Monday, May 25, 2009

A Crisis in Primary Care

We are entering if not already in a crisis of primary care. Each of us needs a competent, caring and available primary care physician but that is less and less possible. Many can’t find one; others cannot afford one; and others have one but cannot get adequate time and attention from him or her. PCPs will tell you that they do not have enough time with each patient; are overwhelmed with paperwork and mandates; and are earning less and less per year. There are about 1000 graduating physicians entering primary care per year in the USA but about 3-4000 retiring. Average income after about ten years in practice of $150,000 has been stable or decreasing for some years while the costs of practice including staff wages, rent and utilities, malpractice insurance and supplies has been rising. Most medical school graduates have about $155,000 in debt to pay off. To make ends meet and retain the same income, PCPs are seeing more patients with longer days and shorter visits. This is not good for them and it definitely is not good for you. Basically they have a non-sustainable business model today as a result of the reimbursement system through our commercial and governmental insurance system.
To counter the problem, more and more PCPs are taking steps to increase their income while decreasing the number of patients seen per day. Some approaches are frankly disappointing such as the doctor with a sign in the waiting room that you may “only raise one problem per visit.” A colleague told me last week that her internist is no longer taking Medicare. She will have to pay for each visit. Perhaps not a problem if you only go for an annual exam and then once or twice for minor problems. But if you develop a complex chronic illness that requires multiple visits it could add up quickly, especially for someone on a fixed income in retirement. Other PCPs are opting for “retainer-based” practices, sometimes called concierge or boutique practices. Here you pay $1500-2000 [or more] per year and in return your PCP reduces his or her practice from 1800 patients to 500 and guarantees that you can be seen the same or the next day, that he or she will be available by cell phone and email 24/7, will visit you at home, will meet you at the ER as needed, and will care for you in the hospital and the nursing home. And each visit will be as long as needed for you and your issues. This is the way it used to be and is the way it really should be now but is not. Another advantage of this type of system is that it becomes a true relationship again between the doctor and the patient with the patient contracting directly for services from the physician – not through a third party. The downside, of course, -- this is extra money out of your pocket since you will still need your insurance for specialists and hospitalization.
What is clear is that the current system does not work and either PCP reimbursements by insurers will go up or more and more PCPs will either retire early or switch to retainer-based practices.

1 comment:

rfclark77 said...

This is the key phrase of your essay-"Basically they have a non-sustainable business model today as a result of the reimbursement system through our commercial and governmental insurance system". What in the health reform bills in either the House (HR3962,HR3600) or the SFC bill is going to change reimbursement by Medicare, Medicaid and the private insurance system that follows those government programs? Nothing. In fact with the huge cuts in Medicare and Medicaid, fewer physicians will opt for PCP concierge or other practice business models because the rembursement will worsen from already unacceptably low levels. Until the volume,procedure based, RBVS, fee-for-service (UCR-Usual Customary and Reasonable)remibursement system changes medical schools will not change heir curriculum or admissions profile to produce more PCP's whether in urban, rural or suburban locations. We will continue to get more PCP practices being absorbed/purchased/joint operating agreements that the dominant market share hospital and hospital systems will have to make money on volume-a entirely different business model than thet are used to. Those systems may well go by the way of GM, U.S. Steel, RCA as they cede each and every level of healthy-medical market segments (i.e first cheap doc in the box businesses like Toyota did with the low margin, high volume Tercel in the 70's creating a low priced car that people could afford ripping market share from GM et. al then up to the mid market of ambulatory surgery centers-ASC's and then the Lexus of health care private specialty care clinics (i.e opthamaology,ENT,Dermtology) leaving only the high volume, high profit cardiovascular,radiology specialities. Doctors will try to create their won hospitals, clinics, ASc and they have done but lacking customer service and business model management they will not be able to compete. The phsyicians who merge or will be bought out so they "practice medicine" not health insurance, will not be able to produce the efficiencies and quality outcomes necessary to maintain market share.They will not be able to alter there busines smodels where they now have 5-60 business models under one roof that cannot be made efficient without taking the business out under the hsopital system umbrella and making the business compete with others (i.e. notably cheaper foreign/international medical graduates) who are smarter and more efficient in their health care dleivery model than American medical school graduates.

Hopefully, absent anti-competitive government activities (in a post Obama Health Reform era), this will begin the process of a competitive, value and innovation driven system.

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