Primary Care Medicine - the Backbone of American Healthcare Delivery - Is Becoming Extinct - The Future of Healthcare Delivery
America is losing the backbone of its medical care system – the primary care physician (PCP.) Medical care costs are high and rising. Patients are not satisfied with their care and PCPs are highly frustrated. The fix to this predicament – a return to market economics - will be both disruptive and transformational. It is basically a return to a direct professional relationship between patient and physician. This reduces costs, improves quality of care and markedly improves both patient and physician satisfaction.
Currently America has 30% PCPs and 70% specialists; most other developed countries have just the reverse. The gap is widening. Medical students don’t choose to enter primary care anymore. Those in practice now are choosing to exit by retiring early or going to work for the local hospital. The era of the “private practice” PCP is coming to an end – unfortunate but true. Why is this happening? Driven by Medicare and followed by commercial insurers, the PCP has seen his or her income remain stagnant or drop over the past decade or more. To maintain current income and pay the ever increasing costs of insurance and office overhead in the setting of flat insurance payments means seeing more patients (“make it up in volume.”) To find the time for more patients, the PCP no longer cares for patients in hospital or ER and limits office visits to 10-15 minutes. The result is no time for good preventive care. Further, the current practice model does not allow “think time” for the PCP--so anything that looks urgent goes to the ER....no thinking, just triage. Additionally, anything complicated -- that could be figured out with probing and time-- goes to the specialist. In turn the specialist runs every test they can think of to avoid a mistake--and this just adds on to the defensive medicine cost of care. And the PCP has no time for care coordination of those with chronic illnesses – just the ones who both need it the most and whose costs of care consume about 80% of all medical expenditures. This is in turn greatly increases the overall costs further with more specialist visits, more tests, more X-rays, and more procedures – instead of time with the patient.
Medicare will soon increase the reimbursement to PCPs but the amount will not be enough to stem the tide of exodus nor to induce new graduates to choose primary care. That is too bad. We need a return to a market based medical economy where the PCP receives a payment commensurate with what the patient believes is appropriate. And that is just what many physicians are now doing on their own.
PCPs still in private practice are beginning to return to a direct PCP-patient contractual relationship. There are a number of mechanisms; all of which exclude the insurer. The PCP may charge a flat fee per visit to be paid at the door – no claim forms to the insurer, no bills to send or collect and a dramatic drop in office overhead. Or the PCP may have a variable fee schedule- more for an annual exam, less for a discussion of a complex problem and less still for a quick check of blood pressure meds. Or the PCP may switch to a retainer-based practice. Here the patient pays a fixed amount per year, usually $1500 to $2000. In return the patient gets guaranteed office visits within 24 hours, email access, the PCPs personal cell phone number to call 24/7, care in the hospital and visits if admitted to a nursing home. The PCP reduces his or her practice size from the former 1200 to 1400 or even more to a more manageable 500 and now has the time needed to give effective preventive care, to think out and evaluate the patient with a non-obvious cause of a problem and, for those with chronic illnesses like heart failure, diabetes or cancer the PCP will coordinate care with the other providers the patient may need. In short, there is a new balancing of rights and responsibilities for both patient and physician which result in better care.
The key attribute in the retainer model (and the others) include returning to a direct physician-patient contractual relationship, bypassing the insurer intermediary. This creates a more effective partnership, one where each party is responsible to the other. A second key attribute is reducing the number of patients cared for by a single physician so that each patient gets the time and attention needed. The third key is the PCP accepting the role of coordinator of care – an orchestrator - rather than just being an intervener.
The end result is good preventive care, careful attention to the patient and his or her history and social situation and good chronic care coordination -- leading to much higher quality, greater patient and physician satisfaction and dramatically lower healthcare expenditures as a result of fewer specialist visits, fewer tests, fewer X-rays and fewer procedures along with less reliance on drugs as a first response. When both PCP and patient accept these new levels of responsibility along with their new rights the end result is much better medicine.
Last Modified: December 13, 2011