PCPs don’t have to suffer silently under employers that deprofessionalize them and treat them as the low people on the totem pole of health care. They can embark on a mission to save U.S. health care, while increasing their earnings and enhancing their status.
This may sound like a pipe dream. But all the essential elements for it are available. All that’s needed is the political will to make it happen.
As many observers have lamented, primary care is declining rapidly, threatening the stability of our health care system. Less than 5 percent of health spending goes to primary care, despite its importance in keeping people healthy and managing chronic diseases. Nearly a third of the population lacks access to primary care, and the amount of time it takes to book a primary care appointment continues to lengthen.
To some extent, this predicament has emerged because fewer doctors are entering primary care and more primary care physicians are retiring or leaving medicine. The percentage of U.S. doctors in primary care has dropped from about a third to a quarter in the past decade. And, despite the concomitant increase in the number of nonphysician clinicians (NPCs), they are not as qualified as PCPs are to handle the wide range of patients who seek primary care.
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For the most part, efforts to address the situation have focused on how and how much PCPs are paid. This is certainly important, as PCPs earn less than most of their specialist colleagues do. But, even if insurers were forced to spend more on primary care, as some states have mandated, many employed primary care doctors would still be unhappy. They would still be forced to see more patients per day than they’d like to, and their clinical autonomy would still be limited. They’d still have to follow clinical guidelines that don’t fit every patient and refer to specialists, labs, and hospitals within their organization. In essence, they’d continue to be valued mainly for their productivity and their referrals.
Yul Ejnes, MD, an internist in Cranston, Rhode Island, and a former member of the American College of Physicians’ Board of Regents, called this trend “deprofessionalization” in a recent Health Affairs article. While he was talking about all employed physicians, his observation especially applies to PCPs.
“In many large organizations, what is ‘special’ about physicians is stripped away, perhaps unintentionally yet with potentially devastating consequences. Not only do physicians face external threats to their professionalism from those who pay for care and the commodification of medicine; there are internal ones as well, from the organizations that employ them.”
A practical solution to PCPs’ plight
As the National Academies of Sciences, Engineering, and Medicine (NASEM) pointed out in a 2021 report, “Absent access to high-quality primary care, minor health problems can spiral into chronic disease, care management becomes difficult and uncoordinated, and visits to emergency departments increase, preventive care lags, and the nation’s health care spending soars to unsustainable levels.”
Five years later, all of this is occurring on steroids. But there is an alternative. If we want high-quality, affordable, universal health care, we need to revive primary care and accord it the respect it deserves. But, simply spending more on primary care won’t achieve these goals. We need to restructure the health care system in ways that prioritize primary care and restore the role of PCPs as the quarterbacks of health care. To make that happen, PCPs should be placed in charge of all basic care, including the lower levels of specialty care.
This can be accomplished in a few steps, as explained in my new book. First, PCPs must be liberated from their employers, whether those be health systems, insurers, private equity firms, or primary care companies. There is a practical route to this outcome: between 30 and 33 states have corporate practice of medicine (CPOM) laws or regulations that, in theory, prohibit corporate employment of doctors. Except in a few states, these statutes are inadequate and/or lightly enforced; but lawmakers could pass CPOM laws with teeth, and other states could follow suit. For our purposes, these statutes need apply only to primary care physicians, who are a scarce and precious public resource.
Second, the PCPs released from employment would join with their independent colleagues to form competing primary care groups of a certain size. These groups would charge subscription fees for all basic care, which would roll up to an annual budget for each group. Consumers would choose a primary care doctor in one of the groups based on their fees and published quality and patient experience rankings. Employers, the government, and consumers would split the cost of the subscriptions, depending on a person’s income. No other basic care insurance would be allowed, so primary care doctors would have little choice but to join a group.
How would this approach benefit PCPs and rescue primary care? First, they’d be able to make their own financial and clinical decisions without interference from health care systems or insurance companies. In addition, having to deliver high-quality care within a budget would incentivize them to improve population health, using care teams and other infrastructure that could be implemented within a few years. By reducing waste and improving population health, these groups could thrive, enabling their PCP owners to earn more than they do now. At the same time, they would be able to restore the luster of their profession and attract more young doctors to primary care.
There is much more to my model, including the “major medical” insurers that would cover the more expensive kinds of care, including hospital and post-acute care and high-ticket outpatient services such as ambulatory surgery and cancer care. I also endorse, in a modified form, Maryland’s pathbreaking use of all-payer hospital rate-setting and global hospital budgets. There is no reason why this approach can’t be successful in other states.
I understand that all these changes would be hard for PCPs and other players in the system to adapt to. But we need fundamental changes in how our health care financing and delivery system is structured, or it will continue on its current path to collapse. If most people lose access to high-quality primary care, our barely functioning system will cease to function. So it is essential to talk now about alternatives to the status quo that will guarantee the future of primary care.
Ken Terry is a veteran health care journalist and author who has written extensively on health care reform, physician leadership, and the structural causes of America’s affordability crisis. He is the author of three books on health care reform, including Beyond Medicare For All: Cracking The Code of The Healthcare Affordability Crisis, published by the American Association for Physician Leadership with a foreword by health care consultant and thought leader David W. Johnson.
Terry’s work focuses on practical, physician-led approaches to improving the U.S. health care system, with particular attention to affordability, care delivery, and policy reform. His latest book is available through Amazon and the American Association for Physician Leadership.
More information about his work is available at Physician-Led Reform, and professional updates are available on LinkedIn.
