Regular readers know that I have concerns about the term primary care. This phrase has suffered semantic drift over the past 20 years. Nonetheless, many physicians still use this phrase in its classic sense. This post will use the classic IOM definition – Defining Primary Care
A set of attributes, as in the 1978 IOM definition, care that is accessible, comprehensive, coordinated, continuous, and accountable, or as defined by Starfield (1992), care that is characterized by first contact, accessibility, longitudinality, and comprehensiveness;
Robin Cook is a famous physician novelist. Although not a primary care physician, he has an opinion piece in yesterday’s NY Times (thanks to KevinMD for the link) which should make everyone think carefully about primary care physicians. Care by the Hour I will quote liberally from his thoughts, because I agree so strongly with his words.
What is the solution? We must make primary care a more manageable business by changing the way we pay for it. Primary care doctors should be paid by the hour. As it is now, insurance companies , following Medicare’s lead , pay primary care doctors according to the number of patients they see. Each patient visit is generally reimbursed at a flat rate of slightly more than $50. The payment is the same whether the patient is a healthy, young person with a runny nose or an elderly person whose multiple chronic illnesses require many tests, referrals to specialists and detailed explanations to both the patient and his or her family. A lawyer in general practice is not expected to accept the same low fee he gets for writing a simple will when he writes one that involves complicated business circumstances. Nor does an accountant charge the same amount for a difficult tax return as for an easy one. Why should the work of doctors be assessed this way? A typical primary care doctor spends slightly more than half of his or her day seeing patients; the other half is spent conferring with specialists, lab technicians and patients’ families, or trying to persuade health insurance companies to cover some needed treatment. This other half of his work day must be considered pro bono. Factor in rising overhead costs (office space, employees and malpractice premiums), and the situation easily becomes untenable. No wonder hundreds of primary care doctors have switched to concierge-style practices, in which patients are charged subscription fees in return for more personal service in markedly smaller practices. But this trend only adds to the problem of accessibility by reducing the pool of regular primary care doctors. Ideally, the hourly rate would not be the same for all primary care physicians, but would be assessed on a sliding scale, predicated on a doctor’s level of education. Internists and pediatricians , the primary care doctors who have had the most training , would receive a higher rate than general practitioners and family physicians would. Reimbursement by the hour might not shorten my friend’s day right away; his patient roster is already too large. But it would enable him to reduce his load over time. By making him feel that his sacrifices are valued, it might also help bring back the joy he used to find in practicing medicine. And by enhancing the prestige of primary care, it might reverse the exodus of doctors and encourage medical students to join the field.
Please read the entire op-ed, it is brilliant. Today’s NEJM has two articles (no subscription necessary) which also address primary care. The first comes from a family medicine leader. Primary Care , Will It Survive?
The great majority of patients prefer to seek initial care from a primary care physician rather than a specialist,2 but their unhappiness with their primary care experience is growing.3 At the same time, primary care physicians are expressing frustration that the knowledge and skills they are expected to master exceed the limits of human capability, making it impossible to provide the best care to every patient.4 The scope of primary care extends from uncomplicated upper respiratory and urinary tract infections to the longitudinal care of elderly patients with diabetes, coronary heart disease, arthritis, and depression , who may also have limited proficiency in English. Reimbursement based primarily on the quantity of services delivered, rather than on quality, forces primary care physicians onto a treadmill, devaluing their professional work life. The short, rushed visits with overfilled agendas that cause patients dissatisfaction simultaneously breed frustration in physicians. Contributing to this frustration is the growing set of demands placed on primary care. The preventive services that a physician either ought to provide because there is evidence of their efficacy or might provide because of the patient’s preferences (which must therefore be discussed) have multiplied. The prevalence of chronic conditions , most of which are handled in primary care settings , is increasing, as are requirements for their proper management. Not only has the number of primary care tasks grown exponentially, but physician performance is being measured and physicians are even being paid according to their ability to perform these tasks reliably and consistently. It has been estimated that it would take 10.6 hours per working day to deliver all recommended care for patients with chronic conditions, plus 7.4 hours per day to provide evidence-based preventive care, to an average panel of 2500 patients (the mean U.S. panel size is 2300).4 These excessive demands contribute to long waiting times and inadequate quality of care for patients. A growing proportion of patients report that they cannot schedule timely appointments with their physician. Emergency departments are overflowing with patients who do not have access to primary care. The majority of patients with diabetes, hypertension, and other chronic conditions do not receive adequate clinical care,4 partly because half of all patients leave their office visits without having understood what the physician said.5 These problems are exacerbated by the system of physician payment.1 Thirty minutes spent performing a diagnostic, surgical, or imaging procedure often pays three times as much as a 30-minute visit with a patient with diabetes, heart failure, headache, and depression. The median income of specialists in 2004 was almost twice that of primary care physicians, a gap that is widening. Data from the Medical Group Management Association indicate that from 1995 to 2004, the median income for primary care physicians increased by 21.4 percent, while that for specialists increased by 37.5 percent. A 2006 report from the Center for Studying Health System Change reveals that from 1995 to 2003, inflation-adjusted income decreased by 7.1 percent for all physicians and by 10.2 percent for primary care physicians. The 5 percent increase in Medicare payments for primary care announced in June 2006 is insufficient to narrow the gap.
