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Primary care medicine: A clinical specialty, or managed care travesty

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Medical practice is “the strenuous task of healing humans as a lone body within the context of its inexhaustible scope of individuality. It is one, and the only science that arrives with indefinite capabilities henceforth obliging knowledge on every aspect of our life without prejudice. Latter is a must-have to heal to the best of the healer’s ability. Mastery around the art of medicine is endless. But in today’s tainted world, such a notion is a matter of argued sentiment.

Medicine is one of the most (if not the only) politicized profession of history. It suffers division into many realms, on many grounds for a multitude of justifications. Over the past two centuries, the practice of medicine has been utterly fragmented by politics and extortions more so over the last few decades. It’s merely due to socioeconomic, bureaucratic, and political motivations, where some have lived relevance of the time and situation, others matter of personal reverence by physicians, but many derivatives of administrative longings such as influence and manipulation. 

It was not until the early 18th-century when only a Few states in the United States facilitated the introduction of medical specialties when already existed in Paris. At that moment, American medicine was dominantly a uniform practice system. Even today, every physician licensed to practice as a physician maintains the concomitant privilege of practicing medicine and surgery”.

Prior to the 19th-century reform, neither hospitals nor the medical schools were publicly governed. Hereafter they faced pressure under” administrative” rationalization, which facilitated specialization on the European continent. Concomitantly, in Britain medical aristocracy was dashingly splitting up; institutionally between physicians and surgeons. By the reform, accountability was coming to be increasingly peculiar. The criterion in the United States was going to integrate three European adopted branches of medicine prescribing, physic, and surgery. But as cities developed, the separation of activities became more pragmatic. In 1765, after spending five years studying medicine abroad, John Morgan who was a well-known founder of Public Medical Instruction in America, publicly declared constraining his medical career to physic by renouncing surgery and drug-dispensing. A half-century after Morgan’s decree, the Boston physician James Jackson, having already abandoned the practice of surgery, was called upon in 1818 to send a message to his patients clarifying his rationale for renouncing the practice of obstetrics.

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Bereft of skepticism throughout its evolution, medicine has been broken down not by personal preference of the healer but based on western socio-political bureaucracy and economic rent. Today we can encounter many specialties as well as sub-specialties that are merely supported by societies, boards, and organizations under the identical 19th-century concept of amenity; and only continues to evolve into a more segregated system of faculty.

One of the most recent crazes is the theme of primary care medicine. The latest concept refers to the upbringing of a three-decades-old program assembly centered on the mission to reduce healthcare costs, make medical care accessible to everyone, and improve its efficiency. Primary Care Medicine is the health maintenance organization (HMO) preferred model for segregating a group of medical professionals under a single umbrella to conform to their objective. However, “Despite managed-cares fiscally driven strives” to acquaint primary care medicine as another embodiment of clinical discipline, yet hard to dismiss the reality that it’s nothing but a title ridden over their bureaucratic appointment of the particular job description to medical doctors.”

Medicine is the science of curing the Human. The body and soul constitute the psychological and physical sphere, each with respective sub-components that function in conformity. Without one part, there wouldn’t be any health,’ hence no life. To heal, a physician needs to appreciate somebody as a single existence. The mastery of convalescence is a skill set with its own particular sub-skills. Since one can never be perfect at every aptitude, ultimately must acquire an adequate understanding to as for the right help from the correct peer. That’s how most people speculate that medical specialties are formulated.

But in certainty, the painting of clinical domains are anything but that! For instance, attorneys, even though they select a specific legal arena to pursue, but they solely incite through mentorship and preceptorship on the given skill, as there is no such dedicated path as family law specialty board for lawyers in the same connotation as there is one for family medicine.

A medical specialty is distinguished as the limb of medical practice that is concentrated on a defined group of patients, diseases, skills, or doctrine. In the preponderance of cases, a physician who advances from medical academy must elect a practical path in one of those branches and pass a written exam to fulfill the minimum provision for a particular capability that supports that territory of medicine. Primary care medicine, in essence, neither has a clinical path not possesses an assessment, but some of the departments are deemed to be considered as primary care practices, such as family practice, pediatrics, and internal medicine. Except for the family practice that occurs as a broad-based training, logically there is no other that possesses a substantial basis for plummeting under the recent classification

In my past writings, I have frequently spoken of Broad-based skillset vs. the vertical skills; and how they have been subjected to partiality to enforce economic-rent. In this article, I prefer to magnify on the monopoly of primary care medicine.

