The Retainer Model or Single Payer — What Will Save Primary Care?
Robert M. Centor, MD; Charles P. Vega, MD
Point: The Retainer Model May Stimulate a Rebirth of Outpatient Internal Medicine
Robert Centor, MD
Outpatient internal medicine has joined the endangered species list, or at least so many commentators have opined.
Fewer internal medicine residents are opting for outpatient jobs. Many outpatient internists are leaving practice, either for fellowships or for hospitalist jobs.
As I consider the medical student’s choice of internal medicine for his or her career, I note that the fascination with internal medicine usually results from the complexity of the field. Internists champion the care of complex patients. We love diagnostic and management puzzles. In the 1970s and 1980s, many internists embraced a definition of primary care that the Institute of Medicine (IOM) codified:
"A set of attributes, as in the 1978 IOM definition — care that is accessible, comprehensive, coordinated, continuous, and accountable — or as defined by Starfield (1992) — care that is characterized by first contact, accessibility, longitudinality and comprehensiveness."
Training programs produced internists who could care for complex disease and also handle a wide variety of clinical issues, including episodic care and preventive medicine. Over the following 30 years, our society apparently has redefined primary care to a definition that degrades the original concept. The American Heritage Dictionary in 2006 provides this definition for primary care: "The medical care a patient receives upon first contact with the healthcare system, before referral elsewhere within the system."
I believe that most insurers and other physicians no longer consider comprehensiveness when they think of primary care.
I would argue that internists do not want and are not trained to do this limited conceptualization of primary care as defined by the American Heritage Dictionary; rather, we are trained to add primary care services to our comprehensive care. Such distinctions underlie the angst of many practicing internists. We have trained a generation of internists to provide comprehensive care, including episodic and preventive care, and yet insurers and especially health maintenance organizations complain that internists are not good at providing quick, efficient primary care. Family physicians are in a similar situation. We have a problem of semantics and thus our discussions about primary care remain confused.
Our reimbursement system also does not pay internists sufficiently to provide high-quality comprehensive care, although our patients are too complex and require more time than what insurers believe constitutes a standard office visit.
Specifically, patients need various levels of intensity. A 30-year-old mother with a sore throat has different physician needs than a 55-year-old man with chronic obstructive pulmonary disease, heart failure, and type II diabetes mellitus.
Clearly, the latter patient will need longer and more frequent visits. Moreover, our current system does not reimburse out-of-office continuity. We have no reimbursement for telephone calls or emails, although patients often have questions
for their physicians. They would like to call their physician for advice, or to …