Marcus Welby, M.D. was a popular TV drama that ran from 1969 to 1976. The titular character was a symbol of a traditional physician archetype that was already fading from reality — the cradle-to-grave general practitioner that took care of patients in the clinic, in the hospital and at their homes. In the very first episode of the series, Welby drily eulogizes the dying off of his own particular breed of doctor when he addresses a room full of medical students, most of whom are destined for careers as specialists.
“General practice is performed standing up, sitting down, outdoors, indoors…wherever there’s illness. And that means everywhere. Because gentlemen, we don’t treat fingers, or skins, or bones, or skulls, or lungs; we treat people. Entire human people.”
That philosophy helped inspire David Meltzer, associate professor and chief of the Section of Hospital Medicine at the University of Chicago Medicine, to create his new idea for saving costs while improving quality: the comprehensive care physician model. At the heart of the program, recently funded by a $6.1 million grant from the Center for Medicare & Medicaid Innovation, is a sort of Marcus Welby for the 21st century, assigned to treat the patients that are most expensive to the U.S. health care system. By treating frequently hospitalized patients both inside and outside the hospital, the comprehensive care physician model hopes to leverage a stronger doctor-patient relationship to produce more cost-effective health care.
“Our goal will be to really understand patients’ needs so that we can give them the care that they need,” Meltzer said. “That should be better for them, and should ultimately be less costly for the health care system and produce better outcomes.”
The model is built upon 15 years of research by Meltzer and colleagues on the changing medical work force in the United States. Health care providers increasingly rely on specialized physicians known as hospitalists to care for inpatients, while primary care doctors are less likely to see their patients while they are hospitalized. Though Meltzer found that this rearrangement has produced modest benefits in terms of health outcomes and reduced spending, it also has created unintended rifts in a patient’s care.
“A whole series of trends have emerged over time that has made the traditional continuity in the doctor-patient relationship between the outpatient and inpatient setting more difficult,” Meltzer said. “It’s not that doctors don’t understand this continuity is important or don’t want to provide it; they face real barriers in caring for patients in both the inpatient setting and the outpatient setting. By focusing on frequently hospitalized patients, our CCPs will be able to have a real presence in the hospital and clinic on an almost daily basis.”
Those patients, dubbed “hot spotters” by surgeon/writer Atul Gawande, account for a significant portion of health care spending in the United States, with one estimate concluding that 5 percent of Medicare beneficiaries account for 40 percent of Medicare spending. In Meltzer’s model, a comprehensive care physician will lead a team of nurse practitioners, social workers, care coordinators and other specialists best suited to address the needs of such high-risk patients. CCPs will carry a panel of approximately 200 patients at a time, serving as their primary care physician during clinic visits and supervising their care while hospitalized.
The trial will enroll patients from the South Side of Chicago who are predicted to spend an average of 10 days a year in the hospital. Many of these patients are expected to be general medicine patients with chronic diseases, geriatric patients living in residence homes or patients with renal disease receiving regular dialysis treatment. Five CCPs will be recruited to serve as team leaders for the demonstration project, which is expected to begin in fall 2012.
Reviving the Marcus Welby model could be seen by some as mere nostalgia. But in its emphasis on the doctor-patient relationship, the comprehensive care physician model runs parallel to the recently established Bucksbaum Institute for Clinical Excellence, directed by Mark Siegler, Lindy Bergman Distinguished Service Professor of Medicine and Surgery. Research studies have found that the bond between physicians and patients does make a clinical and economic difference.
A 1984 Veterans Administration study compared patients who saw the same primary care doctor at every clinic visit against patients who saw a different physician each visit. It found reduced hospitalizations, hospital stays, and intensive care unit (ICU) usage in the group with higher continuity of care. Another study found that advanced lung cancer patients with integrated outpatient and inpatient care were 25 percent less likely to enter the ICU before death.
“There’s a huge literature suggesting that elements of the doctor-patient relationship, including trust, interpersonal relations, communication, and knowledge of the patient, are all associated with lower costs and better outcomes,” Meltzer said. “We believe that this model can produce huge benefits for patients and some real economic savings.”
But the success of the system will rely upon sustaining those benefits without burning out the physicians themselves. In the current pay-for-service health care world, physicians are pressured to see as many patients as possible rather than concentrate more time on those that are most sick. New payment models under review by the federal government through other CMMI grants, such as pay-for-performance and accountable care organizations, could be a more hospitable home for a comprehensive care physician. But no matter what system is implemented, creating a new, sustainable Marcus Welby will depend upon economic factors.
“We’re going to have to create work environments that work for these doctors,” Meltzer said. “The more economic pressure that is put on them in terms of the number of patients they have to see, the harder this job will be to sustain. But the more we can prevent that, the more attractive we can make these jobs look. The better doctors we’ll get, and the more sustainable they will be. That’s going to be a really important goal for us.”