Op-ed: Shortage of primary care threatens health care system

The following op-ed was published on March 13th, 2008 in the USA Today.

Crippling health care bills, long emergency room waits and the inability to find a primary care physician just scratch the surface of the problems that patients face daily.

Surveys suggest that health care is a top domestic priority in the presidential election, and there is no lack of ideas on how to fix our system. Republicans favor using market forces and increasing the burden of health care costs on patients. Democrats, however, focus on covering the uninsured. Sadly, the candidates are missing the bigger picture. We need to address the fundamental issue at the root of our problems: the primary care shortage.

Primary care should be the backbone of any health care system. Countries with appropriate primary care resources score highly when it comes to health outcomes and cost. The United States takes the opposite approach by emphasizing the specialist rather than the primary care physician.

Fragmented care

A recent study from The New England Journal of Medicine analyzed the providers who treat Medicare beneficiaries. The startling finding was that the average Medicare patient saw a total of seven doctors “” two primary care physicians and five specialists “” in a given year. Contrary to popular belief, the more physicians taking care of you does not guarantee better care. In fact, studies show that increasing fragmentation of care results in a corresponding rise in cost and medical errors.

How did we let primary care slip so far? The key is how doctors are paid. Known as “fee for service,” most physicians are paid whenever they perform a medical service. The more a physician does, regardless of quality or outcome, the better he’s reimbursed. Moreover, the amount a physician receives is heavily skewed toward medical or surgical procedures. A specialist who performs a procedure in a 30-minute visit can be paid three times more than a primary care physician using that same 30 minutes to discuss a patient’s hypertension, diabetes or heart disease. Combine this fact with annual government threats to indiscriminately cut reimbursements despite rising office and malpractice costs, physicians are faced with no choice but to increase quantity to maintain financial viability.

Driven from the field

Primary care physicians who refuse to compromise quality are either driven out of business or to cash-only concierge practices, further contributing to primary care’s decline.

Medical students are not blind to this scenario. They see how heavily the reimbursement deck is stacked against primary care. Whether they opt to become a specialist or a primary care physician, they graduate with the same $140,000 of medical school debt. The recent numbers show that since 1997, newly graduated U.S. medical students who choose primary care as a career have declined by 50%. This trend results in emergency rooms being overwhelmed with patients without regular doctors.

Furthermore, if the Democrats’ universal health care proposals come to fruition, the primary care system will be inundated with at least 45 million newly insured patients. As Massachusetts is finding out in its pioneering attempt to provide universal coverage, our system is not ready for this burden. Universal coverage is useless without primary care access.

How do we fix this problem?

It starts with reforming the physician reimbursement system. Remove the pressure for primary care physicians to squeeze in more patients per hour, and reward them for spending time with patients, optimally managing their diseases and practicing evidence-based medicine. Make primary care more attractive to medical students by forgiving student loans for those who choose primary care as a career and reconciling the marked disparity between specialist and primary care physician salaries.

We are at a point where primary care is needed more than ever. Within a few years, the first wave of the 76 million Baby Boomers will become eligible for Medicare. Patients older than 85, who are in the most need of chronic care, will rise by 50% this decade.

Who will be there to treat them?

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  • Toni Brayer MD

    I read about it, I live it, I write about it on my blog and, guess what…nothing changes. The interest in primary care fell again this year in the match and even Duke failed to fill their Internal Medicine slots.

    Any health reform is dead in the water without primary care. Using nurses and PAs will be a tiny bandaid while quality declines and costs rise and the waits we disdain in Canada will look like heaven.

    Lets start by dismantling the RUC…those specialists that decide the payments and codes for Medicare. That secret group has gone on for too long and their new concept of “Medical Home” solves nothing.

  • Anonymous

    This is a good post. However, I must address several points. First, I read all the time that primary care doctors are not making enough money. Usually this statement is not backed up with facts but with general statements.
    According to the NY Times and other newspapers, the average PCP makes $150K per yr. If you break this down (15 min. o.v., 40 hrs. per week for 50 weeks per year), you finally get to the figure of $18.75 per o.v. Figuring expenses as equal to pay (i.e. $150K), one still arrives at a fee of $37.50 per o.v. I don’t think that even the stingiest insurance company is paying that low!
    At $100 per o.v., the yearly total amounts to $800K. If expenses are again 50%, that makes the physician’s income $400K. I find it hard to believe that that kind of money wouldn’t attract eager docs to primary care!
    So what are insurance companies paying for an office visit? What is Medicare paying for an o.v.?
    Second point, I wish you all would retire the incorrect use of the word “reimbursement.” Check the dictionary but your usage is not listed there. I know that Medicare uses this word in that fashion but would you use “prostrate” or “palpitate” instead of “prostate” and “palpate” because some people don’t know the proper word?
    The proper word is “fee” or “compensation”.

