The impediments to being a good primary care doctor

Next in a series.

The primary care physician (PCP) is the most broadly yet deeply focused care giver and as such is the the backbone of the healthcare system. But to do this work effectively requires time — time which all too often is not adequately available.

What constitutes primary care and who are the primary care physicians? They are the first responders, the first line of care, and very frequently the patient’s confidant on all matters related to health and often more. The PCP is often the first physician contacted because of the long standing patient — doctor relationship but also because the PCP tends to be more readily available than a specialist who does not know you. In addition many individuals in managed care plans are required or at least strongly urged with various incentives to visit the PCP before turning to a specialist. The PCP needs to know a broad and deep range of medicine and at the same time needs to know when it is time to consult a specialist. Ideally he or she will enter into a collaborative partnership with the specialist(s) you are referred to so that the PCP can coordinate all aspects of your care. And if you have a chronic illness, the PCP should also ideally coordinate all of the various specialists, tests, imaging and procedures that you might require. It is this coordination of the care over the long term that will mean better care at a lower cost.

The PCP deals with most problems/illnesses with a broad yet fairly deep expertise and knowledge and so is able to diagnose and treat most common and many not so common diseases and problems, including most chronic illnesses. He or she is well versed in the continuity of care for chronic complex illnesses, is in the best position to refer when indicated, and to coordinate care of chronic illnesses or referral for an acute issue. The PCP is or should be focused not just on disease but on the person with the disease, on wellness and disease prevention by means of immunizations, screening (recognizing risk- reward rationales)  and behavior modification — diet, stress, exercise, smoking, etc.

But there are serious issues in primary care.

There are too few primary care physicians, too few medical school graduates choose primary care as a career and there are too few residency slots after medical school for primary care training.

Today the PCP needs to be efficient. This means that it is more efficient to just give an antibiotic for a sore throat than to reassure the patient (and perhaps the parent) that it is likely caused by a virus; that the antibiotic will do no good and could even have some undesirable side effects and that time is the best medicine. But it takes time to do reassurance. And if not done thoroughly, the patient likely will go away unhappy that he got “nothing.” So do the quick thing and give the antibiotic. And add in for good measure — “This should do it!” or “It is good you came in today to be treated.” It also means that the PCP needs to see as few Medicaid patients as possible since Medicaid pays so poorly. And although much can be done over the telephone or with email, preventing a trip to the office or even the ER, the efficient PCP wants to avoid both since there is no payment for either.

PCPs are frustrated. Some see the glass half full and many see it as half empty. Those that see it half empty are quickly selling their practices to the local hospital. Others are trying new payment methods. Either way, they see that today being a PCP is not doing just the “simple stuff” as so often portrayed but the very complex. Many patients have multiple chronic conditions, are on many prescription drugs, have various functional incapacities as a result of aging, and often have problems rooted in family dynamics or their own cultural norms and traditions.  The good PCP understands that the essence of care is the bond that they develop over time with each patient. This is the bedrock of the profession.

But the current “culture” of medicine expects high technology to be the answer, imposes financial frustrations and is always threatening malpractice litigation. This combination, but mostly payment issues, has led to a fragmentation of care and the overuse of specialists, specialty care without coordination and an over reliance on technology. The good PCP, despite all of the frustrations, still understands that that bond with the patient is key, the very heart of their medical practice, the basis of their own satisfaction in their career and (as stated in a book review on primary care) “the essence of a well-functioning medical care delivery system.”

Doctors are departing private practice in droves. Traditionally a newly minted physician would borrow funds to start a private practice or would enter an already established practice in town. In 2000, it is estimated that about 60% of physicians were in a private practice. This had dropped to about 40% by 2012 and perhaps to 33% by 2013. It appears that the rate of decline in private practices is increasing with no apparent end in sight. In 2000, about 20% of PCPs were employed by hospitals; today that is up to about 40% and growing rapidly.

