I was asked recently to comment on how I felt increasing the emphasis on primary care would benefit the “system.” This is an important question because, as I have pointed out here and here, academic health centers and primary care education have no love between them. My answer was as follows:
Good primary care will not contribute a whole lot to the bottom line … As our primary payor is Medicaid and if the Alabama results are anything like the North Carolina, the Adult inpatient spending is down almost 10%with the bulk being in preventable adult admissions. In other words, the job of the primary care doctor is to keep folks out of the hospital and so by the very nature we in FM will be at odds with many of our colleagues. In short, better care will reduce folks in the hospital.
I then pointed out what I thought was an obvious strategy when faced with evidence that a tidal wave is fast approaching:
Our department [can] jump in front or not but I suspect it will happen either with or without us.
Why is the tidal wave coming? The payment system is unsustainable and is changing FAST. I believe (and everyone at CMS that I have spoken with concurs) that Fee-For-Service medicine is in deep trouble. HealthSprings Medicare Advantage plan is distributing a good bit of physician payment in the way of “shared savings” (and recently was purchased by Cigna for almost $4 billion). Commonwealth is about to publish a report on outcomes on PCMH projects across the nation. They have found consistently improved care delivery and CMS is listening. Payment reform can be accomplished without a change in the Affordable Care Act and in the case of BC/BS by fiat. My money is on substantial payment change in Alabama Medicaid, Medicare, and BC/BS of Alabama soon.
Perhaps they’ll need primary care after all to help create a focus on quality instead of having the slickest procedures? While my money is on primary care, don’t know that I’d bet on Academic Health Center transformation just yet.