The meaning and depth of the primary care crisis

First in a series.

The primary care physician (PCP) should be the backbone of the American healthcare system. But primary care is in crisis — a very serious crisis. The first statement is my considered opinion and I will attempt to convince you of its truth. The second sentence is a simple fact.

Accounting for only 5% of all health care expenses, the PCP can largely control the “if and when” of the other 95% and hence can be the one to best affect quality of care and the totality of costs. This crisis limits the effectiveness of the primary care physician such that care quality is nowhere near what it could be or should be and the costs of care have skyrocketed.

This crisis is the most pressing and frankly most urgent issue in health care delivery today. Healthcare delivery must be restructured — now — so that everyone but especially older adults with multiple chronic illnesses can obtain quality, compassionate, cost effective care. And this means having a committed primary care doctor who has the time along with the knowledge and experience to deliver the care needed.

This is the first of a series on the crisis in primary care that will appear on KevinMD.com over the coming weeks and months.

To be effective, the PCP needs, of course, to be well educated, well trained and up to date. This is necessary but not sufficient. He or she can be more effective with an appropriate team approach that puts the patient in the center of the equation — the patient centered medical home concept. He or she also needs to be a deep listener and needs to think extensively. Listening and thinking require time and for those patients with one or more chronic illness, the PCP needs to quarterback all of the other providers involved with the patient’s care. This also takes time. Time is the element that has been lost in the past decade or more for the PCP. Without the time to listen, the full picture of a person and their illness does not emerge. Without time to think, the diagnostic process suffers immensely. Without time to listen, the PCP is no longer a healer but rather a well-paid care giver. Without time to think, the PCP is quick to send the patient off to a specialist. Without time, the opportunity for outstanding preventive care is diminished. And without time to coordinate all of the specialists and other providers that are required for someone with a serious chronic illness, the care becomes disjointed, quality suffers and expenses rise.

A patient story may help elicit the meaning and the depth of the problem.

Monica is 68, married, retired, on Medicare and in generally good health. She has a PCP who she sees intermittently. She began to have a strange sensation in her right chest described as a sort of shooting sensation, almost electrical or vibrational in nature that stretches from high up in her right mid chest down as a narrow line over her rib cage and just onto the abdomen. It seems to be immediately under the skin. It starts intermittently and ends at no set time. There is nothing she has found to make it start nor stop. She visited her PCP and offered this description, adding that she was concerned that maybe it was her heart. The doctor asked additional questions and did an exam and an electrocardiogram. All were normal save the description of the sensation.

The PCP was now about out of time for that 15 minute visit. Here was a fork in the road, two paths to choose between. Given that Monica was concerned about her heart, the PCP chose the path to send her to a cardiologist for further evaluation. The cardiologist found nothing abnormal but nevertheless suggested a stress test and an echocardiogram. Both were normal. The cardiologist suggested since the sensation crossed over to the upper abdomen, maybe it would be a good idea to see a gastroenterologist. The GI doctor found nothing. Nevertheless he ordered a CT scan of the abdomen. All was normal except that in her uterus there was a small cystic structure. The radiologist read it as a probably benign cyst but — feeling the need to be cautious — recommended Monica visit a gynecologist. The gynecologist also said it looked benign but just to be on the safe side, she could remove it. Monica would be out of the hospital the same day and feeling fine in a day or so! The cyst was just that, a benign cyst. Monica still had the strange sensation in her chest and no one had found an answer for her.  But given that it seemed to run in a line with an electrical sort of feeling the gynecologist suggested that maybe it was a nerve issue. So she visited a neurologist who of course found nothing, commenting that nerves run around the chest, not up and down.