  • James Hubbard, M..D., M.P.H.

    On Sunday our Colorado Springs newspaper printed an article on our local shortage of 20-100 family practitioner. I blogged about it and I agree that we must have a radical change in reimbursement for this to improve. I am pessimistic that this will happen because the third-parties involved are not going to increase primary care without decreasing others. I don’t know of many specialists that will agree to that without a fight.

    Another blog I wrote recently concerns the influx of physicians into Texas after malpractice reform. Perhaps if combined with malpractice reform, which is higher in most non-primary care specialities, the reimbursement reform might be more palatable.

    James Hubbard, M.D., M.P.H.
    Publisher, James Hubbard’s My Family Doctor

  • Tannus Quatre

    Until we pay our physicians to “think” (i.e., cognitive analysis) rather than simply “do” (i.e., perform procedures), we’re going to have a primary care shortage. I blogged about the primary care crisis recently, discussing it in terms of simple supply and demand – both from the patient and provider sides. Like it or not, market forces will(and should) play an important role in bringing the primary care situation back into equilibrium over the long run.

    Tannus Quatre
    Vantage Clinical Solutions
    The Healthcare Entrepreneur Blog

  • Anonymous

    Yet here’s a comment from another thread on this site, regarding Tim Russert:

    If Russert were seeing a specialist rather than his PCP, he would still be alive.
    # posted by Anonymous Anonymous : 7:10 AM

    I have no idea if Tim Russert saw a PCP or a specialist or a witch doctor. But you get this all the time. PCP’s are ignorant and terrible, yet their demise will be the ruination of American healthcare.

    I think the problem is without PCP’s, there will be no one to blame when there’s a problem.

  • Anonymous

    Anon 11:23 shows why all the whining to the public isn’t going to change a thing. They don’t get it and aren’t going to get it—and it isn’t their place to do so. They have their own living to make and don’t have time to study medical practice economics beyond the simplistic and completely unrealistic analysis above.

    The fact is, this is an internal matter. We have done it to ourselves. It was physicians who crafted the RVS and individual physicians who one by one make the choice to accept it. You want the public to care? Reject medicare and all other RVS based compensation schemes and soon they will care when a critical mass of docs–each acting on his own convictions–do so. Most of you will never do that because only individualists who value freedom over money will have the guts to do so and judging by all the calls for more laws and mandates on this and other medical blog sites you are basically mostly collectivists and statists.

    If you did go through with it and got the public’s attention, you might not like the response given the low stock of respect for personal autonomy and responsibility overall in the culture now.

    Atlas isn’t shrugging–he is wallowing in self pity.

    To set the record straight on the financial analysis above. It completely fails to recognize:

    The 15 minute visits that turn into 30 minute visits for reasons that are essentially non-reimubursable.

    The expense of collecting the fee which is ever increasing.

    The denied payments for all sorts of reasons–some of which are petty.

    The unpaid services for all the patients whom you choose to give charity care to, or end up giving it to involuntarily, because it turns out that the insurance on the record is canceled due to non-payment of premium or the company is insolvent, or the patient went into bankruptcy, or is just plain deadbeat and wrote a bad check.

    No PCP sees 8 hours of patients in an 8 hour work day–in the best run clinic 1 1/2 hours are spent on unpaid activities such as Rx refills and forms and usually much more. More like 32 clinic visit hours a week in a 45-50 hour work week

    And that is just the clinic. There is then the hosptial rounds and rotating call in the ER where you get your service loaded with all the uninsured indigents that come in on the ER and take 8-15 hours a week.

    But it does no good to explain. Not 1 person in 40 is going to have the attention span to listen to even that much about someone elses problems.

    Just act, buckle down and stop whining, or buy more tissue.

  • Guy

    I agree with the posts that are on here. I see a good number of patients but you cannot expect to walk in and work 40 hours a week and see 4 an hour. It’s not possible and also get paid for all of the patients.

    #1 patients don’t all pay. we get screwed all the time on this.

    #2 free care that is mandatory at the hospital.

    #3 telephone calls, refill requests, records requests, all are not reimbursed expenses on our time

    #4 expenses are fixed and variable. if one brings in 150k a year his expenses are going to higher as a percentage than someone who brings in 800k.

    #5 there isn’t a visit that you can do in 15 minutes that pays 100 bucks medicare/ medicaid/ pvt insurance is around 60 bucks for 15 minutes.

