Most would now agree that we are approaching a fundamental disconnect in two health delivery trend lines. They are: 1) the growing need and demand for services fueled by our aging population and 2) a growing shortage of primary care health professionals.
Where opinions diverge is how to address this growing problem in a manner that will simultaneously increase access and quality while decreasing inefficiency and cost. The majority of leaders in Medicine believe the solution is to produce more doctors – especially primary care physicians. The AAMC , AOA , and AMA have all lent support to the expansion of allopathic and osteopathic medical schools. But even if we were to accept the long lead time required to put practitioners online, voices inside of Medicine itself are beginning to raise uncomfortable questions.
What kind of care are we trying to provide? Who should be delivering that care? Where should that care be delivered? How much training and skill are required to deliver baseline care, behavioral modification, preventive assessment and treatment, and strategic health planning and coaching?
Let’s take a look at just one example of Medicine’s current soul searching – this one an article in the September 6, 2012 issue of the New England Journal of Medicine written by leaders from the Center for Health Equity Research and Promotion at the University of Pennsylvania and Wharton. Titled “What Business Are We In? The Emergence of Health As The Business of Health Care.” , the article charts a new direction – one perhaps that does not well serve the proponents for continued physician workforce expansion. A few excerpts:
“….whereas doctors and hospitals focus on producing health care, what people really want is health. Health care is just a means to that end and an increasingly expensive one. If we could get better health some other way… then maybe we wouldn’t have to rely so much on health care.”
“One signal is that while much of recent U.S. medical practice proceeds as if health and disease were entirely biologic, our understanding of health’s social determinants has become deeper and more convincing. An enormous body of literature supports the view that differences in health are determined as much by the social circumstances that underlie them as by the biologic processes that mediate them….the evidence does suggest that health care as conventionally delivered explains only a small amount perhaps 10% of premature deaths as compared with other factors, including social context, environmental influences, and personal behavior.”
“If health care is only a small part of what determines health, perhaps organizations in the business of delivering health need to expand their offerings.”
“…in the past there was some implicit presumption that doctors and hospitals provide health care of consistently high quality, that presumption is now being challenged, and we’re getting much better at identifying, measuring, reporting, and targeting health outcomes.”
“Today’s standard approach of reimbursing for office visits and hospitalizations is likely to be displaced once better measures of outcomes can provide a substitute that’s more relevant to our key goals. If we can measure success, why pay for process? “
“In the future, successful doctors, hospitals, and health systems will shift their activities from delivering health services within their walls toward a broader range of approaches that deliver health.”
But as Medicine struggles for enlightenment and polite methods to evolve gracefully without upsetting the status quo, less polite competitors from the ranks of both health providers and health consumers see the current high cost and low performance environment as begging for new models of care. When they do their competitive analysis, what do they see?
1. Primary Care physician recruitment is inadequate to meet the demand.
2. Nearly 40% of patients already see a specialist for primary care.
3. Coordination of care and referral to specialty care and hospital services can be managed by non-physician providers.
4. Consumers increasingly will co-manage their own records and continuity of care.
5. Less expensive providers are better trained for chronic disease management, health coaching, health planning, and health prevention.
6. Less expensive providers are more willing and able to put in the time and effort to accomplish #5.
7. Primary care access is often inconvenient, inefficient and expensive compared to other emerging service providers.
8. Primary care physicians are over-trained for 90% of the clinical challenges they encounter in day to day ambulatory practice.
9. Primary care empathy levels decline during training; satisfaction levels are marginal, and burnout is high.
10. Health workforce mobility, mobile diagnostics and information technology, if aligned with consumer choice and consumer empowerment, could bypass the doctor’s office and move care delivery into the home.