Why patients don’t value primary care doctors

“Hey doc, all I need is this referral.”

I’ve been encountering more of this lately. A patient who has not been seen in the office for months to years (well beyond when they were supposed to come back for a follow up visit) walks in and requests a “referral” for a specialist visit but they can’t be bothered with actually being seen and evaluated in the office or to be compliant with their return appointments.

Or they do show up years after their last visit for no purpose other then that the specialist they recently saw after developing a serious illness and being hospitalized, told them that they needed to “go see their PCP to get a referral.”

Seriously? This entire concept of the “referral” system required by insurance companies was designed to contain health care costs by making the primary care provider a so-called “gatekeeper” who controls utilization by deciding who needs a referral and who does not.

In very few circumstances were the “gatekeepers” given incentives to avoid “unnecessary” referrals and more commonly, they were penalized financially for what the insurance company considered to be excessive utilization. Even worse, at least one study found no differences in utilization of referrals whether they were required or not. Hence, there remains no good evidence that this system works to reduce utilization or enhance primary care.

Currently, our health care is a system that emphasizes specialty and complex care over primary care and requires patients to get referrals from their PCPs but does not absolutely require them to be compliant with routine primary care visits and preventative care. As such, the importance and utilization of primary care has been marginalized even by patients who increasingly see it as a bureaucratic burden. Even for patients, primary care is little more than a paperwork hassle.

The irony is that primary care works!

In 2008, a Congressional Budget Office report found huge geographic variations in Medicare resource utilization (health care spending) and that areas with high spending also tended to have high relative populations of medical and surgical specialists (and hospital beds) and actually had worse quality outcomes than areas with lower spending rates and lower relative numbers of specialists.

But it’s not just the relative numbers of expensive specialty care that affects care quality. A 2005 review of the literature by Johns Hopkins University researchers found that primary care does indeed work to prevent and treat disease and health care quality and access is improved in areas that have higher relative numbers of primary care physicians.

But all of this favorable data was virtually ignored by Democrats and the Obama administration in the last – certain to be disastrous – “reform” of health care which didn’t even fix the always impending 21% Medicare physician pay cut.

Patients take their cues from the current system and insurance company and Medicare policy. Primary care providers are seen as little more than purposeless “gatekeepers”, especially when it comes to anything more serious than a cold or vaccines.

But maybe if these patients in question – all of whom had insurance with low co-pays – had been seen regularly then maybe this would have changed. Maybe if the patient noted above would have been seen much earlier when her symptoms first appeared, a simple blood test could have detected her condition at a stage where she could have been evaluated and treated as an out-patient before it became severe and life-threatening.

Avoiding expensive hospitalizations is something that primary care can improve and yet primary care is even marginalized by the insurance companies who end up paying for the hospitalizations and ER visits. Go figure.

Chris Rangel is an internal medicine physician who blogs at RangelMD.com.

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  • Christie B

    My husband and I were recently trying to conceive and I wanted to get a simple semen analysis for $100 paid for out of pocket. It’s relatively cheap reassurance that things have a decent chance of moving ahead – like temperature charting and ovulation predictor tests for women. However, the lab required that we have a doctor’s order for the test. So, I packed my husband off to a primary care provider in the same office as my PCP and he came back with a referral to an infertility specialist (not an order for the semen analysis), and about $600 in bills for hormone testing that the insurance didn’t cover. Going to a PCP was an amazing combination of inconvenient, worthless and financially harmful.

    • KP Internist

      In my system, I would have just ordered it without a visit. There is no financial incentive for our PCPs to make you come in for a visit if it doesn’t provide a value. Unfortunately, in most systems doctors aren’t paid unless they can submit a bill. I agree this is very wasteful.

      • r watkins

        You would have ordered lab studies on someone who wasn’t a patient in your practice (i.e., you didn’t have a chart on him)?

        • KP Internist

          It’s a semen analysis. They called and tell me that they are seeking fertility treatment and want to know if the husband has functioning sperm. Why do I need to have a chart for that. Patients in our KP system are assigned a PCP and that means I am responsible for their care. They are my patient, whether or not I have seen them before. It makes no sense to force patient to come into a office visit for things that can be handled in other ways. I get paid to handle patient concerns and it doesn’t have to be in the setting of an office visit. I phone call and discussion of their PMHx and an electronic ordering of their semen analysis and routine screening labs (cholesterol, glucose) and ask them to drop by the volunteer desk for a BP check and weight can be done without an office copayment. I will meet them when they have a concern that needs me to examine them (“Doc, I have this rash or my knee has been hurting). Heck, we can have a discussion about the meaning of the semen analysis by secure messaging also.

  • ninguem

    I know of no law requiring a physician order for a semen analysis. Anyone knows otherwise, I’d like to hear about it. The physician order has to do with insurance payment. Makes no difference now, I suppose, but the response is to find another lab.

    http://www.anylabtestnow.com/

    …..though I don’t know if they offer semen analysis.

