Part of a series.
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 health care that they deserve and need. This crisis is the major reason that health care in total is so expensive and why costs keep rising. This crisis needs to be fixed and fixed as quickly as possible. The solution is not too difficult.
What is this crisis? The fundamental problem is a flawed and non-sustainable business model that forces primary care doctors (PCPs) to care for too many patients and as a result 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 coordinate care for those with complex chronic illnesses. In other words, they need time to practice at the top of their profession, something they currently are unable to do fully.
This crisis means that doctors are highly frustrated, feel they are on a never-ending treadmill, 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 being actually cared for. The crisis means that there are not enough primary care doctors today, and it will only get worse because students in medical school see the impact of the crisis and choose not to enter primary care as a result.
Why the crisis? It began a few decades ago when insurers, beginning with Medicare, held reimbursement rates low; cost control through price fixing. But the doctors’ office costs were rising, largely resulting from constantly added billing requirements, varies rules and regulations and more recently complying with meaningful use and quality indicators. In order to meet overhead expenses yet maintain their incomes, the PCPs began to see more and more patients per day. PCPs report that they must see about twice as many patients today as a few decades in return for the same income, inflation adjusted. With about 25 or more patients per day, a visit is often only 15 to 20 minutes but the actual “face time” with the doctor is about 8 to 12 minutes. This is long enough for a simple problem but much too short for someone with a complex issue, or someone with multiple chronic diseases and taking multiple prescription medications. And it is certainly not long enough for an elderly person with impaired vision, hearing or cognition. There is not adequate time for compassion, to build trust or to do true healing. Since there is too little time, the tendency is to send the patient off for tests or to a specialist when a bit more time with their history would give the answer. There is not enough time to discuss lifestyle changes, so it is easier to just write a prescription. It is these steps that are the major cause of higher and higher medical care costs in America — unnecessary referrals (now double what it was just a decade ago), 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.
I definitely do not blame the doctors. They are just caught in a terrible conundrum.
When PCPs do have time, they can develop that trusting relationship and then give superb preventive care. This reduces serious chronic illnesses in the future — just the diseases that today account for 75 to 85 percent 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 by reaching out now rather than waiting for the patient to arrive with a problem. The result is better quality care, greater satisfaction for both doctor and patient and much lower total costs.
What to do? 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. A few enlightened employers are beginning to step up. So if there is to be real change, change that works, it will take the PCP and patients to force the issue. Patients need to demand the time they deserve. PCPs need to insist that they will give the time. This means fewer patients per PCP. Patients should migrate toward doctors that have fewer than 1000 patients (compared to today’s more than 2,500) and can, therefore, give more time to each as necessary. The actual number per doctor should depend on the demographics of patients (e.g., mostly older with chronic illnesses means fewer patients). Fewer patients mean more time for each patient and much better access to the PCP. Of course, this will need to be paid for. One approach is to not accept insurance and charge a reasonable amount per visit. Another is direct primary care (DPC). DPC comes in many forms and is also 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.
What does DPC offer? Expanded service (comprehensive) primary care, offering same or next day appointments lasting as long as needed and 24/7 access via the PCP’s cell phone. Often it means generic medications at wholesale prices and reduced cost laboratory and radiology testing. It means much-improved care quality, satisfaction and lessened frustrations for patient and doctor alike. Despite a widespread belief, DPC is not just for the elite, the rich or the 1 percent. In fact, it can be quite reasonable — “blue collar” — and, when DPC is combined with a much less expensive high-deductible health insurance policy, the savings for patients are substantial and the total costs of all care decline quite dramatically as in these two reports.
A small but steady migration of PCPs to DPC is occurring today. To drive the process at a faster rate, the need is for patients to become educated and then to demand the type of expanded primary care that can come from a more reasonable number of patient visits per day.
If patients want to benefit from much better care, if they want a doctor that is not frustrated and can spend time with them listening, if they want their total costs of health care to decline rather than rise, then they will need to educate themselves and then advocate – to legislators, to insurers, to employers and to their doctors. Concerted patient action will force the issue and make change occur. When the PCP has more time, care gets better, frustrations come down, satisfaction goes up and total costs come way down and, as an added bonus, many more students will select to become primary care physicians thus resolving the PCP shortage. Together, this crisis can be solved. It will be a win for everyone.
Stephen C. Schimpff is a quasi-retired internist, professor of medicine and public policy, former CEO, University of Maryland Medical Center, and senior advisor, Sage Growth Partners. He is the author of Fixing the Primary Care Crisis: Reclaiming the Patient-Doctor Relationship and Returning Healthcare Decisions to You and Your Doctor.