The question of course is why the rapid change? Some of it is a change in the desires of the new generation of physicians. They have a desire for more personal and family time. They also have a desire for a better controlled professional life with fewer administrative obligations, no concerns about borrowing large sums to begin a practice, and a steady paycheck. But this change to employed status is also about the current convoluted billing requirements of practice, the administrative complexity of running a business plus being a physician, and the always changing regulatory requirements.

But there are definite tradeoffs. Most important is autonomy. Physicians over the years have valued their autonomy but when one works for a corporation, no matter how benevolent, it will have its own rules and regulations. The hospital might screen patients first for insurance coverage whereas the private practitioner could have made his or her own decision about who to accept and who not.  Autonomy is lost. And although the administrative burdens are lessened the physician is still expected to cover his or her own salary and expenses which means still seeing many patients per day, 24-25 or more to meet productivity standards. So shifting to hospital employment does nothing to gain time — time to listen, to prevent, to coordinate chronic care and to just think.

The primary care physician is your most broadly yet deeply focused care giver and as such is then the backbone of the healthcare system from your perspective. But to do this work effectively requires time — time which all too often is not adequately available.

The next post in this series will consider who chooses to become a primary care physician.

The impediments to being a good primary care doctorStephen 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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  • Dr. Drake Ramoray

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    And if you have a chronic illness, the PCP should also ideally coordinate all of the various specialists, tests, imaging and procedures that you might require. It is this coordination of the care over the long term that will mean better care at a lower cost.

    ===============================================

    Recent data does not support this assertion.

    http://www.kevinmd.com/blog/2014/02/shocking-lack-data-medical-home.html

    • Kristy Sokoloski

      And with these new payment methods that are being tried Primary Care Physicians will continue to lose patients. The reason? Because the patient is not going to be able to afford to see them for medical care when necessary. This is why dentists wonder why more people don’t come to them for regular check-ups and cleanings and such. They have made it impossible for the people to get to them.

      In due time (although don’t know how long that will be) the patients that think that NPs are so wonderful for regular routine care (if there are still NPs in the Primary Care setting because as you say more and more of them are going toward specialization) will not think so anymore when a serious problem that requires the care of a doctor won’t be able to see one.

      I know some people think that specialists listen better to the patients (at least some patients seem to think this), but I have found that is not always the case. And sometimes if a case is too complicated for them to deal with even though they are the specialist they get to where they can’t handle it anymore. I also feel that in time it will be harder for patients to get to specialists (and not necessarily because of the NPs and the PAs even though that is a factor) because it will get to be too costly. And that’s in addition to what I have supposedly heard about that in several years’ time there will be a shortage of specialists. However, I say to you, in some areas of the country there is already a shortage when it comes to certain specialties such as endocrinology, Rheumatology. And I believe that one of the other readers of this blog mentioned a while back that even Endocrinology is changing somewhat in how they practice. They used to be the go to specialists for those that were Diabetics as well, and from the way I understood that reader that is becoming no longer the case.

      • Dr. Drake Ramoray

        That was me. My practice is one of three that covers a service area of about 1/2 of two states. And yes, Endocrinologists are moving away from diabetes (we have a wait list for diabetes). The mandates, pay for performance, the insurance prior authorizations are horrible for diabetes. All of the coming changes are making this worse. You are correct access will worsen, to doctors, to certain specialties, and for chronic care. The coming changes, the PCMH, the interference with the doctor patient relationship is bad for providers and it’s bad for patients. We agree. So why is the author of this piece so Ra-Ra about the coming changes?

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

          Because he is going to end up offering the standard solution: using a team to deal with the “simple things” will allow the PCP to “concentrate” on the complex stuff and have more time for each complex patient. It sounds good in theory.

        • DoubtfulGuest

          So interesting, Dr. DR. As a thyroid + adrenal insufficiency patient, I had trouble finding an endocrinologist who was interested in that stuff. It seemed they were mostly doing (and preferred to deal with) diabetes. Either I misunderstood what they wanted and it was just a matter of patient numbers, or else the few that I saw before my current one were in the minority. I appreciate the different perspective, in any case.