What is primary care medicine?

For the sake of assertion, while I was exploring the web for several definitions. I came across some descriptions from the American Academy of Family Practice (AAFP). Interesting enough, it contains five distinct explanations! without going into the details while attempting to interpret Primary Care, we must first comprehend the essence of the services delivered to patients; furthermore must identify who are the primary care providers. The realm of primary care contains a myriad of skill sets and backgrounds and in allotted cases, may not be graduates of the medical doctor training scheme. Accordingly, definitions can be subject to variation, thus incomplete without any amended portrayal of the primary care practice.

The definition furnished by Wikipedia is the simplest one I could find. It defines the primary care physician (PCP) as one who provides both the initial medical care to the undiagnosed medical concern as well as offering continued care, not limited by cause, organ system, or diagnosis. Although the word primary has been nearly wholly utilized within the United States, nonetheless phrases like General practitioners relate to similar intuition. 

In a pragmatic understanding, primary care is a profile of classification given to denomination of professions spoken of earlier that also comprise the title of General practitioner. 

History of primary care medicine 

In, validity the very early concept of primary care medicine was inaugurated by a Chinese educator and organizer with mass literacy and rural reconstruction expertise. Y.C. James Yen and Liang Shuming were also known as barefoot doctors in the 1920 Rural Reconstruction Movement of China. The movement’s mission was to provide the minimum necessary quality medical service to Chinese rice farmers by training volunteers from the same villages to offer essential primary medical services. The concept of Barefoot doctors came to be desirable to the World Health Organization (WHO), hence it was revised under the Alma-Ata Declaration of ‘Health for all’; 1978. That, in turn, attended as a precursor for the modern primary care practice, the one we can recognize today.

Managed care history and principles

Although exertions of various reimbursement models in the U.S. narrative can be drawn back to the 1940s, however, Health Maintenance organizations (HMOs) borrowing primary care models officially emerged in the early 1980s, after the Alma Ata declaration. The term managed care or managed healthcare are the ownership lent to an assortment of activities in the United States by Health Maintenance organizations (HMO) to curtail the toll of delivering for-profit medical benefit through subsidy of 3rd Party reimbursement model with a purpose of improving quality of care (“managed care techniques”). While Managed care entails a variety of forms, today it has virtually taken over the entire network of delivering health care to most Americans. Heretofore its enactment in the early 1980s has not only been unaffected by the Affordable Care Act of 2010 but even bolstered through stipends collects under ACA policy. Managed care delivery system integrates both the financing and delivery of health care for enrollees. In the layout of the plan, each member has typically appointed a “gatekeeper”,i.e. a primary care physician who is beholden for the across-the-board care of patients allocated to them by the network. Specialists, on the other hand, foresee a referral from the PCP. 

Due to its constantly changing disposition, the managed care concept has become the slippery slope intuition. Its permutations are in a try to impact and diversify the behavior and exercise of physicians along with other healthcare professionals. Even though managed care rationale is overseen by cost-saving strategies while insulating physicians from administrative and business endeavors, nonetheless, a comprehensive appraisal of its outcome is inherently dubious.

Aging, Elderly, Senior, Aged, Person, Mature

Managed care organizations by disposition thrive on curbing medical cost inflation in the 1980s by curtailing undue hospitalizations and compelling physicians to reduce their service expenditures. Over time they strategized promptly conforming to be virtually widespread in the United States. Their brisk expansion has led to a consumer backlash; because oftentimes their cost-control efforts were driven by the enthusiasm to cultivate revenues and not delivering health care. According to the 2004 census by the Kaiser Family Foundation, a preponderance of those questioned proclaimed that they felt managed care curtailed the duration doctors consumed with patients and made it problematic for those who are sick enough to see specialists. Patients also believe HMOs flunked to evoke considerable health care savings.

