Primary care visits are never quick; we don’t give much advice over the phone or online; and we prioritize the government’s and insurance companies’ public health agenda over our own patients’ concerns.
Imagine health care as a retail customer experience for a few minutes:
Imagine you’re going to Walmart to buy a bag of dog food, a new coffee maker or to equip a small kitchen in your newly built mother-in-law apartment.
1. You’ve bought dog food there before, so you know exactly where it is. You just want to quickly grab a bag and get out of there.
2. You have a rough idea of where the coffee makers are; you know some brands you trust, but you might have one or two questions before you select one, and if they don’t have one you like, you might get it somewhere else. Or, you might even check their website to see which models they carry.
3. For the new kitchen, you have a list, but know you probably haven’t thought of everything, so you plan to walk down the aisles in the kitchen and home departments. You plan to spend a fair amount of money, so you might be on the lookout for special sales or promotions. But, you definitely don’t want someone else to choose all the items for you.
Can Walmart meet your needs in all these situations? Probably yes.
Now, think about how your doctor’s office works
1. Can you quickly get in and out if you have a simple problem like conjunctivitis?
2. Are they able to give you information on what your options are for a recurring shoulder dislocation; could they refer you to a shoulder specialist without first waiting weeks to see your primary care doctor?
3. You have lots of issues and try to get an appointment to deal with them all at once; you think of it as a physical, but last time you had a physical, your doctor brought up all kinds of things you don’t particularly see as priorities for yourself.
Here are the existing realities of primary care
We can’t afford to just see you for something quick. Our quality indicators, which more and more will determine how we get paid, will go down if we don’t screen you at every visit and offer interventions for depression, smoking, alcohol misuse, hypertension, weight management, immunization needs and much more.
We won’t refer you without seeing you, and we often hesitate giving you medical advice over the phone. Our providers are not scheduled for anything else besides seeing patients, because the rules of how we are paid still emphasize face-to-face visits over “population management.” So our providers are busy all day long seeing patients for visits that could have been simple but are loaded up with mandatory screenings and interventions and our medical assistants, besides being busy with all our screening questionnaires, are discouraged from giving medical advice they aren’t formally trained to provide.
Is there a doctor shortage?
We are said to have a doctor shortage. We have an aging population with more and more chronic diseases, like diabetes and heart disease. The need for skilled and experienced medical providers is continually increasing.
We have no public health system to speak of in this country, so the government, through Medicare and Medicaid, has mandated that health care providers do the things the public health system does in other countries.
This is, plain and simple, what is clogging up the works in health care today: Too much non-doctor work is crammed into each patient visit, and we can’t charge for giving advice or directing care except in a face-to-face visit.
You don’t need to go to medical school to give immunizations, tell people smoking is bad for you, explain that “low fat” foods cause obesity, or promote regular exercise. You don’t even need to be a doctor, PA or NP to screen for high blood pressure – only to treat it. (Some pundits, in utter desperation, have suggested we send pharmacists to school to learn how to treat hypertension, but there are of course plenty of licensed medical providers who are able and willing to do that if we get freed up from the less-skilled tasks I just listed above.)
Patients and doctors have no control
Now, why are we doing all those things we do if they are so inefficient? Quite simply, whoever pays us has the power to define our work. We call that “health insurance,” but that is not exactly what we are dealing with. Insurance, for home, auto or employer liability, has nothing to do with predictable events or minor issues. Your car insurance doesn’t pay for oil changes or tire wear, not even for a minor paint scratch. But somehow that is what we expect health insurance to cover for our bodies. In terms of auto insurance, most people probably figure an insurance job carries an inflated price tag and lots of paperwork. The same is true for health care, which should not be a surprise to anyone.
For example, years ago the overhead cost of insurance billing for each primary care doctor was reported to be $80,000. That, put very plainly, is money that patients and employers are ultimately paying through premiums and deductibles.
And all the mandated screenings are there because Medicare, in particular, has the right to micromanage doctors’ work because they are paying for health care visits, which could be quicker and less costly if patients had control over their health care spending.
How could we do better?
We do three things in primary care, each with its own workflow and, really, each with its own economics.
1. We could do our part of public health more effectively. Allow us to promote immunizations and other primary preventions outside our already crammed fifteen-minute visits. Pay us a per patient per year stipend to reach out to target populations through mail, phone, web or, when appropriate, in person about general health issues. Stop imagining we can do all of it and still treat diseases, acute and chronic, in our measly fifteen minutes. Right now, that is just clicking boxes with little actual substance. Use some of the government money that should have been spent on a working public health system if you want us to step in and do the government’s work.
2. Make it economically feasible for medical providers to oversee patient care by acknowledging that reading incoming reports, answering phone or web inquiries and coordinating care with specialists and hospitals are essential parts of being a medical home for patients. Such activities should not be unpaid services eked out at the expense of lunch, bathroom breaks or dinner with our families.
3. Allow us to define each office visit together with our patients. It is insulting to everyone involved to have to interrogate someone with a splitting headache, twisted ankle or bleeding laceration about their diet and alcohol habits. I could see many more patients if I could delegate those things to outreach staff or simply not do it every visit. Right now we are made to act as if we will never see that patient again. I was trained to provide care over time, in a relationship based practice. That is proven to be an effective and fiscally sound way to deliver health care.
The third task is the only one that makes sense to pay us for on a per-visit basis, whereas the first two deserve their own payment method. Personally, I wonder if the first few hundred dollars worth of primary care visits are worth churning through the expensive bureaucratic insurance machinery, or if it wouldn’t make more sense to just allow each patient a set amount of spending at their discretion.
I am not writing about privately financed, direct primary care or concierge medicine. Those obviously exist, and may work well for many people, but the health care payment options for most Americans are what desperately need fixing.
Only if we acknowledge that public health, population health, and face-to-face visits are three separate aspects of health care can we move forward in reforming primary care. And only if we recognize and reimburse physicians’ non-face-to-face work fairly will we see the improved customer service and doctor-patient communications we are now only paying lip service to.
Where would Google be if we had to make an appointment to sit down with a search consultant and pose our questions, fifteen minutes at a time? It may be an outlandish analogy, but health care needs some shaking up.
“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.
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