Occasionally, I’ll publish some of the reader mail I receive. Here’s one from a former PCP in California. Fed up with the downward spiral of primary care, he chose to leave primary care altogether. I assure you he’s not alone:
“I am an Internist for over 20 years, and I recently closed my primary care practice as I cannot make a living at it. I made $23K in the last 11 months. And, my departure from practice is only the beginning of a tsunami of closures of primary care practices due to: defections by doctors to the likes of Kaiser (as is already happening here in northern California); or to ’boutique’ practices serving just a few wealthier patients across hi-rent areas like California, New York/East Coast, Florida etc.; and early retirements of an aging Internist work-force. For a population of >250,000, Santa Rosa, CA now has 15 practicing Internists (outside of Kaiser) of which only 3 are under 55 years old. More choose early retirement each day and will not be replaced in the current regulatory and economic climate. Medical students are not going into primary care specialties as they are not idiots. Given the unhappiness of current primary care docs, the huge debt accrued by medical students and the paltry return on investment in Internal Medicine/Family Practice and Pediatrics, the collapse is inevitable and will be truly frightening in its scope and degree.
Our medical & political leadership are still not getting it either. They say they want to address primary care’s survival; but I’ve seen no real action in all the years I’ve been practicing. They couch the crisis in primary care with terms like ‘may’ or ‘will be’ as if the crisis were not already upon us and worsening by the day. They offer ‘pie in the sky’ solutions like the ‘medical home’ while oblivious of the up-front costs of these programs and the EMR’s that would be necessary to implement them.
And to the policy wonks that say; ‘oh, universal single payor will fix everything’, let me remind you all that it was the government run, entitlement driven system for all Americans over the age of 65 that has put me out of the business of seeing my patients.
I am apparently supposed to shuffle elderly and/or complex/complicated patients in & out of my office every 10 to 15 minutes, or I cannot make a living. Alternatively, I can bring them back every week to address one more of their multitude of problems. Frankly, this is not a solution that I, or these debilitated patients can live with.
Primary care is unraveling around us. Indeed, all of the articles about the inordinate strain & crowding of emergency departments across the U.S., overlook the obvious – the impending failure of primary care is going to completely overwhelm emergency rooms. There is no way to prepare for this other than to save primary care.
The whole house of cards has begun to collapse, and all the articles and discussions fail to put it in terms with sufficient emphasis. All of the ‘universal’ systems that actually work are built on very strong and well-funded foundations of primary care. Everything else in health care is built upon that foundation, and that is precisely what is failing across the country. Why are emergency rooms overcrowded? Why are the wait times increasing even for the seriously ill? Because primary care is failing!
Just remember, I told you so.”
Related posts:
- ER visits and health care costs rise in Massachusetts due to lack of primary care access
- Primary care sacrifice
- Op-ed: Shortage of primary care threatens health care system
- Reader take: Ganging up on primary care
- The Boston Globe continues to spotlight the primary care crisis
- Primary care, the reality
- MinuteClinics: Reflects "the sorry state of primary care in America"
{ 36 comments }
That’s just plain scary?
What is scarier is that none of the Presidential candidates of any party has any clear understanding of the problem. I see the collapse of primary care, my patients are already seeing it (I do Pulmonary), but none of these supposedly enlightened candidates have a clue. Health insurance for all will only make access worse – just look at Massachusetts.
Excellent letter.
I could not have said it better.
There is enough blame to go around. The below list is just a starting point:
1. insurance companies, many of whom reimburse below Medicare rates, pit the patient against the doctor and increase our paperwork burden
2. Medicare, that undervalues primary and preventive care, and constantly threatens us with cuts while at the same time insulting our “quality”
3. Medicaid, a disaster of a “beast” that is being “starved” by government
4. Specialists, ie fired anesthesioligists, who have raped and pillaged and now cry “unity” out of fear that their well runneth dry. Where have they been all these years while primary care has been squeezed?
5. Medical societies, ie AMA, who have been blind and ignorant to the problem. Due to specialty dominance, perhaps they have been tacitly complicit?