  • stargirl65

    I think that the requirement that a person needs to get a paper referral to see specialist needs to be outlawed. It is a waste of everyone’s time, money, and effort. It is only another way for insurance companies to deny payment. Primary care doctors are not paid for the time, effort, paper, ink, etc that these referrals require. Some primary care doctors have to actually hire someone JUST TO DO REFERRALS. Why hire someone to do something that you don’t get paid for? In fact, it makes money for the other guy. Some patients will see their primary care doctor one time to get established and then spend the next 5 years requesting referrals to see a multitude of specialists. All of which is not paid for.

    The time of paper referrals (including the electronic version as well) is gone.

  • Primary Care Internist

    “Going to a PCP was an amazing combination of inconvenient, worthless and financially harmful”

    you exemplify the author’s point exactly. i am sorry you feel that way (actually i’m not), but getting a semen analysis is NOT primary care.

    I can’t tell you how many patients i’ve seen for their first visit, when they come in with symptoms of a cold and find that they have hypertension, or dyslipidemia, or learn that yes, they actually are very overweight, or should stop smoking, or are late with cancer screening tests or whatever. THAT is primary care, while semen testing should fall under the service of someone like a fertility specialist. Just because you went to a lab and were told to get a “doctor’s order” for the test YOU requested, doesn’t mean your primary care doctor is worthless because he/she doesn’t routinely order that test and doesn’t feel comfortable taking responsibility for it. And maybe the fertility specialist was right to order the hormone testing???

    After all THEY are the expert, not you.

  • http://afmarcom.com Angelique

    It’s an irony of modern medical care that patients can often choose their own specialists, but not their own primary care doctors. They cannot search for a primary care physician they like and trust and stick with that person. Even people with good insurance — like my family — who are patients of a well-respected medical organization — the Mayo Clinic — have this problem. Mayo patients here in Arizona can no longer be the patients of a single General Practitioner. That kind of medicine is now run like a slightly-more-convenient ER. After Mayo made that switch, the my GP and my husband’s GP left Mayo – I’ll bet they were frustrated, too. My husband and I were going to find non-Mayo GPs until my cardiologist intervened and insisted that Mayo sign me up with an internist; shortly thereafter, my husband was able to to sign up with the same doctor. Now we once again have a single doctor whom we like a trust to see first.

    • jsmith

      Excellent points.

  • May

    The word “compliant” went out with medical paternalism. It is quite passé, since doctors do not create laws. People are “compliant” with laws. People are “adherent” with a physician’s recommendations. Or they may choose not to take said recommendations. Either way, the word “compliant” is not considered an acceptable term by patients or by physicians who practice in a patient-centered fashion. “Compliance” does not imply a partnership between patient and provider; it implies the opposite of that.

    Also, with respect to the previous comment, I had a similar experience with primary care. I had an an acute problem and made the mistake of calling my PCP instead of my specialist. The PCP made me come in and she ran cultures, none of which turned up positive. They did, however, take several days to run, during which time I suffered a great deal of discomfort. The end result of this $500 worth of “healthcare” was my PCP telling me to call my specialist. When I called my specialist, she diagnosed me over the phone and called in a prescription which cost me $60. Oh, and I actually spoke with HER, not her nurse. Guess who I’ll be calling in the future? Hint: it’s not the PCP.

    In fact, the exact same scenario occurred during the year prior, as well. Once, shame on you. Twice, shame on me. I now have a new PCP.

    I don’t use primary care unless I have absolutely no other option. And since I have a high-deductible plan that does not require me to declare a PCP, I have never had “no option.” I pay the first several thousand dollars out of pocket. When someone pulls this $500 stuff on me for what turned out to be a very simple problem to diagnose and treat, and when it doesn’t result in my feeling better or getting better, I get aggravated (particularly when the condition was so rudimentary). So no, I do not have a favorable view of primary care. In fact, I think the national fuss about a shortage of primary care physicians is ridiculous. Yes, I do see them as an added layer that has successfully wasted both my time and money. I’m sure that’s not what you wanted to hear, but it is my opinion based on my experiences with primary care and primary care providers.

  • A.N. Mousse

    I can tell you that I grew up with a wonderful and highly-valued PCP. If I could find one that worked the way he did I promise you I would value him/her far above rubies. Listened, actually cared – referred out only when needed – but followed up to be certain you received the care required.

    My recent experiences with PCP’s – and I promise you I WANT a good relationship – have been horrible. Undiagnosed thyroid disease for 5+ years. Returned regularly with the same admittedly vague symptoms. Once the TSH tests came back within the normal range they stopped thinking thyroid and dismissed my symptoms as unimportant. (here’s a clue – a thyroid is a tricky thing and the TSH alone will not tell you all you need to know – and if your patient had mantle radiation at the age of 20 – assume her thyroid will fail at some point – so maybe a specialist is a good thing). Even after a PET scan (post-chemo for another cancer) revealed a thyroid lit up like a Christmas Tree, the ex-PCP’s nurse actually had the phone halfway back to the cradle after telling me my thyroid was “normal” before I yelled “STOP.” Only then was I asked if I wanted to see a specialist. Whiskey Tango Foxtrot? DX: Hashimoto’s Disease – and 5+ years of true hell – not counting the cancer.