Why not General practice or Family practices?!

The word; primary care is hypocritically conflicting, as it entertains the notoriety of those who are merely illiterate to the essence of the medical care task with a broader footing, e.g.. Family practice and General Practitioners who are well suited within the mighty spectrum of professional roles, while moreover comprise midwives and pediatricians who have a narrower expanse of practice. To conserve the oneness of the human body and health, it’s exceptionally revolutionary to split the skills into the solitary grey territories unless for admin and financial spurs. A notation of family or general practitioner is precisely relevant to the title for a physician who willingly selects broader skill sets.

Primary care to include physician assistants, midwives and nurse practitioners in the classification

There has been fierce controversy over the part and the degree of involvement from allied medical providers such as nurse practitioners (NP), physician assistants ( PA) or midwives who are authorized for primary medical care practice. It has also been a great topic of debate as to if they need to be supervised by a physician. The latter argument inescapably opens up a question of another great significance- how does primary care function discerns the quality and value of a service provided by various clinical disciplines?! If they all stand the same, then N.P.s should not require oversight. Or, if not equal then the intent is clearly to devalue the role of physicians within the general practice vacuum. Or- perhaps the value-based compensation that is being thought of by the existing insurance industry ( more so HMO) is prone to manipulation hinging on the economic stature. Therefore it is essential to solidify the authentic meaning of the value. Otherwise, we may overlook an exponentially heightening burden on physicians who elect to practice general medicine profile identical to the recent efforts put forth by the U.S. Department of health and human services and the center for Medicare and Medicaid to engage primary doctors in delivering merit-based care to Patients and prevent burnout among them.

Primary care is nothing but bundling of the already swaddled set of clinical skills under the explanation of cost-saving and efficiency of healthcare delivery. It’s remote from comprehension that modest mode of family practice does to fill the intention to elicit the same impact.

Previously, I embellished on controversies encircling Licensing and certification. Within the breadth of discussion, I also accentuated how historically regimes have used licensing exercises to Bogart the talent-driven economy, along with many other routes. The concept of primary care conforms exactly someplace within the latest categories. Reorganizing the set of Talents and skills to satisfy an agenda resembles the gamification of job and value through favoritism. Societies and associations function towards enhancement of the latter mission are also noteworthy.

Indicatively, the healthcare system has been the victim of the paradoxical sentiment of medical societies and associations contaminating the core of medical education, establishment, and physician career through a three-century-old pseudo-utilitarian philosophy that has benefited from the patient and physician candor. They have utterly broken the system through illegal unsustain protocols, procedures and their application to physician licensing, reimbursement, ICD / CPT coding practice, and fictitious value. World health organization organizations’ (WHO) stance on Alma-Ata declaration and introduction of ICD-10 coding seem contradictory; hence as of today has not shown any evidence that it’s offering enough solution or motivation to equalize affordable and quality medical service to underserved communities across the world.

Underserved areas are no different than any other parts of the region besides wanting resources. Their problem is not lacking primary care or lack of financial support. Underserved areas are the upshot of impoverished distribution of opportunities for its constituents to be sovereign. Fiscal relief is an interim explanation, where donating reserves must be protected by virtue of immediate locality. Primary care in the HMO system is the buffer tract to debt referral to physicians with vertical skill sets; because- vertical skillset has higher cost through the unsubstantiated economic rents. The pretense of the notion-” quality of the same care is always better if rendered by specialist” is radical and ludicrous. What determines the quality of medical attention is steered by unique individual determinants and realistic criteria. 

The verticality of skill set is not the logical way to deduce quality, as doctoring uncomplicated Hypertension should not be more costly if attained by cardiologist versus a family practice physician! Instead, quality should be independent of medical specialty. In fact, it is the accepted personal determinants between a physician and the patient that decipher into the quality of care irrespective of who is rendering the service.

