The changing landscape of family medicine in Texas

Tags: health care reform, quality, family medicine, delivery, system, health care costs, physician, employment

By W. Mike McCrady, M.D., and Anne McCrady

While politicians debate health care reform in Washington, here in Texas change is already affecting the practice of family medicine. In hospital board rooms and medical staff meetings, local doctors are hearing about the transformation of primary care, payments based on quality and value, and the expectation of providers to capture a larger and larger market share. There is a confounding list of issues behind these pressures: some legislative, some economic, and others technological. In response, around the state, not just doctors, but administrators, legislators, and consultants are weighing in on the critical role of primary care to manage cost, ensure continuity, and meet patients’ needs.

With so much at stake, Texas family physicians face a daunting future. How should we respond to these changes? As with so many things, the answer seems to be to work together. For a rapidly growing proportion of us, that means joining forces with other providers, often as part of a hospital system. A report from the Texas Department of State Health Services shows a drop in the percentage of physicians who identified themselves as being in partnerships from 50 percent to 30.2 percent in the past 10 years. This decreasing number of small medical groups is also documented in national statistics. In fact, a recent New England Journal of Medicine article predicts that by 2012, 40 percent of active primary care physicians will be employed by hospital systems.

The shift toward doctor employment isn’t just a business trend. One of the major factors driving the decrease in independent practice is the changing demographics of Texas. Over the past two decades, the population growth in our state has been in urban areas, where large hospital systems dominate the market. Physicians are locating to follow that growth, and must either align with those systems or compete. The 2010 census shows that only 14 percent of Texans live in rural areas, and an even smaller number of doctors are choosing small towns. This is especially true of younger physicians, whose practice choices are more influenced by lifestyle issues than previous generations, and who prefer the advantages of employment.

Another feature in the growth of integrated health care systems is the Affordable Care Act. Health care reform is already altering the landscape with new processes, incentives, and requirements. A survey by Cejka Search, a leading physicians’ recruiting group, in conjunction with the American Medical Group Association, reports that 64 percent of integrated medical systems find that since the introduction of health care reform, physicians they want to recruit are more receptive to their model of care.

In light of all these developments, the future of Texas family medicine seems to depend on accessing the resources and networks of large integrated medical systems, while maintaining our autonomy and personal commitment to patients. It will be a test for our specialty, but one for which our skills and strengths are well suited. In fact, as family physicians, we have reason to believe we will not only survive the coming changes, but thrive.

First, as family doctors, we value patient relationships; our patients know we will never compromise our personal relationship with them. Regardless of our affiliations or payment structures, our core values about patient care remain valid. Evidence from pilot programs, such as the patient-centered medical home, continues to show that in a wide range of delivery models, family doctors are essential to high-quality, cost-effective health care. As the 2010-2011 TAFP Texas Family Physician of the Year Lloyd Van Winkle, M.D., remarked in his acceptance speech when he referred to a popular television show, “Patients don’t want a [Dr.] House; they want a home.” Family doctors have provided the “medical home” to their patients for decades.

Secondly, family physicians are committed to quality, access, and affordability. Aligning with health care systems can enhance those commitments by providing new services, specialty interaction, information technology, measurement and reporting, evidence-based protocols, and administrative support. Roger Fowler, M.D., a long-time family physician and chairman of the board of Trinity Clinic in Tyler, recently noted that advantage, “When family doctors join groups, they don’t give up their independence as much as they gain resources.”

Finally, family physicians have a long history of providing coordinated care. Our role has always been to guide patients to seek the “right care at the right time” from a wide range of sources. Integrated care is actually an expansion of what we are already doing. Recently, Karen Kennedy, CEO of Medical Clinics of North Texas, a multispecialty group with a strong family practice base, said, “Physicians who have a well-developed sense of teamwork are looking for groups like ours to join.”

While Texas health care delivery systems will continue to expand and evolve, it seems clear that integration, or at least affiliation, will be the choice of many physicians in Texas. My hope is that we, as family physicians, will embrace these new opportunities and remain the essential health care providers and patient advocates we have always been. Using our shared values, medical expertise, and the support of TAFP, we can ensure that family physicians lead the transformation of Texas medical care far into the future.

Dr. McCrady is a family medicine hospitalist and vice president of clinic operations at the Trinity Mother Frances Health System. Anne McCrady is a freelance writer and speaker.

1 Comment

  • Troy said

    I don't see how medical homes can work for low SES pinalutoops. The requirements are expensive to put in place and, as is clear from the AAFP demonstration, don't matter in the eyes of patients. I can't imagine how physicians will recover their investment. Where will their income come from if panel size is reduced to 1500? And where will all the physicians come from if each has only 1500 patients? Successful systems will leverage nurses and lesser-trained assistants in order to expand panel size and generate more revenue, while concentrating physician effort on those aspects of care that demand their participation.

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