Friday, December 8, 2017

What Do We Want From Primary Care, Part I

Forget the plans and even the implementation plans. There's a long list of priorities, and those priorities have yet to be prioritized.

Primary Care Reform.

Once upon a time, those three words brought about an excitement bordering on giddiness in academics, progressives, and idealists. What could be better for population health - at least, outside of addressing people's real needs like housing, clean water, and abject poverty - than getting doctors out of their fee-for-service, conveyor-belt, over-servicing, warped-incentive, solo practices, and putting them in community-based, multidisciplinary, salaried-or-alternate-payment (anything but fee-for-service), comprehensive, prevention-focused teams? No more greedy doctors running their own businesses - which they aren't trained for anyways - in over-doctored cities, inventing reasons for patients to come back more often than they should. No more over-prescribing, especially of antibiotics, because doctors would have time to counsel their patients. No more gifting of precious(?) taxpayer dollars to rich doctors for work that could be done by less costly professionals. No more overuse (and overcrowding!) of the ER, since patients will have 24/7 access to a community-based network of primary care providers. I'd throw in the promise of integrated electronic health records (EHR) into the mix, but in fairness the primary care reform vision predates cloud technology.

Passionate debates still go on about primary care reform, especially online, but there's much less giddiness and much less clarity around the major issues. Fee-for-service medicine remains everyone's favorite scapegoat. But every time a new Auditor General's report comes out, different ways of paying doctors don't score all that well in terms of cost-effectiveness, no matter what arcane formula is used to define it. Rural areas - and even some cities - still struggle to recruit and retain doctors. Government efforts to improve matters tend to be as draconian or convoluted as they are despised...except, of course, when government gives doctors a raise, a move that eases tensions without solving any of the festering structural problems. Oh, and just to really make things fun, most people getting into medical school end up largely disinterested in primary care.

In any policy debate these days, ideas are put forward, reinforced to a great extent, scrutinized to some extent, and challenged to a limited extent. Still, the same themes tend to arise over and over. As to the problem of access to family doctors, we find problems with: how doctors are paid; how much doctors are paid; and how much autonomy doctors do or don't or should or shouldn't have over their scope, hours, structure, and location of practice. As to the shortage of doctors in comprehensive family practice, we hear about: lack of exposure in training; lack of respect in specialist-dominated tertiary academic centres; lack of mentoring; lack of career counseling; lack of resources and supports once out in the community; too many bureaucratic demands; and so on. Almost all of the problems and proffered solutions are correct and sensible on their own, but either can't be fixed or come to fruition, respectively, because of (take your pick): ego; money; apathy; stubbornness; an opaque bureaucracy; an oversized bureaucracy; a sclerotic bureaucracy; lack of data; lack of buy-in; "entrenched interests"; and so on and so on.

What's an idealist or policy wonk to think anymore?

For starters, some perspective. Primary care reform is a problem, even a big problem, but not the problem in health care. That distinction belongs to hospital overcrowding due to lack of long-term care capacity. There is no point in even thinking about primary care restructuring while the entire acute care hospital system is on the brink of critical overcrowding and collapse. But for the sake of argument, let's picture a world where hospitals are no longer sickeningly overcrowded with frail elderly patients and cared for by overworked, stressed-out clinical staff. And let's even say that, magically, the problem of wait times for specialist care is on the mend, and the country's collective mental health improves, with the impact of mental illness showing signs of abatement. What should we do about primary care?

Here's something you almost never hear or read about: the need to identify and set priorities. Unfortunately, the health care system is so all-encompassing and complex, it's easy for policymakers to direct resources to areas that aren't all that critical, but are a) easy to implement, b) likely to win votes, or c) (less commonly) forced by the courts. Rarely, we see spectacularly awful ideas that don't fit any of these criteria, but are enamored by someone in power (let's set those aside for now).

There's an aphorism in the engineering-business world along the lines of, "There's good, cheap, and on time. You can have two."

Right now, the primary care system is seeking to become: comprehensive (without a clear definition); equitable in access along time, geographic, demographic, gender, ethnic/cultural, and socioeconomic axes; multidisciplinary; quality/data-driven; state-of-the-art; safe; integrated into the community; inclusive; cost-effective (again, without a clear definition); "affordable/sustainable"; nimble; compassionate/fair to professionals; and accountable.

It should be obvious that these goals, laudable as they are individually, are not only extremely unlikely to happen together, but work at cross-purposes. The more access we want people to have to their doctor, the fewer hours that doctor will have with his or her family. The more spread-out we want our doctors, the more effort we need to put into support structures. The more data we want, the more we pay in both IT costs and practitioner time. And how much are we spending for oversight and auditing in the name of making sure the money on health care is "well spent"?

None of these trade-offs is simple to get a grip on. But I hope it's clear that singular ideas like putting all doctors on salary, or giving all family doctors a raise, or instituting mandatory rural service, or changing the ratio of residency spots, or sub-regional micro-management, are not going to make things better.

How would I set priorities for primary care, if I were in charge? I wouldn't. That's incumbent on the public that both pays for and uses the health care system. More on that next time.

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