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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