How the purpose of primary care is defeated

My friend Anne loves her primary care doctor.

“He is a really good guy,” She recently told me. You can just tell. You can hear his big booming laugh in the waiting room, the examination room, the bathroom. You don’t even mind waiting for him when his last appointment runs over because you know that he will give you his undivided attention when you’re with him. And you know that if you need additional time at some point, you will get it.”

About a year and a half ago, during a routine physical, Anne’s doctor urged her to follow up on symptoms that seemed benign. She wasn’t too concerned, and she didn’t go right away because she worried about what her insurance would cover, but eventually she decided to trust her doctor and have some tests done.

Anne had an islet cell tumor, and she eventually had to undergo a splenectomy and removal of 1/3 of her pancreas. Throughout this process, Anne’s primary care doctor was her “touchstone” and the “keeper of all the information,” as Anne describes him. This comforted her as bouncing from one specialist to another was very unnerving in the midst of a health crisis. Her primary doctor’s central role on the team helped her make some important decisions and she believes that their trusting relationship essentially saved her life.

Anne continued to receive follow-up care in the capable and caring hands of her doctor. Unfortunately, Anne lost her job and, as a result, her health insurance. She found out, to her distress and disappointment, that her doctor’s practice did not accept the new insurance that she qualified for. This meant not just finding a new doctor but the ordeal of having to let go of a trusting relationship and start over with an unknown name on a list.

Anne’s story, unfortunately, is not unique. Perhaps there are readers who identified with every step in the process of Anne’s treatment and navigation of the health care system because it is just like their own story.  We cannot hear stories like Anne’s enough though. They highlight the unique role of a primary care doctor and how it is often constrained by the fee-for-service model. Continuous, coordinated care simply doesn’t fit in the fee-for-service structure. The current payment model, which focuses on quantity over quality, defeats the purpose of primary care and makes it hard for primary care doctors to build the kinds of relationships they are valued for.  In fact, Anne’s doctor is unable to accept her new insurance because of the plan’s low reimbursement rates and drawn-out payment process.

Patient care is optimal when it is tailored to fit individual needs which may mean spending more time with one particular patient on education and counseling – commodities for which it is currently almost impossible to bill but which empower patients to take charge and eventually drive their own health care decisions as informed, involved consumers. Uncoordinated care only causes anxiety. Anne’s doctor coordinated her care, which was a comfort to Anne and probably gave her better results, but few doctors are compensated for that type of care coordination.

Unfortunately, Anne is still without a doctor and says if a need arises, she will visit an urgent care center until she is able to enroll again in a health plan that her doctor accepts. As a future member of the primary care workforce, I’m dedicated to helping create a health care system in which stories like Anne’s become obsolete.

Deepika Srinivasan is a physician assistant student who blogs at Primary Care Progress.


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  • Guest

    I have not had a PCP in years. I cannot imagine trying to find one; the thought is terrifying. I do not think anyone out there can provide quality primary care. The good docs have either left or cannot provide good care due to being overextended.

    I am a physician, and I feel this way.

  • meyati

    While the medical world isn’t what it was in years past, there is a lot to be said for a patient/patient to have someone vaguely responsible for you. You know-someone to order that yearly thyroid scan-to list your medicine allergies- prescribe stomach meds for IBs or whatever-It might not be the hand holding of years past-but that 15 minute visit or even an electronic communication can keep somebody like me well. Unlike you, Dr. Guest-I can’t self-prescribe or order lab work.

  • Atul Jain, MD

    Thanks for sharing the story about your friend Anna. I hope that her situation will be solved soon, and maybe with the new health insurance exchanges she might be able to find affordable coverage.

    I feel it important to point out, however, that her issue can’t really be directly correlated with the current fee-for-service payment model. I agree that the fee-for-service model is antiquated and clearly does not promote high-quality care. In my perspective, her issue is partially related to the global issue of how the 3rd payor system in the US has become bloated, extremely complex, and quite honestly, feeds off of both patients and providers alike. Premiums outpace the cost of inflation by a large amount yet payments for health care services continue to go down. This means that many health insurance companies are taking in more money than they are giving out, and this leads to physicians and hospitals dropping contracts with certain health insurance companies, and so on.

    While pay-for-performance models such as ACOs and medical homes sound good on paper, it remains to be seen how they will really make a meaningful difference- by maintaining the sanctity of the patient-physician relationship, promoting health quality, and effectiveness of cost.

    Only time will tell. In the meantime, I truly hope that your friend is able to find the care that she needs.

    • Adolfo E. Teran

      ACOs= more bureaucracy and overhead that will not lower the cost at the end of the day. Dear Atul Jain, your post mimic my ideas about the whole enchilada of the ACOs.