Guest Editorial

Time Is Right for 24-hour Primary Care Clinics

(Editor's Note: An earlier version of this article(www.tafp.org) was posted in the Texas AFP blog.)

Luke Fildes' painting The Doctor epitomizes the primary care physician that our younger selves aspired to become. That kind of doctor-owned practice is now slipping away as quickly as the business model supporting it.

[portrait of james walker, md]

J. Stefan Walker, M.D.

Family medicine has been the most highly recruited specialty for more than a decade.(www.merritthawkins.com) With demand and salaries for employed FPs continuing to increase, the prospect of starting or joining a private practice and treading water in a sea of acronyms (MACRA, HIPAA, HMO, ACO, etc.) for margins that barely cover overhead no longer makes sense to most family physicians. No wonder that in 2016, for the first time, the proportion of U.S. doctors who partly or fully owned their practices dipped below one-half.

As inpatient care became a separate field, primary care was mostly sidelined into a 9 to 5 office job in a role now shared with midlevel practitioners, retail clinics and telemedicine services. Unlike many other specialists who still see patients during nights and weekends, primary care is now conspicuously absent in that important space, putting more pressure on family physicians to justify the level of reimbursement that can support independent practices. Now a rarity, small primary care practices -- even those still thriving today -- risk succumbing to this tide of obsolescence, not unlike local department stores and indoor shopping malls.

But the most powerful innovations are borne of necessity. To avoid impending demise, independent primary care must evolve to fill a market niche. As it turns out, doctors, patients and payers alike agree on their most critical need. They call it the Triple Aim: three core tenets of higher quality of care, reduced cost of care and expanded access to care. Despite a decade of efforts, this common goal of U.S. health care remains mostly unrealized, and care has never been more fragmented, patients more dissatisfied or physicians more demoralized than right now.

Here, then, might be a golden opportunity for family physicians to address this elusive Triple Aim by embracing two key elements largely missing in today's health care system: personal continuity of care and authentic commitment between the physician and patient. To achieve this, we will need to fundamentally change our practice logistics to embrace patient care around the clock, as doctors have done for millennia -- but now in the context of a 24-hour clinic.

Enter a practice arrangement in which seven to 15 doctors work on rotating shifts in a physical clinic they themselves own and operate 24/7, 365 days a year. This clinic would always be open, always staffed and always ready to see established patients. Care would be available anytime -- even at, say, 3 a.m. -- and include routine, preventive, chronic or urgent visits.

[The Doctor, a painting by British painter Sir Samuel Luke Fildes showing a physician at the bedside of a critically ill child]

First exhibited in 1891, The Doctor, by British painter and illustrator Sir Samuel Luke Fildes, was inspired by the death of Fildes' 1-year-old son Philip in 1877.

This model normalizes the personal doctor-patient commitment, which is the only way patients maintain access to the practice and its services. Care would be affordable even for uninsured, cash-paying patients -- and would fit several primary care payment models -- insurance, direct primary care and concierge -- simultaneously, under one roof. No more having to miss school or work for doctor visits. No unfamiliar places and provider off hours. No segregation of patients within the same clinic, because all patients would be "concierge class" in this model.

Payers could save millions by eliminating unnecessary ER visits and hospitalizations, resulting in industry-leading fee-for-service rates negotiated by the group practice.

For the clinic's doctors, the satisfaction of delivering true continuity care as a team would be extraordinary; they would be able to address patient needs in real time with excellence, no longer bound by the 15-minute visit treadmill or endless arbitrary paperwork. And they would enjoy the esteem of their outside colleagues, who would witness them taking care of their patients quickly and responsibly, not pushing them downstream to midlevels, ERs or urgent care clinics unless the case at hand truly exceeded physician or facility capabilities.

Doctors in the group who needed schedule flexibility for parental duties or other commitments could sign up to work more odd hours and weekend shifts in their clinic rather than having to moonlight or being forced into part-time arrangements solely because of schedule constraints. Even when not covering the call shift on a given day for walk-ins, any of the doctors could work in their patients off hours if desired or needed, since the facility would always be staffed. The clinic also would have the potential to fully optimize the office space rather than allowing it to lie empty and unused on nights and weekends.

In stark contrast with the tenuous and frustrating experience in many small practices today, the 24-hour primary care clinic would offer a way for family physicians to achieve success on par with or exceeding that of other contemporary models of care, while simultaneously preserving the autonomy so important to the doctor-patient relationship. It appears that now might be the time to deploy this unique practice rubric to actualize better and more sustainable care -- not only in our field, but for the greater health care system.

J. Stefan Walker, M.D., is a board-certified family physician. He is one of five partners at Corpus Christi Medical Associates, PA, an independent adult primary care clinic in south Texas. The practice, established in the early 1980s, is exploring a transition into the 24-hour model described above. Walker may be reached at jstefanwalker@yahoo.com.