From community to corporation: the transformation of primary care [PODCAST]

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In this podcast episode, we have Michael Fine, a family physician and author of On Medicine as Colonialism, sharing his insights on the changing landscape of primary care. He reflects on his experience of practicing in a time when family doctors lived in and supported the communities they served. However, today, primary care has become a huge economic engine generating profits for corporations, and it has led to what he calls “primary care colonialism.” Michael discusses how this kind of colonialism removes the relationships that are essential for sustaining communities, leading to a denuded society devoid of its unique identity and history. He questions whether this is the primary care and medicine we want and suggests the need to change it from the bottom up.

Michael Fine is a family physician and author of On Medicine as Colonialism.

He shares his story and discusses his KevinMD article, “Primary care colonialism: the impact of profit-driven health care on communities.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Get CME for this episode by clicking the CME link in the show notes. Today we welcome back Michael Fine. He’s a family physician, and we’re going to talk about his book, On Medicine as Colonialism. His excerpt today is “Primary care colonialism: the impact of profit-driven health care on communities.” Michael, welcome back to the show.

Michael Fine: It’s great to be with you again. Thanks for doing it, Kevin.

Kevin Pho: So Michael has been on multiple times. Go on KevinMD.com/podcast, upper right-hand corner, and click on the search bar for Michael’s name to see his story in previous episodes. But I want to jump straight into your book, and specifically this topic. So first off, how did this book come together?

Michael Fine: It came together quite specifically at the beginning of the pandemic, when the community in which I worked, which is called Central Falls, Rhode Island, the most densely populated, poorest, and most diverse community in Rhode Island, found itself without access to primary care for most people at the time that the State Department of Health was telling people that if they got sick, they needed to call their primary care doctor. So a bunch of us got together quickly as volunteers and put together a call center called Beat COVID-19. It was fantastic. It worked in four languages. It dealt well with people who were undocumented, and many people in Central Falls were. It was there when Central Falls became the most COVID-infected place in the state, the nation, for a period. I mean, it helped get people the things they needed, from triage, to deciding whether to go to the ER or not, to helping people understand how to do isolation, to disinfectants, to food, to cash for people who were undocumented. We really got people well taken care of.

It ran like that for a couple of months, and we said, “Gee whiz, this is great. We ought to keep it.” So we called up the state and said, “Can you send us the $800,000 we think it’ll cost us to run this for a year?” And the state said, “We’re not sure.” And so we had months of discussions with the state, back and forth, and all of a sudden, as soon as these discussions started, all these people who we’d never seen before started showing up on the Zooms. They were all consultants, very nice young people from Iowa and Minnesota. And so the state would end up paying consultants more than $12 million a year in the first couple of months, and they ended up sending almost nothing to the cities of Central Falls and Pawtucket.

And all of a sudden, the light went off in my brain: Something weird is happening. And what was happening was that people who had something to sell, i.e. these consultants, saw this as an opportunity to make money, and they were making money using the excuse of the people who were sick in Central Falls. And the light went off in my brain that said, “Gee whiz, if it’s happening here, could it be happening in other ways?” And then I started a deep dive and began interrogating what I knew about health policy to see if it was true. And what do you know, it turns out to be true in every other domain of health care.

Kevin Pho: So talk to us specifically about the impact of profit-driven health care, especially on communities, which is what this excerpt is about. I know that profit is the motive in many, many areas of health care. As it relates to your community and primary care, how does it affect it?

Michael Fine: Well, in the following way. For each person in the United States right now, somebody is spending an average of $13,000 per person per year on health care. And that money, if it was spent locally, would buy us amazing primary care, even if we had a bigger portion of it. Remember, primary care consumes only about 5 percent of the health care dollar, so something like $500 to $600 a year is currently being spent on primary care. For the city of Central Falls, most of us think about 15 percent of the total health care spend should be spent on primary care. If we had 15 percent of that $13,000 per person per year, we’d have $30 to $40 million to spend on primary care, and we would be able to have employed physicians who made plenty of money and had patient panels of 500, instead of having one community health center that is stressed beyond belief, with not enough people, who are doing everything they can, with panels of one to two thousand people or more. And that’s the effect.

When you go and look at what’s happened with insurance companies, insurance companies always get 15 percent off the top. Remembering that primary care gets 5 percent, that 15 percent the insurance company gets is money that’s not being spent on primary care in Central Falls. If you look at pharma, pharma basically now takes 20 percent of the health care dollar. That’s money that we don’t have to spend on primary care. The same thing’s true of hospitals. One after the other after the other, these processes are basically ways of focusing on that $13,000 per person per year and getting it from the government, because half of our total health care spend is government funds, getting that money from the government into the pockets of people who are using it for profit, instead of investing in primary care, instead of investing in safe and healthy housing, instead of investing in better education, instead of investing in community centers and public transportation, which are the things that matter for better health outcomes.

Kevin Pho: How do we get to this point? How did we get here?

