The Crisis in Primary Care –Part 2
Primary care physicians (PCPs) have too little time
per patient which means too many referrals to specialists, too little time
listening and thinking, no time to delve into the stress or emotional causes of
many symptoms and substantial frustration by PCP and patient alike.
In my last post in this continuing series on primary
care, I described a patient with a straight forward if unusual symptom who was
bounced from specialist to specialist at great expense, with no one offering a
diagnosis, with no resolution of her symptoms and with no physician ever
exploring the actual underlying causes of her symptom – stress related to a
long ago family issue. Why did this happen? Because the PCP had only 15
minutes, not enough time to listen and to think and from there delve into her
psyche.
Why so little time? The short answer is the
insurance system, attempting to manage costs through price controls. Medicare
has for years set a low reimbursement rate for regular office visits to the
primary care physician. Commercial insurance always follows Medicare’s lead and
has done likewise. Reimbursement rates have remained fairly steady for a decade
or more (Medicare has very recently begun to raise rates a bit as a result of
the Affordable Care Act) but office costs have risen each year. Overhead
includes not just the nurse and receptionist but also the billing and coding
people, accounting and legal needs, malpractice and disability insurance,
health care insurance for the staff, supplies and rent and utilities for the
office. With costs rising and income steady, the PCP tries to “make it up with
volume.” This means seeing more patients per day, usually about 24-25, often
even more. In order to see that many, the PCP has generally stopped seeing his
or her patients in the hospital or ER and has shortened the time per visit –
most visits being about 10-12 minutes of actual “face time” with the patient.
This is enough time for a strep throat, a quick
blood pressure medication check or possibly to diagnose and treat Lyme disease.
But it is not enough time to deal with a more subtle problem like the patient
described in the last post experienced. It is not time to explore family
issues, personal stress or anxiety that so often lead to or accompany symptoms
and sickness. This lady had a straight forward issue that primary care
physicians encounter frequently and those that are experienced know well what
it implies. But it still requires time – time to carefully listen to the
patient’s story, time to put it into the context of the patient’s life
situation, time to do an examination and then some time to think about how to
proceed. And once the management decision is made, it takes time to talk to the
patient, reassure her and yet explain that she should call should are any
further concerns arise – and to come back soon for a further follow-up and
attention to the underlying issues.
The situation is compounded when the PCP has a
patient with multiple chronic illnesses who is taking multiple prescription
medications. Chronic illnesses like diabetes, heart failure, chronic lung
disease, kidney failure or multiple sclerosis by their nature are difficult to
manage, persist for the patient’s lifetime (some cancers excepted) and are
inherently expensive to treat. These patients need very close attention and
often need the benefit of a team approach to care. The diabetic patient for
example may need an endocrine consult at some point, a podiatrist, an
ophthalmologist, a nutritionist and an exercise physiologist, to say the least.
But any team needs a quarterback and this is or should be the primary care
physician. But here again, care coordination by the PCP requires time, the one
thing the PCP most lacks in today’s reimbursement environment. The result is
fragmented chronic illness care, disjointed care and care that is much more
expensive than it needs to be. From a total healthcare system perspective, this
is critical because chronic illnesses consume 75 – 85% of all claims paid by
insurers.
But with little time to listen and think, the action
step of many PCPs, as with the patient described last time, is to send the
patient to a specialist. Indeed, according to an article in the Archives
of Internal Medicine, about nine percent of all visits to
PCPs result in a specialist referral, far far higher than truly necessary. This
is up from about five per cent a decade earlier; 41 million referrals per year
then compared to 105 million in 2010. Something needs to be done. The push for
accountable care organizations, medical homes, population health and a switch from
fee for service to a salaried or capitated system are noble but unless the PCP
is given time and enough of it, these
changes – no matter their apparent utility – will prove valueless.
Meanwhile, fewer and fewer medical school graduates
choose to enter primary care. They are smart and see that PCPs are very busy
and very frustrated. They know that given the PCP’s average income it will take
many years to pay off their high educational debt load.
PCPs are looking for ways out of their dilemma. Many
are retiring early. Others are closing their practices and beginning to work
for the local hospital. But the hospital wants the physicians to earn their
keep. That means high productivity. So it is still 24 – 25 patients per day,
albeit without the administrative hassles of a private practice.
It is clear that the resolution will not come from
commercial insurers, not from the government insurances (Medicare, Medicaid),
nor will it come from the Affordable Care Act. It will likely be in the actions
and decisions of the primary care physician himself or herself to change the
paradigm to allow and encourage better quality of care with lessened
frustrations for doctor and patient alike.
For starters, many PCPs need to look carefully at
their practice patterns and determine if they can adjust their own workload by
maximizing the talents of their team of nurses, nurse practitioners and others
and with better use of technologies. This requires a change in thinking about
how to organize the practice and who does what and when.
Beyond that, some PCPs have decided to no longer
accept insurance. Instead they expect the patient to buy care directly. And
since they no longer have the expense of coding, billing and collection (one
estimate of this is $58 per patient visit!) they can charge a quite reasonable
amount. This can take the form of a set fee for any visit, a sliding scale
depending on the type of visit and its length, or of a set amount for all care
for the year, a retainer-based (concierge) approach. In each of these models
and others the patient replaces the insurer as the actual customer of the
physician and as such has a more appropriate professional-client relationship.
The patient also becomes a purchaser of services directly and thus begins to
ask questions, to challenge and in general to bring down the costs of care
while receiving a higher level of quality along with greater satisfaction and
less frustration for both doctor and patient.
These are but a few of the approaches being taken by
PCPs today in an effort to overcome the current non-sustainable business model
so that they can not only give better quality of care but reduce their sense of
frustration and increase their patients’ satisfaction.
In the posts to follow I will review what primary
care is all about; the characteristics of a good primary care physician and a
true healer; who does primary care and why and why not; the critical role of
the PCP in managing chronic illnesses; the need to listen and think – both
requiring time; the use of teams in the primary care doctor’s office; the
importance of care coordination, wellness promotion and disease prevention; the
current non-sustainable business model; what approaches are being taken to
overcome the current business model; and finally how primary care can once
again take its rightful place as the backbone of the American healthcare system
offering superior quality, outstanding service and greatly reduced overall
costs.
The next post in this series will address the
critical shortage of primary care physicians.
3 comments:
I'd like your thoughts, possibly in a future post, of the potential impact of a hybrid insurance model that guards against the bankrupting expenses of catastrophic illness while encouraging consumers to seek the best value in health care and lifestyle choices. That seems to be the general direction as insurers offer cheap policies with high deductibles.
Could continued evolution of that model also eliminate the administrative burden and lead toward the same vision you describe, but still protecting the consumer financially?
Wayne
I will address your request soon. But for now, I agree that the combination of a high deductible policy with catastrophic coverage may be the best answer for many. And if the insurer (or employer) will also pay for the PCP retainer so that the PCP can reduce the patient panel top 500-1000 it becomes a real win-win-win.
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