HARVARD MEDICAL SCHOOL PRIMARY CARE REVIEW

Where does the individual physician fit in the new medicine?

March 25th, 2019

 I am realizing that practice management in the new medicine is derived more from “group-think” than individual initiative. While this might work well for large medical organizations, where does it leave the imaginative individual physician trying to create improved medical care delivery systems? Of course, I am speaking from personal experience and raising this issue as a challenge to our medical system to be more open and inclusive and take advantage of all available bright ideas for improvement.

When I completed my Family Medicine residency and Psychosomatic Medicine fellowship in 1976, I entered solo family medicine practice in Massachusetts because that was the predominant mode of practice in our region. It required me to create a medical practice from nothing and, on top of the rudimentary preparation I had received in residency about practice management, to learn as I went along. Financial management was much simpler then, mostly involving direct patient or insurance billing techniques and related accounting, most of which I managed with minimal staff. I learned patient scheduling, flow, and public relations by logical reasoning, then trial and error. I had to develop entrepreneurial skills and my goals, accomplishments, and failures were my own.

I also graduated during a time when the medical tradition of “giving back” to the profession was still strong. So I made time to teach medical students and residents in my solo practice, get involved in the Massachusetts and American Academies of Family Physicians to create programs to stimulate student interest in Family Medicine and support starting local medical school departments and residencies in Family Medicine in Boston. I also introduced Family Medicine to our local hospital and we created a separate new department and a residency there as well.

 

Then, in the mid-1980’s, medicine began to change. In response to unsustainable rising medical costs, the concept of managed care swept through eastern Massachusetts. In return for contracts fixing reimbursement at a lower level, it promised to deliver increased patient volume. This established two very fundamental changes for medical providers: the need to negotiate and contract with insurers in a much more meaningful way, and the need to see more patients to maintain the same revenue stream. Primary care providers were also given the enhanced role of needing to approve specialty care and even many procedures before they would be reimbursed (requiring significant time and staff overhead commitment, but providing no extra reimbursement). Managed care also marked the beginning of a really significant primary care/ specialty care divide.

As a solo practitioner I had to adapt by being sure to be involved in physician and physician-hospital organizations that sprang up to deal with the challenges involved with managed care or risk losing further control of practice demands and reimbursement. It soon became apparent that the new realities were: join the new team or be left behind, and, grow or die. 

Time commitments changed significantly too. Now I had to see more patients in the same time to maintain income, while also spending much more time on planning meetings about managed care. The introduction of the EMR also turned out to create a whole new time-consuming area to manage. With continuing medical education and family life still high priorities, I had to make the tough decision to let go of my many volunteer “giving back” pursuits. 

 

Based on these major new practice realities, two other solo family physicians and I decided to bring our practices together in 1997 to form a new, independent, single-specialty Family Medicine group that eventually grew to 10 physicians and 17 nurse practitioners in 3 locations, covering 40,000 lives in our area. We formed our own playbook for team-based care delivery, shared overhead and individual physician reimbursement processes, quality oversight and eventually achieved level 3 Patient-Centered Medical Home designation. We stayed intimately involved in the Physician-Hospital Organization and had clout as a critically important referral source for our hospital and specialists.

But the often overwhelming time commitments for our physicians did not change. Along with rapidly increasing numbers of patient visits, we still needed to commit huge amounts of time to practice management and most discussions between our physician members now centered around financial issues rather than medical ones. Over time, as more and more patient management demands were heaped on primary care physicians by the EMR and evolving medical system (that also required increased administrative staff support), we started to find our net incomes waning significantly. Static levels of fee-for-service reimbursement were simply not keeping up with rising costs. Facing the need to significantly increase clinical support staff and introduce costly new systems for population health management that we simply could not afford, our previously highly successful practice was forced to seek a partner to make the necessary capital infusion.

 

So, as I faced retirement from clinical practice, we sold our practice to a large local health system in the hope that we could preserve physician income while infusing money from that system to tool the practice properly to deliver primary care in the new healthcare paradigm. The hope was also that the new organization might bring helpful new ideas and processes, which has not really happened. Sadly, from our experience with low reimbursement and high overhead demands, it is hard to see how private practice can survive in the current and future healthcare world, but that is one of the challenges that I think is important as we design new healthcare delivery systems.

 

I started in medicine with great optimism and altruism about helping others. That has not really changed. The principles of putting patients’ needs first and providing care in a way that I would like it delivered for my own family are still paramount. But I feel that my winding course in primary care practice has seasoned me by experience and taught me about financial realities and finding different ways to get things done. I feel that the challenge of determining ways to achieve the “quadruple aim” is so great and so critical to our nation’s well-being right now that I really want to continue to contribute to that cause by applying what I have learned firsthand to creating successful healthcare delivery systems for the future. I feel like my experience and insights gained over time and lots of trial and effort can offer important value to how and how not to structure an effective new system for our time now,

 

What is frustrating for me is that it has been very difficult as an individual to find an appropriate and effective forum for my voice. Just like solo medical practice, it seems to me that healthcare analysis and planning have become almost solely the province of large systems and consulting firms. There are lots of good ideas being discussed, many of which reflect systems and solutions that we already arrived at in our own practice over the years, but are only now gaining traction as the best ways to transform healthcare. Team healthcare delivery with shared responsibilities and liberal use of nurse practitioners are prime examples (please see my blog posts about this at www.sbarrettmd-phs.com).

 

I am retired from clinical practice and “out of the system” right now, but I worry that many individual physicians currently toiling within the system probably also feel left out and disenfranchised from the decisions that affect their daily work lives and erode their ability to achieve their patient care goals. The high rates of physician burnout (and its known basis in feelings of disenfranchisement) attest that this is so. The rise of concierge medicine and direct primary care models also reflects this phenomenon.

 

So are we missing a potentially very valuable asset in current healthcare planning,broad-based physician input? I am certain that there are others such as myself who retain the passion to promulgate meaningful and effective change for our broken healthcare system. Just like consumerism in medicine demands that we listen to our patients’ voices to tell us what does and doesn’t work, shouldn’t we also seriously explore the different experiences of our many healthcare providers to determine what will and won’t really work for ground-level healthcare delivery? That would best be done by contributions from all segments involved in that system, considering different generations, practice structures, practice settings, and patient populations served. While I am a very big believer in the power of brainstorming, the value of the output of “group-think” will only be as good as the representational diversity of the group doing the deliberating.

 

Let’s not limit the potential for future healthcare delivery by falling into repetitive and predictable patterns based solely on early successes and established practices. Let’s keep assessing and improving our systems. Let’s develop broad-based forums to shared and challenge new ideas in the interest of providing local healthcare systems with the best solutions for their own top issues. Let’s tapall the available resources and interested parties to participate in those discussions. Let’s balance academic calculations and theories with real-world experience. And let’s judge the value of technological advances on their ground level applicability. As long as we remain open-minded and inclusive and also have the clear goals of achieving the quadruple aim, we will get the best possible result. This is critically important to our nation right now.

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Dr. Barrett was born in Rye, New York and grew up in Bethesda, Maryland. He attended Dartmouth Medical School and received his MD degree from Harvard Medical School in 1972. He pursued Family Medicine residency training and Psychosomatic Medicine fellowship at the University of Colorado Medical Center in Denver and then returned to New England to establish his medical practice in Manchester, Massachusetts in 1976. Dr. Barrett retired from clinical practice after 41 years in 2017. Having seen all the changes that American healthcare has undergone since he started in the field, Dr. Barrett is still passionate about the need for meaningful and effective healthcare transformation and is eager to contribute to that critically necessary process.

 

 

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