Time - The Impediment to Being a Good Primary Care Doctor

Did you get more than a few minutes with your doctor at your last visit? Probably not. Why not? Not enough time.

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.

What constitutes primary care and who are the primary care physicians? They are the first responders, the first line of care, and very frequently the patient’s confidant on all matters related to health and often more. The PCP is often the first physician contacted because of the long standing patient - doctor relationship but also because the PCP tends to be more readily available than a specialist who does not know you. The PCP needs to know a broad and deep range of medicine and at the same time needs to know when it is time to consult a specialist. And if you have a chronic illness, the PCP should also ideally coordinate all of the various specialists, tests, imaging and procedures that you might require. It is this coordination of the care over the long term that will mean better care at a lower cost.

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. 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.

But there are serious issues in Primary Care.                                                                                

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.

Today the PCP needs to be “efficient.” This means that it is more efficient to just give an antibiotic for a sore throat than to reassure the patient (and perhaps the parent) that it is likely caused by a virus; that the antibiotic will do no good and could even have some undesirable side effects and that time is the best medicine. But it takes time to do reassurance. And if not done thoroughly, the patient likely will go away unhappy that he got “nothing.” So do the quick thing and give the antibiotic. And add in for good measure – “This should do it!” or “It is good you came in today to be treated.” It also means that the PCP needs to see as few Medicaid patients as possible since Medicaid pays so poorly. And although much can be done over the telephone or with email, preventing a trip to the office or even the ER, the efficient PCP wants to avoid both since there is no payment for either.

PCPs are frustrated. Some see the glass half full and many see it as half empty. Those that see it half empty are quickly selling their practices to the local hospital. Others are trying new payment methods. Either way, 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.”

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% by 2013. 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.

Your primary care physician requires time – time which all too often is not available. This issue will be a major topic going forward in this continuing series on the Crisis in Primary Care of which this is the seventh installment.

The next post will consider who chooses to become a primary care physician.

 

The Doctor’s Customer Is The Insurer - Shouldn't It Be The Patient?

You the patient are really not the customer of your primary care physician. Since the insurer will determine whether and how much the physician will be paid for attending to your needs, you are largely a bystander in the relationship. The doctor’s customer has become the insurer.  

Our system of care is definitely not customer-focused. Doctors truly believe that they have the patient’s best interests in mind and they do. But their work is not customer focused as it is in most other professional-client relationships. You wait long weeks and sometimes even months for an appointment (the national average is 20.5 days), spend long times in the waiting room and are frustrated that you get just 10-12 minutes with your doctor who interrupts you within less than a minute and who recommends you see a specialist but does not personally call the specialist to explain the issue nor to smooth the path for a speedy appointment. All of this because, in the case of primary care, the doctor must see 24-25 patients per day to meet overhead and achieve a personal income of about $170,000. 

As for the insurers, you are not their customer either. Their customers are the ones who pay them - your employer or your government.  And it shows – by our long waits on the phone, by the complex, often hard to understand paperwork and by the frustration when the insurance you thought you had does not cover your latest tests, x-rays or specialist visit. 

So you are not the insurer’s customer nor are you the doctor’s customer. You are a mere bystander. This is hardly the type of contractual relationship you have with your lawyer, architect or accountant. In those situations, you pay them directly. Want more time? No problem, but you pay for it. Want telephone consultation? No problem, but you pay for it. Not so in medicine. You the patient cannot decide and ask for more time or ask to use of email or telephone. Because you are not paying for the time and your insurance will not do so either. It is just not your choice. 

To be clear. Yes, you are paying the physician directly in the co-pays and the deductibles but it is still the insurer that determines whether and how much the physician gets paid. You just get to contribute whatever portion you are told.  

Who is to blame for the current state of affairs? Each party looks to the other but perhaps each should hold up a mirror and take a close look. Nevertheless, here is what physicians think based on a recent survey. Ninety per cent say the medical system is on the wrong track; 83% are thinking about quitting; 85% think the patient-physician relationship is deteriorating; 72% do not think the individual mandate will lead to improved care; and 70% think that the single best fix would be reducing government intrusion. Further, 49% will no long accept Medicaid patients and 74% plan to stop accepting new Medicare patients. Finally, 80% believe doctors and other medical professionals are the most likely to help solve the mess.  

So the paradox is that America has the providers, the science, the drugs, the diagnostics and devices that are needed for outstanding patient care. But the delivery of health care is truly dysfunctional. What is needed is fewer patients per PCP so that each gets the time and attention really needed. The PCP needs time to listen, to prevent, to coordinate chronic care and time to just think. This means increasing not decreasing the cost of primary care per person. An increase in costs, yes, but an increase that will dramatically lower the total cost of care. More effective preventive care. More attention to the complex chronic illness with fewer referrals to specialists.  Better coordination of the care of those with chronic illnesses, enhanced prevention such that many chronic illnesses don’t develop. Spending  the time to listen and become trusted as the healers that they could and should be -- all leading to better care at much lower total cost.  

