Family physicians train for three years after medical school to learn everything from delivering babies to caring for people at the end of life. It’s a comprehensive scope of practice where the physician gets to know patients through caring for them over time. The patient’s health is the focus, not the episodic illness care that marks most patients’ experiences with the rest of the health care system.
Idaho has too few family physicians. In fact, there are only about 400 board-certified family physicians in our state. Idaho ties with Oklahoma for last place in the United States for its number of primary care physicians per capita.
We’re paying more for our health care, but receiving less. The American health care system is much better known as a sick care system than a health care system. In fact, the World Health Organization ranks the United States 37th in the world for health care outcomes. That’s because our payment incentives reward procedures, x-ray images, and lab tests, not disease prevention and health maintenance.
One reason: We don’t have enough family physicians who can focus on prevention and management.
Most family physicians in Idaho are in small practices of five or less and operate as small businessmen and women. Their margins are small and their practices are precarious. Thanks to changing reimbursement patterns, their revenues are going down while their expenses are going up. Physicians pay more than ever for overhead like electronic medical records, employee health insurance, and liability insurance. Meanwhile, unlike most other businesses, medicine is controlled predominantly by third-party payers. Insurance companies, Medicaid, and Medicare set payments to physicians, and those often don’t even meet the costs of care.
Add to that an increasing number of uninsured or underinsured patients, and you have a real cash flow problem for many family medicine practices.
The consequence? Fewer physicians are choosing family practice as a specialty. Meanwhile, those in practice often opt not to take patients who use Medicare or Medicaid. Instead, they give the appointment spot to a better-insured patient with Blue Cross / Blue Shield, Pacific Source, United, Aetna, Cigna, or Humana insurance.
Family physicians and physicians of all types in Idaho make these business decisions not because they don’t care for the people in their communities with problems. They do it because they must, to meet overhead expenses.
Most of us, in and outside of the health system, agree we need to create a better way of doing business in health, with better health care outcomes and lower costs. Here are a few of my suggestions:
First, we need a new model of payment. The fee-for-service, volume-driven system drives up costs and doesn’t improve outcomes. A better system would be blended payment, including some fee-for-service, a care management fee, and quality incentives. Care management could be coordinated through telephone calls, e-mail, coordination with consultants, nurse case management, and group visits. Those methods keep the patient in the community or at home and away from expensive options like emergency room visits, hospital stays, and unnecessary surgical procedures and x-rays. Quality incentives would reward providers for improving patient outcomes.
Second, we must produce more primary care physicians, family doctors, general pediatricians, and general internal medicine physicians so we can provide health care-oriented Patient Centered Medical Homes – primary care practices that focus on creating health and wellness, not reacting to sickness and illness.
When all patients have access to a Patient Centered Medical Home, we can provide the timely, high-quality, and lower-cost health care that emphasizes health and function.
To move toward this goal, Idaho, under the leadership of Governor Otter, has developed an Idaho Patient Centered Medical Home pilot. This is made up of multiple stakeholders including insurance companies, physician groups, Medicaid, the Idaho Primary Care Association, the Idaho Medical Association, the Idaho Hospital Association, and the Idaho Department of Insurance.
Together we will pilot Patient Centered Medical Homes around Idaho in practices of different sizes. This is exactly what Idaho should be doing in this time of change: innovating and creating higher-quality, lower-cost health care.
If we don’t move toward this model, you’ll see more small Idaho family physician practices closing, and more practices being purchased by hospitals. If we do move toward this model, you’ll see us moving away from the disease-focused system we have now to a health-focused system that improves the health care experience for all Idahoans.
This column was written by Ted Epperly, program director and CEO, Family Medicine Residency of Idaho; clinical professor of Family and Community Medicine, University of Washington School of Medicine; and past president and past chairman of the board, American Academy of Family Physicians.