Book Review Health AffairsVol. 37, No. 8: Medicaid, Markets & More Reclaiming Primary CareJeff Goldsmith AffiliationsJeff Goldsmith ([email protected]) is president of Health Futures, Inc., and national adviser for Navigant Healthcare. He is based in Charlottesville, Virginia.PUBLISHED:August 2018Free Accesshttps://doi.org/10.1377/hlthaff.2018.0670AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSPrimary careSystems of carePhysiciansPhysician-patient relationshipPaymentPatient burnoutIn Paul Starr’s magisterial The Social Transformation of American Medicine, the ominous concluding chapter was titled “The Coming of the Corporation.” Starr argued that the dominant position of American physicians in both health policy and the care system itself was going to be threatened by corporate enterprises and by a commercial ethos that would commoditize their services. Reading Timothy Hoff’s elegiac new work, Next in Line, one concludes that the battle is over and the machines have won.Hoff is a veteran health services researcher who specializes in studying the organization of physician care. His new book is based on eighty in-depth interviews with primary care physicians and patients. One is struck, in listening to their fresh, clear voices, by how little we have heard them in the last eight breathless years of coverage expansion and technocratic enthusiasm for redesign of care and payment schemes.The central goal of Hoff’s analysis is to discuss what has happened to the primary care physician–patient relationship as the health system transitions from a relationship-based care model to a population-health model. What Hoff believes is lost in this shift is an element of trust and interpersonal connection between caregivers and patients, which he convincingly demonstrates is central to improving patient outcomes and to healing from illness.There is great pathos in both physicians’ and patients’ reactions to this change. In Hoff’s interviews, primary care physicians seem to be grieving the loss of the close personal connections with patients that motivated most of them to enter the profession. This loss is a major contributor to a decline in professional satisfaction with practice, and to physician burnout. At the same time, patients seem to have resigned themselves to a less intimate, transactional relationship to the care system, in which their physicians play a diminished role, and their role as “consumers” is increasingly burdened by large personal financial exposure to the cost of care.If, in Next in Line, there is something resembling a “primal scene” in the new medicine, it comes in a primary care physician’s discussion of patients’ reactions to Medicare’s “wellness visit.” According to one rural family practitioner, Medicare patients hate these highly scripted, check-the-box visits because there isn’t sufficient time to actually address their medical problems; patients are angered that another visit will be needed to do that. Yet the physician’s accountable care organization is graded in part by the number of these wellness visits, and there is pressure on him and his colleagues to do more of them.Hoff believes that the Affordable Care Act accelerated the shift to a population health model by focusing on care models that deemphasize one-on-one relationships and attempt to quantify value through elaborate documentation requirements. Hoff refers to the latter as “metrics mania.” In this concern, he finds common ground with Donald Berwick, Peter Pronovost, Christine Cassel, and others who have argued for rationalizing the documentation burden as a key element of improving physician morale and productivity. Hoff’s book dovetails with Robert Wachter’s The Digital Doctor in its emphasis on recentering physician care on relationships to patients.Hoff’s recommendations about reclaiming the relationships at the core of primary care medicine include a better focus on communication skills in medical education; direct primary care models that rely on subscriptions rather than fee-based payments; and employed physicians demanding, through collective bargaining if necessary, more face time with patients, more manageable patient panel sizes, and limits on electronic health record documentation time requirements. Hoff seems to feel that the newly proletarianized primary care cadre are ripe for unionization or less formal forms of collective action against the health care conglomerates that employ them.In Hoff’s view, the central challenge primary care physicians face is reclaiming the human quality of their work as new digital tools and care models emerge. Medicine is the most intimate human service in our economy. Clumsy efforts to “industrialize” this service have damaged both the morale of our clinical workforce and the credibility and effectiveness of the professionals who take care of us. Caring and healing are vital core elements of what our health system provides us, not just “externalities” of some vast economic process. Hoff’s sophisticated analysis is a reminder of what we stand to lose as a society if we don’t get this right. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 6 August 2018 Information© 2018 Project HOPE—The People-to-People Health Foundation, Inc.
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Dec 1, 2018
David B Flannery 
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