Part 2: The Transformation of Primary Care

This is Part 2 of a 4 part series by Stephen C Schimpff, MD covering the important topic of Healthcare in the US, that will be available each Friday in the month of June.

Primary care as we have known it for the past century or more is rapidly transforming before our eyes. This transformation is and will be very disruptive. But when the correct paths are followed, the results are positive. This crisis can be solved with much better care, much improved satisfaction, much less frustration by patient and doctor alike, much less total money spent and with many more students selecting to become primary care physicians. It will be a win for everyone.

Those in private practice today find themselves in a non-sustainable business model brought about by a fee for service reimbursement rate that forces them to see too many patients for too short a time each day. Adequate for straight forward episodic care, it is inadequate for the patient with a slightly less obvious diagnosis and for the patient with serious chronic illness. Given a 15 minute appointment time, the PCP finds himself or herself obliged to readily refer to a specialist when more time with the patient might have been all that was needed. Similarly, a patient with a stress/anxiety influenced problem cannot get the type of humanistic attentive care that they need with just 8-12 minutes of “face time” with their PCP.

Added to this, the rules, regulations and policies of the insurers for billing and collection and for preauthorization are burdensome at best. Government expectations for HIPAA compliance and electronic health record meaningful use are added burdens not to mention the soon to arrive added productivity de-enhancer of ICD-10 coding. Evidence-based medicine while logical can be forced to extremes even when the doctor understands it is not in the best interest of the patient. The loss of autonomy is thus substantial. PCPs are frustrated, burned out, even angry at their situation. Many PCPs are leaving private practice to work for the local hospital thus shedding the burdens of practice administration yet they still must be productive and hence need to see too many patients per day.

What is changing before our eyes? Everything. Many PCPs are seeking employment as noted. Others are retiring early. Many just grin and bear it. But the winds of change are growing rapidly.

More and more PCPs are converting their practices to one form or another of direct primary care – pay at the door, membership/retainer/concierge. This allows the PCP to have the time needed with each patient to offer superior care in a humanistic manner. When paired with a high deductible insurance policy and an HSA, the cost of the retainer is lessened. Many such practices are rather inexpensive and sometimes termed “blue collar.”

Some insurers are initiating approaches that allow the physician more time with the patient thus improving quality, reducing costs and lessening frustrations. This can take the form of higher reimbursements with sharing of the cost savings in a typical commercial insurance plan to a Medicare Advantage plan that pegs the PCP to elderly patient ratio at 400 rather than the typical 2500. The care is substantially improved, satisfaction is high and the costs of care have declined.

What about the socio-economically distressed individual with serious chronic illnesses. A number of new organizations have appeared to offer intense primary care to these individuals in a holistic, humanistic manner. They aim to reestablish the relationship style of primary care so often missing today. With a low PCP to patient ratio and extensive use of teams with health coaches, nurse coordinator’s, social workers, and mental health therapists, these programs can greatly improve care while reducing the use of specialists, ERs and hospitalizations – better care, better health yet reduced expenses.

Employers are also recognizing that good quality primary care can lead to not only reduced insurance premiums but also a healthier workforce with lesser absenteeism and greater productivity. As a result some employers are establishing on site or nearby full service primary care programs that keep the PCP to patient ratio reasonable and include nurse care coordination and often wellness/health coaching. Other employers are paying the retainer for employees that use a direct primary care practice or prefilling an HSA account with funds sufficient to do the same.

In all of these circumstances the quality of care has risen, satisfaction by both doctor and patient has improved and the total costsof care have declined substantially.

Primary care is transforming. Much of the transformation is for the better. Most valuable is when the PCP to patient ratio is lowered to the extent that the PCP can offer high quality, humanistic care with close care coordination for those with chronic illnesses, outstanding preventive care in a proactive manner for all and time for healing conversation as is so often needed. Although this raises the cost of primary care on a per capita basis, it substantially lowers the total costs of care. America needs much more of this to heal its dysfunctional healthcare delivery system.

Next time – Part 3: Achieving More Time with Your Primary Care Physician

Stephen C Schimpff, MD is a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center, senior advisor to Sage Growth Partners and is the author of The Future of Health Care Delivery- Why It Must Change and How It Will Affect You

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