Salvation at Hand - PCPs as Gatekeepers

St. Peter ain't got nothing on these guys.

In Holland in 2004 (Cardol et al., 2004), 95% of complaints brought to GPs were handled by the GPs themselves.

GPs in Holland are exemplary gatekeepers.

Some studies even suggest that the real referral rate to specialists has dropped in the last 15 years (van Weel, 2005) following the 2004 introduction of "incentives against unlimited care utilization" (2006 RiVM Dutch Healthcare Performance Report).

In Holland (and I'm sure you'll all get tired of hearing me use that intro), GPs select the hospital where they'd like to refer patients based on several factors:

1. location;
2. physician they know (connections); and
3. reputation.

Admits are often based on the patient's GP having personal knowledge of a doc at the hospital where they recommend care.

That said, the patient in The Netherlands can still choose any hospital they wish, but many will decide based a combination of:

1. the GPs recommendation;
2. location/convenience/proximity;
3. community reputation; and
4. personal recommendations.

Hospitals in Holland face an interesting challenge as a result of eroding doc-to-doc relationships...GPs are now older Boomers, and the average age of specialists is younger (some boomers, Gen X and Y as well). How to work with the age differential?

How do hospitals, who have established relationships with specialists (it's rare for a specialist to be affiliated with more than one hospital), nurture relationships between GPs and their docs?

Good question. Some hospitals offer educational courses and research opportunities. Others emphasize partnerships and other benefits of being affiliated with internationally-known centers of excellence.

This model may well work in the US - if we take the nature of the problem seriously.

If the US can reinvigorate primary care (Who am I kidding with that phraseology - who's going to call the code? We need to completely re-animate primary care...), we may be able to solve problems that start at the consumer level.

Without trusted, quick, affordable primary care, customers bypass initial medical evaluation and carry issues through to hospital care (now PCP = triage nurse on duty), due to lack of interaction with a 'general' medical partner (i.e. the now severely endangered personal physician) who acts as a gatekeeper.

Example: If my throat really REALLY hurts and has an icky coating on the sides and I'm tired and feel horrid and have a bump on the back of my head (swollen gland/lymph node) and I don't trust my PCP, or worse yet, don't have one, what do I do?

I point my mono-stricken self to the nearest ER, where it takes 4.5678 hours to get tested and get results (+ for EB).

However, if I have a very active, engaged PCP that I consider a partner in my health and wellbeing, I call (or email) and make an appointment.

Because I trust her, and she knows me and my health as well as I do, I'm willing to wait for that appointment (unless of course my condition becomes a true life/limb threatening emergency, not just an emergent PITB).

Happy Hospitalist thinks this is the solution.

John Sharp at E-Health has a good post on primary care here.

Here's another good question: why has the hospitalist specialty grown so fast?

One factor: they're one component of a cadre of new services replacing primary care (Exhibit B = rise of the retail clinics).

Hospitalists do what PCPs used to do...provide comprehensive, personalized medical care across the complete spectrum of your entry, exit, and re-entry into the healthcare system (which in the US has almost become synonymous with hospitals).

So Mission Impossible for the next 10 years? Reinvent primary care.

Luckily, some docs aren't waiting for bureaucracies to generate change - concierge care and personalized medicine a la Jay Parkinson have seen market opportunities and seized them.

How would hospitals do the same?
Build on the hospitalist model.

At AMCs, make PC (personal care) a specialty. Recruit physicians who have shown an interest in both the business (MBAs) and the empathic (PsyDs, etc.) sides of medicine.

Build new partnerships with your cadre of promising PCSs.

Give these docs the opportunity for unique affiliations with your hospital.

House them in the medical mall near your main building, provide them with hospital privileges, outfit their offices with compatible/copycat EMR and HIT systems so when a patient of theirs is admitted, they receive real-time updates at the office. They should be able to access results between visits.

In short, treat them like specialists - because that's exactly what they are.

Give them access to unique benefits including outsourced accounting used by the hospital, etc.

Value them for what they are (gatekeepers and primary partners in care) and for what they could become - acting in concert with consumers, co-saviors of the American healthcare system.