By Stephen C. Schimpff, MD
As candidates for the presidency and Congress offer solutions to healthcare reform, they would do well to focus on primary care. Primary care is the heart of medical care and it is in crisis.
There is a primary care crisis in the United States. You know it because you only get 8-12 minutes with your primary care physician (PCP) who interrupts you within about 18 seconds and never fully listens to you. You are sent for tests, given a prescription or referred to the specialist even though the PCP could – with more time – have figured out your problem without a test, prescription or referral. You are less than satisfied yet the charge is high. Your doctor is no more satisfied and indeed is highly frustrated and feels like he or she is on a never-ending treadmill. PCP burnout topped 79% this year. This leads older PCPs to seek early retirement, mid-career PCPs to sell out to the local hospital and medical students to shun primary care, each leading to a growing shortage of PCPs which will get worse as the population grows and ages.
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This means that Americans don’t get the quality of health care that they need and deserve, that health care is expensive, and that the cost will keep rising.
The solution isn’t difficult. The reimbursement system needs to change, shifting more resources into primary care and out of specialty care. It’s an easy answer but difficult to implement.
The primary care physician (PCP) is the most broadly yet deeply focused care giver and as such is the backbone of the healthcare system. But to do this work effectively requires time – time which all too often is not adequately available. Lack of time is a real impediment to the best possible care.
The PCP deals with most problems/ illnesses with a broad yet deep expertise and knowledge and so is able to diagnose and treat most common and many not so common diseases and problems, including most chronic illnesses — which account for about 85% or more of health care related expenditures. He or she is well versed in the continuity of care for chronic complex illnesses, is in the best position to refer when indicated, and to coordinate care of chronic illnesses or referral for an acute issue. The PCP is or should be focused not just on disease but on the person with the disease, on wellness and disease prevention by means of immunizations, screening (recognizing risk- reward rationales) and behavior modification – diet, stress, exercise, smoking, etc.
There are too few primary care physicians, too few medical school graduates choose primary care as a career and there are too few residency slots after medical school for primary care training.
PCPs are frustrated. PCPs know they are not doing just the “simple stuff” as so often portrayed but the very complex. Many patients have multiple chronic conditions, are on many prescription drugs, have various functional incapacities as a result of aging, and often have problems rooted in family dynamics or their own cultural norms and traditions. The good PCP understands that the essence of care is the bond that they develop over time with each patient. This is the bedrock of the profession. But the current “culture” of medicine expects high technology to be the answer, imposes financial frustrations and is always threatening malpractice litigation. This combination, but mostly payment issues, has led to a fragmentation of care and the overuse of specialists, specialty care without coordination and an over reliance on technology. The good PCP, despite all of the frustrations, still understands that that bond with the patient is key, the very heart of their medical practice, the basis of their own satisfaction in their career and (as stated in a book review on primary care) “the essence of a well-functioning medical care delivery system.”
Your primary care physician requires time – time which all too often is not available. It is a real crisis. Where does the time go? The typical PCP takes 24 phone calls per day, reads 17 emails, processes 12 prescription refills (above those handled during visits), and reviews more than 40 laboratory, x-ray and specialist consult reports. In addition, PCPs need substantial added time with electronic health records and to complete Medicare quality indicators records.
But the major time problem is that primary care providers are caught in a terrible conundrum. Overhead costs (especially the need for added staff to deal with billing, preauthorizations and government mandates) have risen much more quickly than revenues. Their only remedy is to “make it up with volume,” i.e., more patients per day. But that’s not a sustainable business practice and certainly not an acceptable care model. And that’s not all – PCPs (and all physicians) are beset with mountains of added paperwork – quality reports, paperwork, insurer requirements and the requirement to use the electronic medical record which has a system design not conducive to primary care practice. PCPs report that they must see about twice as many patients as a few decades ago in return for the same income. If a PCP needs to see 24 to 30 patients per day then a patient has a 15-20 minute visit with actual “face time” of about one half of that. This is long enough for a simple problem but much too short for someone with a complex issue, or someone with multiple chronic diseases and taking multiple prescription medications. It is certainly not long enough for an elderly person with impaired vision, hearing or cognition and not enough when the problem has an underlying anxiety.