Some argue the value of a medical service ought to be directly proportional to the level of education or years expended to earn the skill. Naturally, the specialist holds mastery that non-specialist absence. That has the value of its own, as a general practitioner does not wield some of the skills clenched by the specialist. But for all-around if one possesses the aptitude to treat an uncomplicated high blood pressure while the treating physician furnishes the optimal quality, thus reimbursement and value of the service must not fluctuate between any physicians with comparable talent.

So again; why create primary care title, and Why not call it merely family practice or general medicine?

Primary care is another bolt in the licensing chain. It is the low-cost dumping turf of the healthcare system composed to deliver identical services at the lowest cost by devaluing the significance of the physician’s role while overvaluing the part of the domains that were signified before to earn comparably less. Primary care is the 20th-century job description for the healthcare management organization. It Conflicts with value-based reimbursement, on the one hand, Physician burnout on second pointer and conflict of extreme application of protocols by rendering primary care as one-size-fits-all model across all the participating clinical disciplines (e.g., N.P., MD, PA, etc.) on another.

Although it was postulated in considerable healthcare facets that the primary care concept plays a central role in the personalization of medicine, nonetheless it is farfetched from being valid. Primary care has been fundamentally ascertained to be the gatekeeper for patient access to liberal healthcare reserves; something that is critical when contemplating the personalized alternative. The conflict between consolidation vs. Collaboration in primary care doctor burnout is worthy of remark, since almost every primary care model, must pursue a set of preordained consolidative protocols as one single component in a system- protocols inscribed by a few but obeyed by everyone. Independent Collaboration between every element of personalized healthcare; from a physician, nurses to patients is essential to protect the quality of service and patient satisfaction. 

Primary care was acquainted on the theory that it puts up with a village to take care of a patient, but what kind of village would it be when everyone follows the same protocol?!

It is not mysterious that millennials expect options. That is only going to prevail further, as the liberated millennial attitude is mainly applicable to all aspects of their lives, to which healthcare is no Odder. The option is the key! -Something managed care systems borrowing of primary care notion to ratify merit-based reimbursement can never extend. Education-based triage of patients to physicians with the corresponding skill set is more inviting to the modern era citizens who have access to the ocean of valuable data.

How about physician shortage?

In contrary to what is being conveyed to us, there is no shortage of primary care physicians or providers. There are indeed impoverished geographic, skillset, and socioeconomic distribution. By forcing universal injunctions on physicians; the administrations are only moving to expand the limited scope of medicine against providing given services that primary health physicians are capable of handling. The approach is going to upset the already uneven distribution of standard of care across all socioeconomic and geographic borders even further. Rather, they must enforce quality, not license and certification; Value delivered, not by whom is being provided; Distribute care based on skills, not the countenance of title.

The primary care designation desires transparency to function as it is intended, needs to have one single definition. We are utterly concealed in The Pitch Dark Tunnel of Healthcare. While we speak of price transparency narrated to clinics and hospitals, all we end up accomplishing is that we make only one portion of the tunnel visible while rest lives pitch dark; hence we get to see only one part of the puzzle, while the rest is obscure.

Accountability, the right way is the government’s responsibility under transparency. To achieve and minimize bureaucracy, we must simplify the process of implementing clearness and responsibility without direct interference with its logistics.

Millennials need to find the ideal personalized care by seeking professional help from the affiliated domain specialists from every industry- That includes medical professions. Technology leadership of the healthcare realm must be incorporated into the medical school curriculum. Physicians must meet millennial patients at the swiveling juncture of altering medical terrain by utilizing the support of baby boomer physician’s intuition for personalized healthcare for everyone. Respect individual expectations, Expand the role of physicians, not just a group within the managed care system.

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Adam Tabriz, MD
Dr. Adam Tabriz is an Executive level physician, writer, personalized healthcare system advocate, and entrepreneur with 15+ years of success performing surgery, treating patients, and creating innovative solutions for independent healthcare providers. He provides critically needed remote care access to underserved populations in the Healthcare Beyond Borders initiative. His mission is to create a highly effective business model that alleviates the economic and legislative burden of independent practitioners, empowers patients, and creates ease of access to medical services for everyone. He believes in Achieving performance excellence by leveraging medical expertise and modern-day technology.

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