Health Care’s Broke: Primary Care Crumbling
Primary care in this country is dying. There are fewer available primary care doctors in this country, as more and more physicians either go directly into specialty care or choose a specialty after completing one of the primary care tracks (internal medicine, pediatrics, family practice, obstetrics and gynecology).
Why is this a problem? Primary care is the foundation of a health care system. Most problems and illnesses most people have can reliably be treated by a primary care doctor. When Iran wanted to develop its health care infrastructure, for example, they asked a family practice doctor to fly over and work with their medical leaders, not a urologist or cardiologist. If you don’t have primary care in your health care system, you end up way overpaying for unnecessary specialist care (think of sending a person to a urologist if they have a urinary tract infection instead of going to their family doctor, for example). You also can’t effectively triage people and get them to the right doctor. If someone is short of breath, do you send them to the cardiologist, the pulmonologist, the allergist, the rheumatologist, or the infectious disease doctor? Lose primary care and you lose the basis for your medical decision tree.
And it’s not just that physicians aren’t going into primary care, it’s that primary care doctors are often actually stopping practicing primary care. They find there are other ways they can make better money (or lose less money). When you see this in a health care system–that DOCTORS are quitting medicine, for whatever reason–think bad, bad health care system future.
Why is this happening? A number of reasons, but I’d argue it depends on who you ask:
- Primary care doctors: Money. All about money. Low reimbursement rates for seeing patients (especially compared to specialists who get paid much more handsomely for procedures). Long hours, relatively low pay compared to your colleagues. Lots of paperwork.
- Medical students: Time. All about time. 15 minutes to see each and every patient, no matter how sick they are? No matter if they’re crying for the first five minutes of it, or if they walk in having active chest pain and you need to get them over to a hospital via ambulance right away? 15 minutes even if they’re asking you to fill out 5 forms that take 5 minutes each? That makes no sense. (Primary care docs certainly care about time, and medical students certainly care about money, just illustrating two of the big issues for primary care today.)
I’d like to discuss each of these issues–money and time–a bit further, because I believe they have wide-reaching consequences on our health care system (since, as we said above, primary care is the foundation of a health care system):
Money. While you might just say, “Well duh, doctors, like everyone else, want more money,” it’s more significant than this. We pay doctors a certain amount based on what they do. Medicare sets these amounts, and most insurers use Medicare’s rates on which to base their own. The way that we pay physicians today, doing is rewarded much more than thinking is. Extreme example: A doctor who performs a surgery is paid much more than another doctor who sees a child for a rash and knows the rash will soon go away, since it’s just a virus. An even more real-life example: a physician gets to bill for a more complex visit (and better-paying one) by prescribing a medicine over not prescribing one. We wonder, “Gosh, why do patients always want something done–a blood test, a study, a scan–when often watchful waiting is the better choice for the patient?” Culture is certainly to blame, but perhaps so are doctors. Patients have learned that more (tests, studies, scans) is better because more is better: for physicians’ pocketbooks. There’s a clear incentive in the system for doctors to do more, so perhaps patients have just learned that more is better by watching us to begin with. (See this NYT article for a perfect example of “more is better.”) I’m not suggesting doctors do this consciously, or that this is the only reason, just one that should be considered as it has drastic consequences for health care costs and unnecessary procedures that unnecessarily place patients at risk.
Time. Borrowing this point from the Panda Bear: when doctors only get 15 minutes to see a patient, you leave them no choice but to start referring a patient out to specialty care when often the diagnosis just requires a bit more time to sniff out. A few more questions to come to the right one. But instead, in this system where each patient only gets 15 minutes of a doctor’s time per visit, everything is referred to a specialist (who often either gets a bit more time to see each patient, or at least is just dealing with one single issue). Can any adult medicine doctor manage someone’s heart failure leg edema? Sure! But put the heart failure in a 75 year-old with glaucoma, dry skin, lung cancer, diabetes, and peripheral neuropathy, and it’s no wonder someone might say “Hey, go see a cardiologist about your leg swelling, I’ve got enough other problems to fix.” This not only leads to increased health care costs from unnecessary specialist care, but also leads to patient confusion (why am I seeing ANOTHER doctor?). I just read some study (can’t find it) linked somewhere saying that most specialists get referrals from primary care doctors without ANY documentation of why the patient is being refered? Perhaps there’s no time for the primary care doctor to write up the referral?
One can look at concierge medicine, which I discuss here and here, as symptoms of this lack of time and money problem. Thanks to Roy Poses for this analogy.
In typical Over My Med Body style, I think we need to address the root concerns identified above: time and money. Lack of primary care affects us all. (We Are All Connected.) I’m probably going to piss off both primary care doctors and specialists with my suggestions here, so please, leave your two cents on how these ideas might be improved.
