Whither primary care


Category : Medical Rants

Regular readers know that I have concerns about the term primary care. This phrase has suffered semantic drift over the past 20 years. Nonetheless, many physicians still use this phrase in its classic sense. This post will use the classic IOM definition – Defining Primary Care

A set of attributes, as in the 1978 IOM definition, care that is accessible, comprehensive, coordinated, continuous, and accountable, or as defined by Starfield (1992), care that is characterized by first contact, accessibility, longitudinality, and comprehensiveness;

Robin Cook is a famous physician novelist. Although not a primary care physician, he has an opinion piece in yesterday's NY Times (thanks to KevinMD for the link) which should make everyone think carefully about primary care physicians. Care by the Hour I will quote liberally from his thoughts, because I agree so strongly with his words.

What is the solution? We must make primary care a more manageable business by changing the way we pay for it. Primary care doctors should be paid by the hour. As it is now, insurance companies , following Medicare's lead , pay primary care doctors according to the number of patients they see. Each patient visit is generally reimbursed at a flat rate of slightly more than $50. The payment is the same whether the patient is a healthy, young person with a runny nose or an elderly person whose multiple chronic illnesses require many tests, referrals to specialists and detailed explanations to both the patient and his or her family. A lawyer in general practice is not expected to accept the same low fee he gets for writing a simple will when he writes one that involves complicated business circumstances. Nor does an accountant charge the same amount for a difficult tax return as for an easy one. Why should the work of doctors be assessed this way? A typical primary care doctor spends slightly more than half of his or her day seeing patients; the other half is spent conferring with specialists, lab technicians and patients' families, or trying to persuade health insurance companies to cover some needed treatment. This other half of his work day must be considered pro bono. Factor in rising overhead costs (office space, employees and malpractice premiums), and the situation easily becomes untenable. No wonder hundreds of primary care doctors have switched to concierge-style practices, in which patients are charged subscription fees in return for more personal service in markedly smaller practices. But this trend only adds to the problem of accessibility by reducing the pool of regular primary care doctors. Ideally, the hourly rate would not be the same for all primary care physicians, but would be assessed on a sliding scale, predicated on a doctor's level of education. Internists and pediatricians , the primary care doctors who have had the most training , would receive a higher rate than general practitioners and family physicians would. Reimbursement by the hour might not shorten my friend's day right away; his patient roster is already too large. But it would enable him to reduce his load over time. By making him feel that his sacrifices are valued, it might also help bring back the joy he used to find in practicing medicine. And by enhancing the prestige of primary care, it might reverse the exodus of doctors and encourage medical students to join the field.

Please read the entire op-ed, it is brilliant. Today's NEJM has two articles (no subscription necessary) which also address primary care. The first comes from a family medicine leader. Primary Care , Will It Survive?