    My “new” PCP’s fancy, slick brochure highlighted the practice’s commitment to patient relationship – a call with a question following my annual physical (I was encouraged to call with questions) was returned by a Medical Assistant (I think that’s a two month course in one of those degree mills). She told me “I have your chart right here. I can answer any question you have.” Huh? How is that possible? So much for establishing a relationship with a patient. At the first opportunity to do so – she failed. Of course I don’t value PCP’s now, not the ones I’ve met lately – do something valuable – like you used to – and I’ll value you.

    Oh, and for the record – my annual exam lasted all of 8 minutes (I checked the clock), was followed by a sales job for the brand spanking new bone density test (not standard of care in a woman my age). The doc was paid $250 for those 8 minutes + the 2 minutes or so it took to look at the lab values later. So, don’t tell me that my follow up call shouldn’t have been included in that visit. A pimply-faced Med. Asst. with her GED and a few weeks in a trade school to learn how to take BP’s and temps is not going to further a good patient relationship. At least get a nurse. Pretend you care.

    Also, since I know how much you docs like to dis the patients for unhealthy lifestyle choices let me be clear – non-smoker, non-drinker, non-drug taker/seeker, BMI of 19, mostly plant-based diet and a regular exerciser.

    Those walk-in clinics look better and better. I have three specialists I see regularly – two oncologists and an endocrinologist – don’t you dare try to keep me from seeing them. Aside from catastrophic illnesses I’m really quite healthy.

    • stargirl65

      I only get paid $75 dollars for a complete physical. This is for a complete review of their entire medical history, medicines, family history, previous testing, etc and then a complete head to foot exam. It also includes a review of all testing ordered and letter to the patient about those test results. I would love to get paid $250 for a physical exam. I will go bankrupt if I were to devote a huge amount of time to physical exams. Apparently health insurance companies do not think these exams are important.

      • A.N. Mousse

        Well, this doc charged and was paid $250 – and the “complete history” ignored some history and failed in other respects. My history of depression was not addressed at a time when even one question about it would have appropriate. The physical exam is often the only time you’ll see an otherwise healthy patient (or one with issues that must be addressed by a specialist) and if you don’t take a few extra minutes to build a relationship (particularly with a new patient) that patient is not going to come back to you – at least this one isn’t. I think my $250 buys me more that 10 minutes of a doctor’s time. Even your $75 for an 8 minute exam and 2 minutes to review labs is $7.50 a minute.

        • family practitioner

          250 is a lot for a physical.
          I get closer to 150.
          We also allow 30 minutes for physicals. I agree that 10 minutes is too quick.
          The problem is that patients will come for a preventive visit with as a laundry list of concerns, which is understandable. However, that puts us in a quandary, because, if a separate E & M service is done, in addition to a preventive service, it is hard to get paid for both. You should be able to submit both with a modifier, and get paid for both, but many insurance companies ignore this, or ask for notes, etc.

          • stargirl65

            I used to give 30 minutes for a physical but now that they only pay $75 I only allot 15 minutes. They still usually take 20 minutes. If they person has other problems then they are advised there will be other extra charges on top of their physical. I cannot do a complete physical including review of all results PLUS evaluate for new problems or manage complicated long term problems all for $75. I would be out of business.

        • stargirl65

          Did you want to address you depression? Or just have it noted in the chart? Management of depression is NOT part of a physical exam. Now, maybe for $250 it would be part of the exam. Not for $75.

          • Mike

            Exactly why you should just go to the specialist and not bother with the PCP. Why go to someone who will demand that you come in for TWO appointments because you have questions to ask? Just go to the specialist and get diagnosed AND treated/managed all in one appointment. You spend vacation time off of work that way. Who needs to sit around in someone’s waiting room twice? Someone above said something to the effect of “I guess insurance companies only think a physical is worth $75.” Well, the way they are done, they *are* only worth $75. If that. I’ve been misdiagnosed and undiagnosed by my PCP. I have never been properly diagnosed by my PCP. And then I’m usually told “call your specialist” anyway. Primary care is a gigantic waste of my time. Whether or not they get paid “enough” for their services is of no concern to me because I see no use for their services.

          • A.N. Mousse

            I would think that for an initial visit and taking a thorough history that asking if the depression was in control is appropriate – an annual exam is about the whole health of the individual, I assume – but – as you imply – if your only concern is the physical health of the patient – then – well – why are you a doctor?

    • rwatkins

      “Your attitude, so pervasive, and so obvious to us patients – yeah – we got some skills too – like being able to discern arrogance and condescension – are driving patients away from seeking care – any care.”