A new vision for our system must make it a healthcare not just a medical care system. It must recognize the importance of intensive preventive care to maintain wellness. It must address the needs of those with chronic illnesses to both improve the quality of care while dramatically reducing the costs of care. And it must be redesigned so that the patient is the customer that he or she should be. And, critically, to make it work effectively, America needs many more primary care physicians – they are and should be the backbone of the healthcare system – who are able to offer outstanding preventive care, care for the vast majority of complex chronic illnesses, offer coordination for those with chronic illnesses and do it in a manner that is satisfying to doctor and patient alike – with true healing along with expert medical care. It’s doable but it means a rethinking of how our delivery system is structured and assuring that PCPs have fewer patients for more time each.  

It is possible but it will require both doctor and patient alike to demand it. There are many ways to skin the cat but the most promising is direct primary care (membership/retainer/concierge) practices. More on this later.

 

My next post in this series on the crisis in primary care will be about today’s impediments to good primary care.

The Paradox In American Healthcare

We have a real paradox in American healthcare. On the one hand we have exceptionally well educated and well trained providers who are committed to our care. We are the envy of the world for our biomedical research prowess, The pharmaceutical, biotechnology and diagnostic equipment industries continuously bring forth lifesaving and disease altering medications, devices and diagnostics. So we can be appropriately awed and proud and pleased at what is available when needed for our care. 

But, on the other hand, we have a very dysfunctional health care delivery system. A fascinating paradox. One wonders just why it is that Americans tolerate this paradox of incredible medical advances and outstanding providers yet a dysfunctional delivery system. 

Our medical care system works poorly for most chronic medical illnesses and it costs far too much. Chronic illnesses are ones like diabetes with complications, cancer, heart failure and neurologic illnesses like stroke. 

These chronic illnesses are increasing in frequency at a very rapid rate. They are largely (although certainly not totally) preventable. Overeating a non-nutritious diet, lack of exercise, chronic stress, and 20% still smoking are the major predisposing causes of these chronic illnesses. Obesity is now a true epidemic with one-third of us overweight and one-third of us frankly obese. The result is high blood pressure, high cholesterol, elevated blood glucose which combined with the long term effects of behaviors  lead to diabetes, heart disease, stroke, chronic lung and kidney disease and cancer.  

And once any of these chronic diseases develops, it usually persists for life (of course some cancers are curable but not so diabetes or heart failure). These are complex diseases to treat and expensive to treat – an expense that continues for the rest of the person’s life.  

Primary care physicians can deal with most of the issues of these patients – if they have the time to do so. But referrals to specialists is often necessary. Primary care physicians generally do not have the time needed to coordinate the care of those with chronic illness – which is absolutely essential to assure good quality at a reasonable cost. Over time, most chronic illnesses will need a team of caregivers. Consider a patient with diabetes who may need an endocrinologist,  nurse practitioner, podiatrist, nutritionist, personal trainer, ophthalmologist and perhaps vascular surgeon and cardiologist and many others as well. But any team needs a quarterback and in general the person is the primary care physician. He or she needs to be the orchestrator as much if not more than the intervener. This need for a team and a team quarterback for the patient with a chronic illness is much different than the needs of the patient with an acute illness where one physician can usually suffice. It is this shift to a population that has an increasing frequency of chronic illnesses that mandates a shift in how medical care is delivered. Unfortunately, our delivery system has not kept up with the need.  

In healthcare the money is in chronic illnesses. These consume about 75-85% of all dollars spent on medical care. So we need to focus there. 

Since most chronic illnesses are preventable, what are needed are aggressive preventive approaches along with attention to maintaining and augmenting wellness. This would reduce the burden of disease over time and greatly reduce the rising cost of care. Unfortunately, America places far too little attention and far too few resources into wellness and preventive.  Most primary care physicians do not give really high level preventive care. Yes, they do screening for high blood pressure and cholesterol and for various cancers and they attend to immunizations. But this is not enough. Patients need counseling on, at least, tobacco cessation, stress management, good eating habits and a push toward more exercise. They need an admonition to not drink and drive, not text and drive and to buckle up. They need to be reminded that dental hygiene today pays big dividends in the later years of life. And they need someone to really listen closely to uncover the root cause of many symptom complexes as in the story given in the first of this multipart series on primary care. 

When a patient is sent for extra tests, imaging or specialists’ visits the expenditures go up exponentially yet the quality does not rise commensurately. Indeed it often falls. But primary care physicians are in a non-sustainable business model with today’s reimbursement systems so they find they just do not have enough time for care coordination or for more than the basics of preventive care.  And they just do not have time to listen and think. 

So the paradox is that America has the providers, the science, the drugs, the diagnostics and devices that are needed for outstanding patient care. But the delivery is not what it should or could be. The result is a sicker population, episodic care and expenses that are far greater than necessary. The fix is change the reimbursement system to get PCPs the time needed to listen, to prevent, to coordinate and to just think. This will lead to better care and less expensive care.

The next post in this series will be about customer focus.