What is the main cause of the primary care crisis?

Next in a series.

Primary care physicians (PCPs) have too little time per patient which means too many referrals to specialists, too little time listening and thinking, no time to delve into the stress or emotional causes of many symptoms and substantial frustration by PCP and patient alike.

Previously in this continuing series on primary care, I described a patient with a straight forward if unusual symptom who was bounced from specialist to specialist at great expense, with no one offering a diagnosis, with no resolution of her symptoms and with no physician ever exploring the actual underlying causes of her symptom – guilt related to a long ago family issue. Why did this happen? Because the PCP had only 15 minutes, not enough time to listen and to think and from there delve into her psyche.

Why so little time? The short answer is the insurance system, attempting to manage costs through price controls. Medicare has for years set a low reimbursement rate for regular office visits to the primary care physician. Commercial insurance always follows Medicare’s lead and has done likewise. Reimbursement rates have remained fairly steady for a decade or more (Medicare has very recently begun to raise rates a bit as a result of the Affordable Care Act) but office costs have risen each year. Overhead includes not just the nurse and receptionist but also the billing and coding people, accounting and legal needs, malpractice and disability insurance, health care insurance for the staff, supplies and rent and utilities for the office.

With costs rising and income steady, the PCP tries to “make it up with volume.” This means seeing more patients per day, usually about 24-25, often even more. In order to see that many, the PCP has generally stopped seeing his or her patients in the hospital or ER and has shortened the time per visit — most visits being about 10-12 minutes of actual “face time” with the patient.

This is enough time for a strep throat, a quick blood pressure medication check or possibly to diagnose and treat Lyme disease. But it is not enough time to deal with a more subtle problem like the patient described in the last post experienced. It is not time to explore family issues, personal stress or anxiety that so often lead to or accompany symptoms and sickness. This lady had a straight forward issue that primary care physicians encounter frequently and those that are experienced know well what it implies. But it still requires time — time to carefully listen to the patient’s story, time to put it into the context of the patient’s life situation, time to do an examination and then some time to think about how to proceed. And once the management decision is made, it takes time to talk to the patient, reassure her and yet explain that she should call should are any further concerns arise — and to come back soon for a further follow-up and attention to the underlying issues.

The situation is compounded when the PCP has a patient with multiple chronic illnesses who is taking multiple prescription medications. Chronic illnesses like diabetes, heart failure, chronic lung disease, kidney failure or multiple sclerosis by their nature are difficult to manage, persist for the patient’s lifetime (some cancers excepted) and are inherently expensive to treat. These patients need very close attention and often need the benefit of a team approach to care. The diabetic patient for example will need an endocrine consult at some point, a podiatrist, an ophthalmologist, a nutritionist and an exercise physiologist, to say the least.

But any team needs a quarterback and this is or should be the primary care physician. But here again, care coordination by the PCP requires time, the one thing the PCP most lacks in today’s reimbursement environment. The result is fragmented chronic illness care, disjointed care and care that is much more expensive than it needs to be. From a total healthcare system perspective, this is critical because chronic illnesses consume 75 – 85% of all claims paid by insurers.

But with little time to listen and think, the action step of many PCPs, as with the patient described last time, is to send the patient to a specialist. Indeed, according to an article in the Archives of Internal Medicine, about nine percent of all visits to PCPs result in a specialist referral, far far higher than truly necessary. This is up from about five per cent a decade earlier; 41 million referrals per year then compared to 105 million in 2010. Something needs to be done. The push for accountable care organizations, medical homes, population health and a switch from fee for service to a salaried or capitated system are noble but unless the PCP is given time and enough of it, these changes — no matter their apparent utility — will prove valueless.

Meanwhile, fewer and fewer medical school graduates choose to enter primary care. They are smart and see that PCPs are very busy and very frustrated. They know that given the PCP’s average income it will take many years to pay off their high educational debt load.

PCPs are looking for ways out of their dilemma. Many are retiring early. Others are closing their practices and beginning to work for the local hospital. But the hospital wants the physicians to earn their keep. That means high productivity. So it is still 24 – 25 patients per day, albeit without the administrative hassles of a private practice.

