By John K. Frederick, M.D.
I’ve been at this right at 20 years now. Some things are the still the same and will never change: the importance of a smile, a touch, a listening ear to a worried or discouraged patient, or wise counsel to a parent facing the health crisis of a child. That’s the clinical stuff, and it’s still “all good.” On the business side of my medical practice, things aren’t still the same. For all sorts of reasons the business has steadily gotten worse—lower payments, longer hours, and ever more forms to complete. Yet the same national politics which have caused an erosion of private practice over the years seems now to have turned, and may now offer us a golden opportunity. The crafters of the new federal health care law put us right back in the middle of things, requiring new vertically integrated health care ACOs to be built on a foundation of primary care! As a result this is the best, most timely opportunity for family medicine doctors since the advent of our specialty! What we do in the next 24 months may well either cement our validity with the public and general medical community, or relegate us to lapdog status.
Until now we have been putting out fires, providing episodic care driven by patient demand. There are a number of lesser-trained medical folks quite capable of working at this level. Our response has been to increase visit volume, and perhaps become more accurate in our coding. But in the near future our broader skill set, our breadth of training, and our ability to see the big picture will set us apart. Chronic medical care drives most of the health care costs in our country, and we are in a perfect position to put a significant dent in those costs with the help from one of the good EHRs now on the market. The really good news is that voluminous data now exists that health systems designed and led by primary care provides for lower costs and improved patient outcomes. And the politicians now know it.
There will be a price. We must get to know each other again and gather into teams. We can maintain our physically separate clinics, but only if tied together financially to maximize our negotiating and purchasing power. We will have to work collaboratively with lesser-trained providers so that the episodic care can still be delivered in a timely fashion since there are not enough hours in the day for us to physically provide for all the demand. We also must be willing to have our work measured, thus allowing us to show how we indeed are better, smarter, and cheaper. Now we can prove what we’ve been saying all along—people need us and we are not expendable. In addition, we’ve got to be more available and accessible. In a world increasingly dominated by smart phones and iPads, it only makes sense that new methods of interaction must become part of our practices. Let’s welcome Googling, blogging, video chatting, and whatever the next communication trend is. This openness to new things makes us unique and valuable, especially as we harness and craft those technologies for the good that family medicine can do.
In this new paradigm of physician payment brought by health care reform, small- and medium-sized practices have the most to gain and to lose. The economics will only work for those that cooperatively share expenses and collaborate with the data. Those that do will gain market share because insurers and employers will prefer them. Those that don’t will become gradually more irrelevant and be either absorbed by large multispecialty groups or purchased for a song by a hospital. In either case, personal and professional autonomy may be diminished or lost altogether.
Now is our time. The new federal health care law has created attractive incentives for family doctors to acquire software that will make sense of it all. I suspect most of us, at least in spirit, are already collectors of “meaningful use” data. Now we may get paid just for recording it, something most top-rated EHRs can do with relative ease. Data collection is our friend, allowing us to be prompted and reminded, to be thorough and complete, and to implement best ways of doing things. New technologies can help us overcome the difficulties of data entry and even us old dogs must be willing to give it a try. Obsolescence awaits those who do not.
There are some big ifs: if those provisions in the law are left intact, if the legislation is funded by the new Congress, if the political winds continue to move those in charge toward significant change. But even if the ACO clamor dies, we and the public will still be better off if we work together.
All of this will require leadership, from us, now. It has been too easy for us to retreat into our silos, hoping for the best yet allowing events to dictate our futures. Are we happy where such passivity has left us? I think not. It almost feels like the survival of our specialty hangs in the balance.