The Changing Relationship Between Primary Care Physicians and Specialists

Thursday, August 3, 2017 | Larry Sobal

 

 

Artificial intelligence, wearable sensors, virtual reality, and medical robots – these disruptive technologies are thought to be on the verge of completely changing the way patients and doctors think and act about health care. The roles and relationships among and between physicians are changing as well. What used to be a somewhat simple model of primary care physicians (PCPs) and specialty physicians has now evolved to include a dizzying array of physicians including internists, hospitalists, intensivists, nocturnists, geriatricians, palliative care and all sorts of super sub-specialized physicians such as neuro-radiologists.

What hasn’t changed is that in order to ensure the best treatment for patients, physicians in different specialties and practices need to work collaboratively. Especially for chronic diseases, such as heart and vascular disease, effective clinical care requires a team of different types of physicians. It’s not uncommon for complex hospital patients to have five or more different specialists involved in their care. And while hospitalists have assumed more of the “attending physician” role, there are still instances where it’s not clear who the “captain of the ship” really is. The level of collaboration needed to ensure optimal patient outcomes requires that all participants throughout a patient's continuum of care make partnerships efficient and beneficial for all parties, especially the patients.

What I find interesting to watch is the changing relationship and dynamic between primary care and specialty care. Back in the good old days (20 years ago), primary care physicians admitted their patients, came to the hospital to round on them, and likely had various opportunities to interact with their specialty colleagues in the hallways, operating rooms or medical staff lounge. Today, it is more common to find specialists and primary care physicians who only know each other through notes in the EHR and the occasional phone call.

That’s unfortunate since poor coordination and communication between PCPs and specialists contribute to avoidable patient morbidity and mortality, fragmented care, and increased costs. Despite more focus on the quality and safety of patient care during the last 20 years, the ways in which specialists interact and communicate with PCPs seems to have largely escaped attention or transformation.

It is more common to find specialists and primary care physicians who only know each other through notes in the EHR and the occasional phone call.

There are many new care concepts designed to improve on the collaborative roles of physicians. Multiple models for the PCP/specialist relationship have emerged, including primary care-based, shared care–based, and specialist-based models. You can also include the patient-centered medical home, the specialty practice medical home and the multi-specialty group practice.

Few of us can forget the heyday of HMOs when there was quite a bit of angst around the “gatekeeper model” and the common requirement that every HMO patient have a primary care physician and receive pre-authorization in order to be seen by a specialty physician. For a variety of reasons, this didn’t sit well with all physicians or patients and, along with other concerns about corporate medicine and withholding treatment in favor of profits, the HMO and gatekeeper models have largely disappeared.

I believe we are on the cusp of another wave of health industry changes, some of which will continue to challenge, and possibly improve, the PCP/specialist dynamic. Let’s explore three of those.

1. Although I have occasionally argued in these blog posts that the “volume to value” tsunami is still just an overused and overstated ripple, there has never been more conversation about the relationship between cost and quality in health care. And while many physicians still live, for the most part, in a fee-for-service environment (especially specialty physicians), you can see evidence where primary care is paying more attention to data related to specialty physician quality and cost, and starting to change their referral patterns. No doubt this is influenced by that fact that there are now over 1,000 Accountable Care Organizations (ACOs), and countless numbers of clinically integrated networks, most of which are in different stages of maturity in terms of learning how to optimize quality and cost. This will likely impact PCP/specialist relationships.

2. Another emerging program that specialists need to know about is the CMS CPC+ program. CPC+ is a five-year, multi-payer initiative designed to strengthen primary care through regionally-based multi-payer payment reform and care delivery transformation.

Implementation of CPC+ began January 1, 2017 with 2,891 primary care practices participating in 14 regions. This first group of practices and regions is referred to as Round 1. A second group of up to 1,000 practices will make up Round 2 of CPC+ and will begin on January 1, 2018, in four new regions of the country.

PCPs in the CPC+ program are already voicing that the program is providing them with new data and incentives that are influencing how they interact with specialists because they are paying much more attention to their patients’ health status and utilization of services outside their office visits. While it might appear to some to reinvent a gatekeeper thought process, the reality is that there are now real financial incentives for PCPs to manage their patients’ care across the continuum, and that includes which specialists are consulted and what they are consulted for.

3. Finally, there is the emergence of the multi-specialty employed physician group. As recently announced by an American Medical Association study, less than half of practicing physicians in the U.S. owned their medical practice in 2016, marking the first time that the majority of physicians are not practice owners. For many PCPs and specialists, this means that they are now on the same team, at least employment wise. Although not as prevalent as it should be, I am seeing some examples where being in the same group is now leading to some new and interesting PCP/specialist collaborations such as figuring out what (and who) is the best way to manage anticoagulants, lipids, etc., or setting some standards for how communication should occur between PCPs and specialists. The potential is exciting and endless.

Good relationships among physicians are essential for good patient care, and the new organizational and financial realities of American medicine are changing the rules by which physicians interact with each other. With these changes come new aspects of physician relationships. The interaction between primary and specialty care is a critical fulcrum in medical decision making, especially about the efficacy and cost of tests and treatments available.

It will be interesting to watch how it all evolves, and whether there are new and innovative bonds formed, or whether there are growing tensions and conflicts between PCPs and specialists. The medical profession, not only for its own self-interest, but also because of its ethical duty to care well for patients, has an obligation to avoid self-defeating animosity and foster PCP/specialist relationships in the best interests of patients. As with so many changes happening in health care today, I suggest you stay tuned on this one.

 

 

Illustration: Lee Sauer

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Larry Sobal is Executive Vice President and a Senior Consultant at MedAxiom. He has a 35-year background as a senior executive in medical group leadership, hospital leadership and health insurance. Larry consults, writes and presents on topics relevant to transforming physician practices and health systems. His weekly blog post comes out on Thursdays and can be accessed at www.medaxiom.com.

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