In the 1970s, Marcus Welby, MD, became a prime-time television hit by showing audiences a primary care physician as a wise grandfather who spent unlimited time with patients, listening to their complaints, learning about their family issues and diagnosing their problems with the acumen of a William Osler. He used only his ears to hear the story, his well-honed physical exam skills and a few simple instruments in his black bag. He made house calls and never seemed to receive a complaint about his bills -- in fact we were not privy at all to how he was paid. He rarely needed specialists and most of his patients got better. Dr. Welby was much like the family physician who cared for my family in the 1950s. He was my role model for choosing medicine as a career. But the sub-specialization of medicine, the increasing burden of paperwork, the changing expectations of patients and other factors increased my physician's frustration to such an extent, he retired. I suspect that, except in some rural areas, the days of the solo physician practicing medicine like Marcus Welby are numbered and eventually will be extinct.
The Reality
It is all but impossible for doctors today to be Marcus Welby. The volume of patients has increased substantially and only will grow as the population ages and the uninsured get coverage and seek medical care. This fact, combined with a marked shortage of primary care physicians, a huge increase in paperwork and the need to get prior authorization from insurers before performing some testing, as well as decreasing reimbursement, means that doctors spend less time with an individual patient. This results in modern day practitioners relying too much on technology and referring to sub-specialists, in place of more listening or applying simple physical diagnostic skills (e.g. ordering an echocardiogram rather than putting a stethoscope on a patient's chest to diagnose the cause of a heart murmur). Of course, tapping expensive technology worsens the financial crisis that the U.S. faces in health care costs. That, in turn, leads to less money available to cover the cost of physicians spending more time with patients.
Since the Marcus Welby days, we also have seen an explosion in medical information, with a multitude of clinical trials and the emergence of evidence-based medicine leading to best practices. These are based on data derived from scientific studies in populations of patients, rather than on anecdotes. But no physician can keep up with all of the advances and the medical literature; they, therefore, must rely on tools to summarize and grade the information.
At the same time they're coping with an information revolution, physicians have sought to keep step with the burgeoning development of effective pharmaceuticals, devices and invasive and noninvasive therapies to treat many of the ills patients bring to doctors. To choose what's most beneficial for a particular patient requires both knowledge and often decision-support through computer programs. These and other factors have driven many medical school graduates away from primary care, let alone solo primary care.
The Solution
To improve our health care system, we must persuade more graduates to choose primary care medicine as a career. To meet the needs of all Americans, our nation has set a goal of one primary care physician for every 2,000 people. That means the country needs 17,722 more doctors, mostly to fill the void in underserved rural and inner city areas. To generate interest in primary care as a medical career and to encourage physicians to practice in underserved areas, the government recently announced a program to repay more than $9 million in medical school loans for students who will work in those areas for at least three years full-time, or six years part-time.
We like to think of medicine as a higher calling, and in many ways it is. But it's also a business and medical students, often with hundreds of thousands of dollars of school debt, specialize partly for money. Here's a stark contrast: primary care doctors earn an average of $186,582 a year, according to a recent study, while orthopedic surgeons earn $442,450 annually. If we're going to get the primary care physicians we need, we must begin to change financial incentives and reimburse these physicians better for what they know and the care they give.
Second, since we are unlikely to get the number of primary care physicians that our country needs through incentives, we must make these practitioners more efficient. The best way to do this is truly to make medicine a "team sport," with the primary physician serving as the captain of the team. One such approach is called the "medical home," where a student working part-time may take your blood pressure, pulse, temperature, height and weight; a nurse practitioner might take your history, examine you, diagnose the problem and treat you, or ask that the doctor see you if the problem is more complicated than a cold, sprain, or other common condition; a pharmacist, either attached to the office or at the pharmacy, would educate you about your new drug, your other meds, their interactions and side effects. Since only a third to half of patients with chronic conditions follow medication regimens completely, it's important for a pharmacist to be part of your medical team. If you're overdue for monitoring of a chronic condition, a medical assistant might nag you with a call. At many health maintenance organizations, trained medical assistants already review charts of patients with diseases like diabetes for routine follow-up; they call patients overdue for care.
This type of care, may appear fragmented, but actually can work well as long as there is close communication among all members of the team. This can be done through huddles where each patient is discussed by the team or via the electronic medical record. This proposal has the advantage that not only will patients have multiple sets of eyes and ears evaluating them but each of the professionals -- the nurses, pharmacists and primary physicians -- will be practicing to the top of their license, that is, we'll make maximum use of their skills and credentials.