      But, A. N. Mousse, when you are so sarcastic and condescending in commenting on the education and the complexion of a medical assistant you spoke to on the phone, we need to question your attitude and arrogance.

  • http://thehappyhospitalist.blogspot.com Happy Hospitalist

    In the last two days I have had four families tell me they want me to be their doctor outside the hospital. It breaks my heart to tell them I am a hospitalist and don’t have clinics.

    The other day the nursing, RT staff and I saved a guy’s life who was just minutes from dying.

    When I did finally get to to talk to the family, I told them I stabilized their loved one and he’s critically ill, but stable.

    “Are you the cardiologist”, they asked?
    “No,I’m the internal medicine trained hospitalist”, I said.
    “Thank you so much”, they said.

    You see, nobody knows what us internists are capable of. I don’t take it personally. I simply perform and people get what we do. We are not primary care. We are their care, primarily. Or we should be.

  • Christie B

    Actually, “Primary Care Internist”, let me clarify that the PCP ordered all the hormone tests, just not the semen analysis. It would have been much better if the PCP felt himself out of his depth interpreting a semen analysis that he would have left that whole workup to the infertility specialist. After all, according to you, a PCP is not an expert in such matters, and only an expert could possibly judge. So, PCI, it seems like maybe we either both get to have an opinion or neither of us do.

  • May

    By the way, AHRQ puts out a small booklet about what doctors should do and ask during an annual physical. Primary care doctors should try reading it sometime. It’s fascinating reading. I think both PCPs in my past did/asked maybe 2-3 of the things it suggests… then ordered a boat load of labs that had recently been ordered by my specialist. I guess the PCPs were too busy to look at my record before putting pen to paper. Too bad I was the one who got stuck footing the bill for duplicate tests because of their laziness.

    • stargirl65

      Did your PCP have access to the labs ordered by your specialist? I do not have access to those records and only rarely receive them from the specialists or the lab. HIPAA and the lack of computer integration of the health care system have made things disconnected and incomplete.

  • j

    Over the last 10 years, I have been diagnosed with 5 medical conditions. Each time I went to my PCP when the symptoms arose and each time, a specialist made the diagnosis. I could have saved a lot of money skipping primary care.

  • AmyT

    The problem with most of the above logic is this..How do you know what specialist to refer yourself to. If a woman has right lower quadrant abdominal pain, who does she need to see? A general surgeon? A gastroenterologist? A gynecologist? A urologist? Physicans, including PCPs, are trained to go over your symptoms, do a physical exam, and decide which condition is the most likely to be causing your ailment. Sometimes the ailment can be treated by the PCP and sometimes it needs to be referred to a specialist. Are PCPs correct 100% of the time. NO!!! But are any of you correct 100% of the time? NO!!!! That does not mean that PCPs are not able to diagnose and treat millions of patients out there.
    The second problem with your logic is that you have no idea how to interpret lab tests that you have ordered yourself. Christie B, what exactly were you going to do with results of a semen analysis showed a volume of 1 mL, concentration of 10 mill/mL, motility of 15%, and 20 normal morphology. Is that normal??? You don’t know!!! What are you going to do with this information? It is worthless in your hands. You need a physican to interpret these results. The majority of lab tests and imaging studies are not black and white. It takes some background knowledge in anatomy, physiology, and pathology. The other problem with lay people ordering and interpreting thier own lab tests is something called false positives and false negative results. This is a margin of error inherent to ALL tests. It is basic statistics.

    The amount of arrogance out there never ceases to amaze me. You really think your google searches can replace the knowledge of a trained physician. If so, you are sadly mistaken. However, we should probably allow you to diagnose and treat yourselves…you will reap what you sow.

    • A.N. Mousse

      “The amount of arrogance out there never ceases to amaze me.” – yes, in you and others like you. Your failure to include patients as a partner in their own care, to treat them as idiots who can’t understand complexity – yes YOU will reap what you sow. In fact you already are. Primary Care has been devalued – whatever the original fault – but giving less care in response – failing to value and respect your patients – well you reap what you sow.

      • Laurie

        “The amount of arrogance out there never ceases to amaze me. You really think your google searches can replace the knowledge of a trained physician.”

        Yes, I have been misdiagnosed 6 times. My Google searches were correct and the doctor-sorry, physician assistants – werw wrong.

  • Keegan Duchicela

    Based on these comments, one might get the impression that primary care physicians are overbooked, undereducated and overpaid (only one of these is true). I cringe at how the commentators must feel about NP’s and other midlevels.

    In reality, the specialties of Family Medicine and Internal Medicine produce highly trained, empathic individuals who are experts at cognitive medicine. Unfortunately, these individuals are then placed into a system where they are paid according to the number of patients they see. One can spend an hour on hypertension, a. fib, discussing advance directives and filling out a 10 page form for adult day care and still get paid the same amount as if they’d removed an ingrown toenail.

    It’s the system, not the doctor.