Michael Fine: Yeah, no, I think we boiled the frog. This happened gradually, over years. And this is a place where I think the physician community kind of failed the nation in a certain way. Instead of focusing on building a health care system that’s for people, not for profit, we kind of got seduced by the jobs and the money and the academic appointments. And so we focused on those things instead of our profound ethical responsibility, which is to build a health care system that’s for people, that starts by providing robust primary care in every American neighborhood and community.

You know, Kevin, I don’t know if this is widely known, but there’s pretty good evidence now that less than 43 percent of Americans have a good primary care relationship. What’s even more amazing to me is that less than 67 percent of people with Medicare, with Medicare, the best insurance we have, when you really think about it, only less than 67 percent have primary care doctors. So we have just taken it on the chin. We’ve all just buckled down and worked harder. We’re all sitting in front of computers between 8 and 11 or 12 at night, dealing with the task boxes. Our patients get to see our ears, not our faces, because we’re looking at the damn EMR. And we haven’t rebelled. The challenge and the opportunity is for us to stand up and demand that we make a health care system that’s for everybody.

Kevin Pho: You mentioned that some of the onus is to be placed on physicians. You mentioned things like chasing academic appointments instead of building a strong primary care system. So specifically, what should physicians have done?

Michael Fine: Well, I think we should have refused to do a lot of the things that we’re asked to do, like the home health plan of care. I think that’s what it’s called, this kind of ridiculous document that shows up every two months for everybody who’s getting home health from Medicare. There is nothing meaningful about that document. We should have all, as a group, said, “Uh-uh, we ain’t doing it.” When they came up with the EMRs that really exist mostly for billing, not for patient care, we should have said, “Uh-uh, I’m working on paper, because this is crazy.” Our colleagues in other countries who use EMRs that aren’t focused on creating encounters for billing love their EMRs. We’re the ones who hate them, because much of the work we’re being asked to do has nothing to do with patient care. It’s a huge distraction.

And when you look at it, over the last 20 or 30 years, we’ve had a speedup. All sorts of work has been downloaded on us, and so everybody can’t understand why primary care docs are burned out and exhausted. The reason is, and this is one thing that I think we’ve learned from the direct primary care movement, from the direct primary care movement we learned that the optimal patient panel is probably 500 patients or thereabouts. And that’s because of the extra work that’s been downloaded on us for the last 30 years. And many of us are carrying patient panels, I think the average patient panel for primary care docs is now 2,200. So the reason people are tired is that they’re doing the work of four people. And instead of saying, “This is crazy, we’ve got to change it,” all of us just kind of work harder and wear out and get the moral injury of trying to do primary care for people in communities who have kind of abandoned us.

Kevin Pho: Crazy. Now, why don’t physicians band together? Because I’ve been doing this podcast for, well, three years now, over a thousand episodes, and I really can’t find any physician who speaks positively about the EMR. And we’ve had multiple episodes about the supposed death of primary care and how difficult it is, and we’ve had countless episodes on burnout and whatnot. Now, what’s preventing physicians from banding together and just saying no?

Michael Fine: Well, you know, I don’t think there’s anything really preventing us. Remember, we are selected to be individualists. We’re not selected for our ability to kind of hang out together and do things together. That’s what organic chemistry was there for, to weed out people who did that. So I think one challenge is who we have been trained to be, which is people who are responsible for everything and accept this notion of endless responsibility without any leverage or power.

The other thing that’s been challenging is I don’t think there’s anybody who’s organized physicians to do this work now, to do this sort of pushback, how to resist and where to resist. There’s a learning curve associated with that, and I’m hoping that some of us will figure it out. I’m working with a couple of colleagues to try to figure that out now and to build the kind of organization that we need to sort of stand up together. The nation is desperate for us to do that. It is desperate for that leadership. I mean, we just haven’t delivered on it yet.

Kevin Pho: I think we talked offline before, and you mentioned there was a shortage of about 200,000 primary care clinicians in this country. Is a solution as simple as money? If we simply diverted some of that money that goes to for-profit entities toward primary care, is that going to solve the problem?

Michael Fine: Well, not money by itself, but money plus the development of infrastructure. We basically, right now, need a Marshall Plan for primary care. There are medical schools in the Caribbean that are training classes of a thousand. Our classes of 100 or 150, that’s a legacy approach to medical school training. We’ve got to quadruple or more the number of people we’re training. We’ve got to make sure that every state has a scholarship program, so that people who go and do primary care are going to go for free, in exchange for an obligation to serve in that state. There are a number of things that we can and need to do. We’ve got to get to CMS and get the craziness of how GME is funded changed, so that there’s basically a requirement that 60 percent of the people in residencies are primary care docs.

These are things that matter. I mean, they matter not just because I’m a primary care doc and I like primary care. They matter because, remember, primary care is the only medical specialty that’s ever been shown to be associated with improvements in health outcomes and reduction in costs. So the failure to train enough primary care clinicians every single year costs the nation billions, and probably goes to a trillion dollars a year. The money is all there. It’s not like we’re not spending the money; we’re just spending it wrong.

And even worse, the whole process is kind of under the purview of the government. Every health professional is regulated. Half of the spending is Medicare and Medicaid. CMS regulates all graduate medical education. It’s not like the government is not involved appropriately; it’s like the government is involved but doing the wrong thing. The challenge is to get the government to do the right thing, because we stand up together and tell them what it is that we need.