          • Dr. Drake Ramoray

            It takes substantial additional training outside of fellowship to be able to have a viable endocrine only (no-diabetes) practice. This is one of the reasons that I don’t already have one. There is certification for ultrasound and required licensing from the state or federal government to be able to use radioactive materials for medical purposes. Almost no fellowship programs in the country provide sufficient training in these areas. It is a fairly long and arduous road. Much like everything in medicine there isn’t much money in thinking about things but we can perform ultrasounds, nuclear medicine studies, and treatments, at a fraction of the cost of hopsitals

            One of the reasons that I am responding so vehemently against this piece, and PCMH, and coordinated care is that at least in my field I can provide better, more timely, and more cost effective care with very little support (as long as it’ not diabetes). I am even entertaining doing so as direct pay at very reasonable prices without taking insurance. (I have no interest in primary care so a traditional “concierge” practice may not be viable for me).

            But a very low cost, direct pay, specialized service, that includes tests that cost a 1/4 of what they do at the hospital is potentially a viable model. I wonder how many people would be willing to pay $100 for a thyroid ultrasound when the hospital charges $500 to their insurance and often puts it to their deductible? All without, administrators, PQRS, meaningful use, and all of the BS that is drowning primary care. Two rooms, phone, ultrasound, nuc med, someone to answer the phones, schedule, and keep track of my billing. As I grow may add in house labs in this scenario but that would have to wait for down the road. Hospitals and PCMH is for lemmings.

          • DoubtfulGuest

            I think your idea of direct pay practice is great. You ought to pursue your dream. I have an excellent care group at my teaching hospital for my mitochondrial disease (with lots of endocrine problems under that umbrella). Otherwise I’d gladly seek out something like that. I know quite a few other patients who have hypothyroidism only, who feel their endocrinologists are overwhelmed taking care of diabetic patients, and their PCPs aren’t much more help. It seems thyroid diseases as a group are quite common. So, there’s a real need for the kind of practice you describe. And it sounds quite reasonable for the patients. All the best to you.

    • southerndoc1

      “Edge of their license”
      Very good. I’m going to steal that.

    • buzzkillerjsmith

      “… a cog, a data entry corporate drone,
      spending time on initiatives, mandates, and dictats, …”

      I resemble that remark.

  • southerndoc1

    Agree. I’m not convinced that Dr. Schimpff will try to lead us down the PCMH primrose path. In other postings, he’s been a strong advocate of direct pay primary care.

    • futuredoc

      Yes, I am a strong advocate of direct pay in any of its forms (pay per visit, membership, retainer-based,etc). To me the key point is to allow the PCP to have time with the patient – time to listen, time to think. With today’s insurance-based reimbursement system that time is just not available. To go further, it would be good for PCPs to have a smaller panel of patients so each can get the time needed. But that is impossible with the current system. As to the PCMH, I think it makes good sense but again only if there is time. Not to take the patient away from the doc but to use others to assist as appropriate so that the PCP has even more time with the patient. Time with the patient is the key element – and so often missing today.
      S Schimpff

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

        My apologies. I stand corrected. But I think that when addressing direct primary care, which is in my opinion the correct model, one should make an attempt to address how that type of practice can be scaled to all people (in our current environment), not just the ones willing and able to go outside the system, and I personally think it can be, but I would very much want to hear your thoughts on the subject.

      • Dr. Drake Ramoray

        My response within your link of PCMH evolving in a positive way speaks for itself.

        And who is going to pay and how are you going to pay for all of these people that “assist” the doctor to have more time to see less patients?

  • Dr. Drake Ramoray

    ============================================
    “It is this coordination of the care over the long term that will mean better care at a lower cost.”
    ==============================================
    Reads like every plan for the PCMH model. This piece not be associated with PCMH, although it is one of it’s stated goals. If not then great, but if that is the case I would prefer a more full throated defense of primary care doctors with a plan, and what will help then. More talks about systems, and coordination of care.

