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Can Specialists Save Primary Care?

Elyas Bakhtiari, for HealthLeaders Media, May 7, 2009

The problem with most solutions to the primary care shortage, including the increased reimbursements that I wrote about last week, is that meaningful changes won't be seen for several years. Medical training is by necessity a lengthy process, and attempts to widen the pipeline of primary care doctors—by increasing medical school enrollments or raising payments—do little to address the problem in the short term.

But perhaps we're missing an obvious solution by thinking only in terms of training a fresh group of primary care physicians. What if current physicians—specialists—could be retrained to fill gaps in primary care coverage?

The turnaround would be much quicker because these physicians have already completed training and in many cases have a base education in primary care. It wouldn't be enough on its own, but combined with other efforts to combat the primary care shortage, it might produce quicker and longer-lasting results.

This solution hadn't crossed my mind until Dale Keshishian, CEO of HealthWorks Academies, an organization focused on building the health delivery workforce, pointed out the possibility to me in response to last week's column. For Keshishian, this was a potential unintended consequence of shrinking the payment gap between primary care and specialists. She was concerned that specialists might represent themselves as primary care providers, effectively cutting into primary care doctors' turf and providing inferior care coordination, if increased reimbursements made it worthwhile.

But I have since seen the option discussed in a more positive light. Joe Paduda argues that it would be far "easier, faster, and cheaper" to retrain specialists than to increase primary care training from the ground up. Specialists already have the medical background and could be easily trained to practice primary care with a specialist tilt. Cardiologists, for instance, could take a more active role in follow-up care and overall coordination before and after a patient undergoes a major heart procedure.

This model only works, however, if it is worthwhile (i.e., profitable) for specialists. "The primary care shortage is already forcing many specialists to provide preventive services. If they were paid more for office visits, and less for procedures, you just might see more proceduralists take on primary care responsibilities," writes physician-blogger Kevin Pho, MD.

That's looking a little more likely after last week's Senate Finance Committee hearing in which a proposal was submitted to increase primary care and rural physician pay by at least 5%.

Is that enough to entice specialists to pick up more primary care services? Probably not. But it's enough to start a lobbying war between physicians looking for higher reimbursements and physicians afraid of a reimbursement cut.

And that's part of the reason this solution might never work. Individually, physicians work together and focus on patients' needs, but as a whole, physicians operate in specialty cliques and often let specialty interests override what's best for the overall healthcare system.

Furthermore, the effectiveness of retraining specialists as primary care doctors is limited. Real primary care doctors specialize in managing co-morbidities, as well as the relationships between specialists, hospitals, patients, and families. Retrained specialists will probably only be able to provide a watered-down version of that.

"If specialists are incentivized to provide primary care, we may see a decline in the care we have come to expect from primary care physicians," says Keshishian. "Would you want your cardiologist to manage your arthritic hip? Perhaps your orthopedic surgeon could manage your early Alzheimer's disease? What kind of ongoing follow up do you think you would get from your general surgeon to manage your routine health concerns?"

So there are pros, and there are cons. And truth be told, I don't know if this is a solution worth pursuing. But given the projected severity of the primary care shortage and the unique opportunity for healthcare reform, every solution is worth at least considering.


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Elyas Bakhtiari is a freelance editor for HealthLeaders Media.

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