Money: The simple answer is “pay primary care doctors more.” I believe this should be at the expense of specialists, meaning that the gap between specialists and primary care doctors’ incomes should shrink. Primary care is an incredibly challenging field–one of the most, in fact–and doctors should be better-compensated for practicing it. Perhaps, as well, they should be rewarded for good long-term outcomes for their patients.
Another idea I’d like to float down the river: pay primary care doctors per hour, like lawyers, instead of per patient, with minimums and maximums based on a patient’s comorbidities. So if a patient takes 15 minutes to see and 5 minutes to document, and another 5 minutes to arrange a CT scan for, the doctor gets paid for all 25 minutes (currently they only get paid for the 15 minute visit). All other doctors would still only receive payment for the 15 minutes to see a patient. I’ve suggested this idea before–pay primary care doctors for their paperwork–and I think it would pay primary care doctors better, allow them to provide better care for their patients, and encourage more medical students, residents, and other already-trained doctors to go into the field.
Time: Simply, doctors need to be given more time to see more complex patients. With the 15 minute system we’re in today, I think it has had the effect of trimming the fat from the patient visit, but it leaves little to no room for patient complexity or severity of illness.
I do think also that there are plenty of primary care options that should be open to nurse practioners and physician assistants. There are lots of circumstances where a patient needs to be seen by a doctor, but if the diagnosis is viral upper respiratory infection, why not allow a physician assistant to reassure a patient? I have trouble seeing the other side of this argument.
According to the data in Ontario there is the same number of GP’s per 10,000 population but they are becoming less generalized. See
http://www.ices.on.ca/file/mod2rp1.pdf
for data. Assuming that being less of a generalist (less hosptial, nursing home and obs) is required to maintain income & patient safety (and sanity) then the answer is not just more pay but better integration with specialists. I think the new model should be group practice with GP/FP and specialists with pay-per-patient rather than pay-per-visit/hour/procedure. The more patient’s effectively managed the better the pay and there is reason for all levels of care to work towards prevention. GP are the cornerstone of healthcare wiht 4 vists/yr for those under 65 and 7 per year over 65. If we (Canada and US) don’t do something soon it will collapse.
http://www.waittimes.blogspot.com
@Ian:
I see where you’re going, but I’m not sure pay-per-patient is the right way to get there. Pay-per-patient actually encourages GPs to spend less time with patients because they get paid for seeing more. If I’m a GP under that system, why would I not schedule my patient’s medical exams every two years since I’d get paid more for taking on more patients? It might help with unnecessary procedures by specialists because they would get paid regardless of which/how many procedures they perform.
Another great post in the series.
I think the impact of the lack of availability of primary care doctors, coupled with the insurance crisis, is that the emergency room has become primary care for a subclass of patients.
Graham, you are going into emergency medicine, right? What do you think about the emergency room becoming the place where primary care becomes urgent? I am sure it not only affects the quality of health of the patients who cannot afford or do not have access to regular preventative care, but also impacts the quality of care an emergency room can deliver.
Until physicians are willing to take the financial risk that is entailed in breaking free from the insurance/govt. payor system, they’ll not get paid any more. Trouble is, it’s a pretty good living under the current system, so who has the nerve?
Good suggestions. A friend of mine with multiple medical conditions doesn’t even HAVE a PCP. She finds specialists and sets up appointments on her own. Her reasoning is that an internist would just refer her along to someone else, so she “cuts out the middleman.”
Ironically, the gatekeeper paradigm may contribute to the problems you’ve outlined.
@Ian: I think this model is an interesting one, and may work for large groups, but there may not be opportunities for group practices for a lot of docs.
@Brian: You’ve hit the nail on the head about why this stuff is hard to figure out–how do we set in place a system that encourages thoroughness in doctors without abusing the system or encouraging people to be lazy and do the least possible?
@Hilary: I think the ED doing primary care is totally inappropriate, but I understand why it happens. That’s why in my EMTALA piece I said we should give people other options for “free” care.
I am an ED nurse and the primary care issues directly effect us where it hurts. 70 people in the waiting room all with fevers for under 3 hours is very annoying! I think waiting 4 months to get in to see you r PCP is also not an option. I think Walmart and the retail clinic model is very good. This allows anyone to get a check-up, get referred or “triaged”, and cuts down on the ED and PCP routine visits. As these pop up there needs to be a marketing campaign to get patients to use that as a first line and then see the PCP.
I also agree that the use of NP’s and PA’s is essential. One does not NEED to see a doc for a cold, or even a complex issue. We have NP and PA that work in the ED and diagnose and treat very complex patients. This will allow the doc to be more of a supervisor, watching over the care and “THINKING”.