The great majority of patients prefer to seek initial care from a primary care physician rather than a specialist,2 but their unhappiness with their primary care experience is growing.3 At the same time, primary care physicians are expressing frustration that the knowledge and skills they are expected to master exceed the limits of human capability, making it impossible to provide the best care to every patient.4 The scope of primary care extends from uncomplicated upper respiratory and urinary tract infections to the longitudinal care of elderly patients with diabetes, coronary heart disease, arthritis, and depression , who may also have limited proficiency in English. Reimbursement based primarily on the quantity of services delivered, rather than on quality, forces primary care physicians onto a treadmill, devaluing their professional work life. The short, rushed visits with overfilled agendas that cause patients dissatisfaction simultaneously breed frustration in physicians. Contributing to this frustration is the growing set of demands placed on primary care. The preventive services that a physician either ought to provide because there is evidence of their efficacy or might provide because of the patient's preferences (which must therefore be discussed) have multiplied. The prevalence of chronic conditions , most of which are handled in primary care settings , is increasing, as are requirements for their proper management. Not only has the number of primary care tasks grown exponentially, but physician performance is being measured and physicians are even being paid according to their ability to perform these tasks reliably and consistently. It has been estimated that it would take 10.6 hours per working day to deliver all recommended care for patients with chronic conditions, plus 7.4 hours per day to provide evidence-based preventive care, to an average panel of 2500 patients (the mean U.S. panel size is 2300).4 These excessive demands contribute to long waiting times and inadequate quality of care for patients. A growing proportion of patients report that they cannot schedule timely appointments with their physician. Emergency departments are overflowing with patients who do not have access to primary care. The majority of patients with diabetes, hypertension, and other chronic conditions do not receive adequate clinical care,4 partly because half of all patients leave their office visits without having understood what the physician said.5 These problems are exacerbated by the system of physician payment.1 Thirty minutes spent performing a diagnostic, surgical, or imaging procedure often pays three times as much as a 30-minute visit with a patient with diabetes, heart failure, headache, and depression. The median income of specialists in 2004 was almost twice that of primary care physicians, a gap that is widening. Data from the Medical Group Management Association indicate that from 1995 to 2004, the median income for primary care physicians increased by 21.4 percent, while that for specialists increased by 37.5 percent. A 2006 report from the Center for Studying Health System Change reveals that from 1995 to 2003, inflation-adjusted income decreased by 7.1 percent for all physicians and by 10.2 percent for primary care physicians. The 5 percent increase in Medicare payments for primary care announced in June 2006 is insufficient to narrow the gap.

This article, written by Thomas Bodenheimer, M.D., proceeds to call for public policy to rescue primary care. He writes eloquently with a sense of desparation. The second article comes from a general internist, Beverly Woo, MD, who I have known for 25 years. As an academic general internist, she has been active in SGIM. She starts her perspective extolling the virtues of being a primary care physician. Primary Care , The Best Job in Medicine? Unfortunately, she then takes a realistic look at the prospects our nation has in satisfying the need for enough primary care physicians.

It is disturbing to me that changes in our health care system have made primary care medicine less satisfying for practitioners and less attractive to students and residents. Primary care physicians are under pressure to see patients at a faster pace than ever before, even as their responsibilities increase. Add to these difficulties the increasing administrative burdens and the fact that the remuneration for primary care specialties is at the bottom of the pay scale for physicians (see line graph), and it is no wonder that primary care medicine is in crisis.


Some have said that this decline reflects a lack of commitment among the current generation of trainees. I disagree. Medical students and residents are no less idealistic or dedicated today than they have been in the past. But the decrease in job satisfaction, the increase in educational debt (which now routinely exceeds $100,000), and the growing disparity in salary relative to other specialties could together create a strong sense that becoming a primary care physician may be a fool's errand. If the current problems of primary care practice are not addressed, the number of students and residents entering the field will undoubtedly continue to decline. With all the changes in our health care system, one thing remains constant: the needs of patients. Patients want a continuing relationship with a doctor whom they trust, and they increasingly need that doctor to act as an advocate to help them get the best care within a fragmented health care system.4 A strong primary care infrastructure is associated with better health outcomes, lower costs, and a more equitable health care system, since primary care is key to providing services to vulnerable populations.5 There is an urgent need to reverse current trends. Although the line of students signing up for a career in primary care medicine is getting shorter, the line of patients in need of primary care doctors is getting longer every day.

Why have we reached this stage? Several problems have lead to the current status. First, we (family physicians and general internists primarily) made a huge mistake in the 1990s. We thought that managed care was the answer to improving the quality of life of primary care physicians. Just like politicians, we failed to carefully consider the externalities of the managed care movement. The managed care movement cause the semantic drift in the meaning of primary care. 'Dictionary.com' now has this definition – "The medical care a patient receives upon first contact with the health care system, before referral elsewhere within the system." This definition implies the gatekeeper concept (another big mistake was accepting the label of gatekeeper). This definition is the truth, but only a small part of the truth. When I first joined the GIM faculty in 1979 as a primary care internist, I understood my job. I believe that the current graduates of both internal medicine and family medicine programs understand their jobs. The above definition does not adequately describe those jobs. The primary care physician cares for the patient, whether the problems are episodic or chronic. He/she provides care in the context of the patient's medical problems and their psychosocial situation. When the patient has multiple problems (as occurs with increasing frequency), the primary care physician has the responsibility of weighing the various treatments to maximize quality and quantity of life. The primary care physician takes responsibility for preventive medicine (both primary and secondary prevention). Finally, the primary care physician coordinates the patients journey through the health care system. He/she arranges appropriate consultation when necessary. This job is in my opinion the most challenging and satisfying job in medicine. The breadth of knowledge necessary to meet our patients' needs is remarkable. We must reinvent our reimbursement system to allow physicians to enter this field. I chose my verb carefully there. Many physicians (due to debts) cannot financially succeed in primary care specialties. I think that Robin Cook understands the answer. I have speculated about this solution previously in these pages. His essay probably makes too much sense for policy makers to consider strongly. But one can always hope.