Monica illustrates the problem so common today in primary care. The PCP did not truly listen to the patient. And he did not stop and think the issue out carefully. He had no time because there was a waiting room full of patients and he needed to see about 24 to 25 each day. So instead, he took the easier path and referred the patient to a cardiologist since this seemed at least logical given that the strange sensation was in the chest and the patient was personally concerned about heart disease. Had he followed the other side of the fork in the road and had listened long enough and then thought about it he would instead have concluded that the patient was hypersensitive to minor — albeit real — sensations. He would have offered reassurance that it did not represent a life concerning ailment. He would have said that it was real but of no concern. He might have offered a few weeks of a low dose anti-anxiety medication, offered further reassurance and told her to return in two weeks for a follow-up. At the follow-up he would have explored the issues producing anxiety or stress in her life — financial, marital, a disruptive child, an overbearing in-law. Had he done so he would have soon discovered that Monica was deeply concerned and feeing guilt about a family issue. What Monica really needed was assistance to overcome her sense of guilt and shame — not months of specialist hopping. Anxiety and stress are often components associated with a physical symptom and these can only be addressed with more time to carefully listen and then time to respond with suggestions.

But this was not the way it was to be for Monica. She was shipped from doctor to doctor, test to test, even an operation yet with no one really listening enough to figure out her problem. All each specialist could do was say it wasn’t in their “organ system” and left her with a sense of floundering and without a sense of closure from any physician. Each one said it wasn’t in their sphere — not the heart, not the stomach, not the nerves, etc. And the “surgery went fine.” But she still had the unpleasant sensation. So it resulted in far less than adequate medical care and obviously cost a king’s ransom. Neither was necessary. But that is what all too often happens today. And, I assure you, Monica’s saga is not uncommon.

Monica’s experience is all too common and results largely from the PCP’s lack of time — time to listen and time to think. The result is less than adequate care, certainly not humane care, not healing care and very high costs.

In the next post, I will address the causes of this crisis in primary care.

The meaning and depth of the primary care crisisStephen 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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  • Thomas D Guastavino

    “The PCP was out of time for that 15 minute visit” Well, it seems the problem is already solved, its called “direct pay”. More time can be spent with each individual patient which, according to your logic, is all that is needed to save primary care and health care in general. Time to move on to the next problem.

    • NPPCP

      Hi Thomas, love all of your responses on here and interacting with you. Respectfully, stables are for animals. I am an independent provider; I’m not an extender. Your post is one of the biggest reasons why the “team concept” will never work. NPs treated as tools. It will never happen. We will never go along with it.

      • Thomas D Guastavino

        Actually , I believe that the future of healthcare belongs to the extenders. I have enjoyed an excellent working relationship with the PA, nurse practitioners, CRNAs and many others. My own son just graduated as a PT assistant and has had multiple job offers. My post was directed toward the constant handwringing over the state of primary care when, in fact,the future is already here.

        • NPPCP

          I understand. I didn’t know how to phrase my response without seeming “nasty.” A large portion of physicians enjoy throwing those terms around specifically to irritate. I am always quick to respond. Thank you. Congratulations to your son! What a great career choice!

          • Thomas D Guastavino

            Your Welcome. I am very happy with his choice

    • Patient Kit

      How exactly does the direct pay (no insurance) model work when the patient gets very sick and needs care beyond the PCP? Would we still need to buy insurance to cover specialists, hospitals, surgery, lab and imaging, physical therapy — everything but primary care? So two separate payment systems for most patients who aren’t rich? Direct pay for PCP and insurance for everything else?

      • Thomas D Guastavino

        The author of the post was bemoaning the fact that there is a continuing crisis in primary care because the traditional insurance models afford primaries less time with their patients. Through the use of extenders, direct pay, and other models such as concierge care the problem has already been addressed.

        • Patient Kit

          I understand what the main point of the OP was. But I see the direct pay model mentioned a lot here when it comes to primary care. And I really don’t understand how it would work for most patients with limited cash.