This article, written by Thomas Bodenheimer, M.D., proceeds to call for public policy to rescue primary care. He writes eloquently with a sense of desparation. The second article comes from a general internist, Beverly Woo, MD, who I have known for 25 years. As an academic general internist, she has been active in SGIM. She starts her perspective extolling the virtues of being a primary care physician. Primary Care , The Best Job in Medicine? Unfortunately, she then takes a realistic look at the prospects our nation has in satisfying the need for enough primary care physicians.
It is disturbing to me that changes in our health care system have made primary care medicine less satisfying for practitioners and less attractive to students and residents. Primary care physicians are under pressure to see patients at a faster pace than ever before, even as their responsibilities increase. Add to these difficulties the increasing administrative burdens and the fact that the remuneration for primary care specialties is at the bottom of the pay scale for physicians (see line graph), and it is no wonder that primary care medicine is in crisis.
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Some have said that this decline reflects a lack of commitment among the current generation of trainees. I disagree. Medical students and residents are no less idealistic or dedicated today than they have been in the past. But the decrease in job satisfaction, the increase in educational debt (which now routinely exceeds $100,000), and the growing disparity in salary relative to other specialties could together create a strong sense that becoming a primary care physician may be a fool’s errand. If the current problems of primary care practice are not addressed, the number of students and residents entering the field will undoubtedly continue to decline. With all the changes in our health care system, one thing remains constant: the needs of patients. Patients want a continuing relationship with a doctor whom they trust, and they increasingly need that doctor to act as an advocate to help them get the best care within a fragmented health care system.4 A strong primary care infrastructure is associated with better health outcomes, lower costs, and a more equitable health care system, since primary care is key to providing services to vulnerable populations.5 There is an urgent need to reverse current trends. Although the line of students signing up for a career in primary care medicine is getting shorter, the line of patients in need of primary care doctors is getting longer every day.
Why have we reached this stage? Several problems have lead to the current status. First, we (family physicians and general internists primarily) made a huge mistake in the 1990s. We thought that managed care was the answer to improving the quality of life of primary care physicians. Just like politicians, we failed to carefully consider the externalities of the managed care movement. The managed care movement cause the semantic drift in the meaning of primary care. ‘Dictionary.com’ now has this definition – “The medical care a patient receives upon first contact with the health care system, before referral elsewhere within the system.” This definition implies the gatekeeper concept (another big mistake was accepting the label of gatekeeper). This definition is the truth, but only a small part of the truth. When I first joined the GIM faculty in 1979 as a primary care internist, I understood my job. I believe that the current graduates of both internal medicine and family medicine programs understand their jobs. The above definition does not adequately describe those jobs. The primary care physician cares for the patient, whether the problems are episodic or chronic. He/she provides care in the context of the patient’s medical problems and their psychosocial situation. When the patient has multiple problems (as occurs with increasing frequency), the primary care physician has the responsibility of weighing the various treatments to maximize quality and quantity of life. The primary care physician takes responsibility for preventive medicine (both primary and secondary prevention). Finally, the primary care physician coordinates the patients journey through the health care system. He/she arranges appropriate consultation when necessary. This job is in my opinion the most challenging and satisfying job in medicine. The breadth of knowledge necessary to meet our patients’ needs is remarkable. We must reinvent our reimbursement system to allow physicians to enter this field. I chose my verb carefully there. Many physicians (due to debts) cannot financially succeed in primary care specialties. I think that Robin Cook understands the answer. I have speculated about this solution previously in these pages. His essay probably makes too much sense for policy makers to consider strongly. But one can always hope.
In the long run, paying by the hour could save money. It would provide doctors the time they need to investigate symptoms themselves rather than reflexively refer patients to specialists. After all, every headache doesn’t need to be evaluated by a neurologist; nor does every painful shoulder require an M.R.I. It would also increase the pool of primary care doctors, so that more health problems could be handled in doctor’s offices rather than in emergency rooms, where the cost of care is more expensive. And finally, better long-term doctor-patient relationships might reduce the number of malpractice lawsuits. Paying for primary care by the hour would be better for both doctors and patients, and it would return a measure of rationality to our health care system.
