Conehead, originally uploaded by powerbooktrance

A week ago, Market Strategies, Inc. (MSI) announced its findings from a recent survey regarding retail health clinic usage.  The press release leads with a whammy:

12% of retail clinic patients with a primary care physician agree with the statement “retail clinics have mostly or completely replaced my primary care physician for the type of treatments offered at retail clinics.”

In other words, nurse practitioners (who garner an average salary of $77k according to salary.com) are replacing primary care physicians (PCPs) for the simple stuff.  That makes sense and I’m sure we’ll see the 12% figure growing in the near-term. 

For PCPs, though, the above adds to a burgeoning list of woes that’s worth examining.  Consider the American College of Physicians’ (ACP) January 2006 report entitled, “The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care.”  The paper paints the picture of misaligned incentives.  At the forefront, and underemphasized therein, lies a growing income gap between primary care and the specialties that is (1) causing PCPs to opt for early retirement and (2) causing students, in increasing droves, to choose specialization.  Data from the Medical Group Management Association indicates that PCPs earned an average of $162k in 2004 vs specialists who took home $297k on average.  Fundamentally, the disparity lies in a payment structure which rewards specialists for scalable delivery of imaging and other diagnostics while PCPs are stuck in a non-scalable service model constrained by docs’ time.  In an effort to keep up, PCPs have attempted to serve more patients in the same amount of time, but it’s a losing battle.  In the five years from 2000 to 2005, laboratory tests per Medicare beneficiary have increased 530% while office visits for ”established patients” in the same group have increased 12%.  Guess who’s reaping the bulk of spend for (and from) those lab tests?  Not the PCPs. 

For more on the complexities underlying the above, read this February’s important ”Perspective” piece from the Annals of Internal Medicine, titled, “The Primary Care-Specialty Income Gap: Why It Matters.”  Unfortunately, while the piece does an excellent job of explaining the problem’s source, it does little to address “why it matters.”

So why should we care?   Well, the ACP would have you believe that system costs will go up and quality of care will decline as the supply of PCPs becomes increasingly strained.  I think that’s a proper conclusion.  Anecdotally, I’ve seen a few good PCPs throw off the reimbursement albatross and start requiring patients to not only pay upfront but also deal with reimbursement on their own.  Free markets forces are emerging.  And that’s a good thing.  Most markets value the “solution hub” more than the “spokes” because the hub tends to own the client relationship.  I’m afraid critical care of chronic conditions is landing those relationships primarily in the laps of specialists.  Color me “green,” but a more holistic approach to care, one that emphasizes prevention and empowers the PCP, is key to fixing the system.  PCPs, take heart, take charge, and earn your “hub value.”