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Thursday Jul 23, 2015

FPs Can Help Curb Spending on Services Patients Don't Need

Recently, I was treating a woman in her 70s who was due for a repeat upper endoscopy due to her chronic Barrett’s esophagus.

“Can we help you schedule it at the local hospital with Dr. X?” I asked.

“No, thanks," she said. "I always get this done at the Costco hospital. It’s just more convenient for me.”

“Costco hospital?” I asked, feeling somewhat confused.

“Yeah, the hospital with the Costco in the parking lot,” she replied, as if what she was referring to should be as clear as day.

There is a good, large hospital nearby that does, indeed, have a Costco in its parking lot. Just as Costco offers nearly everything a consumer might want in a retail store, that hospital offers nearly any diagnostic procedure or treatment imaginable.

The problem for many of us when shopping at Costco is that we invariably spend more money than we intended for things that we don’t necessarily need, thus leading to a lot of waste. Unfortunately, the same problem -- spending too much on things we don't need -- persists in our health care system.

I have never actually worked in my patient's hospital of choice, but a friend of mine was admitted there a couple of weeks ago. When I went to visit her, I could not find the front door because of the sheer size of the hospital. I found the emergency department, outpatient clinics, surgical entrance, etc., but could not figure out how to get to the inpatient wards. I eventually got to her room by trudging through the ED and receiving directions from multiple people.

I can’t imagine how people find their way in such a massive facility.

And yet that has become the norm in health care. Large hospital system conglomerates often disrupt small, independent practices, buying out physicians, even in rural areas. From a global standpoint, this can either be good (consolidating services in one location with increased ease of coordination) or really bad (raising costs through large influence on third-party payer rates without the benefits of consolidation). These large systems often dance around the bad to avoid antitrust litigation (although they do have better protection if they qualify as an accountable care organization) tightening their grip on health care.

Hospital systems also tend to dramatically fuel subspecialty care to maximize revenue and, thus, tend to view primary care physicians as little more than a source of referrals to the better-reimbursed service lines.

So what controls the impact these "integrated" systems have on patients and physicians? Payers certainly have a lot to do with this; nowhere is this more evident than by looking at how CMS chooses to pay physicians. Recent efforts to move from fee-for-service payment to value-based models will undoubtedly lead to a shift from the subspecialty-centric model to primary care physicians becoming the foundation of value-based medicine. Payers in general are starting to see family medicine as the solution, as evidenced by a recent survey showing that family physician income has increased by a percentage higher than that for the majority of other specialties in the past year. But payment itself does not ensure an efficacious system for patients.

Local efforts by family physician leaders can make the biggest difference in ensuring that our hospital systems do not get too big for their britches. Filling leadership roles at all levels of the organization, including participating on hospital boards -- whether employed by the hospital system or not -- can go a long way to driving local policy. Participating in local politics also provides valuable input locally and regionally. Even more important, these venues provide a prominent voice to ensure that patients do not receive unneeded care in a nonpatient-centered environment.  

The Health is Primary campaign is a more national expression of the same desire. Family medicine is spreading awareness of the role and importance of primary care to overcome these exact issues. The health of the patient needs to be directed by the patient in conjunction with his or her primary care physician to make the best choices. Although many hospital systems support this framework, way too many don’t.

A Costco-like health system, full of waste and overutilization of health care services, is bad for everyone but administrators and subspecialty physicians. That means we as family physicians are the ones most capable of overcoming this all-too-common trap. With our help and guidance, patients and physicians will indeed be able to find the front door of our system and make that system work for all of us.

Kyle Jones, M.D., is an assistant professor at the University of Utah Family Medicine Residency Program in Salt Lake City. He is the director of primary care at the Neurobehavior HOME Program, a patient-centered medical home for those with developmental disabilities. You can follow him on Twitter @kbjones11.


"Recent efforts to move from fee-for-service payment to value-based models will undoubtedly lead to a shift from the subspecialty-centric model to primary care physicians becoming the foundation of value-based medicine." Really? Maybe if you substitute "NPs and PAs" for "primary care physicians" in that statement it will be true.

Posted by keith dinklage on July 24, 2015 at 07:11 AM CDT #

Keith, I thought exactly the same thing when I read that sentence. Between subspecialists and midlevel providers, family physicians are going to be squeezed out of existence.

Posted by William Stueve on July 25, 2015 at 11:57 AM CDT #

I disagree with the above two comments entirely. Patients are not going to stand for the disappearance of family physicians. Many people do not want an NP to be their PCP. The care from APCs is not the same as that delivered by physicians and patients know it.

Posted by Simon Whitaker on July 26, 2015 at 07:48 PM CDT #

Now that we've entered the era of patient-centered care, what real patients actually want is not considered to be of any importance. Insubordination will not be tolerated.

Posted by R Stuart on July 27, 2015 at 01:00 PM CDT #

If you look at the career paths of the graduating classes of NPs and PAs, it is not primary care they go into. For all the same reasons primary care docs are struggling. So the argument that we are being replaced does not fit the facts. What primary care really needs is for our income to double, not go up 1-3%, The penalties out there ( MU, PQRI, sequestration, etc.) exceed that by a long shot. We need help with too much micromanagement and need the tools to do population based health. It is a very new complex world we are heading into. Primary care is not for the meek and should be respected for that, and given income to enable us to flourish with the tools we will need.. We are not being replaced, We are dying for the lack of needed support at the ground level.

Posted by Scott Macleod, MD on July 30, 2015 at 11:54 AM CDT #

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