American College of Physicians: Internal Medicine — Doctors for Adults ®

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Friday, March 15, 2013

Primary care's future is now clear

As a physician who is involved in educating medical students, I am often asked for career advice. Medical students are by nature smart and ask very good questions. "Will I be able to pay of my student loans if I choose primary care?" "Will I have a balanced lifestyle if I decide to go into primary care?"

I try to be both encouraging and realistic. However, far too often I have found myself telling students that the future of medicine, primary care in particular is not clear.

That is no longer true.

The future of health care, and particularly primary care, is now very clear.

Several recent events along with trends that have been in place for the last few years have clarified the future of health care over the next few years. The passage of the Affordable Care Act (ACA), the decision of the Supreme Court to uphold the constitutionality of the individual mandate, the re-election of President Obama, and the fiscal cliff/sequester have all set into motion changes to our health care system that are likely irreversible and clarify the future of health care. Essentially, there are two paths:

1. Health Care in Large Integrated Systems. Health care costs are skyrocketing. The major fixes to the problem that are accepted on both sides of the aisle are an end to fee for service, bundled payments, and incentives for improving quality at lower costs. Accountable Care Organizations (ACOs) are one model being tested. However, even if the ACO turns out to be HMO 2.0, and ultimately fails; health care will be delivered in large integrated systems. This trend is already occurring with hospitals, academic medical centers and other health care systems gobbling up (through incorporation or outright purchase) smaller private practices. Because payment will be linked to performance, and performance must be measured and reported; the only way physicians will be able to make money is to not only have a large, robust electronic medical records, but also a staff that can help collect, process and report the important data. Even large private practices don't have the economies of scale to make this happen. Thus, private practice as we know it will cease to exist. This trend is already happening. According to a report by Accenture, over the past decade, the number of independent U.S. physicians has dropped dramatically, from 57% in 2000 to 39% in 2012.

The move to large, integrated is not necessarily a bad thing. Integrated systems allow for quality improvement. Large integrated systems like Mayo, Kaiser, and the VA have some of the best outcomes for health care in our country, usually at significantly lower costs. For physicians, being a salaried employee also has its benefits which include a guaranteed paycheck, reasonable hours, good benefits and no worries about running a practice. The current generation of medical students tends to value work life balance over the potential opportunities seen in private practice.

The down side of large integrated systems is less personalized attention. Rather than seeing your doctor when you are sick, a patient will likely wind up seeing a member of the doctor's care team. Other modalities such as group appointments might be employed.

2. Health Care Outside the System. Some doctors (likely the ones currently in practice) will refuse to join these large integrated groups. Some patients may decide that access to their own personal physician has some value. These patients are tired of waiting forever to get an appointment or a call back from their doctor, and want to see their doctor when they are sick, not a team member. They are even willing to pay beyond what their insurance premiums cover. These patients and providers will go outside the system. Growth of retainer (often called concierge) practices, cash-only practice, or direct primary care models demonstrate that going outside the system is already happening. This will likely be limited to primary care, as one might be able to pay cash for a doctor's appointment, but not a colonoscopy or cardiac catheterization.

Health care delivery is already occurring in large integrated systems as well as outside the system. The aforementioned changes will cause these trends to continue, squeezing out the current physicians who are still in an insurance-based private practice. These changes are certain. What is unclear is the proportion of health care that will be delivered in either model. Will large integrated systems become so effective, that only the very wealthy will deem it worthwhile to get their care outside the system? Or, will large integrated systems become so impersonal and inconvenient that only those with modest incomes will be forced to get their care in these systems? The truth is likely somewhere in between, i.e. 70/30, 50/50 or 30/70.

Regardless, medical students and residents who are trying to determine a career path should now have a clearer vision of the future health care. Patients who are currently receiving their care by a private practice physician who accepts their insurance should also realize that their current situation will likely not exist in the next few years.

Matthew Mintz, MD, is a Fellow of the American College of Physicians. He is board certified in internal medicine and has been practicing for more than a decade. He is also an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients. This post originally appeared at Dr. Mintz' Blog. Conflict-of-interest disclosures are available here.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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