It is clear that the resolution will not come from commercial insurers, not from the government insurances (Medicare, Medicaid), nor will it come from the Affordable Care Act. It will likely be in the actions and decisions of the primary care physician himself or herself to change the paradigm to allow and encourage better quality of care with lessened frustrations for doctor and patient alike.

For starters, many PCPs need to look carefully at their practice patterns and determine if they can adjust their own workload by maximizing the talents of their team of nurses, nurse practitioners and others and with better use of technologies. This requires a change in thinking about how to organize the practice and who does what and when.

Beyond that, some PCPs have decided to no longer accept insurance. Instead they expect the patient to buy care directly. And since they no longer have the expense of coding, billing and collection (one estimate of this is $58 per patient visit!) they can charge a quite reasonable amount. This can take the form of a set fee for any visit, a sliding scale depending on the type of visit and its length, or of a set amount for all care for the year, a retainer-based approach. In each of these models and others the patient replaces the insurer as the actual customer of the physician and as such has a more appropriate professional-client relationship. The patient also becomes a purchaser of services directly and thus begins to ask questions, to challenge and in general to bring down the costs of care while receiving a higher level of quality along with greater satisfaction and less frustration for both doctor and patient.

These are but a few of the approaches being taken by PCPs today in an effort to overcome the current non-sustainable business model so that they can not only give better quality of care but reduce their sense of frustration and increase their patients’ satisfaction.

To develop this series of posts, I have done in depth interviews lasting about an hour and covering, at least, twenty two specific questions with over twenty primary care physicians.  Most are in private practice, a few are in an academic setting; some are internists and others family physicians; some are men and some women, some have been in practice for a long time and some are only recently beginning their careers. I have also tapped my contacts built up over a long career, looked back on the 150 plus interviews done for The Future of Health Care Delivery and used my own fifty years of clinical activities (albeit not primary care), management and leadership experience and observations of healthcare delivery.

In the posts to follow I will review what primary care is all about; the characteristics of a good primary care physician and a true healer; who does primary care and why and why not; the critical role of the PCP in managing chronic illnesses; the need to listen and think — both requiring time; the use of teams in the primary care doctor’s office; the importance of care coordination, wellness promotion and disease prevention; the current non-sustainable business model; what approaches are being taken to overcome the current business model; and finally how primary care can once again take its rightful place as the backbone of the American healthcare system offering superior quality, outstanding service and greatly reduced overall costs.

The next post in this series will address the critical shortage of primary care physicians.

What is the main cause of the primary care crisis?Stephen C. Schimpff is a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center, senior advisor to Sage Growth Partners and is the author of The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You.

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  • NPPCP

    Excellent synopsis! As a Family Nurse Practitioner, this article relates directly to my practice as well. As other PCPs (primary care providers), we lead teams as well. I have found the “team approach” (team approach in name only for small practices) inefficient, piecemeal, bloated with bureaucracy and unappreciated by patients. As PCPs family physicians (MDs/DOs) and NPs are the answer to the primary care crisis. Quarterbacking a team (I do it daily) is not the answer in my opinion. At any given moment, the RN or LPN in my private independent practice may be leading the team. I might lead it. Right person, right place, right time. So lets go Dr. Schimpff! As PCPs, NPs, MDs, and DOs must work together to solve the access situation and the income situation. Direct pay is working on a limited basis in my clinic – I think in the end, it will be the way to go! Thank you for the insightful article!

  • RolloMartins

    What impact do you see Single-Payer as having on patient visits?

    • buzzkillersmith

      Single-payer would only work for PCPs if we had more time per pt and made more money for the time. I don’t see this happening. Not that I see single-payer happening either. This is the USA, after all.

      The government is in the thrall of subspecialists, so I doubt single-payer would our lives much better. Money would have to be redistributed to us from other docs. I doubt this would happen to the degree required to have a robust primary care sector.

      The gov has ponied up for a 10% bonus for Medicare and a bit more for Medicaid but a raise of 50% or more is likely required. In addition, of course, if the gov pays, the gov naturally sets up even more burdensome admin requirements. Prognosis

      The baseline scenario is for the hellishness to continue. I see no way out.

      Two other pts: I could be wrong, and single-payer would be good for the uninsured to get access to emergency depts and community health centers.