    As for skipping primary care completely… a word of caution: 1 specialist is fine, 2 is manageable, 3 makes it a little hectic, 4 means you have Medicare… by the time you acquire the 5th specialist, you are dizzy all the time from polypharmacy, you’ve had everything under the sun burned, scraped or dug out of your skin, you’re being the guinea pig for the newest (and most expensive drugs), you’ve had a colonoscopy and echo every other year “just to make sure everything’s okay” and you’re 70 with COPD, intubated in the ICU twice and STILL no one has discussed advanced directives with you.

    Clear the field. Dump the medicines. Hire a quarterback you can trust.

    Good primary care is out there. There are many great FP’s and IM’s in the system. There are also great ones leaving the system for retainer practices, cash, and other innovate practices. Seek them out. Establish with them early. Their numbers will grow.

    • Laurie

      “Hire a quarterback you can trust.”

      I have been quarterbacking my own health care for quite awhile. The failure of primary care has made this necessary and I have done just fine. I don’t need someone to discuss diet and exercise and advanced directives. I need appropriate medical care which primary care seems to fail at most of the time. I have never had a specialist go crazy with procedures or drugs.

  • Julie

    Don’t even get me started…..

    I work in a hospital and have worked in healthcare in various capacities for 30 years. I’ve had “good” PCP’s and horrible PCP’s. Rarely if ever a stellar PCP.

    I have to say, I’ve had few stellar specialists as well. The reason? I stay the heck away from doctors as long as I can. I take care of myself as best I can.

    Physicians cannot know everything and never could. Educating yourself about your own health and health conditions is the best thing you can do.

    Most people I work with also take care of themselves first. Doctors, especially PCP’s are last resort. Most issues can be resolved without a trip to a doc unless it is life threatening.

    Then again, if you are clinically trained, you know when you really need to call 911.

  • CSmithMD

    The patients’ comments here are very disheartening and illustrate the plight of Primary Care. Physicians are there to serve patients and that includes considering the financial impact of the tests and medications we order. I think all parties would be best served in a non “fee-for-service” system in which the physician has more time to think and discuss options with patients and can also offer more access via email, phone, etc.

    • stargirl65

      Though I do consider the financial impact of what I do for patients, I do not have access to the prices of every medicine or the cost of every test. Many of these prices are negotiated by the health insurance companies and it illegal for the lab to share that cost with me. Crazy right. Also (as illustrated by other posters) if I miss something because I avoided spending money on you and missed something, I am sure you be likely to blame me and maybe sue me. I need to protect my livelihood as well. People can sue for bad outcomes, you do not have to commit malpractice to actually lose a case.

  • joe

    You know as a specialist I have to say, the majority of the self referrals (ie. skip the PCP) didn’t even have a problem related to my specialty. I am sorry guys but google doesn’t replace medical school and an FP/IM residency. You don’t know what you don’t know.

    • Julie

      That may be true for your specialty and with the majority of your self referrals.

      However, have you encountered a patient that has the intellect to understand and has spent the considerable time researching and gathering information from the same medical texts and journals you read?

      Many docs have minimal time to spend with patients and precious little time to stay current on the multitude of illnesses that can present in the PCP office.

      Today, there are conditions that could be treated by multiple specialties and yet none of the specialists nor the PCP’s have a grasp on the depth and breadth of the patient’s issues.

      I know this personally and know many others with similar experiences.

      Dr, Joe, I can say the same thing… you don’t know what you don’t know. This is way beyond google.

  • Former HBO tech

    Hey May,

    Do you know if you’re PCP may have communicated with your specialist and forwarded your lab results? Perhaps the specialist reviewed the labs, ruled out certain diagnoses in conjunction with your phone call.
    As for not speaking in person with your PCP, sorry to hear that. Your PCP was probably tied up speaking in person to your insurance company arbitrating on your behalf.

    What I’m suggesting is your may be getting displeased towards your PCP when in actuality that emotion is better aimed at the scientific diagnostic deduction process. Did your Specialist diagnose you without prior knowledge of the PCP ordered labs or their results? If not, who’s to say the specialist wouldn’t have ordered them anyway.
    Thank you for the contribution.

  • http://medicallymindnumbing.blogspot.com Shawn

    This post, along with this group of comments is incredible. And people wonder why medical students aren’t choosing to go into primary care. It’s not the lack of money – that isn’t going to fix anything. It’s the kind of attitudes that patients and healthcare systems have towards PCPs.

    • A.N. Mousse

      Blaming the patients is not the answer. We didn’t start this. I’ll say again – I value a good PCP far above rubies. I grew up with one like that. I know the restrictions that poor reimbursement place on current PCP’s. I sympathize. Really. I do. I am desperate for a good PCP. I HATE GOING TO SPECIALISTS! I want someone who sees me as a whole person.