6. Hospitals, who in starting their “clinics” have starved community-based practices.
7. Other primary care doctors, for letting it get this bad, for forcing new partners to sign ridiculous covenants that they never had to sign when they were starting out, for “eating their young”
8. Medical directors of HMO’s, usually primary care doctors, who are the “capos” of this system and lend credibility to HMO decisions. Where would Cigna be in their recent public relations debacle (involving a 17 year old needing a liver transplant) without their “medical experts” to hide behind?
9. Politicians, ie Newt Gingrich, Hilary Clinton, who are ignorant. Foolish Gingrich thinks technology, ie emr’s will solve the problem.
10. Other policy wonks, from government, “independant” think tanks, or whatever, who think the problem “quality” (a concept that insurance companies/HMOs jump on because it makes doctors the problem, rather than them)and the remedy “P4P”, a bureaucratic formula that will increae paperwork significantly but pay minimally
11. Lastly, the patients, be they from Medicare, Medicaid or private insurance. The ones who think the doctor negligent if he/she cannot see them immediately for their cold. The ones who think their doctor should their call right away, or wait to the last minute for refills, or blame their doctor for their insurance companies recent formulary change, or are upset and do not want to come in because their employer and HMO have raised their copay to thirty dollars, or no-show, or complain about a twenty minute wait like you are a restaurant.
Am I bitter?
You betcha.
Signed underpaid, overworked, underappreciated family practitioner from upstate New York
Yeah anon 10:29. the Mass experience really makes me want to vote for Mitt Romney….not in a cold day in hell.
well then, How are PCP’s in the Kaiser arena faring? Are there access problems in the Kaiser system as well due to physician shortage?
Primary care is not withering at the vine; it is being intentionally murdered. The main technique whereby unelected bureaurats and their allies seize permanent political power is through the disempowerment of the populace, rendering the citizenry fearful, powerless, dependent, and lacking options. The goal is that there is nowhere to turn except the government.
Cases in point: Medicaid, the Indian Health Service, and (now) Medicare. I believe that the Department of Health and Human Services (in tandem with corrupt politicians) has intentionally destroyed primary care for political gain.
Ed Sodaro MD
I had also posted a similar story last week and took the entire comment and gave it full attention as well. Being a consultant I unfortunately see some of what works in the background at physicians offices and it’s not pretty…nor easy to deal with as I work to help create solutions to better manage and help the small practices. Here’s the story from last week, similar but pretty much saying the same thing..
http://ducknetweb.blogspot.com/2008/01/medical-quack-doctors-seek-cash-when.html
“And, my departure from practice is only the beginning of a tsunami of closures of primary care practices due to: defections by doctors to the likes of Kaiser”
As alluded to by Anon 11:54, the original post is more about the death of small primary care practices rather than the death of primary care (though I think primary care is in trouble too).
Although as a physician I am bothered by the corporatization of medicine, the average patient probably doesn’t care if he goes to a small Family practice clinic or if he sees a family practitioner at Kaiser or a hospital-owned practice.
Kevin, this is indeed an excellent letter. As a primary-care Pediatrician burned in government-sponsored “public service” to the hospital in my own hometown (during the Clinton administration) . . . and then by the beyond-corrupt NC legal system (while John Edwards was still a Senator) . . . I’ve been on the blogs FOR YEARS begging for help (i.e. a little press attention and prosecution of the culprits – ala Nifong).
Our entire system is now designed to CRUSH anyone who really wants to get out there on the front lines and advocate for individual patients/practice good primary-care medicine.
What makes it even worse (as other commenters here note) is that our so-called professional advocacy associations are a JOKE.
Even worse (for those of us who value that physician-patient relationship), the average patient (for all he/she says he/she “loves” his/her doctor) doesn’t really care who provides the care . . . as long as he/she can get it on the cheap.
And the politicians feed off all of it.
If YOU, Kevin, really want to help pull back that veil, the first thing you can do is LINK MY BLOG on your blogroll. Get the many stories like mine OUT THERE to the masses. Tell people the TRUTH about what is happening to good doctors – as opposed to this hair-spray-coated irrepsonsible populist drivel that candidates like Clinton and Edwards (both of whom have done very nicely for themselves in “public service”) are spewing. I’ve asked you nicely on multiple occasions. What is stopping you except fear of your own corporate sponsors?
