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Jack M. Colwill, James M. Cultice, and Robin L. Kruse Will Generalist Physician Supply Meet Demands Of An Increasing And Aging Population? Health Affairs, May/June 2008; 27(3): w232-w241. [Abstract] [Full Text] [Figures Only] [PDF] [Reprints & Permissions]

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Generalist Physician Supply -- Potential Solutions

Arvind R Cavale   ( 5 May 2008 )

Generalist Physician Supply -- Potential Solutions 5 May 2008
Arvind R Cavale, MD, FACE, FACP Private Practice Send comment to journal: Re: Generalist Physician Supply -- Potential Solutions mdllcoffice{at}gmail.com Arvind R Cavale	The findings and analyses in this article are quite real, although not surprising. Based on my personal practice experience, I would like to provide some ideas for further study. First, it is generally inaccurate to club FMs and pediatricians with GIMs based on the fact that IM residents are primarily trained in an in-hospital setting whereas FMs are primarily trained in an office-based setting. This clealy leads IM grads to be naturally fluent with becoming a hospitalist as compared to FP grads to manage office-based practice. Therefore, further discussion of primary care should include primary care of ambulatory as well as hospitalised patients, if such a concept is feasable. Second, the idea/expectation that primary care physicians (mainly IM) should work like "mini-specialists" should be done away with. Based on my own early years as a general internist, I can say that it was rather unsatisfying. Third, the best solution that I see working smoothly for FPs, myself, and our mutual patients, as well as providing cost-effective, efficient, and appropriate care (as evidenced by a 2006 analysis by our largest insurer) is what we practice in our region, mainly in the care of diabetics. We've established an unwritten understanding between our referring FPs and our practice of endocrinology. In summary, we manage the active diabetes management of all diabetics referred to us (for diabetes management), coordinating this with routine/preventive care at the FPs and other speciality care providers (ophthalmologists, podiatrists, nephrologists, cardiologists, etc.). This method provides unambiguous instructions to the patients as to who is responsible for what type of management, and that the patient is responsible (for the most part) to be the main link between different physicians (patient-centered). Obviously, the patients are adequately educated on how to handle this. This practice fundamentally recognises that effective diabetes management is complex and requires all these pieces for the long term. Finally, given the demographic shift, and the rise of chronic diseases, it will serve everybody well to understand that a significant proportion of a PCP's role should be coordinating care among subspecialists and providing preventive and routine care, which PCPs are good at. In order to achieve this, policymakers should completely scrap the current reimbursement system of CPT codes, which was set up to favor procedure-based subspecialists (or keep it for such specilists only) and device a method to compensate physicians to provide coordination of care, health maintenance programs, disease prevention programs, etc. It is also critically important for policymakers to realise that preventing a heart attack is equally valuable as providing a coronary bypass after one has occurred. Similarly, preventing an osteoporotic fracture should have the same monetary value as fixing an osteoporotic fracture. Now that Medicare is working on nonpayment for "non-events" in a hospital setting, why not devise a payment method for ambulatory practices for every event that is prevented, such as an ED visit for fluctuating blood glucose or every heart attack that is prevented with proactive metabolic disease management. In summary, shortages of PCPs can potentially be lessened by redefining primary care and providing innovative ideas for rewarding the practice of effective primary care.