Ideally, primary care physicians (PCPs) are the doctors that people see the most, the family physicians and pediatricians working in small community practices. However, the healthcare industry is suffering from an extended shortage of PCPs. Recent research from the Association of American Medical Colleges shows that the United States will face a shortage of up to 49,300 PCPs by 2030.
As the first point of contact for patients, PCPs offer continuous care that supports lifelong health, allowing patients to seek advice in doctors’ offices instead of in emergency rooms. With PCPs disappearing across the country, discontinuities in patient health management have led to inefficiencies in care coordination and increasing administrative wastefulness. In the current fee-for-service system of physician reimbursement, inefficiencies are already abound, as doctors and hospitals are incentivized to practice costly defensive medicine. Repeating MRIs and x-rays, a common practice perpetuated by the lack of information sharing between institutions, allows hospitals to accept more insurance money while claiming to placate patients. Combined with large patient-to-physician ratios and over-prescription, these practices ultimately drive up the cost of care in a way that has caused increasing concern in the healthcare community. The PCP shortage exacerbates the impact of these consequences by causing more discontinuities in care. To combat these adverse effects, the industry has begun looking for different strategies of healthcare organization outside of the current fee-for-service system. Many potential substitutes claim to benefit both patients and practitioners, emphasizing value-based reimbursement arrangements—as opposed to fee-for-service arrangements—that put patient care first by encouraging physicians to focus on implementing best practices and avoid defensive testing and overprescription. One alternative, formed by physician collaboratives, returns any net savings to the providing clinic and focuses on improving population health through coordinated team care; another bases provider reimbursements on a fixed cost per episode of care, such as a hip replacement or cancer treatment, from start to finish.
While these models tackle inefficiencies on the provider side of primary care, another model attempt to reduce inefficiencies on the patient side. This alternative, known as a pay-for-coordination model, places PCPs at the center of a patient’s care network, empowering them to create health plans for patients in collaboration with other providers and specialists with the goal of ensuring care efficiency and quality. The Patient-Centered Medical Home (PCMH), the most popular pay-for-coordination scheme, allows different specialities to collaborate in a centralized setting. By utilizing more advanced information technology to store and navigate patient health information, these organizations aim to make care more accessible and personal to the patient. This strategy streamlines patient care with increased logistical and technological efficiency and improves quality of care through a collaborative interdisciplinary approach. This model has received support from players across the healthcare industry and beyond. The American College of Physicians (ACP) published a detailed communication in favor of the PCMH in 2006 to launch a national movement in support of this model. In the years since, the ACP has spearheaded a collaborative group charged with promoting the widespread adoption of the PCMH supported by over 700 member organizations across many different industries.
The group has encouraged the development of pilot commercial PCMH activities across the country, following up with these programs to test the model’s care quality, efficiency, and financial sustainability. One such pilot program, the Group Health Cooperative in Seattle, Washington, saw a 29 percent reduction in ER visits and improvements in diabetes and heart disease care. Pilots in other states saw similar results—most notably, long-term cost reductions. As the ACP acknowledges in their publication, starting up a PCMH requires both financial investment and modern technology systems. In addition, the switch from a fee-for-service system based on illness or trauma to a value-based system focused on wellness and prevention requires the PCMH to provide different professional services, like those offered by dietitians, exercise coaches, and mental health experts (none of which have previously been included in primary care practices). The ACP is calling for a change in the current reimbursement system for medical organizations to address these new services and offer financial support for practices and physicians to make necessary changes. However, the organization’s proposal noted one exception: integrated group practices largely funded through prepayments.
This type of practice, called concierge medicine, has also been gaining attention in recent years. In the concierge healthcare model, members pay monthly or yearly retainer fees, ranging from $149 to $500 per month, or even more. Depending on the practice, concierge clinic memberships can offer benefits as exclusive as in-home visits or as simple as expedited lab results. The strongest criticism of concierge medicine is that its retainer model advantages wealthy clients who can pay exorbitant fees to receive “a la carte” benefits that are inaccessible to the middle or lower classes. This has been well-documented; an article in Healthcare Dive identified MD2 as the first concierge practice in 1996, advertising a 50:1 family to physician ratio and charging $13,200 annually for an individual or $20,000 for a family. Though fees like these have been the trend in concierge medicine, a prepayment business model may be the unlikely catalyst that the value-based care revolution needs. By directly addressing the causes of today’s PCP shortage—low reimbursement and professional dissatisfaction—concierge medicine can drive forward the changes necessary for the US healthcare industry to turn to a value-based system.
