Causes of the Crisis in Primary Care

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.

The Shingles (Herpes Zoster) Vaccine Really Works But Many Older Folks Don’t Receive It - They Should

Herpes zoster (or shingles) is caused by the same virus that causes chicken pox. Zoster increases in incidence with advancing age. It is estimated that over 1 million Americans get shingles annually with the resulting acute discomfort and often chronic pain thereafter. A vaccine was introduced by Merck in 2006; the initial studies of 38,546 patients indicated that it reduced the incidence by about 50% and for those who still got shingles, the severity was lessened substantially. But acceptance of the vaccine has been slow. It seems that this is due to a combination of lack of knowledge that it is available and is effective; failure of physicians to inform their patients; and a fairly high cost of about $200, often not covered by insurance.


A new study was reported in JAMA January 12, 2011. Kaiser Permanente, Southern California and Centers for Disease Control and Prevention investigators evaluated 75,761 Kaiser members who had no underlying immunological disorder and who had been vaccinated between January, 2007 and December 2009. These were compared to a control group of 227,283 age matched members who had not been vaccinated.

Among the unvaccinated individuals, this study showed that, as anticipated, shingles incidence goes up with age from - 60-64 years of age (9.7 infections per 1000 person years) to over age 80 (17.3 per 1000 person years).

Vaccination reduced the frequency by about 50% from a total of 13.0 per 1000 person years to 6.4 per 1000 person years. This halving of incidence was found at all age intervals, indicating that the vaccine works as well in the very elderly as in “younger” individuals. The incidence of zoster was steady over time. For example, at one year, slightly more that 1% of the unvaccinated individuals had developed zoster compared to less that 0.05% in the vaccinated group; at two years the numbers were about 2 ½ % and 1%, respectively. During the time of patient follow-up, this can be stated as one case of herpes zoster was prevented with each 71 vaccinated. However, since the follow up was only about 1 ½ years for most individuals and since it is estimated that beginning at age 60 a person has a 20% lifetime risk of zoster, it is my presumption that it actually takes many fewer individuals vaccinated to prevent one episode of zoster over the rest of one’s life.

Not part of this study, the original Merck investigation demonstrated that many older people do not respond well to the vaccine with increases in antibody production. This finding is consistent with many others that those over 60 years of age respond much less well than do those who are younger. This raises the question as to whether it would be useful to measure antibody production after vaccination to determine who has and who has not responded well. Perhaps those who do not should get a second vaccination. This is an important issue for all vaccines in older people. The same occurs with influenza vaccine which is why, this year, the dose for older people was doubled. But perhaps there are other approaches as well to improving the response rates for those at increased risk in their older years who respond less well to vaccines.

The study makes clear that this vaccine is effective, including for those over 80 years of age where the incidence is the highest. Given the implications of herpes zoster in immediate and longer term suffering and the attendant costs, I believe this is a vaccine that essentially everyone over the age of 60 (other than immunocompromised individuals) should receive. Insurance should pay for it just as with the influenza vaccine.

Even if paid for out of pocket, it is worth it. Patients need to ask for it and doctors need to encourage it.

Misconception - “Health care reform” will improve the delivery of care and offer us better care opportunities.

In fact, healthcare reform is not about healthcare; it is mostly about paying for medical care for the uninsured and only somewhat about the rising costs of medical care. I use the term medical care here to emphasize that today American “healthcare” is all about treating disease and injury and very little about promoting wellness and preventing illness. The reforms being proposed are about addressing the financing of medical care but not the quality, the safety or the way that healthcare will be delivered nor who will deliver it given the coming shortages of professionals at all levels. Certainly it is important to assure access to care for everyone but don’t let that confuse you into thinking your healthcare delivery will be improved. It will not.

One Approach To Improving Care Coordination While Assisting PCPs

Good care coordination will improve the quality of care for the individual patient and yet will reduce costs by eliminating excess visits, tests, procedures and, by improving care quality, it will reduce the need for hospitalizations. With primary care physicians [PCPs] not able to take the time necessary, it is clear that something needs to be done to get care coordination for those with complex, chronic illness.

Here is what one insurer, CareFirst Blue Cross Blue Shield [CF] of Maryland, DC and portions of Virginia is planning. CF knows that about 65% of their medical expenditures go towards the care of just 5% of patients and 80% go for about 15%. These are patients with catastrophic problems in the 5% and complex chronic illnesses for the remainder. CareFirst also knows that primary care physicians receive about 5% of total healthcare expenditures yet they are in a position to impact the other 95%. So the agenda is to create incentives for them to do so in a way to reduce that total while improving the care of the patient. It would work like this [somewhat oversimplified to account for space limitations here.]

PCPs would form into groups of 5 to 10 and enter into an agreement with CareFirst. In return CareFirst would increase their reimbursement by 15% for each visit. There will be another 5% increment in return for using an electronic system provided by CareFirst that will assist with billing. This system will check their submissions, do edits and corrections and then submit the claim to CareFirst [or any insurer], all automatically and electronically. I am told it is easy to use and will greatly improve the doctor’s office productivity thus creating savings. No longer will there be claims denials over billing errors or the need to repeatedly resubmit until the claim is remediated – it will be correct the first time. In addition, Carefirst will agree to pay the physician within one business day, dramatically reducing the need for working capital.

CareFirst will do an analysis of the PCP group’s patients using claims data from the prior year. CF will be able to “flag” the 15% or so of patients that need care coordination.
The PCP’s obligation in this new system is to give the patient whatever added time is needed per visit and to create a good care plan and post it in an electronic medical record. This will serve as automatic preauthorization, no further calls to CF will be needed for tests, procedures, etc. – another major time saver for the PCP and his or her office staff. When the patient needs to see a specialist, the PCP will refer the patient but also call the specialist and clarify expectations and review the results of the referral when done. Finally, CareFirst will make available a “care coordinator” [a nurse] to call the patient as often as necessary to check on medication use, medication side effects, weight gain or whatever that the PCP has built into the care plan. If the care coordinator cannot resolve an issue or sees a developing problem, she will report in to the PCP.

The expectation is that this approach of incentives for giving the patient the care coordination needed will enhance quality yet reduce the overall expenditures for that patient’s care.

To further add to the incentives, CareFirst will do an actuarial analysis of the expected claims for the coming year for the PCP group’s patients. If, at the end of the year, the patients have had fewer claims, CF will give back a portion through yet higher reimbursements. With this added incentive, it is anticipated that the PCP will be sure to carefully coordinate care so that there are no excess specialist visits, no unneeded tests or procedures and, with better care overall, less hospitalizations. The end results, hopefully, will be higher quality care, lower total expenditures for that care, enhanced income for the PCPs and a more satisfying practice. It could be a win for everyone. Of course, the devil is in the details but it seems to be a worthy plan, one that might just have a real impact. It appeals to me because it begins with an attempt to improve quality and improve the PCPs situation as a means of reducing costs – rather than the other way around.