Editor’s note: Doximity Advisory Board member Peter Alperin, MD, is a
board certified internist currently practicing at the San Francisco VA
Medical Center. He previously led informatics at Brown and Toland Medical
Group, and has also worked at Epocrates.
By 2015, according to the American Association of Medical Colleges, the
U.S. health care system will be short approximately 30,000 primary care
doctors. Yet, everything we read says that primary care physicians are the
linchpins of the new (really rediscovered) coordinated care models being talked
about by health care policy cognoscenti. What gives?
Since the mid-1990s the number of medical students pursuing a career in primary
care has been on a steady, sinking decline, a trend likely fueled by the
realization that the traditional Marcus Welby-style primary care practice
doesn’t pay the bills. Throw in hefty malpractice insurance fees and the
average overhead often hits 60 percent. There’s also the question of boredom
and prestige. In medical school, future physicians are exposed to a breadth of
compelling cases; in primary care, they’re asked to refer the majority of those
away. And if you are interested in interesting procedures, medicine has clearly
evolved to favor specialists.
And about the pay disparity–it is stark. Most residents looking at a career in
primary care can expect to earn about $29.58 an hour. This, compared to $74.45
per hour as a specialist (by retirement, specialists will have earned about
$3.5 million more). The main reason is that the options for reimbursement in
traditional primary care practice are limited. Much of what PCPs do is
cognitive work–checkups, simple diagnoses, referrals–and that just doesn’t pay
as well. As for the reimbursable procedures that PCPs are able to perform,
they’re few, but of a wide variety; getting such a breadth of claims paid is
often a job in itself.
So here’s something surprising: In 2010 and 2011 the number of primary care
residency matches increased by ten percent per year. For 2012, those gains were
at least maintained, when the National Resident Matching Program last week
reported a one percent rise in such matches.
Two factors may be accounting for this welcome change of tide. First, there’s
accountable care. Within this premise of having one group–an accountable health
care provider network–hold all the risk and be paid on quality measures and
outcomes, primary care physicians can be even more effective quarterbacks,
coordinating care for a team of specialists. Even more targeted are
patient-centered medical homes, currently being tested within a number of ACOs.
Here, PCPs are available for consultation, and for mapping out care, which is
then put into action by a staff of physician extenders.
The second development is the Direct Care (also referred to as
Concierge) model, such as One Medical and MD VIP, which have
become a viable economic model for PCPs who want to maintain a
traditional primary care practice. While the exact structure of direct
care practices can vary widely–whether insurance is accepted, or scope
and kinds services a patient can expect, for example–they all rest on
the idea that patients pay annual or retainer fees to their primary care
physicians.
If these trends continue, the primary care doctors of the future will
have to be experts at communication, system change and quality
improvement. They will need to focus less on traditional hospital tasks
like putting in a central line (already largely atrophied skills given
the widespread use of hospitalists), and more on skills like promoting
teamwork, being able to build consensus and persuasively articulating
ideas. Many will become experts in healthcare IT. What’s interesting is
that already we’re seeing more young doctors and residents who possess
these skills. We find them every day on Doximity, coordinating
referrals and patient care–using a state of the art platform for
communication. It is these physicians who will lead the charge of
translating medicine into the digital age.