.
Maybe this is a good topic for the next white paper? In the meantime, please enjoy the work of my favorite health economist.