Reimagining Primary Care: When Small is Beautiful

by Eric J. McNulty

The attempts to “fix” the U.S. healthcare system have taken at least one well-worn market-based path: strive for economies of scale. Hospital consolidation is on the rise, a trend that shows no signs of abating as providers try to streamline back-end operations and deploy big data analytics in hopes of improving outcomes and lowering costs. Businesses try this every day.

However some primary care physicians are looking at the exact opposite approach: de-scaling and taking cost out by radically simplifying their practices as a way to make them clinically, financially, and personally sustainable.

What makes these practices different?  1) Each is based on relationship quality rather than production volume; as a result, each is smaller than the average U.S. practice; 2) Visits are longer and the doctor may provide a broader range of services with minimal support staff; 3) They have business plans that demonstrate how their model can be financially sustainable; and 4) Each used their variation on the general model to offer greater satisfaction to their patients as well as to their own personal and professional lives.

My colleagues Leonard Marcus, Barry Dorn, and I met three such physicians in the course of researching our book, Renegotiating Healthcare: Resolving Conflict to Build Collaboration. We recently revisited them to see how the evolution of their distinct approaches to primary care might inform the larger discussion of the future of healthcare.

Dr. Pamela Wible of Eugene, Oregon, had considered leaving medicine. She contemplated waiting tables so that she could have more meaningful interactions with people. She was burning out working in a typical large practice with its fast-turn appointments and gatekeeper-to-specialists role for the primary care provider. Instead of tying on an apron and heading to the local diner, she turned to her patients and asked them to help her reimagine a model medical practice. They gave her more than 100 pages of ideas.

The result is something as unlike the typical primary care practice as you can imagine: It is a living room-like setting with minimal electronic equipment. Wible is the only staff. Patients never have to wait in a waiting room. Appointments start on time and are 30 to 60 minutes long. Conversation and physical touch are central to diagnosis. Wible chose to cut the size of her practice to restore some balance to her life and to have more meaningful relationships with her patients. Thanks to lower overhead, she is able to earn a full-time salary working part time.  ”It’s actually very easy to run a solo ideal medical clinic in 2013,” she said.  She now consults with physicians and hospitals nationwide as they learn to design true patient-centered practices.

Dr. Gordon Moore of Rochester, New York traveled a parallel path. He could not see a way toward a viable financial future given the expenses of a traditional primary care practice with a large support staff. Like Wible, he decided to practice solo to minimize costs though he eventually added a nurse when his practice reached 400 patients. Even with the additional duties of scheduling, greeting, and billing, he found that he could spend more time with patients and was deriving great personal and professional satisfaction from these relationships. He made himself available 24/7 to his patients yet they called him less than when he was the on-call physician in a larger practice; he granted full access to them and they, in return, were greatly respectful of his time.

Moore left his practice in 2008 to help build a movement around what is called the Ideal Medical Practices or IMP. Not limited to solo practitioners, IMP rests on the pillars of access to care, time for relationship to build, and comprehensive, coordinated care and services. Patient experience is the critical variable for both controlling costs, improving outcomes, and keeping physician caseload manageable. There are now 500 IMP practices nationwide.

Dr. Richard Donahue had been the only year round physician on the island of Vinal Haven, Maine for a decade. He said that his patients frequently told him that if he couldn’t treat something, they’d learn to live with it rather than incur the expense and take the time to travel to the mainland for treatment by a specialist. He said that this pushed him to continually improve and expand his skills so that he could meet patient needs. He has taken his “island doc” philosophy to the city and is currently Medical Director of a family-oriented concierge practice that serves “CEOs to social workers” in Boston.

There are, of course, challenges. According to Dr. John Brady of Ideal Medical Practices, these are often administrative as initiatives such as basing payment on productivity do not take alternative practice models into account. It can also be harder for small independent or solo practices to coordinate care with a large hospital system or specialists. However these can usually be overcome through planning, technology, and tenaciousness.

Practices like these are a tiny minority yet they highlight important issues for our health care system. First is that a system designed by policy makers and business interests may look markedly different from how two critical stakeholders envision it: doctors and their patients. Those differences may have implications for both costs and outcomes. Second, when patients have a meaningful, trust-based relationship with their primary caregiver, they may actually ask less of the overall system: fewer optional tests and unnecessary trips to the emergency room, for example. Third, it may be useful to ask primary care physicians to do more for fewer patients.

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