          I get that we would pay cash directly to the PCP for each visit. But what happens when our PCP says “ut oh, this looks like cancer”? Most of us couldn’t direct pay for oncologists, anesthesiologists, surgery, chemo or even an uncomplicated appendectomy. So, PCPs would be free of insurance, but not patients? We’d still need to buy it to cover everything but PCP? Would insurance be significantly cheaper for us if it didn’t include PCP? Or. would we still pay the same for insurance but all PCP would be out of pocket? Just trying to understand how this would work for patients. I see how it would work for PCPs. It certainly would define the economic population they want to care for.

  • NPPCP

    Stephen, Been taking care of patients for YEARS just like the one mentioned in your essay. Your entire premise is not real world. It is based in academia and the need for family physicians to remain in control. How many times is this going to be regurgitated and reframed. As a Family Nurse Practitioner, I do everything you are mentioning and do it extremely well. Family physicians are needed – but they are not the only answer. The REAL WORLD is proving this daily. My clinic proves it. The 18 states where we practice independently prove it. Health care is changing. You can produce all of “the series” you want. But we have already heard it. All of it. I mean all of this respectfully. It just gets really really old and these types of articles are very self serving for your profession. Thank you

    • NewMexicoRam

      OK, so NP’s and PA’s help to solve the healthcare crisis in primary care. What happens when the reimbursement to primary care continues to fail to keep up with inflation? Won’t those same non-MD providers be forced to see even more people in a shorter amount of time? If so, has anything been solved?
      I think not.

      • NPPCP

        I agree sir. Right or wrong, I’m just thinking about the here and now. We are rearranging chairs on the ship. I agree.

      • Thomas D Guastavino

        Perhaps……..but not today.

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

        Oh, but it has. Once we establish that you don’t need doctors for primary care, it becomes so much easier to assume that you don’t need NPs and PAs either, and do we really need a college education at all? I mean, out in Rwanda (or something like that) they are having great success with “trained” community workers…. and since this is the U.S., we can throw in some high-availability, cloud-based medical expert as well… to the tune of $5 per primary care visit at most. Now that’s some serious savings, and I am certain that the first thing this system would do for “Monica” is to put her on Prozac or some cheap knock-off that provides comparable levels of happiness.

        • NPPCP

          You can’t argue with that either. How much education is enough education? I can’t argue with Margalit’s premise. I have opinions on the length of training, type of training, etc. It wouldn’t “jive” with most here but I guess it is a critical question. Increase the length of NP school? Shorten medical school? Do away with both of them and go to a government trained “health worker”? I don’t know. I do know this – MDs/DOs are safe; NPs are safe. We all have studies showing this. Just where does it go from here? I don’t know. I am just doing and want to do freely what I do and what I am very good at with years of training and more years of hard core experience. :-/

        • ninguem

          I helped train such workers in Malawi.

          Some trained in just obstetrics or just anaesthetics or just orthopaedics, etc.

          “Clinical officers” I seem to recall was the term.

          Tribalism the way it is in Africa, you had to get people from the individual villages and train them and send them back there.

          The Rwandan training programs would not want to take a Tutsi clinical officer and send him to a Hutu village.

          And that’s fine if you have a simple fracture to set or a general anaesthetic to administer or an uncomplicated delivery.

          What to do with the complicated cases, or how to sort out a protean problem (I’m tired), still required the physician.

      • Bob

        Don’t look now, but there also is a shortage of nurses in general and each one that becomes a NP reduces the ranks and experience of the remaining nurse supply, and I might add usually go into specialist offices and do not open there “own shop”. Do they then compete with PCPs and get the same pay, for doing the same work? Are they any more knowledgeable of ICD-10′s? Do they refer more to specialists if they run their own practices? Time alone will tell.

  • buzzkillersmith

    As Dr. S. will note in a future post, it’s the work/money tradeoff that is the problem here.

    I keep coming back to EHRs. These are an absolute nightmare for PCPs, adding up to 2 hours per day or more of work, work we do for free.

    Coming down the pike is ICD-10. We recently had a training session on this, 10 experienced primary care docs trying to guess what we are supposed to put down in terms of documentation and diagnoses. It was quite funny actually. We failed completely.

