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Primary care medicine in Delaware
Primary care medicine in Delaware today is largely a cottage industry of small private practices. But things are starting to change. The hospitals have hired some primary care doctors and set up satellite offices throughout their service areas. The federally qualified health centers provide some primary care. In the region and nationally, we see physician practices merging to form large practices. Most practices have purchased computerized electronic medical records. We are all having trouble recruiting new primary care doctors.
The future of primary care in Delaware and in our region
They say that the primary care provider will be at the center of the medical delivery system of the future. The primary care physician is trained to evaluate a patient’s overall health status and co-morbidities – something a heavily specialized health care delivery system fails to do effectively. He serves as the patient’s principal guide through the health care system maze. Primary care is on the frontline, diagnosing new illnesses and managing chronic ones.
But what will this look like? How do we change the way physicians are organized in practice and how they are paid? How can we get the investments in infrastructure required to deliver comprehensive primary care so that the patient does not have to resort to expensive emergency rooms, hospitals and specialty procedures when they are not necessary?
Here are some changes we are seeing already or may see soon.
1. The primary care provider may not be your doctor. He may be a nurse practitioner, a physician assistant, a pharmacist or a health coach. He may be somebody from your health insurance company. Although most agree that your physician should be the manager of the medical team.
2. Doctor visits may not be in the office. The visit may be by phone or by secure web visits. Or it will be a group office visit for such things as routine diabetes management or for a routine blood pressure check-up.
3. Access to primary care will be 24 hours a day and 7 days a week. So when you are real sick at 10 PM on a Friday night, you talk to a provider by phone or by the web who has access to your electronic medical records and your doctor’s latest notes. He can either solve your problem or direct you to the best urgent care or emergency care facility for the problem you are having.
4. Depending on whether federal funding is available, we may see continued expansion of the federally qualified health centers, such as Westside here in Dover. The federal centers offer the ideal of a centralized point of delivery for, not only medical care, but also dental, psychiatric, psychological, social support services, and case management. Because of these additional services, their overhead costs per physician are many times greater than any private practice could possibly afford. This may be an example of the government taking the lead in redefining primary care, but it is being done with large government subsidies. No private practice could afford to provide this full array of services. Unfortunately, they don’t seem to be able to recruit and retain physicians any better than the private practices.
5. The trend nationally is toward large, merged physician groups. An example nearby is PMSI, a physician-owned multispecialty group practice with about 17 offices in Berks, Chester and Montgomery Counties in Southeastern Pennsylvania. Another example in neighboring Virginia is Riverside Health System which has over 300 physicians in the Hampton Roads area. A third example is Primary Care Health Partners of Vermont which is a large primary care medical group with offices throughout Vermont and upstate New York.
Electronic Medical Records (EMR)
Doctors are buying EMR systems for their offices. We are doing this because we want to and we know it is useful, but also because we are getting sizeable incentive bonuses from the federal government when we achieve certain benchmarks in the implementation of EMR. Plus we know our pay will be cut in the near future if we don’t have an EMR. EMR allows us to email prescriptions, track our performance, and identify deficiencies in your health care. It also allows the insurers, both the government and the private insurers, to track our performance and collect large amounts of data on the doctors and the patients. EMR is supposed to reduce errors, improve documentation, and reduce wasteful duplication of services such as lab work and x-rays. Plus, it gives you online access to your medical records.
Despite the incentive bonuses, EMR systems are very expensive to buy and maintain, especially for a small practice. The high cost of EMR is one reason why new primary care doctors do not want to go into private practice. Many small practices are already feeling the panic of a failed financial investment in EMR. Also, the EMR systems that are being sold today do not communicate with each other which becomes a barrier when doctors try to coordinate your care with other providers.
Private practice doctors or hospital employees
Can primary care medicine best be delivered by physician groups independent of the hospital or should primary care physicians/providers be employed by the hospital? Does a business association between doctor and hospital, especially if it is a for-profit hospital, create a conflict of interest? As employees of the hospital, do primary care physicians have an equal voice in the management of health care delivery or would there be financial incentives and constraints that prevent them from meeting their professional commitment to patients.
The attraction of the hospital is it has the financial resources to invest in and maintain an EMR system and to hire support staff such as nurse practitioners and health coaches. But if the doctors merge into very large private practices, they may be able to make these investments on their own. And I think that the doctors can better direct primary care if they are outside of the influence of the hospital’s financial concerns and the historic dominance of the specialists such as the cardiologists and the surgeons.
Our Challenge
The only way primary care providers will achieve the respect and attract the investments we need is to organize ourselves to deliver the care that matters to patients, to deliver that care at lower cost, and to provide value to employers and insurers. We must become creative at solving the problems of high quality and efficient care.
Here are some questions that I ask you to think about:
1. What are your experiences with primary care medicine?
2. Would you be willing to attend and pay for a “group visit” with say five other patients and a nurse practitioner to discuss your hypertension in place of a regular one-on-one visit with the doctor?
3. Would you be willing to pay to talk to your doctor on the phone for a “phone visit” to take the place of a regular office visit?
4. Would you be willing to pay to communicate with your doctor through a secure web site for a “web visit” to take the place of a regular office visit?
Source: delaware.newszap.com
