3. Undervaluing of Cognitive Work Pulled PCPs Away from Complex Care
Payment models kept PCPs from the generalism that enables the missing piece to bend the complex patients' cost curve. Time for change.
In Post #1, I argued that after three decades of reform, complex patients still drive ~80% of health costs, and costs keep rising. What's missing? Whole Person Longitudinal Complex Care (WP LCC).
In Post #2, I said the reason WP LCC is missing is that it is possible only if we have true generalists, but most of today's PCPs are no longer true generalists.
In the 1960s, knowing 150-200 diseases at late presentations was enough, but today it takes 400+ across both early and late presentations. The scope of generalist cognitive work changed — but primary care didn't.
Why not?
- Fee-for-service set by third party payors discouraged true generalism's much greater cognitive work per patient encounter.
- Capitation enticingly provides PCPs with financial predictability but rewards simple care and punishes whole person complex care. It doesn't just discourage; it hollows out true generalism.
- Value-based pay models have diverted bandwidth into metrics and reporting, leaving even less for any heavier cognitive work.
As payment pulled PCPs away, training programs followed.
In my next post, l'll lay out some paths on how incentives can come to be aligned in the future to bring about whole person longitudinal complex care.
- - - - - - - - - -