      But, in my recent experience – those “cognitive” skills PCP’s pride themselves on have not manifested – even given a medical history that ought to have raised enough questions to warrant at least one referral to a specialist if the PCP in question was unwilling or lacked the compensated time to tease out an answer. That was 4 PCP’s in a 5 year time span.

      Your attitude, so pervasive, and so obvious to us patients – yeah – we got some skills too – like being able to discern arrogance and condescension – are driving patients away from seeking care – any care.

  • http://fcgadgets.appspot.com/ Jay

    The majority of things a PCP can do, a nurse practicioner can do more cheaply and just as well. A good internist can be worth a lot, but in the current system, PCPs will continue to be marginalized by specialists on the one hand and nurse practicioners on the other. If I need someone to cut me open I need a physician; I do not expect that to change. But anything short of it, economically, favors the nurses. Failure to subsidize medical education more or less ensures that the cheaper (less loan-burdened) labor will win the day.

    • stargirl65

      The majority of things a PCP can do, a nurse practicioner can do more cheaply and just as well.

      Nurse practitioners’s can do a lot well. They have been well trained to follow very specific protocols for managing medical issues. They do not have the extensive education and training that PCPs have. They tend to order more tests. Also I have seen many patients mismanaged and misdiagnosed by NPs and PAs time and time again.

  • drjebj

    This all makes me pretty sad. I trained in primary care Family Medicine 20 years ago and things have definitely changed. There is a fundamental differences between specialist physicians and primary care physicians. That said, there are good and bad docs on both sides of the aisle. Even the measure of good or bad docs is a very subjective decision. Some may say that a good doc is “one who listens to me” and another may say “he is the one who gets me in and out the quickest and I always get well.”
    I can say the fundamental differences between healthcare now and 25 years ago are the ghosts in the room: the insurance company, the attorney, a practice management consultant, Medicare, OSHA, CLIA, ADA, Medicaid, AHRQ, WebMD, and for an increasing number of docs and patients, the employer yours and ours.
    I have hope for primary medicine but I am afraid we may have to wait for the lights to go out before we get back to the basic vision of Hippocrates: you and me in a room building a relationship between the two of us.

    • rezmed09

      Right on, friend.

  • Dan

    Having been a family docfor 40 years, I have seen many changes( Think of no PPIs, SSRIs, CAT and MRI, and taking insurance an individual choice).
    Most of these changes have added great knowledge and skills to the art of medicine, but also large profits and costs. It is the main reason these grugs and services are controled in any government healthcare program.

    The rise of the specialist has been spectacular, and ,marred by only the small blip of HMO PCP required visit and referrals. This was evisorated by public complaint, and the removal of these type of requirments, by the HMOs, and the states.This essentially ended any attempt at managed care by health plans. It is all now about cutting costs for all services.

    It has been calculated that by requiring the patient to see his PCP first, the number of initial visits to specailists would be cut dramatically, with 35 to 40% reduction to costs.

    Can there be any doubt, that a movement to ARNAPs and PAs will continue? Since medicare and insurance companies want to or do pay them at 80 to 85% of what they pay a physician, it is more cost effect to use them.on the surface.
    The problem, is that the amount of referrals made by ancillary providers, lab and studies done, increases and that more than offsets the cost difference, and in fact raise the total cost of healthcare. Combine this with hospital groups who use their PCPs, and ancillaqry providers acting as PCPs, as enter points to their systems, costs contimue to rise.

  • m. Kathryn Keene

    After reading the comments to this post all I can say about my retirement from primary care in Feb. 2010, thank goodness I am done.

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    May I suggest to all the folks that treat themselves and refer themselves that you are not representative of most patients that are actually sick. There is a minority of people that have the ability, time and willingness to do research and direct their own care, but most folks are ill equipped for such responsibility, and those that need care the most are usually the least capable.

    • A.N. Mousse

      Agree completely. When I started my medical journey at too young an age for complex issues I blindly believed all I was told about my health. In the beginning it was enough because I had that awesome PCP – but more recent experience has forced me to learn more – to protect myself and advocate for myself. 4 PCP’s (same practice, PCP’s kept leaving – should have been a clue) over five years didn’t dig deep enough into my vague symptoms – ignoring a key piece of my medical history that should have sent me to a specialist earlier. I dumbly nodded and agreed – must be my fault – not getting enough sleep – working too hard – can’t manage my emotions – bad, bad me. Too bad I had to get a second cancer to get thyroid disease properly diagnosed.

      • Laurie

        I only wasted 2 years in primary care before I got on the internet and self referred myself to a specialist. I have a wonderful relationship with my specialist…he always keeps up on all of my health issues, makes suggestions when indicated. Appointment times are longer and when I something urgent comes up, he will talk to me on the phone…and squeeze me into his day if necessary. Why would I trade that for a 10 minute appoinment with a PA, medical assistants answering my questions, medical history ignored, and no relationship. Like A. N. Mousse, I would love to have a PCP that would provide excellent medical care.