      • buzzkillersmith

        vaya not via

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

        Just one observation: money doesn’t necessarily have to be redistributed to primary care from other docs. It could be redistributed from the ginormous bureaucracy of thousands of “plan designs” and all the marketing they do. So you guys don’t really have to fight each other.

        • buzzkillersmith

          I guess I figure that if talking money from the subs is like taking meat from a black bear, taking it from Corpmed is like taking it from a Griz.

        • Steven Reznick

          Astute and accurate observation

          • ninguem

            And that’s were it becomes political, and I an not confident we have organized medicine on our side. CorpMed gets the money because they rig the rules.

  • Dr. Drake Ramoray

    The answer is politics as money. What was the question?

    • Dr. Drake Ramoray

      I actually meant to type politics and money. Freudian slip?

      • NPPCP

        Same thing.

  • NewMexicoRam

    I’m beginning to consider a retainer style practice. I will lose a lot of good patients, but I’ll be able to practice the way I think will be best for the patients that sign up.

    • NPPCP

      I charge less than a plumber and they pay it all day long – cash. Make sure you have lots of education, service value, and kindness and compassion (along with excellent diagnostic ability) in the visit. They will tear your doors right off the hinges.

    • Mengles

      Trust me, with Obamacare making people lose their providers, people (with cash) will be breaking down your doors to see a primary care doctor.

    • guest

      I’d pay cash to see a doc. In fact, knowing the hassles that come with insurance ( and I have private insurance) I often offer practitioners cash rather than billing through insurance. That way I know they get paid without pulling out their hair, and they can spend some time with me. No one has taken my offer yet, but I bet it’s a matter of time before one of them does.

  • Patient Kit

    I sincerely want to understand the direct pay model, but I don’t get how it will work for patients. I understand the basic concept that we patients would pay our PCPs directly and, theoretically, we’d have more time with our doctors. But what about lab and imaging tests? specialists? hospitals? surgery? chemo? What happens when your patients have cancer or something else equally serious? Or even just appendicitis or a badly fractured leg? Would we still need to buy insurance to cover everything but PCP visits? Because most patients can’t afford to pay for all of that directly. If so, would insurance be cheaper if it didn’t cover PCP? How would we know what the cost of direct pay would be? I’m having a hard time imagining any doctor visit her in NYC costing the patient $58.

    Please, somebody, help me understand how direct pay would work — and be better — for patients? Wouldn’t healthcare overall get more expensive for most of us if we had to keep our insurance plus direct pay our PCP?

    • guest

      It would kind of work the same way that paying for repairs on your car works, or paying your plumber works. You have insurance for catastrophic events like car crashes or house fires, but for routine care and maintenance of your home and car, you pay out of pocket.

      Rob Lambert has written some excellent pieces here about his new direct pay practice, and how it works for patients. I think if you check those out you will understand how it’s a better model for both patients as well as doctors.

      • Patient Kit

        Thanks. I will search out some of his pieces on direct pay and read them. I really am curious. Is it possible to be open to the idea yet skeptical at the same time? Maybe it’s a good model for young, basically healthy peeps with no pre-existing, chronic or serious conditions. But for anyone who already has ongoing health issues, I can’t see how it wouldn’t be a more expensive model for us. But I will search and read and keep my mind open.

        • guest

          I think most patients are blissfully unaware of the overhead costs that doctors incur in accepting their insurance. When the patient pays directly, those overhead savings can be passed on to them.

          Why we ever allowed ourselves to get into the position of functioning not only as doctors but as billing clerks is a mystery to me. It has produced an entire generation of patients who believe that they should be able to see any doctor for only a minimal co-pay, and it is killing primary care providers who honestly cannot afford to provide insurance collections services for their patients.

          • Patient Kit

            I am increasingly aware of the costs of running a medical practice, even more so since I began reading KevinMD. I have friends who work in healthcare. I’m not unsympathetic. I see the appeal of cutting out the middle man and I hate health insurance companies as much as anyone.