Many share the concern that the American healthcare industry will not be able to support the aging US population. After all, the population of individuals over age 65 is projected to increase by 50 percent by 2030, compared to an 11 percent projected increase in the overall population. Unfortunately, relative to that expansion, younger generations are not expected to fully replace retiring physicians. Recent medical school trends show fewer graduating generalists because students are put off by both the lower salaries and overall difficulties of the current primary care system. In 2016, the average annual wages for PCPs ranged around $200,000 while the top 10 earning specialty practices all make upwards of $430,000. Due in part to these low salaries, there was a seven percent drop in American graduates entering primary-care residencies, in addition to a five percent increase entering specialist residencies over the period from 1995 to 2006. Previous attempts to address the issue have led to increased salaries for PCPs who move to rural areas, which are particularly underserved. However, this strategy has not solved shortages in more populated regions because of more deeply rooted problems with the lifestyle sacrifices that PCPs have to make. Studies estimate that PCPs spend six hours of each workday dealing with electronic forms and records. They are laden with between 1,200 to 3,400 patients, limiting their ability to provide satisfactory care for each one. With so many patients to care for, physicians are only able to provide 54.9 percent of recommended acute, chronic, and preventative care services, All of these factors have contributed to a feeling of professional dissatisfaction: 53.9 percent of physicians describe their professional morale as somewhat or very negative.
In pilot concierge practices at hospitals across the country, many of these issues are being addressed once again. Massachusetts General Hospital (MGH) rolled out a concierge medicine program in 2016, inviting members to pay $6,000 per year for 24/7 access to primary care physicians who have much more manageable panels of 300 to 500 patients. In a 2018 interview, the Boston hospital’s chief marketing officer noted that the program’s biggest value is its offer of time, a benefit that both doctors and patients appreciate. The longer appointment times and increased accessibility allow both parties to better work towards preventative care rather than illness-centered care. The program’s primary care physicians, marketed by the hospital as “quarterbacks” dedicated to patients’ health needs, also promote continuity of care. They participate in patients’ hospitalizations at MGH, providing valuable context that can minimize wasteful procedures or tests while offering support in the form of a friendly face. MGH’s concierge program has been very successful, growing its patient pool and drawing additional physicians. And importantly, the practice is able to support itself, a self-sustaining revenue generator.
Concierge programs hold a lot of promise for the primary care system, solving many of the root causes of the PCP shortage. An increased focus on care coordination and continuity will be especially valuable for the aging population, as boomers’ health conditions become more challenging. The increased demand for PCPs in these care coordination and relationship-building roles may, in turn, encourage medical students to take a second look at primary care—the decreased panels and increased salaries would certainly attract attention, contributing to a virtuous cycle. A brief comparison shows that the PCMHs and concierge practices share many of the same principles: the centrality of the primary care physician, the focus on continuity of care, even the rejection of the industry status quo. The main difference between these models is in their financial output. PCMHs are able to cut costs for physicians and patients, but these benefits mainly become apparent in the long term. Concierge practices use retainer fees to enjoy profits in the short term, while simultaneously offering services that appeal to patients to recruit members. Thankfully, these models are not mutually exclusive. The concierge business model can help PCMHs get started, addressing the high overhead costs and funding the financial investments needed to make the necessary large-scale changes. And ultimately, a PCMH approach to care provision, emphasizing the quality of care and the cooperation of the care team, can help address the issues of accessibility, security and member retention that some concierge practices face.
The compatibility between the PMCH and concierge models will provide health care providers and patients with new access to technological and social innovations. A San Francisco-based concierge practice was able to replace patients’ insurance and copayments with a $149 monthly fee using artificial intelligence, wearable monitoring, and other technologies to change up basic screenings and wellness services. The money saved can do good in other ways, too: Massachusetts General actually uses the margin from its new concierge program to provide more funding for substance misuse disorders clinics and other community initiatives. Programs like these, which allow practices to reach out to underserved regions and populations, hold a lot of promise for rural communities and those uninsured due to unemployment or pre-existing conditions. Furthermore, alternatives to the hospital-centric healthcare model could be valuable for communities with poor healthcare infrastructure. In developing countries, where many citizens cannot afford to travel for care and suffer from relatively curable illnesses, concierge-style models could increase access to care. Collaborative PCMH-style practices, meanwhile, could hire and train community health workers to promote wellness, distribute health information, and reduce the strain on the limited numbers of hospitals and physicians in any given country.
Opportunities like these emerge when individuals decide to challenge the status quo to allow health care to continue improving lives. PCPs can innovate together with specialists, medical schools, and nonprofits to enact the change they want to see in order to improve the state of the healthcare industry—both for the dedicated professionals who staff it, and for the patients they swore to serve. Today, the primary care system cries out for help. To paraphrase the modern Hippocratic oath, innovation may be the key to preserving the finest traditions of the medical profession and passing on the joy of healing to those who seek to help.