        • AmyT

          Laurie,
          Are you even listening to what you are saying? Do you realy think that all physicians can be grouped into primary care and specialists and some how the specialists are all inherently more compassionate, understanding and complete physicians? Except for a few years during residency, we all have the same basic training. We are all taught the same basic physiology, pathology, and art of physical exam and diagnosis. Do you think they choose all the noncompassionate, money grubbing jerks and say “hey, you are going into primary care”? That is ridiculous. The problem is the SYSTEM that primary care works in, NOT the PEOPLE who practice primary care.

          • Laurie

            ” Do you think they choose all the noncompassionate, money grubbing jerks and say “hey, you are going into primary care”? ”

            I don’t understand where this comes from. For whatever reason, I have found the care from specialists better. I gave my PCP 2 years. In that two years, I usually saw a physician assistant. I am not sure why my doctor never stepped up. Do you think I should have continued to suffer to show that my PCP wasn’t a “money grubbing jerk?” It’s easy to blame the system for poor outcomes. I like my specialist. We have this great relationship and I get excellent care. If complimenting my specialist says that PCP’s aren’t compassionate, it must be “the system.”

      • r watkins

        “(same practice, PCP’s kept leaving – should have been a clue)”

        Excellent point. Sounds like this was a troubled practice that couldn’t retain bad docs, much less attract and retain good ones. Was this practice part of a large organization or was it privately owned?

        • A.N. Mousse

          Private. One doc owner – I think he was trying to bring others into the practice. He hired them young, just out of residency – but they kept leaving within a year or two to start their own practices, one became a hospitalist – finally he was the only one left. I inherited him when the doc I carefully chose, and really liked – moved away and sold her practice to this guy. I was too busy to find a new PCP. That was my mistake.

          • Vox Rusticus

            He was probably abusing them, no matter how it may have seemed to you. This sounds like a typical revolving-door practice, with new doctors arriving every year or two to replace the ones that quit. There are all sorts of ways this happens, but the most common is that the better-paying patients are sent to one doctor and the others are sent to the new hire.

  • rezmed09

    There are several reasons I do testing and eval prior to referral:
    1. The patient may not need a specialist. Patients often are mistaken about what can be simply done by a PCP. If they are not happy with this, they should change health plans to one that they pay more for more access to specialists. DO NOT BLAME THE PCP’s. You want more freedom? – pay more.

    2. Liability: This is a biggie. If you see me for a problem and somehow do not get in to see your specialist, I am legally the target of the law suit. If I touch you, even for a referral, I am legally involved. If there were a special category, without liability, for me to give patients what ever they want, OK then, here is what ever you want. But liability is a real part of our thought processes.

    3. But the final comment is that we don’t have to do it this way. The French require higher co-pays for self-referrals to specialists. Our health insurance industry needs to expand this option. All who complain about the existing restrictions need to complain to their insurers and inquire about what this will cost them. Money talks.

    In the end, I do not understand why docs need to sort this out. Phone triage by the insurance carriers should figure out the appropriateness of referrals and the cost. Oh, I forgot, they are not liable.

  • Christie B

    AmyT, I completely understand that not all lab tests are black and white. (Actually, I’m a nurse.) However, I can interpret a semen analysis enough to say, “These levels are all stellar, it’s probably worth trying for a few more months before spending a lot of money on invasive testing”, “Some of these are questionable, so let’s only give it a couple months and then get the full workup,” or “Wow, there’s no point waiting with results like this.” In fact, given that only I would really know my financial situation and how important it would be for me to maximize my chances of conceiving a child quickly, no one else could come to those conclusions for me.

    It has been interesting to hear about the difficulties that PCPs have with billing codes and liability. I’m sure under time constraints it is difficult to really handle your patients individually and assess their capabilities for taking responsibility for and directing their own healthcare – especially in this liability climate. I wish all of the PCPs out there luck in developing a better balance and look forward to continuing to hear your ideas on policy that will make this feasible.

    • Primary Care Internist

      “However, I can interpret a semen analysis…”

      WOW, REALLY? because i can’t. And i don’t know any non-fertility docs that claim they can.

      I guess they’re teaching semen analysis interpretation in nursing school???

      It’s scary that you just don’t know how vast your vacuum of knowledge in medicine actually is.

  • jsmith

    The future of American medicine over the next 5-15 years: Med students will continue to avoid primary care. As numerous pts here have said so eloquently, primary care does not get the job done for them. The main reasons are beyond the control of primary care, namely underfunding and a hollowing out of this field of medicine, but this problem will worsen, not get better. In any case, doctors will throw primary care into the laps of midlevels and decamp for sub-specialties and hospital work. Good work if you can get it. A few will stay in concierge practices, giving the well-heeled excellent primary care access and service.
    The downward spiral will spin faster. Midlevels, left on their own, will flounder, resulting in even worse experiences for pts and, incidentally, for the midlevels. A midlevel shortage is likely as they too flee the field. The cost of care will escalate as referrals and ER visits explode in number. Much useful medical care will simply not get done.
    In time, all this will strain America’s finances to the breaking point, setting the stage for hard-core rationing, the endpoint here.
    The bad news: The service aspects of your medical care will get even worse. Think Canada and Britain but at much higher cost.
    The good news: Your death rates will not go up and your medical inflation rate will eventually come down.