In the long run, paying by the hour could save money. It would provide doctors the time they need to investigate symptoms themselves rather than reflexively refer patients to specialists. After all, every headache doesn't need to be evaluated by a neurologist; nor does every painful shoulder require an M.R.I. It would also increase the pool of primary care doctors, so that more health problems could be handled in doctor's offices rather than in emergency rooms, where the cost of care is more expensive. And finally, better long-term doctor-patient relationships might reduce the number of malpractice lawsuits. Paying for primary care by the hour would be better for both doctors and patients, and it would return a measure of rationality to our health care system.

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Comments (22)

As a patient, I would love to be able to pay my PCP by the hour. I would go even further to suggest that hourly rates could also be useful for specialists who are able to treat patients largely within their offices. For example, I see a urologist twice a year. In addition to a consult, I usually get various ultrasound tests, uranalysis, etc. The bill usually comes to $1,500 or more at list price while insurance pays about $500 or so. Why can’t I just pay $500 per hour regardless of the mix of consulation and testing instead of by CPT-4 code? Hourly rates would also neatly and easily resolve the pricing transparency issue.

The reason doc’s get paid a cetain fee is the same reason all paid employees get paid a certain fee. Medicare is a voluntary program, if you sign the contract you get what the government allows.

Lawyers and accountants who are self employed at times do very complex work, but they generally do not sign contracts with group payors. They have a fee schedule and the client can take it or leave it.

It is not surprising that concierge and other non insurance company fee based practices are sprouting up. This is how the world works for everybody else.

Doc’s who run ofices do have choice, sign up for contracts that pay poorly or go out in the free market like many other professionals do, or do some thing else to earn a wage.

Fantastic articles and commentary.

Rather than bemoan that “policy makers” will be deaf to the logic of well-reasoned complaint, why are we as physicians still waiting for a “policy maker” to take pity on us? Certainly any other profession comparisons are made to (Accounts/Lawyers etc) would have taken policy into their own hands by now.

So maybe it is up to us. Maybe we will have to be the first to throw off the protective shackles of the large mega-insurance contracts.

Only when physicians walk away from bad contracts and government sponsored health care will patients and policymakers appreciate the value of our services.

Robin Cook “brilliant”? I don’t think so!

How does accountability for quality work into this? What is the incentive for doctors to give more value for their time? If payment is from the patient on an hourly basis (like my accountant and attorney) I can understand. If it is from third parties, it makes me nervous.

Regarding Oskie’s comment, it is possible to walk away from some contracts, but survival depends on taking what you can get. A big group will have the power to negotiate, but a small one will just be ignored. I personally would only walk away from Medicare as a very last resort, as I see a social responsibility to care for these patients.

This blog posting, and the commentaries in the New York Times and the New England Journal were interesting and thought-provoking.

What was lacking was a sense of how we got into this predicament. If primary care is so good for society (and I agree that it is), why is it paid so poorly, and why are primary care physicians so burdened with paper-work and bureaucracy? The implosion of primary care has happened while the rest of the health care system has prospered unlike any other part of the economy.