    So what we have here is a crisis of supply while American society is adding more clinically pointless tasks for us to do.

    Don’t do it, med students. Subspecialize. Let NPs and PAs have it, although after a few years most of them will realize they’ve been taken for a ride. There is no solution. It will get worse. Do not listen to happyhappyjoyjoy knuckleheads, which Dr. S. might turn out to be if and when he offers solutions that will fail. Don’t listen to any of the knuckleheads. Listen to me.

    See the stupidity, med students, analyze it, and sidestep it. You’ll be glad you did.

    • NPPCP

      Buzz, I agree. Right now we want to be a part of the solution. It may (probably will) all turn out to be a nightmare in the end. But paying a physician 10-15000 to sign a piece of paper and do nothing else is ludicrous! There are other answers to the crisis (right now anyway). How it will all turn out with Uncle Sam involved has to be bad. But in the mean time, stop arguing and suppressing for no good reason. Let me do what I am fully educated to do. You (physician) might not agree with it. But the proof is local – patients every day – more than we can handle. Where would they go without us? We are as big a part of this as you are. It’s just the way it is.

      • buzzkillersmith

        Other docs might have problems with NPs and PAs,but I don’t. Do whatever you want, run the primary care show. Docs don’t want to anymore.

        But you all might want to be careful what you wish for.

        • NPPCP

          I’m on board with you and believe that – you know it.

          • Bob

            What’s missing in this article is the word “experience”, that applies to physicians, NP’s, PA’s and all other care givers. Sometimes and I believe most times experience trumps test and referrals, and many PCP don’t last long as they transit to specialties. So the system is geared to 15 minutes to write, prescriptions. test and referrals which cost more than a “little more PCP time, extending the total time and costs.

      • Bob

        Why they’ll go to the Emergency Rooms at Hospitals, even in states which do not accept the Medicaid increased payments.
        How they will be coded or if the bills will be paid and by whom will remain the question; or will they be treated at all and sent to the local Emergency Care centers which have popped up all over?

  • VKA

    I like how this has descended into another NP vs MD debate.

    • NPPCP

      Nope. It didn’t. The author is just leaving out a huge part of the solution. And it is being pointed out. I see no problem with that and see no devolution. There is no “debate”. There is another solution that I FEEL should have been included in his “series.”

      • VKA

        The same studies that show that NP care is supposedly safe and equivalent in outcomes to PCP care also show that NPs order more tests and referrals than PCPs. How is that a solution to the problem mentioned above? If anything, they would order a breast MRI, CBC, and a BMP to go along with the cardiology referral.

        I agree that NPs have a role, I’m even undecided on autonomy- but having more NPs is not the answer to the problem listed above with “Monica”.

        • NPPCP

          Now it may be “devolving” just a little. There are NO studies that show NPs specifically order more tests. All of that talk is anecdotal. Otherwise, thank you for your confidence. I agree with you – what is needed is more hands on deck -MDs, DOs, NPs.

          • VKA
          • NPPCP

            Got it. I stand corrected. I have never seen this. I will comment (many physicians here comment on the supposed sorry construct of every NP study conducted by nursing organizations) that this IS the VA. There is no motivation for cost control in that setting. One could also attribute the blame to the supervising physician as there are 60 medical groups yelling right now that allowing NPs independence in the VA will destroy the “team concept.” Sarcastically speaking, weren’t these NPs that were over utilizing being “closely supervised” by their physician supervisor? This is what team care is. I would like to see outpatient, private practice, head to head studies. It is my opinion they would be completely different. Thank you so much for pointing this out. As mentioned, I am corrected!!

          • Allie

            There definitely are motivations for cost control in the VA; more so than in other systems in my experience.

          • NPPCP

            I understand. I said that wrong. There is no PROVIDER motivation for cost control in the VA. There are MANY motivations! You are right! I agree!