What happens if there is not enough time to resolve an issue? Often it is a referral to a specialist. It is here that the costs of medical care begin to skyrocket. The referral to a specialist when just some more time with the PCP would have been sufficient; a prescription when time to address life style changes would have sufficed; a battery of tests when more history would have uncovered the problem.
Patients and PCPs will need to take charge and change the paradigm of primary care. Patients need to demand the time they deserve. PCPs need to insist that they will give the time.
This means fewer patients per PCP; 500-800 rather than today’s 2,500-3,000. Fewer patients mean more time for each patient and much better access to the PCP. Of course, this will need to be paid for — by the patient directly (e.g., direct primary care, membership, retainer, concierge) or by enlightened employers, insurers or government.
Comprehensive primary care offers same or next-day appointments lasting as long as necessary and 24/7 access via the PCP’s cell phone. Often it means generic medications at wholesale prices and reduced cost labs and radiology. It means improved care quality and satisfaction and fewer frustrations for patient and doctor alike.
Fewer patients mean more time for the patient and doctor to interact. It means more time for listening, building trust and healing. It means better diagnostics and improved treatment plans. This results in fewer tests, X-rays, prescriptions and referrals. Combined with a much less expensive high-deductible health insurance policy, the savings for patients are substantial and the total cost of all care declines quite dramatically. Putting more resources into primary care is definitely cost effective.
Most Americans do not realize how important and valuable comprehensive primary care can be to their overall health. But if patients want to benefit from much better care, if they want a doctor that is not frustrated, not burned out and can spend time listening to them, if they want their total costs of health care to decline rather than rise, then they will need to educate themselves and then advocate – to legislators, to insurers, to employers and especially to their doctors. Concerted patient action will force the issue and make change occur. It will be a win for everyone. Now is the perfect time.
As we watch the debates and Tweets, it is clear that our political leaders just do not understand the health care delivery system, its dysfunctions, its causes nor do they understand its resolution. Some debate Medicare for All as a solution but that will only lead to more of the same because it will not abet but probably harm primary care further. Others want to eliminate Obamacare but do not understand what to replace it with. Politicians running for president and Congress need to understand the primary care crisis, appreciate the value of comprehensive primary care and place its resolution front and center in new legislation. It will mean better health, better medical care and much reduced total costs of healthcare.
But there are serious issues in Primary Care.
PCPs are departing private practice in droves. Traditionally a newly minted physician would borrow funds to start a private practice or would enter an already established practice in town. In 2000, it is estimated that about 60% of physicians were in a private practice. This had dropped to about 40% by 2012 and perhaps to 33% or less by 2015. It appears that the rate of decline in private practices is increasing with no apparent end in sight. In 2000, about 20% of PCPs were employed by hospitals; today that is up to about 40% and growing rapidly.
Why the rapid change? Some of it is a change in the desires of the new generation of physicians. They have a desire for more personal and family time and a professional life with fewer administrative obligations, no concerns about borrowing large sums to begin a practice, and a steady paycheck. But this change to employed status is also about the current convoluted billing requirements of practice, the administrative complexity of running a business plus being a physician, and the always changing regulatory requirements.
But there are definite tradeoffs. Most important is autonomy. Physicians over the years have valued their autonomy but when one works for a corporation, no matter how benevolent, it will have its own rules and regulations. Autonomy is lost. And although the administrative burdens are lessened the physician is still expected to cover his or her own salary and expenses which means still seeing many patients per day, 24-25 or more to meet productivity standards. So shifting to hospital employment does nothing to gain time – time to listen, to prevent, to coordinate chronic care and to just think.
About the Author
Stephen C Schimpff, MD is a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center, senior advisor to Sage Growth Partners is the author of Fixing the Primary Care Crisis: Reclaiming Relationship Medicine and Returning Healthcare Decisions To You And Your Doctor.
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