I don’t have all the answers, but surely some of the reasons have to do with how power has become concentrated in large health care organizations, pharma and device companies, managed care organizations and insurers, hospitals, academic medical centers and health care systems, government agencies, etc. Furthermore, this power has often been abused, and there have been too many instances of managers and executives of these organizations who were clueless, entangled in conflicts of interest, or even outright corrupt.

Plenty of examples of concentration and abuse of power in health care can be found on Health Care Renewal

If we physicians do not address concentration and abuse of power in health care, we will continue to cry out in the wilderness while good clinical care implodes around us.

“The reason doc’s get paid a cetain fee is the same reason all paid employees get paid a certain fee. Medicare is a voluntary program, if you sign the contract you get what the government allows.

Lawyers and accountants who are self employed at times do very complex work, but they generally do not sign contracts with group payors. They have a fee schedule and the client can take it or leave it.

It is not surprising that concierge and other non insurance company fee based practices are sprouting up. This is how the world works for everybody else.

Doc’s who run ofices do have choice, sign up for contracts that pay poorly or go out in the free market like many other professionals do, or do some thing else to earn a wage.”

This is a fantasy. Medicare currently controls 60% of all healthcare dollars spent. Thats a de facto monopoly. ONly a few doctors can “opt out” and go the concierge route, that market is quickly going to be saturated.

Doctors lost the war when Medicare was created. Ever since that moment, the fed govt has slowly but assuredly been acquiring market control of healthcare. The federal monopoly over healthcare leads to artificial wage suppression. Ohter insurance companies base their rates on Medicare.

The federal government has decied that healthcare is a right, and not a privilege. Ever since that moment, doctors were going to get screwed.

The comparisons with lawyers and accountants dont work because neither of those professions has the federal government dictating that its a “right” and not a privilege.

Dr. Poses,

I agree Primary Care is good for the country and is undervalued. Much like a safe water supply and garbage collection. It these two things weren’t there, disease would explode. However, society works to MINIMIZE these costs even though their value is infinite. (check your latests utility bill–its a bargain!!)

That is what congress is doing with primary care. Only when there aren’t enough of us will there be an increase in the fee schedule. That will never happen because thousands of (mostly excellent) foreign doctors enroll in community hospital training programs to become family practioners and general internists.

The solution is on the micro level. If you do not like what you are doing, find a different job, or work less and buy a smaller house. I’m not being flip, I followed that advice. We are powerless to change the predicament we are in, regardless of how many scholarly, accurate articles are written by the ACP and NEJM.

i disagree with b completely.

Those who use the healthcare system most (chronically ill, elderly, etc) are often those who have the least capacity to pay.

Concierge medicine selects out of the payment pool healthier individuals who can afford to pay out-of-pocket.

As the practices switch to concierge, it bankrupts the existing (Medicare) system. This may not be a bad thing as a system that does not function well should not be supported by those it harms.

That is EXACTLY why I have never considered going to the concierge model. I think that doctors are changing to it for their financial survivial, so I can’t fault them. It is just a further sign that primary care is in trouble unless something is done for the payment system.

“The solution is on the micro level. If you do not like what you are doing, find a different job, or work less and buy a smaller house. I’m not being flip, I followed that advice. We are powerless to change the predicament we are in, regardless of how many scholarly, accurate articles are written by the ACP and NEJM. ”

well said, it is this “micro level” solution which is being done, by every phsyician who does or did or thinks about doing primary care. For those young trainee physicians they come to a micro level solution by not training in primary care, for those who are in primary care, they make their own varied solutions by
1. taking pay cuts or doing other things that enhance income earnings (concierge medicine, cosmetic crap, …)
2.leave primary care and do something else (hospitalist, VA system, etc..)
3.retire early
4. subspecialize
5. etc…

waiting for the government to make it better, is like waiting for Santa.

” Medicare currently controls 60% of all healthcare dollars spent. Thats a de facto monopoly. ONly a few doctors can “opt out” and go the concierge route, that market is quickly going to be saturated.”

in 2006 it is estimated that 46 million people have no health insurance….there are probably millions more folks who have health insurance but choose to pay cash for to see the physician of their choice. I see a large opportunity for physicians to test the conceirge /cash only evironment.