          • Allie

            There are no provider motivations to overtreat or over-refer either. You can’t sue individual VA providers for malpractice; you sue the federal government.

          • NPPCP

            Again, I understand. Have worked for another federal branch as a provider in another life. So let’s say there is “no motivation one way or the other?”

          • VKA

            I think Allie’s point is that in the VA, the providers have far less incentive to over-test/over-treat than in private practice, since they can’t be sued and since the resources available in the system are limited. Meaning a head to head comparison in private practice is likely to show a greater disparity than in the VA, rather than less of one.

            And at the VA, NPs (and cRNAs) have traditionally been given a great deal of independence: http://www.medscape.com/viewarticle/810982 to the point of proposing that every NP and cRNA be able to practice independently and unsupervised regardless of state laws. I’d put it to you that in such an environment, it is likely that any supervision was cursory at best as is.

            This is not necessarily an argument against NP independence, but perhaps it is an argument that NPs have to refer complicated patients to a (any) PCP and not directly to a specialist.

    • Kristy Sokoloski

      That’s what I was going to say. Here we go again. Even if we had NPs doing a lot it still doesn’t change the fact that we need more doctors.

      • NPPCP

        No. Sorry. Not here we go again. There was a part I felt was missing and I added it to the discussion. It has turned out to be a healthy discussion. Which it generally does, now that comments are being moderated.

        • PoliticallyIncorrectMD

          Agree, except about your comments about moderation. It is out of control – makes it one-sided discussion. It’s ok to disagree with ones opinion, but to silence it undermines good discussion. Similarly, I think it is bad form to down vote someone without commenting on why you disagree.

          • NPPCP

            Hi Doctor, I understand there. But the – “you are a nurse and will always be a stupid nurse” or “go empty a bed pan” or similar statements were just way WAY out of line. Several posters were forthright and honest with their comments without unfounded nastiness and letting insecurities shine through. This is a civil forum. It isn’t a barbaric nursing or med student forum. The nasty name calling is gone and it is better in my opinion. I would vote for no moderation again – but we both know what would happen. I think everyone has to be respectful and acknowledge what everyone else does – “I know you are an NP and know you own your own clinic and I am sure your patients are very happy; but I must say I completely disagree with the entire concept, feel you are practicing medicine without a license, and believe your patients would go to a physician given a fair choice.” I am not offended by that statement at all. The moderation keeps one group from belittling and insulting another group – it also requires one group to respect the other group and their opinion as well. This should happen in the first place anyway. Yes, the down comments are ridiculous. A screen name of NPPCP gets a minimum of three down votes for no good reason – immaturity and whatever else.

  • lord acton

    I think that N.P.’s and P.A.’s are awesome. I worked with P.A.’s in Alaska who had a wider scope of practice than 98% of the physicians that I ever met.

    I feel like a broken record, but I want to scream from the rooftops about how awesome the direct primary care model is. It could be a critical component of fixing much of what ails our health care system. My enthusiasm is tempered by pessimism that we are capable of doing anything that makes sense.

  • ninguem

    What primary care “crisis”?

    There is no shortage of primary care docs.

    There is a shortage of primary care docs willing to be screwed.

    That there are no docs accepting Medicaid does not mean there is a shortage of primary care docs. It means there is a shortage of primary care docs willing to go bankrupt.

    Because that is exactly what will happen to a doctor who accepts any more than a minimum of Medicaid.

    And that will never be fixed, as long as payment is so bad, no matter how many nonphysician practitioners are trained. They will simply gravitate to higher-paying fields and locations, or leave the profession.

    You want to fix the problem? Pay more. That’s what happens with many community health clinics and other big box places, they just have ways to extract higher payment for the same services. “Facility fees” and all that.

    Or……..find ways to lower the doctor’s overhead. Tort reform. Onerous license fees, far in excess of other professions. I could go on.