            That said, perhaps many doctors are blissfully unaware of what we patients face in this country when we don’t have health insurance. I was without insurance for the first time in many years last after a layoff and I can tell you what happens: a blood lab test that government and private insurance might pay $100 for, the uninsured get billed $500 for. I get that they are making up for the low reimbursement rates of insurance by charging the uninsured a much higher “full” price. That may be do-able, though still very unfair, if the patient has plenty of cash. But in this economy, a lot of the recently laid off and uninsured don’t have a lot of cash. Believe me, it can be terrifying to be without health insurance in the US.

            It sounds to me like the direct pay model wouldn’t work well for the middle and working classes. I’m guessing that $500 blood test wouldn’t be covered by catastrophic care insurance, nor would many tests and specialists. I could be wrong but it sounds like the direct pay model would define the population you will treat as the upper middle class and up and the basically healthy. Doctors might have the freedom to charge sliding scale fees but we patients need to KNOW upfront what PCPs, specialists and tests will cost before agreeing to a direct pay model.

            At this point, I’d prefer a single payer system, all docs on good salaries (I do value good doctors very much) and medical education greatly subsidized by the government to increase the pool of good peeps who can afford to go to med school and eliminate that huge med school debt from the equation for doctors.

            I’m still going to read more about the direct pay to try to understand it better. I’m new here and really enjoying the exchange of ideas about healthcare, something we all feel passionately about, one way or the other.

          • NPPCP

            Hello Patient Kit, You sort of answered your own question with your post! With direct pay, a full panel of lab testing in my clinic (the basics) would cost you around $100 – for everything! Plus an office visit. So you can see the savings. Pay cash for the basics – you and me deal with each other. Then pay for catastrophic coverage ($5,000 deductible). You will actually end up saving money in the end! Addendum – you also know exactly what everything will cost before we ever treat you in any form or fashion. :)

          • Patient Kit

            Actually, direct pay for PCP plus insurance with a $5,000 deductible does not appeal to me at all. Would that $5,000 deductible insurance cover everything other than PCP? or only dx deemed catastrophic by the insurance co? And what would the premiums and co-pays be in addition to that deductible?

            My $500 blood test was a CA125 test ordered by my GYN. Where would the cost of that blood test and GYN fall within the direct pay model? I was diagnosed with ovarian cancer right after I lost the Blue Cross insurance I had for 20 years. Navigating our healthcare system without insurance to get the life-saving surgery I needed was scarier than my Cancer dx (only because it turned out to be early stage). Suddenly, not only did I have no insurance but I had a newly diagnosed pre-existing condition. I scrambled and found a way to get the surgery and treatment I needed but it wasn’t easy. I have a terrific GYN oncologist. But if I waited a year until Jan 1, 2014 for the pre-existing condition clause of the ACA to kick in, it almost certainly would have been a very different story for me. As you know, 80% of the time OC is found in later stages.

            So then, where would my every 3 months GYN oncologist, CA125 test and sometimes imaging fall in this model as I’m being monitored for recurrence? Would it be considered catastrophic by insurance or routine care for a cancer survivor?

            I have a lot of questions going forward about what would be best for our healthcare system. But thankfully, I’m alive and, you might have noticed, kicking!

          • EmilyAnon

            PK, we share the same cancer. If you’re not insured, the most expensive place to get blood tests is at the hospital, mine charges $450 for CA 125. Check out these blood test brokers where you can buy any test and take the coupon to an outside lab near you for the test. No doctor’s prescription necessary, only you will get the results. Prices range from $48 to $60.

            Do a google search for:

            My Med Lab

            Private MD Labs

          • ninguem

            Exactly.

            The price inflation, and the requirement for a physician order, comes when you want “free” lab work, meaning you want insurance to cover it completely.

            If you want to pay for a lab test on your own, out of pocket, you can walk into any of a number of laboratories that will me more than happy to run the test for a competitive price.

          • Patient Kit

            Thanks but I think I’ll reject the idea of self-treating and self-monitoring for ovarian cancer. CA125 tests are tricky enough. I’m more comfy having my GYN ONC interpret the results.

          • guest

            Any lab can send the blood test to your doctor, who can continue to treat and monitor you. The point being made is that it is possible, if you have to pay for certain healthcare expenses out of pocket, to shop around and get vastly better prices than the “rack rate” that people assume is the going rate, as they are accustomed to having insurance and not having to think about the price of anything as it related to their medical care.