I agree that opting out of medicare is hard for many physicians, yet many do opt out…probably it would help to search out those practioners and see how they are doing. From what I have seen, there is a 10-15% drop in income when going to cash only but about a 30-45% reduction in work hours…so ultimately one can choose the environment that is most suitable.

Of course “opting out” can also mean that you can opt out of primary care. I did this over one year ago, and as a hospitalist I average about 48hours/week ( in primary care I averaged@ 62 hours/week…many weeks were closer to 70). It has been a very positive experience for me, so I am a proponent of opting out.

Hey, don’t make fun of Santa! I don’t know about you, but I get Christmas presents every year.

Look folks, we all will kick the bucket eventually. Medicine just postpones the inevitable. If people didn’t abuse their own bodies as much as they currently do, we might need half as many docs as we do now.

My current plan is to work as a hospitalist until about 40 and then get out. In all likelihood the world will continue to turn.

The problem with primary care is not really so much about the skills and training which physicians bring into the practice arena. The problem also is not so much the dysfunctional environment in which physicians practice in.

I would venture that the true problem is the lack of value perceived by the public. Perception is more powerful than objective evidence.

Society ,as it is now, glamorizes the most pitiful things…we focus on consumption, the profit motive, cosmetics and the trappings of materialism. We spend enourmous amounts of money doping ourselves up to avoid reality and we spend our riches in consumption.

Primary care caters to a different dimension. Primary care offers a service which for the most part society does not value and hence primary care is “whithering”

“Primary Care” enthusiasts do not seem to realize that science is not on their side. As science and medicine get more and more complicated, as our knowledge base expands, it is apparent that no one person can be an expert at everything. This really calls for specialists rather than generalists.

Gone are the days when a general surgeon is adequately trained to make vascular surgery a big part of his practice – without a vascular fellowship. Even radiologists are finding the need to do fellowships in MRI, bone/neuro/body imaging, interventional radiology, etc. Orthopedic surgeons are finding it necessary to do fellowships in spine, hand or oncology. Anesthesiologists are finding it necessary to do fellowships in cardiac or pediatric anesthesiology or pain medicine. Even intensivists find the need to further subspecialize. All these “specialists” feel the need to do further fellowships not because they’re suckers for punishment or are greedy. The science of medicine has expanded that much. Newer procedures are available. Our expanding knowledge base requires specialization.

As such, I would rather take my children to a pediatrician (who has at least done 3 years of a residency taking care of pediatric patients) rather than a family practitioner who has done a few weeks of a peds rotation during a 3 year residency. Likewise with obstetrics and gynecology needs. No freaking way an FP can read a chest x-ray as well as a radiologist who has read thousands just during residency.

Thus “primary care” is dying a natural death – merely a result of our expanding medical knowledge and menu of procedures. There’s not conspiracy here. Science, knowledge an complexity demands specialization, not generalists. The inflated value of primary care physcians is just a deluded political fantasy.

Many thoughtful comments; here are my rants:

I agree with the above poster who suggested specialists should also be paid on an hourly basis. Moreover, there already ARE some doctors paid hourly, in a manner of speaking–these are ones who work for the NHS and the Department of Veterans Affairs I believe; The VA is getting plaudits of late for its quality of care, although I continue to encounter veterans who are unhappy with some aspect of their treatment there. Perhaps we need a careful review of what systems that employ salaried physicians achieve (versus the entrepreneurial medical practices that have been the rule)?

I am guessing both newbie posters are healthy, and haven’t had to navigate through endless specialists, who provide untold tests and procedures without ever taking away the uncertainty involved in trying to diagnose and treat an ailing human being. This is the illusion of medical specialization and ‘progress’ in science — in reality, the uncertainty never really goes away. Patients still have to make choices, and they recognize that many specialists have a vested interest in doing procedures and tests, and often don’t seem to connect specifically with the particular person in front of them. Don’t get me wrong–I believe we need the specialists–I just don’t think all cardiology patients need echocardiograms yearly, and asymptomatic patients need angiograms, for example. Yet I see this stuff all the time and it bothers me. Many, many patients value having a physician who works with them as DB describes above; I believe this is particularly true for the chronically ill who NEED to see one or more specialists from time to time. May the newbies never have the need for such a physician to help them make life-or-death decisions!