“Signed underpaid, overworked, underappreciated family practitioner from upstate New York”
I am sure that is all true. Ultimately you have been economically devalued, just like the rest of upstate New York. There is certainly enough displaced anger and frustration to go around these days. Believe me that there are plenty of other people who are not family practitioners who feel the same way, including every specialist I know.
Did you ever consider another line of work, or at least another location, like one in a part of the country that is growing? Unless there is demand for your services and people are willing and able to pay, you will be out of business; this is basic economics.
It is fascinating that all this has been predicted for many years. Back in the 1980’s when I was a college student, my roommate’s father was an FMG family practitioner. He lived waterfront is a beautiful house in south Florida, drove the largest Mercedes available, and lived a wonderful life. His father said it wouldn’t last. My other roommate’s father was a general internist from Atlanta. They had a second beachfront home in St. Simons, a third mountain home, and a wonderful life. His father said it wouldn’t last. Guess what? They were right, they are retired, and their children are not doctors!
Funny, no diatribe against ambulance chasers by the under loved PCP from upstate NY.
Food for thought. I like how this was in the Fashion section of the New York Times. I guess physicians (and lawyers) are out of fashion!
http://www.nytimes.com/2008/01/06/fashion/06professions.html
If a 15 min appointment isn’t enough time for a patient interaction, why not have the patient come back for another appointment and why, for God’s sake make some use of the internet to communicate with patients?
Why are the well patients given some sort of a reduction on their health insurance, instead of making them pay the same as if not more than the patient permanately in poor health?
anon 11:13 (and a general comment on the situation): if the only person who thinks you’re underappreciated is you, this suggests the problem is yours.
Sodaro is right. Nothing offends those in power as much as anything occuring outside of their control. Corporatize the docs and then centralized control becomes doable with just a handful of coporate entities to deal with.
The population doesn’t care yet because the other shoe hasn’t droped yet. They will care when they find that they have lost all choice and privacy, but they will only discover that one person at a time over a generation so it will not be a political problem.
Also the American people are already so institutionalized that they are an emarassment to their forebearers . Most do not value freedom and personal independence enough to deserve it.
The only real question is will their even be any legal loopholes to allow for the legal practice of traditional medicine for those few people independent minded enough to want to keep their healthcare purely a private matter?
I would like my primary care from someone who will take cash, with an inhouse lab, and who dispenses basic common drugs–so that I can get basic primary care without leaving a trail in the centralized databases that sweep up the data from the pharmacies and big labs. Just me, the doc, and Ben Franklin.
Thanks to all the regulations, such a person does not exist anymore. The only way to keep medical care truely private is to get a fake identity. Maybe if I fake an accent and tell them that I am afraid of imigration.
The average patient doesn’t care whether they see their PCP in a small private office, at the Kaiser or hospital-owned clinic, or in the Wal-Mart store. In fact, I think many would prefer the Wal-Mart. The market is deciding the future of primary care. Americans equate health care with procedures. That’s what they want to pay for, even if it’s taking them straight to the poorhouse. Primary care has little worth to those who are currently healthy and those whose current illnesses are managed by specialty care. What we are seeing is economics in action.
To all those who think this is a small operator/sole practioner problem, let me explain the mathematics of primary care, even when practiced in the Kaiser model or large multispeciality groups.
You lose money seeing primary care patients unless you negotiate above medicare and don’t see medicaid patients. Most multispecialty groups don’t have a bench full of hard working rich specialists who want to give money to the peon primary care guys. They would rather cut the cord and let them rot.
Joining Kaiser doesn’t eliminate the mathematics of price ceilings. By definition, when a price ceiling is inacted, shortages will follow. (see USSR, Nixon’s policies, rent control, I could go on)
I left primary care after 5 years for the exact same reason. I think it is the noblest profession and went out of my way to try to make it work, but it was clear to me that I had to pick between being a matyr and maintaining my sanity. While I’m glad I left, as a fellow, I see people all the time who are shuttled from one specialist to another as no one wants to take responsibility for the big picture. That’s the primary care doctor’s responsibility (or the hospitalist, the new whipping boy).
Why do we pay the primary care guy the least amount of money, but expect them to know everything, talk to the family, organize referrals, screen for a gagillion things, all in a 15 minute visit.
