The year is 2025. The last patient-centered medical home in the country closed last week. This is final result of a major policy initiative that ignored the fact that physicians didn’t go to school to spend 50 percent of their time coding, charting, and training, and the other 50 percent caring for a panel of 2,500 patients.
It appears that not only have thousands of medical groups been negatively affected, but the health systems who acquired or employed them over the past few years have suffered as well. In fact, the number of hospitals in the United States over the last 10 years has shrunk from more than 5,000 to just under 2,500. More than a decade ago these health systems decided primary care was the place to be, so they acquired these practices one after another, the same way they did in the 1990s. During the first go around the strategy failed because patients wanted nothing to do with managed care. This time it failed because doctors wanted nothing to do with accountable care.
Oh, there were predictions of a primary care shortage. But those predictions never included a complete disruption in who employed the doctors.
It began with a few private urgent care centers who realized family practice doctors were probably sick of too many administrative tasks and might like a change of pace. They promoted higher salaries, some suturing and casting to break up their day, and a whole lot less of the stuff they didn’t sign up for when they chose medical school.
Then some new primary care models entered the scene, most notably concierge medicine. Then concierge medicine morphed into direct primary care (DPC), where for $60 a month a person could have access to a doctor the same way they have access to a health club. Alongside DPC is a high-deductible catastrophic plan at $300 a month. Employers jumped at what became known as “DPC and a Wrap,” a new kind of health benefit plan that took insurers out of the equation, along with all of their policies, procedures and administrative costs. The most active employers opting for this new option were those with group sizes of 50-250, self-insured and wanting desperately to gain control of their healthcare destiny.
Under the DPC model, the family doctors have panel sizes of between 800 and 1,000 patients. They have more time with their patients, which resultsin far fewer referrals to specialists and subspecialists. Give a patient enough time and they will tell you what’s wrong with them. Best of all, these family docs can see their patients in person, via a high-definition web cam or even a simple email. And there’s no need to file a claim form because it’s covered by one simple monthly fee.
But it isn’t health systems or large traditional medical groups that these doctors are working for. It’s private-equity-backed corporations, who began as startups seeking to disrupt inefficiency, inflexibility and poor quality. Ten years ago more than half of primary care doctors were employed by these health systems. Now it’s less than 10 percent.
It took a while, but now medical schools are finding more and more of their graduates are wanting to go into primary care again. Predictions of a shortage of 100,000 doctors is a distant memory. And not only are healthcare costs no longer rising as fast, they are actually going down, the result of fewer unnecessary referrals, a tighter rein on prescription drug spending and a lot more competition for complex cases.