A model whose time has come
J. Stefan Walker, MD
Luke Fildes’ portrait “the doctor” epitomizes the primary care physician that our younger selves aspired to become.That kind of doctor-owned practice is now slipping away as quickly as the business model supporting it. Where $300,000 per year is the new benchmark for employed primary care positions, the prospect of starting or joining a private practice only to tread water in a sea of acronyms (MACRA, HIPAA, HMO, ACO, etc.) for margins that barely cover overhead no longer makes sense to most family physicians. No wonder that in 2016, for the first time, less than half of American doctors partly or fully own their practices.
As the care of inpatients became a separate field, primary care was mostly sidelined into a 9 to 5 office job in a role now shared with mid-level practitioners, retail clinics, and telemedicine services. Unlike many other specialists still seeing patients during nights and weekends, primary care is now conspicuously absent in that important space, further putting pressure on family physicians to justify the level of reimbursement that can support independent practices. Now a rarity, small primary care practices — even those now thriving — risk succumbing to this tide of obsolescence, not unlike local department stores and indoor shopping malls.
But the most powerful innovations are borne of necessity. To survive impending demise, independent primary care must evolve to fulfill a market niche. As it turns out, doctors, patients, and payers alike agree on their most critical need. They call it the Triple Aim, a concept one might interpret as three core tenets: higher quality of care, reduced cost of care, and expanded access to care. Despite a decade of efforts, this common goal of U.S. health care remains mostly unrealized and care has never been more fragmented, patients more dissatisfied, nor physicians more demoralized than right now.
Here, then, might be a golden opportunity for family physicians to address this elusive Triple Aim by embracing two key elements largely missing in today’s health care system: personal continuity of care, and authentic commitment between the physician and patient. To achieve this, we will need to fundamentally change our practice logistics to embrace patient care around the clock, as doctors have done for millennia — but now from the context of a 24-hour clinic.
Enter a practice arrangement in which seven to 15 doctors work in a physical clinic they themselves own and operate 24/7 and 365 days a year by rotating shifts. This clinic is always open, always staffed, and always ready to see established patients. Care is available anytime — even at, say, 3 a.m. — and includes routine, preventive, chronic, or urgent visits. This model normalizes the personal doctor-patient commitment, which is the only way patients maintain access to the practice and its services. Care is affordable — even for uninsured, cash-paying patients, and fits all three primary care payment models — insurance, direct primary care, and concierge — simultaneously, under one roof. No more having to miss school or work for doctor visits. No unfamiliar places and provider off hours. No segregation of patients within the same clinic, as all patients are ‘concierge class’ in this model.
Payers save millions by eliminating unnecessary ER visits and hospitalizations, resulting in industry-leading fee-for-service rates negotiated by the group practice.
For the clinic’s doctors, the satisfaction of delivering true continuity care as a team is extraordinary, being able to address patient needs in real time with excellence, no longer bound by the 15-minute-per-visit treadmill nor by endless arbitrary paperwork. The 24-hour group’s partners enjoy the esteem of their outside colleagues, who witness them taking care of their patients quickly and responsibly, not merely pushed downstream to mid-levels, ERs, or urgent care clinics, unless the case at hand truly exceeds the physician or facility capabilities.
Doctors in the group needing schedule flexibility for parental duties or other commitments can sign up to work more odd hours and weekend shifts in their clinic as opposed to having to moonlight, or being forced into working in part-time arrangements merely due to schedule constraints. Even when not covering the call shift on a given day for walk-ins, any of the doctors can work in their patients, off hours if desired or needed, since the facility is always staffed. The clinic also fully optimizes the office space, which would otherwise lie empty and unused on nights and weekends.
In stark contrast with the tenuous and frustrating experience in many small practices today, the 24-hour primary care clinic offers a way for family physicians to achieve success on par with or exceeding other contemporary models of care, while simultaneously preserving the autonomy so important to the doctor-patient relationship. It appears that now might be the time to deploy this unique practice rubric to actualize better and more sustainable care — not only in our field, but for the greater health care ecosystem.
J. Stefan Walker, MD is a board-certified family physician. He is one of five partners at Corpus Christi Medical Associates, PA, at an independent adult primary care clinic in south Texas. The practice, established in the early 1980s, is exploring a transition into the 24-hour model described above. Dr. Walker may be reached at firstname.lastname@example.org.