Five Questions With: Dr. David Marcoux

Dr. David Marcoux is co-founder of University Internal Medicine and president of the Community Physician Partners Inc. / COURTESY LIFESPAN
Dr. David Marcoux is co-founder of University Internal Medicine and president of the Community Physician Partners Inc. / COURTESY LIFESPAN

Dr. David Marcoux is co-founder of University Internal Medicine and president of the Community Physician Partners Inc., an independent physician association comprising Anchor Medical Associates, Medical Associates of Rhode Island, University Internal Medicine and University Medicine. An affiliation between Community Physician Partners and Lifespan allows the physician groups to remain independent while contracting with insurers to share responsibility for total cost and quality of care delivered through their patient-centered medical home practices.
Marcoux received his medical degree from the Medical College of Wisconsin and completed his residency at The Miriam Hospital. Marcoux, who also serves as an associate clinical instructor in medicine at The Warren Alpert Medical School of Brown University, talked with Providence Business News about Community Physician Partners Inc. and how its new relationship with Lifespan will impact patients, the partnership, Lifespan and the larger medical community.

PBN: Can you briefly explain how the partnership will work, and identify what you regard as the key benefits to Lifespan, to the physician groups and to the affected patients?
MARCOUX:
We believe that the primary care practice we have created is growing as we speak, and will help us organize our efforts as never before. While the practices are independent, each has a long and proven track record of quality care for patients. As primary care physicians, our expertise is in the management of the whole patient. We are in the unique position of providing comprehensive care for our patients; when the need for specialized care arises, we believe we know who is best able to provide that care well and cost effectively. We believe that we’re in the best position to assess the ‘value proposition’ in care. While this has always existed, it never came with financial repercussions, and that has become increasingly important.
The benefits of the partnership between CPP and Lifespan are truly bi-directional. We believe Lifespan to be the best and most complete hospital and specialty system in the state and in southeastern New England, offering the depth, breadth and quality of care that our often ill and complicated patients need. In turn, we can support Lifespan with needed and appropriate referrals, which will help to keep its piece of the health care delivery system going. And, we know we, in return, are receiving quality care for our patients. Personally, I strongly believe that good care is cost-effective care. Patients benefit when they get the right level of care, by the right doctors – primary care and specialists working as a team – at the right time.

PBN: In announcing the news of the new partnership with Lifespan, you said that PCPs want to go it alone, “but in this day and age, we just can’t.” What are the challenges and limitations that prevent physicians from doing so?
MARCOUX:
I may have misspoken about going it alone in the past. We absolutely know that good medicine is very much a team sport. As PCPs, we have certain skill sets that are essential and fundamental to care. However, our patients need specialty care – good cardiac, oncologic, orthopedic and GI care, to name just a few – that PCPs are unable to provide. I think in principle the PCP is best positioned to manage the often complex nature of the care that a patient needs, but as independent groups, and now even as one larger group, we need those services that Lifespan can provide – both the services our patients need and, from a business standpoint, the organizational foundation for an evolving Accountable Care Organization. We need high-level operational people for contracting, negotiating with payers and legal assistance to be sure that everything we are doing is proper. Lifespan has this infrastructure in place and has offered to work with us in getting our organization up and running, which is something we need and appreciate.

PBN: With the existing shortage of PCPs in Rhode Island, how will this new initiative – and perhaps, future partnerships – impact this shortage, which is only expected to increase? Will medical students be more or less likely to go into primary care, given this limited autonomy these partnerships present?
MARCOUX:
The physician shortage in primary care is real. I won’t say it is dire, but it is something that must be remedied if we are going to improve health care overall. There is no practice of PCPs in the state that couldn’t add another doctor or two tomorrow.
We hope that the primary care status increases with the recognition of its importance in managing and coordinating complex care. As that changes, incomes for primary care can grow and more medical students might move to primary care. The unfortunate truth at this time is that the gap between primary care and specialty pay is enormous, and I believe it does affect career decisions of medical students. Also, so much of career choice is affected by modeling. Unfortunately, PCPs are again at a disadvantage, as medical students have a very limited exposure to primary care in the office setting. They spend so much of their time in the hospital working with specialists, doing interesting and challenging work. It’s no surprise to me that given that, coupled with the chasm in income, leads more students to choose specialty care over primary care. I don’t think there is going to be an easy fix here; some of this will need to be done at the medical school level in terms of their curriculum and training venues. I don’t think having our incomes increase over time will hurt recruiting. The problem is partly that there is only so much money to go around, and any increase in pay for one kind of doctor will ultimately likely result in a reduction in pay for another.

PBN: This partnership will limit patients’ and physicians’ discretion to choose a specialist not affiliated with the Lifespan network. How can you justify these limitations of choice, and what response do you expect from patients?
MARCOUX:
The limited network issue is a real one. I would reframe this kind of problem as one of a ‘preferred quality’ network. On one end of the spectrum is the Wild West – patients going anywhere, anytime to see whomever they want to see, often with no communication between that provider and the PCP. On the other hand, a completely closed network totally limits patients in terms of choice. Some balance between the two will surely need to be struck; we hope and expect that our partnership with Lifespan will enable us to care for our patients nearly completely with a suite (vetted for quality and value) of services that will enable us to sustain good health care over time. After all, someone is paying for patient care – employers, The Centers for Medicare & Medicaid Services and us, as small business owners.
We all recognize the near runaway cost of health care in the United States – 18.2 percent of the nation’s Gross Domestic Product is spent on health care. This is about 50 percent more than any other industrialized Western country is spending on health care, and those other countries are often providing health care to 100 percent of their citizens. The current cost of health care growth is unsustainable and literally could bankrupt us as a country if we don’t get it fixed. The sad truth is that some cost controls by limiting networks may be needed so that something is in place at the end of the day to pay for patient care. Again, the difference will be in the quality of the system in which the patients and providers elect to participate.

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PBN: What challenges do you anticipate the entities will experience during the transition and do you expect to add even more medical practices to the Community Physician Partners?
MARCOUX:
There are enormous challenges ahead. First, we need to organize ourselves in a way that independent PCPs have never done before. There are issues of structure, governance and financing that every good organization must have in place to succeed. There are also the unanswerable questions about the financing from CMS and the commercial payers that we need to address. Taking on risk is something that we have never had to do before and this is expected to create some angst amongst all providers, specialists and PCPs, alike. We recognize that, if we are responsible largely for cost, then we also must largely have control. We have no delusions about imperiously managing patient care, but doing so cooperatively with all the parties involved –ourselves, our patients, our specialty colleagues and Lifespan. We have a common purpose – taking good care of patients and minding the cost of that care.
And finally, we hope and expect that our PCP numbers will grow both from within and without. As our practices succeed and prosper, hopefully we can add more physicians to our individual practices. If, as I expect, our organization succeeds, then more providers from without will want to participate and, when properly vetted, will be asked to join us in this endeavor. It’s a bit scary and challenging, no doubt, but fraught with the possibility of improving health care and reducing the cost. It’s not only what we want, it’s something we need to have happen.

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