    #6 My expense ratio is around 60-65 percent. so using the login of 4 visits an hour at 60 bucks, including 10 percent no-pay, but expenses on the whole number is…144k, pretty close to average.

    #7 biggest problem is that we don’t get an increase in our fees but staff salaries have to increase. healthcare for my employees increase. supplies increase in cost. etc..

  • Anonymous

    I believe, and this is unfortunate, that to increase primary care physician salaries doctors will have to become part of Health Care companies or form large doctor groups. This is the only way there will be enough physicians bargaining together to demand more from insurance companies. The solo doc has no leverage because there are lots of other clinics for insurance companies to contract with.

    Physicians cannot form unions or discuss their prices with each other. The only way to get a large number of physicians working together is by their employment at Health care corporations or in very large physician groups.

    Once this happens, primary care docs will be able to demand a reasonable fee from insurance companies and get it.

  • Anonymous

    “biggest problem is that we don’t get an increase in our fees but staff salaries have to increase”

    That is because staff salaries are determined by the labor market of free people bargining for themselves and you aren’t taking control of compesation. Actually you set your own fees and can increase them–but you aren’t getting paid your fee. You are in the position of taking whatever is given you–or leaving it.

    Regarding large groups–if that were a fix, it would be fixed as PCP’s have flocked to group and institution practice. I was a partener that owned our own HMO. PCP’s did no better–that HMO had to compete with the other insurance companies.

  • Anonymous

    “Regarding large groups–if that were a fix, it would be fixed as PCP’s have flocked to group and institution practice. I was a partener that owned our own HMO. PCP’s did no better–that HMO had to compete with the other insurance companies.”

    How big was the group? I’m talking about consolidating physicians into 3-5 groups per million people in a city. If the majority of docs worked together they would have the bargaining power to raise their payments.

  • Anonymous

    Anon 7:35 is so right. The public can’t help you. Not because they are callous to your position, but because most get far less reimbursement than you do already. And, they can’t make the health insurers negotiate better contracts with you.

    Only you can do that. So the question is, if all of you can find the time march on every state capitol to make your insurers more money via tort “reform”, why can you not show that level of organization to put money in your own pockets? Where is the reimbursement “crisis map” from the AMA? Where are the PR stunts like “disappearing docs” ads to scare patients on this issue?

    Is the only time you guys can accomplish anything is when your liability carriers pay for and organize it?

  • Anonymous

    “Is the only time you guys can accomplish anything is when your liability carriers pay for and organize it?”


    I have been in practice for fifteen years and been involved in advocacy for our profession. I have never seen or heard of any kind of assistance for our cause organized and payed by liability carriers. Please provide some examples.

    “Tort reform” is only one part of advocacy. It shows how myopic you really are on the overall topic.


  • cjd

    “I have never seen or heard of any kind of assistance for our cause organized and payed by liability carriers.”

    JB, your ignorance of the political lobbying system is sad. Who do you think funds those “crisis maps”? Who do you think writes the legislation you are advocating for? Who do you think puts together the “statistics” you spew? Do you have any clue?

    You know where the seed money for all those “Citizens Against Lawsuit Abuse” groups came from? Tobacco industry. You know who their primary lawyer is? Philip Howard, Director of “Common Good”, who puts out all the “health courts” propaganda.

    And you accuse me of myopia.

    I only point to your screwing of the injured because in my state that’s the only time I’ve ever seen doctors en masse at my state capitol, and only when it’s before Congress have I seen that many doctors at the US Capitol. Let me know another issue where you guys have accomplished anything. How’s that reimbursement method change going?

  • Anonymous

    My older Canadian Doc friend says that in the when they went single payer in the ?60′s, most docs laid off about 50% of their office staff. My younger Canadian Doc friend runs his office with his wife and fills out one piece of paper and usually/always gets paid. We may not want single payer, but we need to strive for a single form with uniform rules for payment and denial. If this were simplified maybe future PCP’s would not be so frightened off by the business side of medicine: billing, hiring, firing, buying,and real estate management. If want our docs to be businessmen we should put more business classes in med school and pre-med requirements – but is that what America wants?

  • Anonymous

    Amen to “Guy” above. As a primary care physician for 17 years, I finally quit private practice after watching declining reimbursements and increasing costs every year. I now work in the prison system. Sound bad? On the contrary, I now have regular hours, a decent salary, actually receive some benefits, and have the time needed to provide good care. It’s kind of a shame we can’t do the same in the rest of society, but I guess health insurors have other priorities, which don’t seem to be changing soon.

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