I also agree that the system needs to change and those that take a risk to break out of the cycle of medical waste should be rewarded. An hourly pay rate seems reasonable. As a nurse I may start the IV, calculate the doses, run the drips, monitor the patient, chart for 12 hours, coordinate care, suggest plans of care to the doc, and make sure the patient does not die, but i don’t get paid per task. No matter how many IV’s i start, or chest compressions I do, I get paid the same… I think this cuts down on doing procedures just because. IF i got paid per IV, even that guy with the stubbed toe gets a 14gauge!
The reasons you pose(Time and Money) should be condensed to Value. Primary care is not currently a reflection of this nations values. But it should be.
Primary care is(should be) efficient.
Our country, our medical system doesn’t value efficiency. It’s bloated.
Primary care can and should be low tech.
We are addicted to technoCare.
Primary care could be the medical home where personal care, personal knowledge (continuity)occurs. It should be the place to emphasize personal responsibility and possibly influence behavior.
Our country, our society, and The Medical Industrial Complex are not strong on personal responsibility. Sure we want THEM to be more responsible. No mirrors please.
It really isn’t about the money. I worked for years making about $100k, two weeks vacation. I loved it. But the income goes down($80-90K, still a good income) and the new hires expectations go up(they want $120K and 6 weeks vacation)…I have to admit I am in a business that can’t be sustained…So I got out.
I am glad to work for $100k. But it does irk me that the hospital recruits a new Rad for $350k…HE’S valuable….I agree that paying specialists less would do well to emphasize the values we supposedly have sworn to. Can’t see a Senator floating that proposal. Or the AMA.
Again, family docs aren’t valued. I don’t think patches will do it. More pay just monetizes the system. Values should direct the system. And our values in medicine have become corrupt.
It is intriguing to see that similar primary care problems exist across different health care systems.
Being a hospital based internist in Europe myself I can see that:
1. obviously the primary physician (in our case, the gatekeeper) lacks time to treat patients right the first time. When I run the secondary level internal-medicine-emergency-room only a small proportion of patients need emergency care. Mind you, a doctor has seen them before and has sent them to the hospital for sorting out those pathologic liver function tests, headaches lasting for three years and such. Aside from obvious and non-urgent and non-invasive work-up all these patients need is reassurance and some time. The problem is that all physicians here are paid per hour. And since the original problem persists regardless of paying pattern, I think it is urgent to consider other contributing factors: defensive medicine, patient rights, health demands, non-medical factors. I have nothing to add to the first one. The second one is very hard to tackle. Who is to tell the masses used to have the right to everything possible they have either to pay more or risk being sick or bankrupt. (Virtually everyone here is health-insured and very aware of it; elections come every four years and everyone in power is paying more attention to getting elected again than to long-term solutions).
Health demands have changed in the past decades from treating low-cost acute conditions to treating high cost chronic conditions. The system seems not to follow.
Non-medical factors include but are not limited to aforementioned distorted values in medicine, low respect of PCPs by everyone and lack of efficient management (at least here).
2. The money pays a big role in medicine, but it is a hygiene factor (to use Herzberg). Not enough attention is payed to the motivation factors which keep docs running high-speed. Research. Praise. A little of glamour. Such.
Continue the good work and good luck with matching!
First, thanks for your nice post.
Here a little not from The Netherlands.
Here in Holland we have a quite intensive primary healthcare system with a very important place for the gp.
Gp’s cover 96% of the complaints for only 3.5% of the total costs of healthcare in the Netherlands. Gp’s can treat a lot of complaints them self, if necessary they refer patients to the appropriate specialist and they collect and manage! their patient’s healthcare.
In most cases it is not possible to see a specialist if you’re not referred to one by your gp. Everyone has his own gp here, and a lot of people are very “faithful” to their gp.
I do agree with you, they have a very important role in healthcare. They have an overview of the patient’s situation and can over very personal care.
Time and money are important factors, but you forgot another big one: prestige. As long as family med has a reputation for taking anyone with a pulse, it’s mighty tempting for anyone who can “do better” to do so. Internal med and ob/gyn don’t have quite the same PR problem, but it’s a big disincentive for family medicine. And I’m coming at this from the DO world, which produces a disproportionate percentage of primary care docs. Despite the begging and cajoling of our elders, many of my classmates still see primary care as where you might wind up if you don’t succeed, rather than where you might choose to go. Specialists are far more respected.
Found your Single-Payer animation. It was awesome! I’ll share it with my Social Problems class. Great job on explaining a very complicated topic so simply. Something very drastic has to very quickly change when it comes to this health care crisis. Thank you again and have a safe trip!