I agree with the poster above listing the 15 different people responsible for the decline of primary care. Shame on all of you. I hope you make enough money in your own respective lucrative careers to afford the concierge internist for your parents and family.
b
+1 dr. rack.
although i still think it is possible for the primary care groups to band together and corporatize themselves, rather than turning to groups such as kaiser.
it is indeed sad to see dedicated professionals not able to maintain their practices despite having a desire to do so.
i see a lot of attention devoted to controling income of physicians. how about turning some of that energy towards ways to control overhead?
how about a presumption of innoncence for board certified physicians? let the insurers pay first and then have to adjudicate denials through cms or some alternate board? in the meantime, let the primary care docs at least keep the money to allow their practices to remain solvent. they also could potentially eliminate 1 fte currently involved in non-revenue generating and non-efficiency generating work.
Well said b
How is fellowship. Must be half-way done now
Larger organizations like Kaiser will increasingly use non-MDs to provide more and more care–the economics of primary care demands it. The problem is that these folks are not trained to deal with the complicated patients who chew up the largest chunk of Medicare dollars–these are the folks with multiple chronic diseases, and they use something like 60% or more of Medicare dollars.
The 15-minute visit simply is not good medicine for these people–some of them can’t talk that fast! Seriously, it is difficult to begin and complete a visit in that small amount of time with a patient who has multiple medical problems AND needs preventive care also. Four 15-minute visits are not as good as 2 30-minute, or even 3 20-minute visits; it has to do with the nature of a satisfying interaction between a patient and doctor that will actually achieve something besides sending the patient out with new prescriptions.
The letter-writer’s numbers vis-a-vis the number of general internists for Santa Rosa are similar to what we have in the South Sound (WA State).
I started a few months early, so April will be the end of my first year. It is strange though as they place 90% of the clinical responsibilities in the first year and leave most of the second and third to self-directed research. So work wise, I’m almost done.
I still have this rage about what is happening to primary care that I can’t let go. My wife tells me it is illogical for me to come back to this blog and vent, but I explain that it is illogical the way medical care has been structured in our country and the only way to explain such a large illogical system is to place blame on the policy makers who made it and perpetuate it.
Hope things are going well for you. Is this your second year?
b
QUOTE:
“the only way to explain such a large illogical system is to place blame on the policy makers who made it and perpetuate it”.
Why not place blame on the MDs who don’t do anything about changing the system?
QUOTE:
“Health insurance for all will only make access worse – just look at Massachusetts”
I live in Massachusetts and have health insurance. Nothing has happened to my access to
health care.
What are you talking about?
Have you ever been in Massachusetts?
Folks,
This is the beginning of the end. Just like the housing/subprime mortgage bubble that everyone could see coming but heads were kept in the sand.
I did primary care, saw this coming and reinvested in myself as a specialist. Now I think there is about 5 years before all of medical care collapses. Primary care and ER care is already feeling the crumble.
Organizations like Kaiser will survive a bit longer because they skim the cream off of healthy people. Doctors I know who work at Kaiser are stifled and handcuffed by the organization but they tolerate it because of the security of promised benefits and retirement. This won’t last. Any type of socialist health plan will likely put Kaiser and specialists at great risk because they won’t be able to just skim the cream.
At work I run across a lot of pre-med students. I feel so sorry for them. Although I try to tell them, they just don’t have a clue as to how destitute they are going to be.
I am sorry I left attorneys off my list. However, this is the one area of the current healthcare situation that has affected specialty care more than primary care. My current malpactrice is 15,000 per year, a lot of money to be sure, but nowhere near the amounts other specialties pay, ie ob-gyn.
Another point: any statements that healthcare obeys market forces are incorrect and convey a lack of understanding of the issue. Healthcare is not like choosing what restaurant to go to. People utilize healthcare when they are sick, making it something they need, not something they choose to utilize. Preventive care is different, requiring a very motivated patient; like a tax rebate, people will spend their money elsewhere if given the chance, totally defeating efforts to pick up/treat illnesses early.
underpaid family practitioner in upstate New York
For many of the reasons listed by the other commenters I resigned from ownership of a family practice group and now work seeing urgent care patients 40 hours a week. I get paid a salary and get home on time. I do not have to spend several hours per week filling out forms for which I receive no reimbursement; I do not have to argue with faceless utilization nazis about prescriptions I have written or imaging studies I want to order. Do I miss the continuity of family medicine? You bet I do! But after 25 years in the trenches with no sign of relief, only “improvement” schemes proposed by private and government policy wonks, I felt it was time to take care of me for a change.