Kevin Pho: So how do we do that? How can we course correct? Because we’ve been talking about how to fix primary care for what seems like decades now, and you listed off many solutions that can change the course. What can we do differently to get the government’s attention?

Michael Fine: Well, I think we need to start talking to each other, developing some simple talking points. And then I think we need to start talking to our patients in our exam rooms. If you think about it, we take care of something like 130 million people. That gives us a phenomenal opportunity to tell people what the nation needs, not what we need. This can’t be about a better salary for me. This has got to be about training more people and making sure that everybody’s got access in their own neighborhood and community.

Kevin Pho: Now, what about our current lobbying bodies in primary care, whether it’s the ACP or the AAFP? How do you assess the job they’re doing?

Michael Fine: They basically haven’t shown up yet. They are great at sort of lobbying for pocketbook issues, but that’s not what the nation needs. We need people who will speak for what the nation needs, not what we need first. As sort of health professionals, we have an obligation to shun self-interested advocacy, and we need to start advocating for our patients and communities and helping people understand the noxious effect of how the market has disrupted or prevented the existence of a health care system that takes care of all of us, gets us the best health outcomes, and is affordable.

At the end of the day, if you compare us to other countries that perform well in terms of health outcomes, health care in the United States ought to cost half of what it costs now, and we ought to have money left over to use for education and housing and those public services that are critical to how communities function, and how democracy works. Because with some of this stuff, the diversion of money into the pockets of people who are profiting means that democracy gets torpedoed. Most people don’t know that the folks who do lobbying now spend $718 million a year on lobbying, which is a tiny fraction of their actual take. It’s like 0.01 percent of their profits. It’s nothing; it’s budget dust. And yet that $718 million is enough to convince Congress and state legislators to do what the sellers of profitable services want, instead of what their communities want and need. Democracy is getting beaten up in this, and part of that is because we haven’t said clearly enough, and repeatedly enough, “We’ve got to do it differently.”

Kevin Pho: So what we’re seeing now, and I’m sure that you’re aware, is that it’s very difficult to recruit primary care physicians in many, many areas. And those positions, because there aren’t any physicians, are being filled by nonphysician practitioners like nurse practitioners and physician assistants. And it’s certainly not out of the realm of possibility that physicians are going to gravitate to and fill a lot of the specialty roles, whereas advanced practice practitioners are going to fill the primary care roles. That’s the trend that I’m seeing. In fact, 50 percent of primary care is now provided by nurse practitioners. So has the horse already left the barn? Is it too late for physicians to get that primary care space back? Should they just concede it and focus on specialties?

Michael Fine: I don’t think so. I mean, I think that we bring unique and valuable training. I don’t want to disrespect the training of our PA and nurse practitioner colleagues, but I think we end up consulting less. We end up being pretty good at listening. We’re pretty good at being with people. Those are important things that we bring to the table. Obviously, this is a partnership, not a competition. But I think physician training is particularly valuable in the primary care space, and we are serving the public when we fight to make sure that there are enough physicians, but also PAs and nurse practitioners, and enough investment in primary care.

I mean, think about it. Even with 50 percent of the primary care workforce being nurse practitioners, we’re still only providing primary care to 43 percent of the country. That means 57 percent are not getting primary care, which means there’s inadequate prevention, which means that the 50,000 lives that we lose a year to colon cancer, we could probably cut in half or more. And the many lives we lose to heart disease, we could really shrink.

I mean, think of what happened in COVID-19, where many people didn’t believe in the vaccine, because who was telling them to go get the vaccine? Somebody who was going to profit from it. We all got left out of that process. CVS got asked to do vaccinations; basically, we didn’t. And yet the relationships we have with patients are the relationships that, if the thing had been set up differently, patients would have come to you or to me and said, “Gee whiz, what do you think about this vaccine?” And we would have made the argument, and I think the number of people who got vaccinated early would have climbed considerably. When you look at the numbers, we lost 900,000 Americans we didn’t need to lose, because we screwed this thing up. And part of the way we screwed it up was that we didn’t have enough primary care docs.

Look at what’s happened with life expectancy in the United States over the last 10 years. Over the last seven years, we’ve lost life expectancy each year, for the first time in the last hundred years. That tracks right with the loss of primary care and primary care docs. So this is a public health issue of the first order, and we just need to understand our own value and importance and start to speak to it.

Kevin Pho: Michael, my final question: What are some of the take-home messages that you want to leave with the KevinMD audience?

Michael Fine: Take-home messages. Look at what has happened. Look at how we have been used to make profit for others, instead of doing what we came to do, which was to listen to and take care of people. And take-home message number two is that probably the only people who can change it are us. We have amazing ability. We’ve done amazing things for public health over the last hundred years, and the next hundred years ought to be even more amazing, based on making sure we have more primary care docs, making sure every person in the community has primary care, and building those relationships that are so magical, that make our professional life satisfying and make so much difference for patients.

Kevin Pho: Michael, thank you so much for sharing your time and insight. Thanks again for being on the show. Here’s to the book.

Michael Fine: Thanks.

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