    You don’t need to be a doctor to coordinate care or prevent disease. Doctors are expensive. Corp med knows this. I believe in the current climate primary docs are training for a job that will be obsolete. Why receive specialized training in something where the pendulum is moving to those services being provided by people not having as expensive or legthy training?

    I would like to see a full throated defense of primary care and physicians role in primary care, and a way to change the system that’s not PCMH that would make things better.

  • tom davis

    It seems that you are the somewhat rare, collaborationist endo that my patients come to me, in part, to find. Developing such a team is part of the value i generate a an individual’s personal physician. As always with bureaucracies, codifying that will result in the end product generating no value whatever

    Family Physicians training today will be obsolete only to third party payers, the direct pay model, however flawed, is the best remaining way forward

  • buzzkillerjsmith

    Except for the niche of direct care, physician-based primary care makes no sense for med students. Everyone here knows this and Dr. D. put it well.

    The PCP-physician relationship might not be dead, but it is coughin’ up a lot of blood. One idea that might work for me after the funeral of that relationship would to have the PCP act like an old-time med school attending–coming in for a few seconds to consult on a case–feel a belly, look at a skin lesion-whatever, and then have the NP or PA do all the documentation and fiddle-farting with med refills and suchlike while we rotate around the clinic helping with diagnoses, eating salted mixed nuts, and yukking it up with other life-is-easy members of the health care team. “Workin’ hard or hardly workin’?”

    What color is the sky on my planet?

    Instead, the PCMH idea is for us to manage one disasteroma after another, jockey the computers, get whipped for missing financial targets and clinical targets that make damn sense at all, and avoid referring to subspecialists so as to be responsibility stewards of scarce health care dollars. Plus feeling the bellies and looking at the skin lesions.

    Put a fork in my specialty.

  • Vikas Desai

    The actual primary care is mostly uncompensated, Primary care docs only get compensated for patient visits and small ancillary tests like strep and EKG. But real Primary Care like call backs, patient referrals, chronic medication management, records maintenance, coordinating other specialties IS ALL UNCOMPENSATED. Our patients are always refusing to come in to the office due to high copays to go over bloodwork and expect everything to be handled on the phone including medication adjustment/specialty referrals. i just spent 15minutes with my staff trying to get a referral with an insurance company because the username/password was expired to that specific provider. WTF??? I spent 15 minutes writing a narrative to a lawyer for disability who I should charge 50 bucks to him for but then he will just pass on the charge to the patient who will may permanently lambast me on the internet as a doctor ‘who only cares about money’ so i do it for free. I am now calling in Rx’s because my Medical assistants can’t do it as many because they are stuck on hold for more than 20-40 minutes authorizing GENERIC meds such as valcylcovir, pantoprazole, atorvastatin, dicyclomine and sumatriptan, god forbid a patient wants a branded drug. I can’t begin to describe the Mind numbing stupidity that is trying to figure which testosterone replacement the insurance wants to cover this month. I’m just asking medicare/medicaid and private insurance to give us a $10-30 per patient per month management fee for all this work. Hopefully payment reform can help save this great profession.

    • buzzkillerjsmith

      We hear you, man.

    • Dr. Drake Ramoray

      Testosterone coverage is a mess. So is the coverage for GLP-1 agonists in diabetes. Do you do pre-visit labs for chronic conditions. Won’t help you with acute care, or new patients but its great for managing chronic problem management appointments. Document that you reviewed the labs an acted on them at the time of the visit and it can increase your level of service on your billing. It makes for way more productive patient visits too.

      You may already be doing this, but if not you may encounter the single most assinine policy in the insurance industry. Charging patients co-pays for lab only visits.

    • rbthe4th2

      I am in favor of doctors getting paid for emails and phone calls to patients. That’s patient care. If they’re talking to a patient, you can bet it is NOT about the flowers and whether the car needs washing. Why shouldn’t they get paid?

    • Deceased MD

      My god I feel for you! I don’t know the setting you practice in, but You have to set limits even if there is a bit of backlash. remember they need you more than you need them. But it is a dog and pony show for sure.