(jump to the end for report card)
I love reading the medical mystery cases written by Dr Lisa Sanders.
A few years ago (when I was still working at a traditional fee for service clinic) I read about a man who was ultimately diagnosed with a rare infectious disease. He had a story that was all too familiar to those of us in healthcare - he was initially seen in the ER, the ER doc did an appropriate work up, and when no answer was found and the patient was deemed stable, he was sent home with instruction to follow up with his primary care physician. Of course, he could not get in with his primary care doc. The next step testing that should have been done was never done. The patient landed back in the ER again and again, and continued to deteriorate until he almost died.
He finally got in with his very capable primary care who ordered the next step testing, from there he was diagnosed and cured. The truth is, I don’t remember all the details of this medical mystery. What I do remember was author Dr Sanders criticizing the patient’s primary care doctor for not following up on the ER labs and ordering the next step studies or making time to see the patient the day after his ER visit. I remember this so well, because I found it personally offensive. Those of us in primary care have an insurmountable amount of work that we are faced with on a daily basis. We are doing our level best, but we work in a system that is absolutely set up for us to fail (Some say our health care system is broken, but some say it functions exactly how it was intended to - a revenue generating machine).
The irony of that NYT medical case is that I bet that primary care doc would have loved to see this patient - who doesn’t want to see an interesting rare condition and help to solve a medical mystery? I bet that doc never even knew that patient was in the ER. There is no way they would have had time to hunt down and puzzle over those labs during a busy clinic day where they likely had 20-30 patients scheduled. I know my reaction stemmed from the moral trauma that comes with pouring your heart, soul, and youth into a helping profession only to have people frustrated with you for failing through no fault of your own. What I also know is that the reason that doctor did not review those labs and make time for that patient (in addition to being overburdened by the sheer number of patients and tasks already in front of them, is that seeking out and reviewing labs and studying the results brings in absolutely no income. Things that don’t generate income get squeezed out.
The most important work of a physician - deep mental work, gets squeezed out.
Our current healthcare system is very good at incentivizing stuff we do to people and squeezing out anything and everything that you cannot bill for. I wonder how many bogus visits that primary care doc did that day in order to cover their overhead when they could have been doing actual medicine? (Some studies estimate that 20% of primary care visits are unnecessary.) These unnecessary visits occur because they generate revenue - a procedural intervention is quicker and pays better then a counseling session or series of sessions to educate someone on their non-procedural options for care - so let’s schedule the procedure. A visit to the clinic generates revenue whereas an email or phone consultation does not. For example, a mom who is worried about her toddler’s head injury takes just as long to assess and reassure over the phone as she does in the clinic - easier to schedule the child for a visit than talk through the widely available PECARN criteria.
This NYT case is an example of a failure of primary care. Anytime someone ends up in an Emergency Room with a non-emergent condition that is a failure of primary care and upwards of 60% of emergency room visits are entirely unnecessary. Having practiced direct primary care for almost 5 years now I am certain that the current fee for service, insurance based reimbursement model creates a tremendous amount of bloat in the system and leads to an unnecessary strain on primary care. Are we short primary care physicians? Yes. Do we need to train more? Yes, but the problem is amplified by the busywork of prior authorizations and the unnecessary visits generated by a fee for service system. The shortage is partially manufactured. The strain continues to contribute to physician burn out and less and less people going into primary care which further amplifies the crisis.
Earlier this year The Milbank Memorial Fund published this report which seeks to identify problems in the US healthcare system, and help identify a pathway for improvement. Here are some highlights:
- Spending on primary care was under 5% in 2022 and continued its decline across all payers, with primary care spending in Medicare and Medicaid decreasing the most since the last Scorecard, down to 3.4% and 4.3% in 2022, respectively.
- Reimbursement rates for physician visits illustrate the way the US payment system rewards procedures over the comprehensive care of patients, undervaluing primary care. In 2022, primary care physicians’ reimbursement per visit averaged $259, compared to $1,092 for gastroenterology. This relative lack of revenue limits practice capacity to provide high-quality primary care and hinders the field’s ability to draw in new clinicians.
- The number of primary care clinicians (PCCs), including physicians, physician associates (PAs), and nurse practitioners (NPs), dropped from 105.7 per 100,000 in 2021 to 103.8 per 100,000 in 2022. The number of primary care physicians (PCPs) per 100,000 population remained flat at around 67 while the number of advanced practice providers per 100,000 population in primary care fell slightly (from 38 in 2021 to 37 in 2022).
- The percentage of NPs and PAs in primary care dropped to new lows of 30% and 24.3% in 2022, respectively, compared with 34% and 29.7% in 2021, respectively. More than 30% of US adults lacked a usual source of care (USC) in 2022 — the highest level in a decade, despite historically high rates of insurance coverage during this period. The percentage of children without a USC dropped from 13.6% in 2021 to 12.4% in 2022.
Couple the decline in primary care access with our pending “grey tsunami” and we have a healthcare crisis of unparalleled proportions coming our way. You can find a summary of the Milbank funds’ report here.
So what is the path forward? In 2021 The National Academies of Sciences, Engineering and Medicine published a pathway for rebuilding primary care. The summary can be found here
It includes these objectives:
Objective 1: Pay for Primary Care teams to Care for People, Not Doctors to Deliver Services
Objective 2: Ensure that High Quality Primary Care is Available to Every Individual and Family in Every Community.
Objective 3: Train Primary Care Teams Where People Live and Work
Objective 4: Design Information Technology that Serves Patients, Their Families, and the Interprofessional Primary Care Team.
Objective 5: Ensure that High Quality Primary Care is Implemented in the United States
If you’d like to learn more you can access the full report.