Part of a series.
Primary care needs to change. That change will need the concerted efforts of patients, doctors, and other constituents. Many are cynical and believe that no worthwhile change can ever occur; others are simply resigned. But optimism can be realistic with intense advocacy and simply taking the initiative to make change. This may surprise you, but change will only happen when patients along with doctors become outspoken advocates. It is worth the effort to get involved; otherwise, there will be no change — except change orchestrated by the central planners who know nothing about the intricacies of actual patient care.
In this series of posts on KevinMD, I have written that primary care physicians need to care for fewer patients — not more — and should be able to earn an appropriate living at the same time. Fewer patients means more time for the patient and doctor to interact. It means more time for listening, building trust and healing. It means better diagnostics and improved treatment plans. It means fewer tests, x-rays, prescriptions and specialist visits. The result is better care, satisfied patients and doctors and dramatically reduced total costs of care. In order to drive down total health care costs while improving health care quality, we need to spend more money per patient for primary care.
Primary care, as it has been delivered for the past century, is rapidly transforming before our eyes. Many of the changes are quite disruptive. Some are for the good and some not so good. You as a patient and others like yourself can have a definitive impact on how primary care is practiced in the future. It can be practiced in a manner that offers superior care, a strong relationship between patient and doctor, at a reasonable price, all while dramatically reducing the total costs of care. This will require your active participation in the transition. The alternative — rushed visits, lack of a close doctor-patient relationship, an emphasis on specialty care and excessive prescription medications all leading to higher costs yet less quality, less satisfaction, and more frustration.
Change will emanate only from the front lines: the doctors, nurse practitioners, physician assistants and others who provide primary care and their patients who demand a better deal. Innovation only occurs from those actually involved. In health care today, more decisions are made in a centralized way by well-meaning “experts” who have little or no idea about what it takes to provide real care to a real person by a real doctor. Once the centralized decision is made, it always requires many rules and regulations for implementation, which further impede progress, the doctor’s autonomy, and the ability to innovate and improve the system.
This excerpt from an op-ed in the Baltimore Sun by long time geriatric-focused primary care physician Andy Lazris, MD cuts to the heart of the issue of central planning in health care. In it, he is referring to the Medicare dictum that soon doctors “are paid not for visits and procedures but rather for the value of their work.”
Sounds good but “the truth is that we cannot measure quality. Medicare’s quality indicators often diverge sharply from true quality geriatric care, yet it is our compliance with those numbers that will now determine our salary … To Medicare and ACA reformers quality and value are broken down into discreet measurements that must be entered into a computer exactly as Medicare dictates … No wonder patients must face doctors who stare at computer screens and do not have time to listen … There is a better way forward … Eliminate the templates and scripted notes we have to complete, erase the erroneous measures of quality to which we are told to adhere, reduce the paperwork burdens needed to obtain health care and allow us to meaningfully care for our patients … Allow us in primary care to steer the ship. Enable us to treat patients as they want to be treated, to discuss with them the pros and cons of test and treatments, and to personalize care. Provide patients with choices: They can go to the hospital or get care at home for the same price; they can get an MRI for their back pain or have acupuncture treatment. It does not take a room full of experts and a book of rules, regulations and acronyms to fix our health care system. It takes common sense. Talk to practicing primary care doctors. You may learn something of real value.”
In primary care today, most of the innovation has come not from a centralized authority but from individual primary care providers who decided to step away from the policy wonks in commercial insurance companies or the federal and state governments, and work directly with patients. Free of bureaucratic regulations, they innovate with direct pay/retainer/membership/concierge and other models. They follow the precepts of the patient-centered medical home without worrying about the associated rules, regulations and documentation. Some are beginning to address population health in a proactive manner. They are more satisfied, less frustrated, find they are giving superior care and having a real impact on total costs of care.
With this as a template that progress can be made, it behooves doctors and patients to agree and demand change; don’t wait for the bureaucrats because they will not deliver. Abraham Lincoln once said, “With public sentiment, nothing can fail. Without it, nothing can succeed.”
We need to advocate for change and do it together.
Stephen C. Schimpff is a quasi-retired internist, professor of medicine and public policy, former CEO, University of Maryland Medical Center, and senior advisor, Sage Growth Partners. He is the author of Fixing the Primary Care Crisis: Reclaiming the Patient-Doctor Relationship and Returning Healthcare Decisions to You and Your Doctor.
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