Wow! We should start a support group for former PCPs now doing fellowships. It’s tough to go back, but it is proving to be worth it!
I bailed on primary care in upstate NY after a few years of severe beatings. Now I am half way through fellowship and the job offers (outside upstate) flooded in. It was a joy to behold. More money, less work, more respect and a better place to live.
Let me start the refrain of the future: “Primary care who?” Never heard of it.
It’s nice to no longer have to worry about it.
“Why do we pay the primary care guy the least amount of money, but expect them to know everything, talk to the family, organize referrals, screen for a gagillion things, all in a 15 minute visit. “
Because it is “we” who pay, not the person who needs the service, and “we” use RVS to fight over the payment levels and decide how much it is worth. “We” naturally think “we” are worth more than “you”.
You have let someone who doesn’t need you decide how much you are worth. It is like letting vegetarians decide what hamburgers are worth.
b:
fellwship is going well. No regrets at all. Government, insurance company’s, and society all treat primary care like dirt. Well guys you get what you pay for. Garbage in….garbage out. I just feel bad for my friends who haven’t left it yet. Somehow I think I will end up being the PCP by default on a subset of my patient’s down the road as there will be not be enough PCP’s left to see them
Honestly, I know I’m not old yet, but I think the emphasis for the new generation should be self-care – diet, exercise, psychological health and then healthcare providers won’t be so overwhelmed. How many people old and young alike are going to the doctor for useless reasons? Why is our society addicted to fear? Fear of having cancer, heart attack, diabetes, etc?? Aging brings with it, unfortunately, a decrease in our body optimization. How can patients tell when it’s usually nothing or something to look out for? These days there is a ton of info on the internet, but elderly people often don’t know how to use the internet.
I know it’s extremely hard to prove, but I am a strong believer in a person’s psychological health and its link to physical health. Psychology should be equally considered with “chronic” ailments.
I’ve been a practicing chiropractor for 25 years and have greatly valued the relationships I’ve had with primary care physicians. During my time here I’ve seen a dramatic decrease in the number of primary care docs a situation that my patients are only recently beginning to notice. Why is this happening, many of them ask. Numerous reasons I tell them including financial strain imposed by insurance. They still don’t appear to understand until I put it in other terms. Look, in some instances your doctor may not be making anymore for an office visit than you pay your hair stylist. Now who has more education and a greater impact on your life, I say to them. Now they get the point and just maybe we need to make sure more of them get that point to assure that the time honored family physician is around for all of us to benefit from. My dad’s family physician was the beacon of light in the last few months of his life, being taken by prostate cancer. I’ll never forget the day he touched my dad on the shoulder and told him, you’re one of the lucky ones, your pain in under control. That single statement brought a smile to my dad’s face soemthing no other specialist was able to do.
Thanks Frank!
b
b:
You’re welcome. All I can say to ya’ll is try and fight the good fight. Someone has to do it and your patients’ need you. Being a DC I’ve been abused by insurance carriers for what seems like forever. I’ve battled them when the situation was right and have enjoyed giving a few of them a blackeye.
“……Health insurance for all will only make access worse – just look at Massachusetts……”
I’m no particular fan of schemes like Massachusetts, though I prefer the individual mandate approach of this plan. If it’s going to be done at all, at least try it by that approach.
Nevertheless, I’ll remain an agnostic.
Easy for me, as I’m nowhere near Massachusetts……
But is the access issue a sign of failure or success? Can’t tell from just that statement.
Does it mean that patients now have health insurance, want doctors, and supply has not caught up with demand? That would be a sign of success. Evidence would be an increase in people wanting to practice in The Bay State.
Or do these people have some sort of government-conceived insurance that no doctor wants? Like if Massachusetts uninsured suddenly got Medicaid, paying Medicaid rates, and doctors don’t take Medicaid ’cause a high-Medicaid practice would go bankrupt.
I suspect the latter is the case, but not being from there, I don’t know. Can someone provide the details?
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