    • Dan

      I would agree, except I don’t see how death rate will decrease. Medical inflation will drop of course, because under government control, there will be no pay increases for physicians, hospitals, or mid-levels.
      Soon mid-levels will be discouraged and will not enjoy malpractice concerns. Over ordering, referring and proscribing will become a worse problem as lawsuit fear strikes.

      • jsmith

        I did not say decrease. I said will not increase, if the international data are any guide.

  • http://blog.headache-treatment-options.com/appliedobjectivism/ David Allen, MD

    As a specialist, I routinely refer patients to their primary care physicians or ask them to get one. It is amazing to me how many people with basic complaints (cough, shortness of breath, abdominal pain) want me – an inappropriate specialist – to evaluate them – even after they have a reasonable opinion from their primary care physician! I keep explaining to them that the primary care physician IS THE SPECIALIST for their complaint.

    My theory is that I have more time to spend with them and therefore they build rapport with me, and therefore want to return. Many primary care physicians simply don’t have the time to talk a lot with their patients.

    • jsmith

      Your theory is correct, sir!

  • labrat

    Wow! You are a credentialed Internist and you don’t feel comfortable interpreting a simple semen analysis? It isn’t rocket science. Volume, viscosity, count, motility and morphology. I can teach you right now. If there are lots and lots of hansome and hale swimmers – look elsewhere for the problem.

  • http://cbdmd1@gmail.com TenchDoc

    Laurie
    Do you think that your experience with the specialist was better than the PCP because the specialist was paid more? Do any of you unhappy patients think that your better experience with the specialist has anything to do with the fact that that the specialist is valued and paid more by your insurance company than the PCP. What will you think will happen to that when the specialist pay drops?

    • Laurie

      Do you think I should have given my PCP more than 2 years for a diagnosis?

  • Trench Doc

    Laurie
    You should have gone to another doctor the minute you felt uncomfortable with his care. But your experience should not be extrapolated to all PCP. After all many of us do the scut work for the specialists like calling you back to discuss a test the specialist did our seeing you in an emergency Friday afternoon office visit because you cannot get an appointment too se the specialist for 2 weeks

  • A.N. Mousse

    For me, I would say that I don’t really think it’s my job to be concerned if the doctor I’m seeing is being paid enough. I think I have quite enough to be getting on with on my own. My visits with my doctors are about me.

    While I follow this debate regarding low reimbursements for primary care, and I do sincerely sympathize, when I’m with my doc (or at any other time) I don’t think I should have to concern myself with his/her income.

    I will say that the endo & 2 oncs I see for check-ups are reimbursed less than my PCP was for an annual exam and one visit to remove some sutures (for surgery I had out of state). The suture removal was reimbursed quite nicely for about 5 minutes of work – over $100. The onc & endo each get about $80 (all of which I pay out-of-pocket – as I have a high deductible plan) for follow-up visits. The initial complex visits were reimbursed at a higher rate.

    My visits with my original PCP were always good and satisfying experiences – when I had a PCP with whom I had a relationship. In fact, those PCP visits were the best I’ve ever experienced.

    He diagnosed my first cancer – and it was only because I had a great relationship with him that I went to him with a vague symptom (I actually thought it was nothing – but used it as an excuse to see him). Had we not had that relationship, it is unlikely the cancer would have been found early enough to treat (age 20 – lymphoma). As it was we barely caught it in time.

    That’s what’s so troubling about this debate. These relationships the PCP’s say they don’t have time to forge – those relationships save lives – not so you can see them in the short term – but the long view – life-saving. I promise you – it’s every bit as important as the sexy surgery stuff.

  • stargirl65

    I am on vacation this week. I spent 2 hours this morning checking labs, refilling prescriptions, sending out letters and giving my staff instructions. This will be every day on vacation because primary care never gets vacation.

    During the regular work week I often spend 1-2 hours per day as well reviewing paperwork. This time is NOT paid for. This time has to be paid for by the time I already spent with the patient. So, when you complain about time spent with you, remember it may include time reviewing reports from the lab, other doctors, radiology, etc.,

    Also I do not get paid anything while on vacation. In fact I lose money as I have to pay my staff and for my building expenses.

    Don’t feel sorry for me if you don’t want to. But most people I know get paid vacation and do not have to pay their office while on vacation while still working.

  • Caruna

    When you, the patient, come to me, your PCP, with a list of tests you want done and a request for a specialist referral, that shows me that you did not even consider asking me for my opinion. If you think that my job is just to put a signature on the paper you bring me, you are wrong. I am a doctor and I do consultations and I give medical advice, nothing less.

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