  • futuredoc

    Delighted that this post generated so any excellent comments. Thanks to all.
    My fundamental premise is that PCPs have too little time per patient encounter, the result of inadequate insurance reimbursement. Since insurers are unlikely to assist, it will fall to the PCP to change the paradigm. The direct pay approach — pay at the door, membership or retainer based — look best to me. PCPs often need to also restructure to a team based medical home preferably population based model to increase quality and shift work to others as appropriate
    Stephen Schimpff

  • futuredoc

    Another big issue noted by many here is the EHR which is just not designed for those who do cognitive medicine. PCPs need to band together and demand better.

    • Bob

      EHR should travel with patients in a way that they can be downloaded and added to, as the military use to do and I believe still does. Having numerous EHR’s that are incompatible with each other , while being the only way government sets up computer systems, when they don’t “talk to each other” and use the same standards they simply don’t work and the patients can’t correct errors or even “follow the bouncing balls” as they never see the contents! losing your Medical records is a hard thing to recover from and hacking is a constant.

  • http://www.zdoggmd.com ZDoggMD

    I’m biased but I think the solution is simple, and it’s more a bottom-up grass roots one rather than a policy one:

    1. Decouple fee-for service insurance from primary care. Flat fee, membership models can free providers from the 15 minute hamster wheel and give them time and resources to listen and provide amazing care.

    2. Deploy a collaborative team that includes non-clinicians, such as health coaches, as well as licensed clinical social workers and nurses to allow everyone to practice at the top of their licenses while providing patients with a longitudinal type of care that looks beyond the visit “episode.”

    3. Create an EMR that doesn’t waste bytes and keystrokes and time on ICD-9/10 and CPT codes (basically making it a billing platform with a patient care function tacked on), but is instead designed from the ground up to focus on team-based care and patient engagement, as well as population health management to allow proactive, preventative care.

    4. Wrap a catastrophic insurance policy around this core of primary care, then put it on the exchange so everyone can participate. Concierge care? For the masses!

    I said I’m biased because we’re already doing all these things in Las Vegas at Turntable Health. And they’re working.

    http://turntablehealth.com

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

      Sounds great. What’s the average panel size for each physician?

      • http://www.zdoggmd.com ZDoggMD

        Given leveraging of health coaches, with our population it can be around 1000-1500 pts per provider (less if the population is sicker).

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

          Thanks. Not bad, not bad at all. Now if only Medicare would agree to run a CMS innovation “pilot” for this model….. sigh….

  • Judith Johnson

    As a family nurse practitioner I am wondering, where are the transitional education programs in medical schools so those NPs and PAs already working in a limited way in primary care could become primary care physicians? TTUHSC in Lubbock has a fast track medical school for this but it still requires pre med majoring at university. If such transitional programs were more available and AFFORDABLE perhaps this crisis could be ameliorated.

  • Judith Johnson

    Thanks Martha! I am an NP in Texas which has limited independent practice. I am licensed in NM which has independent practice (but at this time I do not work therand my Mom sees an NP there whom she loves. Mom is 86 and her NP takes excellent care of her.

  • Thomas Luedeke

    Great article, I hope you get into your opinions on the resolution.

    I’ve got a lot of interest in the issue, and see plenty of hand-wringing (including more than a little bit that is completely hypocritical), but few actionable proposals to take on the AMA RUC, the government, the Medicare/Medicaid systems, the health insurance companies, and the general influence of the specialists.

    In fact, matters seem to be getting worse with Obamacare, which just institutionalizes a number of the flaws exacerbating the PHP crisis..

  • NPPCP

    The “fair salary” is definitely an opinion. And your practice is still “for profit.” Someone is getting all those extra dollars you are “saving.” It probably just isn’t you. I own a “for profit” NP practice and wouldn’t have it any other way. I think the way you approach practice and the way you feel is a healthcare employer’s dream. You are willing to take what you think is “fair” and they are glad to pay that “fair” salary. You will “save” them money and will have no part in the savings or the money. Follow the money – unless, you don’t want to.