For more eloquence on the uncertainty in medical practice and its effects on physicians (and more), check out an essay by Eric J. Cassell from many years ago: “The Changing Concept of the Ideal Physician”. I believe it was originally published in the journal Daedalus, but later was a chapter in his 1991 book “The Nature of Suffering and the Goals of Medicine” (Oxford University Press).

Dude, as a traditional internist I sweat every day whether someone has a tumor, could be dying of a heart attack, etc. I have to worry about these things in young people who can think and in others who are easily confused, on 9 pills with at least two names, have an insurance company which constantly changes what they will pay for, bureauocrats trying to nickel and dime me out of my ability to keep the lights on, work horrific night hours, and have lawyers lying in wait with nothing better to do than to slap a suit on me (fortunately I haven’t been sued YET).

I do all this while some dermatologist makes three times my income to take spots off, pass out creams, and work 9 to 5 five days a week. Many specialists often just rule out their little areas, make lots of bucks, and don’t ever deal with the real suffering many patients have to go through on a chronic basis. They often just wash their hands and move on.

Primary care is very important but unfortunatetly absolutely doomed in our current system. The few docs filling in the ranks will barely speak English and be of low quality for many years to come.

PH has proivided the best description and what I think is thee best prediction
“Primary care is very important but unfortunatetly absolutely doomed in our current system”

note that he states ” in our current system'” doc’s are controlled by the system and are responding.

oh yeah one other thing PH, your comment supporting the rumors of Santa being alive and well are perhaps doomed. As I was leaving from the ER I saw an unfortunate fellow, looked just like Santa, being admitted to the ICU….he ,I believe ,is admitted with the typical HONDA POPA
complex….Hypertensive, Obtunded, Noncompliant, Diabetic Alcoholic, Passed Out Prior to Admission. I think he ran out of his lactulose . you might not get his presents this year.

Why can’t primary care doctors get off of the PPO’s, have the patients pay up front, then have the assignment of benefits go to the patient – or just let the patient deal with it themselves? I have gone to primary care doctors and have my kids go to pediatricians but have NO CLUE how much an appointment costs because they accept assignment and I just pay a co-pay. If GP’s are having that much trouble they should just say F off to the insurance companies and have patients pay cash/credit and have the insurance check come to the patient. You could see half the patients, have a one room clinic in a professional building, a laptop and a prescription pad. Answer your own phone and do your own scheduling. Keep track of your patient’s prescriptions and specialist referrals, modern day low overhead home base country doc – people would love it. Why don’t I have one?!?

You guys are struggling while the CEO’s of the insurance companies have bank accounts in the MILLIONS/BILLIONS – off the sweat of whose back?

I am in dental, and getting off PPO’s is different for us because not everyone has dental insurance. And we don’t have to deal with Medicare. . .but if you had a low overhead practice. . .hair salons make good money for goodness sake, but people pay CASH!

Naive outsider looking in

the decsion to take cash only…appeals only to a narrow spectrum of the physician workforce. Any physician who does hospital work or does surgical procedures cannot find a large enough population of patients who are willing to pay cash for surgical oe in hospital related services.

For the primary care physician who wishes to provide care to patients in the hosptal setting…a cash only practice would virtually eliminate any possibility of doing hospital related work.

So then the cash only models is limited to the primary care providers who do not want to do hospital work. From this pool of purely outpatient primary care providers, many will have enourmous educaional debts to pay off, As the large majority of patients have health insurance the cash only practice has a much slower rate of financial reward.

Insurance then becomes a necessary evil for the physician.

Also Medicare has an onerous opt out clause barring any physician who want’s to stop billing medicare (even on a trial basis) from re-participating with medicare for 24 months. Many physicians cannot take the risk of being barred from participating with medicare for 24 months.

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