Blog | Thursday, January 27, 2011

Why 'the end of internal medicine as we know it' might be a good thing


A recent post on the Health Affairs blog proclaimed "The End of Internal Medicine As We Know It." What the post is really asking about is the future of primary care in the world of health care reform and the creation of accountable care organizations (ACOs). While doctors should be naturally concerned about change, I don't completely agree with this article.

ACOs are organizations that are integrated and accountable for the health and well-being of a patient and also have joint responsibilities on how to thoughtfully use a patient's or employer's health insurance premium, something that is sorely lacking in the current health care structure. These were recently created and defined in the health care reform bill.

Yet the author seems to suggest that this is a step backwards: "Modern industry abandoned command-and-control style vertical integration decades ago in favor of flatter, more nimble institutions."

Not true. Successful organizations are ones that are tightly integrated, like Apple, FedEx, Wal-Mart and Disney.

The author talks briefly about how Europe in general does better than the U.S. in terms of outcomes and costs and has a decentralized system. All true. However, contrasting Europe and America isn't relevant. After all, who isn't still using the metric system? Therefore solutions found outside the U.S. probably aren't applicable due to a variety of reasons. Americans like to do things our way.

What I do agree on is that doctors need to be part of the solution and ensure that the disasters of decades ago, like labeling primary care doctors (internists and family physicians) as gatekeepers rather than what we really do, never happen.

I love primary care. I've worked at Kaiser Permanente in Northern California since 2000. I have long-term relationships with my patients. They see me when they are well. They see me when they are sick. They have me as their personal doctor. There are no mid-level practitioners (nurse practitioners or physician assistants) in my unit. I'm supported by information technology, staff to help those members with chronic conditions, and collegial specialist colleagues.

In other words, I'm doing what almost every primary care doctor wants: long-term meaningful relationships with patients, no hassles from insurance companies, the ability to retrieve information quickly and easily, and support for specialty colleagues who are equally focused on the well-being of the patient and who respect me as much as I respect them.

Perhaps the death of primary care as it currently exists with crushing administrative hassles, loss of work-life balance, increasingly short office visits, and paper charts which often has inadequate information or are unavailable isn't a bad idea after all.

Now I understand that Kaiser Permanente looks very much like an ACO. I also know it isn't for everyone--doctors or patients--and isn't the only solution for the country. Certainly doctors should be wary if every self-proclaimed ACO is really that or more of the same in the fee-for-service world but simply disguised in the ACO term.

However, for primary care doctors looking for a better way to care for patients, it is a very viable and sustainable solution. If the future for primary care looks like what I see and do every day, then I believe the future will be bright.

Primary care doctors looking for a better future in primary care and willing to move to Northern California should do more research here.

In the end, patients may benefit from ACOs. I know my patients do.

This post by Davis Lu, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.