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The Cost-Effectiveness of Family Physicians – Complexity

June 16, 2013
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We continue to examine the results of our recently published study on the ways family physicians deliver better care at a lower cost than a multi-ologist approach.

The next concept is complexity. Family physicians are more comfortable with complexity than any other physicians, especially in their ability to negotiate the diagnostic and treatment options of all the sub-issues for complex patient situations.

This finding that family physicians are more comfortable with complexity was also reported in the Future of Family Medicine project. When non-FP community physicians were surveyed about which physician they would rather have manage a patient with multiple complex problems, family physicians or internists, these community ologists overwhelmingly chose family physicians.

This is an area where the disconnect between reality and the perception of family medicine of the U.S. public is the greatest. Much of the public believes the role of family physicians is merely to mange colds and perform disease screenings. But the real efficiency of the attitudes and skills of family physicians blossom when they take ownership of the most difficult cases.

What is the best way to manage a patient with six chronic diseases, who says she can only afford four of her medicines, who has mild dementia, who has family in town that fight with her constantly, who refuses to allow anyone inside her home to help her, and who doesn’t speak the language of the treating physician?

There is no right or best answer for this scenario, but family physicians, especially those who work in safety net clinics, have to deal with situations like this every day. No ologist would ever take responsibility for the totality of the interacting forces in this situation. Each would slice out only the direct issues related to their favorite body part and let somebody else worry about the rest of the patient’s needs.

Unfortunately, several political winds are pushing family physicians farther from fully managing these types of patients.

  • Neither CMS (Medicare) nor insurers adequately pay family physicians to manage these complex patients in the hospital.
  • For that matter, neither CMS nor insurers adequately pay family physicians to manage these complex patients in the clinic.
  • The guideline/measurement movement incentivizes physicians to dump the complex patients with social, financial, and mental health challenges so the physicians can look better on HEDIS-type scorecards.
  • The monthly fee/concierge movement also incentivizes physicians to dump complex patients. I don’t think any risk-adjustment tool adequately corrects for complex patients with social, financial, and educational challenges.

And where is the AAFP on this? I don’t recall ever hearing a statement from the AAFP touting the skill of family physicians in managing complex patients. A glance at the page describing family medicine to the public on the AAFP website only uses the word “complex” once to describe the healthcare system; implying that the family physician’s job is to be a sort of medical traffic cop directing patients to other physicians for the hard work.

Family physicians shouldn’t and can’t do everything themselves. Some aspects of team-based care have merit. Ologist help is often needed, but it’s best utilized when it is focused and either brief or clearly defined. But what some of the primary care advocates don’t say clearly enough is that patient-centered medical homes don’t make complex decisions for complex patients, family physicians do.

Unless family physicians are willing to step back up to the plate to take responsibility for the sickest most complex patients, billions of U.S. healthcare dollars will continue to be wasted and family medicine will continue to operate only on the margins of the U.S. healthcare system.

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