Tuesday, June 16, 2015

Solving the Crisis in Healthcare Requires Solving the Crisis in Primary Care

There is a crisis in the provision of primary care in the United States. If you are a patient, a primary care doctor, an insurer, an employer or a policy maker, this crisis is exceptionally important to you. The crisis means that Americans do not get the level or quality of healthcare that they deserve and need. This crisis is the major reason that healthcare in total is so expensive and why costs keep rising. This crisis needs to be fixed and fixed as quickly as possible. Fortunately, a solution exists that is within reach. It will be a disruptive and transformative change so it will not come easily to a profession that is “conservative” by nature. My new book Fixing The Primary Care Crisis, addresses all of these issues in easy to read language.

Contrary to what many assume, PCPs are much more than providers of “simple” stuff. They are more correctly specialists that deal with the very complex. Comprehensive primary care includes wellness and health maintenance, prevention and risk management strategies, attending to the episodic events that occur in life, and especially the care of those with complex chronic illnesses including coordination of care when a specialist is needed. It also includes developing a strong relationship between doctor and patient, building trust along the way and offering true healing. This means that the PCP can competently handle the vast majority of our health needs. To appreciate this is to begin to understand why the current system just does not and cannot work and why it needs to change.

The fundamental problem is that primary care doctors (PCPs) care for too many patients with too many short visits per day, and as a result do not have the time they need to provide high level care. They need time to listen, time to think, time to give quality preventive care and time to offer care of complex chronic illnesses and to coordinate care for those actually do need a specialist referral. They also need to be able to build a trusting relationship with the patient and to offer true healing, something that also takes time. In other words, they need time to practice their profession, something they currently are unable to do fully or effectively.

This crisis has led to a culture of highly frustrated doctors who feel they are on a never ending treadmill, and are leaving private practice or retiring early. It means that patients are equally frustrated at the long waits, short visits, high costs and no sense of being listened to, of not receiving empathy, of not being actually cared for. The crisis means that there are currently not enough primary care doctors, and it will only get worse because students in medical school see the impact of this crisis and choose not to enter primary care as a result.  It’s a downward spiral that needs to be reversed.

The crisis began a few decades ago when insurers, beginning with Medicare, held reimbursement rates low (cost control through price fixing). At the same time, doctors’ office costs were rising. In order to meet basic overhead expenses while maintaining their incomes, PCPs began to see more and more patients per day. The average PCP’s income in 1970 was slightly more than today (in inflated dollars) but the PCP was seeing only one half the number of patients as today. Now, with about 25 or more patients per day, a visit is often only 15 to 20 minutes: actual “face time” with the doctor is just 8-12 minutes. If you’ve been a patient recently, I’m sure you’ve experienced this. While this amount of time is long enough for a simple problem, it is much too short for someone with a complex issue, or someone with multiple chronic diseases and taking multiple prescriptions. And it is not nearly long enough for an elderly person with impaired vision, hearing or cognition. There is no time for compassion, to build trust or to be a healer. Since there is too little time, the tendency is to send a patient off for tests or to a specialist when a bit more time with their history would provide the answer. There is not enough time to discuss lifestyle changes, meaning it is easier to just write a prescription and hope for the best. It is these steps that are the major cause of higher and higher medical care costs in the United States: unnecessary referrals, unnecessary tests, unnecessary X-rays and unnecessary prescriptions. And with it has come the loss of the close and trusting doctor-patient relationship and the lack of true healing.

When PCPs do have time, they can develop a trusting relationship and then give superb preventive care. This type of care will reduce serious chronic illnesses in the future, the diseases that today account for 75-85% of all medical costs. When they do have time, PCPs can treat the vast majority of issues brought to them by their patients without the need for specialist referrals or excessive testing. When PCPs do have time, they can coordinate the care of those patients that truly do need to be referred, ensuring high levels of quality at a reasonable cost. When PCPs do have the time, they can appreciate the underlying stress and anxieties that propel so many illnesses and trips to the doctor. When PCPs do have time, they can give truly proactive preventive care – population health - by reaching out now rather than waiting for the patient to arrive with a problem.