          • Patient Kit

            Obviously, I did not know this and I’d bet most people don’t know that they can shop around for better rates on lab tests. Is the same true for MRIs, CTs, ultrasound? I think the prevailing image, both from media and experience, is that if you’re uninsured, most health services will charge you 10x what they accept from most insurances. Similarly, the prevailing media image of concierge/direct pay medicine is Royal Pains taking care of wealthy peeps in the Hamptons. If doctors want a real shot at selling the idea of direct pay to the public, I think you need a campaign to start getting the word out in a big way to educate us about these options.

            That said, in my case, none of this would have worked. Obviously, if I qualified for Medicaid, I didn’t have cash flow to shop around and pay cash. I was also too terrified with a new serious dx to shift into crafty consumer business model. I just needed major surgery asap. I will say that the GYN ONC who took excellent care of me will keep my business as I segue off Medicaid and back onto new private insurance. And I will recommend him to anyone who has the misfortune to need a GYN ONC.

            It’s a very complicated healthcare system for sick people, who are often in shock and frightened, to navigate. I’ve had an angel on my shoulder this year but it’s been an education. And you need nerves of steel to walk a tightrope without a net indefinitely.

          • Patient Kit

            My $500 bill for my first CA125 blood test came from a private lab that my private practice GYN used. I saw her one time after I could no longer COBRA my Blue Cross insurance at $700 per month. That’s when I got the bad news. She said I had to “find the money” for surgery.

            That’s when I went into survival mode. Triage doesn’t only happen in the ED. I triaged my life situation and decided that finding a way to get surgery for ovarian cancer asap was my biggest priority. I happened to be broke for the first time in my life, so I applied for Medicaid. Medicaid paid for my state of the art robotic surgery by a wonderful GYN oncologist at a good teaching hospital in NYC and for all my followup care since. My CA125 test is now done at the hospital every 3 months. I haven’t seen the bills so I don’t know how much the hospital charges Medicaid for the test.

            I was suddenly stranded with a serious preexisting condition, ten months before Jan 1, 2014, terrified of losing Medicaid, the only insurance that would cover me for cancer treatment.. Now that my preexisting condition is no longer an insurance issue, I can claw
            my way back to the middle class and get off Medicaid, which I’ve had for less than a year.But thank god for Medicaid..Without it, my story would not likely have a happy ending.

            Going forward, when I choose new insurance, whether it comes via a new employer or I buy it myself, if I have any choice at all, I will choose insurance that will allow me to continue seeing my awesome GYN oncologist. I will probably have to find a new PCP. again.

          • guest

            I personally agree that a model in which medical education is generously (or completely, as in other developed countires) subsidized and we have a single payer system of care, would be a better choice than what we have now, which is a dysfunctional mess.
            However, American voters and more importantly, American healthcare corporations (hospitals and insurance companies) and their lobbyists are not about to let that happen any time soon. Both patients and doctors are victims of the crossfire; the only entities who benefit from our dysfunctional system are highly paid specialists, and corporate executives and shareholders.
            The solution is for doctors is to remove themselves from the mess that our third-party payor system has become and go back to directly caring for their patients, unencumbered by governmental or corporate intrusion. This is not something that would substitute for having insurance, however, so to equate it to a situation where the patients are uninsured is fallacious.

          • Patient Kit

            I agree that healthcare corporations and their lobbyists are formidable opponents to doctors and patients. And as long as for-profit health insurance companies are at the center of our system, our healthcare system will be driven by the profit motive above all else. At the same time, I think the direct pay model will be a hard sell to many patients, partly because it will likely make healthcare even more expensive for patients since we will still have to pay for insurance but it would no longer cover primary care. In theory, I love the idea of putting the money directly into my doctors’ hands instead of the insurance co’s. But in reality, I think it would just make healthcare more expensive for me. I don’t know what the answer is and I would love to be wrong about direct pay. I do know that it’s a very difficult time to be sick in the US. That’s why I swim a mile 5x a week. Trying to stay healthy is the best defense.

  • guest

    We have a shortage of PCPs because they are being abused by our healthcare system and medical students are electing in droves not to go into primary care. Plain and simple. PCPs are not seeing more patients because there’s a PCP shortage. They are seeing more patients because they have to in order to keep the lights on.

