In most other human activities, there are two speeds, fast and slow. Usually, one dominates. Think firefighting versus bridge design. Health care spans from one extreme to the other. Think code blue versus diabetes care.
Primary care was once a place where you treated things like earaches and unexplained weight loss in appointments of different lengths with documentation of different complexity. By doing both in the same clinic over the lifespan of patients, an aggregate picture of each patient was created and curated.
A patient with an earache used to be in and out in less than five minutes. That doesn’t happen anymore. Not that doctors and clinics wouldn’t love to work that way, but we are severely penalized for providing quick access and focused care for our well-established patients.
Why is that?
Our quality mandates have ended up creating perverse roadblocks and disincentives for taking care of the simplest needs of our patients. Any time we don’t screen for depression, alcohol use, smoking and readiness to quit, obesity, immunization status, blood pressure control and so on, we lose brownie points and, increasingly, money.
This is happening near me:
The primary care practices in Ellsworth, Maine have lost many, if not most, of their providers in recent years after some belt-tightening due to running the clinics at a loss. They are not able to see new patients for six months or more. But the hospital is actively promoting its walk-in urgent care center — and they don’t seem to have trouble staffing it, and don’t appear to be losing very much money on it.
Bangor, Maine, home of a small Catholic Hospital and a 400+ bed hospital with a level 2 trauma designation, cardiac surgery, neurosurgery, and many other specialties, has a severe lack of primary care doctors in spite of having a family medicine residency. Yet, a private out-of-state company is building a brand new freestanding urgent care center a couple of blocks from the Catholic hospital.
Quick and easy acute care visits could generate revenue with positive cash flow for primary care practices, especially for Federally Qualified Health Centers with their flat-rate reimbursement, but possibly for all practices, if CMS’ new proposal to scrap differentiated evaluation and management codes becomes a reality. But the requirement to weigh down the simplest visits with all those screening requirements eliminates the incentive to meet patients’ need for access nimbly.
The end result will be that primary care providers will become chronic care providers only, and care will be fragmented so that anything profitable will be siphoned off to freestanding entrepreneurs or hospital-owned profit centers. Meanwhile, primary care practices risk becoming more and more of a millstone around their hospital owners neck because all their patient visits are more complex and costly than the reimbursement scheme can support.
And more and more providers will be tempted to jump ship for the easier work and greater predictability of a doc in a box career.
The only solution is to acknowledge that family medicine and all primary care is meant to assess patients over the continuum of time. You don’t have to fix the whole person when all they ask for is some penicillin for their strep throat.
Sometimes you need to be quick, and sometimes you need to be slow. Without the freedom to adapt, in a patient-centered way, to the situation each patient presents with, primary care risks going under.
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