To address this crisis, both patients and PCPs will need to take charge and change the paradigm of primary care. Government will not do it. Insurers will be slow at best to do it although there are some examples to the contrary that we’ll explore in this book. A few enlightened employers are beginning step up as we shall also explore. But if there is to be real change—change that works—it will take PCPs and patients to force the issue. Patients need to demand the time they deserve. PCPs need to be able to give them the necessary time. This means fewer patients per PCP. Patients will need to migrate toward doctors that have 800 or less patients (compared to today’s standard of 2500 or more) and can therefore give them more time as needed.  The actual number per doctor should depend on the demographics of the doctor’s patient panel (the doctor’s patient load)—for example, a panel of mostly older individuals with chronic illnesses means fewer patients. Fewer patients means more time for each patient and much better access to the PCP. We’ll take a look at what some innovative physicians, insurers, and employers are doing—separately—to transform primary care and bring it back to being “relationship medicine” with a heavy emphasis on health and wellness and the care of complex chronic illnesses in addition to typical episodic primary care: true comprehensive primary care. One of many innovations is to not accept insurance and charge a reasonable amount per visit according to a posted price list. Another is using some form of “direct primary care” (DPC).  DPC comes in many variations and is known as membership, retainer or concierge medicine, but in essence it means charging a flat rate by the month or year for all primary care services, reducing the number of patients under care to about 500 and offering same or next day appointments for as long as necessary and access to the PCP via his or her cell phone twenty four hours per day and via email. It means comprehensive primary care not just episodic care: attention to health and wellness, reduction of risk factors, preventive actions, intense management of chronic illness and coordination of specialist care when needed and a return to relationship medicine with trust and healing. The latter is essential if we want to move from a reactive to proactive approach to healthcare. That means much improved care quality and satisfaction, and lessened frustrations for patients and doctors alike. Often it means generic medications at wholesale prices and laboratory and radiology at deeply discounted rates. Despite a widespread belief to the contrary, DPC is not just for the elite, the rich or the 1%. In fact, it can be quite reasonable – “blue collar” –  and, when DPC is combined with a high deductible health insurance policy (which is much less expensive than typical policies,) the savings for patients are substantial and the total costs of all care decline quite dramatically.

Among other options is capitation, as in some Medicare Advantage plans, but where the payment to the PCP is sufficient per patient that he or she can afford to have a reasonable total number of patients. Another is for insurers to create incentives for reducing patient numbers. Yet another is for employers to create their own primary care clinics with a low employee to physician ratio or to offer a payment into a health savings account (HSA) to purchase the membership in a direct primary care practice. One additional example is to place extensive primary care resources for the management of the “sickest of the sick,” often the socioeconomically disadvantaged with insurance via Medicaid – a team of PCP, nurse practitioner, nutritionist, mental health therapist, etc. We will explore each of these and other options.      

In all of the examples cited in the last two paragraphs where the PCP to patient ratio is reduced to a manageable level, the care quality goes up and the total costs of care come down very substantially. Throughout Fixing The Primary Care Crisis, we’ll look at the details of how that can be.

Fixing The Primary Care Crisis explains the crisis and its origins. It details what outstanding primary care can be for patients and society as a whole. It explains how and why illness has changed from the acute infectious diseases of the past (e.g., typhoid, pneumonia) to complex chronic illnesses (e.g., heart failure, diabetes with complications, kidney and lung disease) of today and why chronic illnesses now constitute 75-85% of all healthcare costs. It reviews how healthcare insurance went from covering unexpected expensive medical care (“major medical” and the catastrophic) to now include primary care; how employers have adjusted their assistance by expecting employees to pay a larger and larger portion of premium plus co-pays and deductibles. It then delves into some of the approaches referenced above that are being taken to return primary care to true relationship-based medicine.

Finally the book ends with a chapter that gives explicit recommendations to patients, doctors, insurers, employers and academic medical center leaders to effectively transform primary care to achieve the outcome of the very best care in a cost effective manner that improves quality yet reduces the total costs of care.

Together, this crisis can be solved with much better care, much improved satisfaction, much less frustration by patient and doctor alike, much less total money spent and with many more students selecting to become primary care physicians thus resolving the PCP shortage. It will be a win for everyone. But the change will only occur if and when patients become educated and then advocate for the new paradigm.  Fixing The Primary Care Crisis provides the information needed to make that transformation happen.

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Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).