    Maybe if primary care could be made more attractive by popularizing a model in which the doctor is allowed to provide adequate care to his or her patients, and is paid fairly for those efforts, then primary care would be a more attractive career choice for medical students, and we would not have a shortage of PCPS.

    • Pat Brown

      Amen. I am old enough to remember real-life Marcus Welby practices, along with being ADMITTED once a year for a “complete” physical (not advocating for the latter!) I know that as an experienced RN I skew the bell curve, but I would cheerfully pay to continue to see my own awesome PCP. He has to take a few minutes to give me rationales, but I also listen to him and am “compliant” (well, semi-so with weight loss…) Me and mine go to ED’s for life, limb, and 9/10 pain only….and there are more like us out here. I value his time, and vice-versa. Sadly, I think health care is going to separate not into the “haves” vs “have-nots” but the “knowing” vs the “clueless” when it comes to the self care that my grandmother, with a sixth grade education, knew.

  • Bradford Lacy

    I agree that Primary Care Physicians and Clinicians should be properly compensated for the valuable service they provide. And as a patient I don’t mind paying the cost of using a direct pay clinician. If anything it is motivation to take better care of yourself to save money on the cost of seeing a physician. However, if I am going to start paying my PCP diretly I would like to see my health insurance premiums reduced. There is no reason to pay for insurance that you can no longer use.

  • buzzkillersmith

    I think the change in the types of pts I have seen over the last 25 years is huge. The percentage of complex cases with multiple medical problems has gone way up, while the time per pt has stayed stable or even worsened. And of course the pay differential between cognitive specialties and procedural ones has increased markedly.

    My guess is that the hand-wringing that is now being seen even in the mainstream media will continue and any changes, if the occur, will be inadequate to address the problems and things will continue to spin down. Witness that real average pay for male Americans has no increased since the 1970s. People can put up with a lot, especially now with diversions like 24/7 internet. Bread and circuses, bread and circuses.

    I’m old enough to remember the semi-comical rhetoric in the mid-80s about how our urban schools were failing and how teachers needed to be paid more and on and on. Even at the time as a young med student with only passing knowledge of the issues I smiled and shook my head. And the problem of failing schools is no better and society has moved on to other “critical problems.” Of course I’m not smiling much now, having been teacherized.

    There is no hope, except for med students going into rads or gi.

    • Mengles

      Exactly, funny how corporatists have moved on from attacking teachers and police officers to doctors.

  • buzzkillersmith

    Direct pay is good for some docs and their pts, but there would be many pts left without docs. This actually was the model for a good chunk of the 20th century. Those left out went to the county hospital. If they weren’t sick enough, they were told to hit the bricks.

    Now of course the emergency depts have to see everyone and they are squawking–see the recent post here by an ED nurse. Not that I blame them really, but we PCPs are feeling our own pain, so via con Dios, EDs.

    And the private hospitals that have mostly replaced county? Again, they’re on their own. At the local yokel hospital hereabouts the CEO likes to tell us how poor the hospital is at the docs’ meeting. Those few that stay mostly awake after the mediocre dinner roll their eyes and fool with their smartphones.

    It’s hard to get in the hospital these days–gotta be really sick. So the EDs and the drug stores and the community health centers are the new outpt versions of county and are where a lot of the sick-and-doctorless will be getting medical care.

    Be nice to your doc, pts, lest you lose him or her. You can be replaced.

  • Patient Kit

    And yet, I know plenty of Canadians who are happy with their healthcare.

    • Mengles

      Yes, the ones who don’t use healthcare much or use it for the mundane. But when you need a hip replacement surgery or cataract surgery, you have to wait for months, I doubt they would be happy then. Nice try.

      • Patient Kit

        Actually, among others, I was thinking of a wonderful Canadian woman who fought a 10+ year tough battle against breast cancer in Canada before finally losing her battle recently. She was an amazing spirit who touched many and I think of her often, especially this year when I fought my own battle with ovarian cancer here in the US. We met each other in Mexico and I never heard Terri complaining about the medical care she received home in Canada. Her illness was far from mundane.