A Composite, a Way Forward
Please be clear: Parts of this whole are in place in some physicians' offices, hospitals and academic medical centers. But I'm presenting a composite of how our health care system might be improved without pointing to any particular model as perfected. By looking at these scenarios, we can see how and why our collective efforts, small and large, can "bend the curve" of those burgeoning health care costs.
In the medical team scenario I've outlined so far, some laws may need changing so, for example, nurse practitioners or physician assistants can take on more responsibility -- to order tests or prescribe meds. Even if these steps don't occur, it still will be key for doctors, nurses and other highly trained caregivers to be freed from time-consuming tasks that can be done as well by those with less education.
None of this is new or fancy. Your care should be delivered by a group of qualified providers, all talking and working together seamlessly, providing you as much medical expertise as is appropriate at a given time.
With physicians and health care workers as a cohesive team, communication and coordination are enhanced. Today, one specialist often can be unaware of what another already has done. Worse, patients often are kept in the dark about their own care. A recent national survey of patient experiences found that 27 percent of those who had had a medical test in the past two years either failed to be told results or had to call their doctor many times to get them.
And when more than one doctor is involved, communication breaks down: 18 percent of patients said their specialist did not receive basic medical information from their primary care doctor; 24 percent of specialists, in turn, failed to give the primary care doc reports after a patient visit.
This uncoordinated system means that patients make more calls to get basic information and do more running around to repeat tests. Worse, we all pay for it. So imagine, instead, a true medical team where members talk together, work together and where everyone is invested in the same goal -- your health.
The U.S. military, as I have written, already has shown impressive, favorable outcomes with tightly coordinated care from complex teams working with badly wounded troops, many traveling great distances after battle-field injuries. So, we know that this can be done effectively.
Bundled Payments
The third factor we must address is aligning incentives. A team approach to care could provide a big fiscal push for the health care system to get more efficient. It is the basis for "bundled payments," pressing doctors, nurses, technicians and other providers to coordinate each patient's care.
It works this way: Instead of every provider getting paid separately, payments would be bundled into just one. That single sum would cover all the services needed for patients' episode of care. It means everyone in the team has the same incentive to keep you healthy, help you stay out of the hospital, undergo necessary and vital tests but avoid redundant or superfluous procedures.
When all your providers draw from one pot of money for your health care, it shifts everything: If doctors order repeats of already-done lab tests or if patients are readmitted to the hospital because discharge planners failed to prepare them for follow-up at-home care, all the medical providers see their pay cut. The bundled sum won't stretch to cover errors, redundancies or preventable costs.
With bundling, all your caregivers must work together to be as efficient as possible. Quality outcomes are tracked and they matter. That's because successful care means that patients don't return for more procedures or unnecessary hospitalizations.
Despite some start-up problems that no doubt will be part of such a major change, we're beginning. Medicare, under the Affordable Care Act, has provisions to make bundled payments the new model for the U.S. health insurance for Americans 65 and older. These Accountable Care Organizations are groups of providers who accept responsibility for cost and quality of patient care. Pilots are starting up to extend the payment model to private insurers, and, in some states, to Medicaid, the state-federal insurance program for the poor. Even among seniors who get their care from an array of physicians, research has shown that most Medicare recipients get treated by physicians connected to the same hospital; so a team made up of extended hospital staff is one promising possibility for cohesive care.
Researchers predict that bundling across the health care system could cut spending by more than 5 percent over 10 years. Much of that saving would come from reducing costs of avoidable complications.
Bundling turns the current system upside down: In the U.S. fee-for-service system, it's in physicians' interests to do more -- to run more tests, order more procedures and hospitalize patients. Physicians are human, sometimes giving in to temptation to placate a demanding patient by ordering unnecessary but harmless tests or medications. With bundled payments, the doctor knows that kind of appeasement will cost the team money without enhancing the patient's health.
Before we get too exuberant about bundling and the team model outlined here, understand that it is not, for now, the standard way that health care works. Putting in place an improved system such as this will require big changes by insurers and health care providers, not to mention lawmakers. There also are risks in the transition for providers. It could be disastrous for hospitals and medical centers if they slash patient stays and achieve greater efficiencies in procedures, only to find that insurers and policy-makers won't provide a fair, reasonable bundled payment to them.
But if we don't start tackling improvements I've described immediately, we'll be like the patient with the hacking cough who says, "Yes, I'll worry soon," only to find his untreated cancer has advanced past care.
Just as providing coverage for the nearly 50 million uninsured Americans is only one of multiple difficulties that must be solved, so, too, is a health care payment system that provides the wrong financial incentives. One by one, we must deal with each and every problem.
And so, as with so many other changes that are occurring in our society because of technology, the economy, and population growth, the practice of medicine in the future also will change. It may not be better or worse than what Dr. Welby delivered, but it will be different.