A new "ist"?
Since the term hospitalist was coined in 1996, this new specialty has grown faster than any other in the history of medicine. Continued financial pressures on primary care, combined with increased restrictions on resident work hours and the desire of physicians for a more manageable lifestyle, created a perfect environment for the rapid growth of this field. The success of this model has spawned the creation of similar models in obstetrics (the laborist) and, most recently, surgery (the surgicalist). As I read through and began to digest the proposed rule for implementation of ACOs over the last week, I began to wonder if we were once again creating the perfect environment for the creation of a brand new kind of specialist….
The proposed rule has more than 50 pages dedicated to defining specific quality measures, how they will be used, and how physicians will be rewarded (or punished) based on their performance. There are 65 metrics currently outlined, the majority of which are to be measured in the outpatient, primary care setting. Metrics include seven measures on patient satisfaction in the primary care setting, rates of 30-day post discharge visits, surveys for patients on how well they understand their care plans, “ambulatory sensitive conditions” (diabetes, CHF, dehydration, pneumonia, and others) measured both on how well you manage them as well as your ability to keep patients with these diagnoses out of the hospital – and the list goes on. The rule goes on to outline that you must report on and perform well on each and every one of these metrics if you wish to participate in any available shared savings. The potential financial rewards for many organizations are great as are the adverse risks of underperforming.
Primary care has been thrust into the center of medicine once again (can anybody say capitation?), but this time it appears that at least some of this model may actually stick. Although putting the primary physician in the proverbial driver’s seat will have advantages for managing care and outcomes, there is only so much a physician can do in a day. How will primary care physicians find the time to continue to do what they have always done – diagnose, treat, and care for their patients? Ladies and gentlemen, I give you, The Preventionist.
The Preventionist will focus solely on the optimization of care as defined by CMS, BCBS, and any other outside entity or payer. They will only see patients with conditions defined as focus areas for cost and quality, nothing more. Diagnostics or other conditions? Leave that up to your family physician. Acute illness? We have a nurse practitioner that will see you now. Without this focus on the ever-rising bar we are being measured against, how will any organization be able to truly succeed? This may be taking this looming model of primary care to an extreme, but ask any internist who has practiced more than 10 years if they ever thought, when they first began, they wouldn’t be caring for their own patients in the hospital?
The new rules are upon us and I do believe they were well intentioned and designed (at least in theory) to lead to better care for patients and populations at a lower cost by charging primary care, once again, to steer the ship. However, in our haste to create a model to save money and to care for the most challenging patients, I fear we may be creating just what we are trying to avoid – misaligned incentives and a model of care that is even more fragmented than the one we have today.
Great insights about "ists" and the potential for the preventionist. The ACO doesn't appear to put the primary care physician in charge as I read it. You're correct,though, in noting that the already overworked family doctor doesn't have a lot of time to take on anything else. Risks, benefits, quality and other phony concepts for the next wave of reform won't be successful. In fifteen years, no one will be left from the old non-system to complain, then we'll be OK.
Your post also inspired me to write about the "Incidentalist" for incidentalomas. apj
I like it. But the way I interpret the ACO paradigm, geographic based generalist specialties are counterintuitive to ACO goals. The traditional(ist) Marcus Welby type doc is exactly what is needed for an ACO to be successful. By creating a model where the PCP drives the bus (in this case a minivan, with an attenuated patient panel) caring for patients throughout the continuum of care, we may provide the best chances of keeping patients out of the hospital and well. Yes, I am a militant hospitalist and have bern one since the movment began. However,the geographic specialty silos only detract from care coordination. Hospitalists were a solution to a problem, not necessarily an innovation or essential element of healthcare delivery. If PCPs could have made a living doing "it all" hospitalists would not exist. If there were more incentives placed on quality/coordination and less on FFS/productivity, the traditionalist could thrive. And so the pendulum may be on the back swing....if we dare to look at our past and learn from our mistakes, there would only be one "ist" in healthcare.