  • Martha55

    My father needed a knee replacement and he had to wait for months..

  • ninguem

    “…..Shortage of PCPs leads to needing to see more patients per day….”

    Why?

    I’m sorry, I missed the part where you and I have been made responsible for every human being on the planet Earth. I will see as many as I feel comfortable seeing, compatible with my own survival as a human being, and the survival of my family.

    • Justin Smith

      I guess it depends on your understanding of what our responsibility is and to whom that responsibility lies. I have worked in a town where there simply wasn’t enough pediatricians to see the children in the town. There was an even worse situation for Medicaid children. It was a smaller town so recruiting new physicians was difficult.

      I certainly understand what you are saying here: “I will see as many as I feel comfortable seeing, compatible with my own survival as a human being, and the survival of my family.”

      This was a constant tension that I walked in every single day.

      • ninguem

        If you feel you have a responsibility to the entire planet, you should be in Zimbabwe.

        I trained in a whole department of faculty with a “family doctor on the cross” mentality. Fortunately, the program no longer exists.

        • Justin Smith

          I see where your experiences have certainly shaped your view and I understand where you are coming from. However, it seems like you are trying to convince me that you are right and I am wrong. Maybe I’m interpreting things incorrectly here but it’s also hard to leave alone.

          The post is not about health care for the world. The post is about the ACA and Medicare which I’m assuming gives us a ground to have this discussion about health care in the United States.

          I’m sure there is a great need in Zimbabwe, but I’m talking about taking care of children who I lived in a community with that had a hard time getting health care due to a shortage of PCPs.

          I’m admittedly saying that these are hard decisions and knowing where to draw the line is difficult. Chasing the logic to Zimbabwe doesn’t solve the problem.

          • ninguem

            Neither does burning yourself out in your own community.

            If you think it’s tough treating kids with Medicaid, try adults with Medicaid.

            Recognizing that it varies by state, but at least in my state, pediatric Medicaid is about Medicare rates, still not great of course.

            Adult Medicaid is about twenty dollars a visit.

            My office gets phone calls……regularly…….with callers convinced that “Obamacare” means that I am now forced to see all comers for any and all reasons. So schedule my adult Medicaid visit and get that narcotic pad out, it’s party time.

  • futuredoc

    I am incredibly pleased that these first two posts on the primary care crisis have led to so many comments and back and forth discussions. Hopefully, those posts to follow will be thought equally worthy of comment. Thank you all.
    A thought about the issue of whether retainer-based or direct pay means “elite.” My wife and I are on Medicare and it costs us about $6000+ per year for the privilege. Fortunately we are in good health. We have excellent PCPs who shifted from typical insurance to retainer-based for about $1500 each per year. So we are now paying an extra $3000 for our care. It is a lot of money, since as one of you noted, we still have to pay for our insurance. But we both feel that it is worth it. In the end it is not about elite but all about prioritization of one’s expenses. Deciding what is most important to spend our money for. Maybe we will go to Starbucks less often and only use our smart phones when we are in WiFi range . Our PCPs now have the time to listen to us and that makes all the difference.
    Stephen Schimpff

  • Vikas Desai

    Unfortunately direct pay can almost never be an option, only a minority of people really care enough about their health AND have the money AND have the willingness to spend said money on a direct pay system, having PMD’s switch to direct pay will basically perpetuate the PMD shortage.

  • SCNP

    I had a practice with literally a box on the wall for payment. A 400 sq ft office, no receptionist and answered my own phone. I did this part-time but it could work full-time. Patients set their own fee. I gave no guideline. This way I didn’t turn anyone away. Some paid cash, some check and I guess now you could use Square on an iPad for cards. I had wealthier people pay $100 or more and poor single moms pay $20. In 5 years I only recall two occasions (I know of) when a patient didn’t put something in the box. No billing staff. Now I would use free Practice Fusion as an EMR. My overhead with malpractice was less than $1500 a month.At the end of the day I emptied the locked box on the wall, filled out a deposit slip, stopped by the bank and went home. No billing software, coding or meaningful use. It is not how much you make but how much you keep.

  • RES

    Can’t speak for Canada, but two of my aunts in the UK had hip replacements within weeks of medical need being established (i.e. a prescription). No charge.