There is a crisis in primary care. There are too few primary care physicians (PCPs), and the shortage is getting worse. More than 50 percent of them show some signs of burnout, and, most importantly, those in practice have too little time with each patient. Short visits mean not enough time to listen and think, resulting in excess testing and x-rays, unnecessary prescriptions and frequent referrals to specialists, thus driving up the cost of care.
The root of the problem is that insurers have paid relatively little for primary care, placed ever increasing non-clinical work burdens on the PCP, and created billing and coding conundrums that have forced rapid escalation of overhead costs. As in any business this means trying to "make it up in volume." More patients seen per day (25 or more) means less time per patient (often only eight to 10 minutes of "face time").
PCPs are generally thought of as only dealing with the "simple stuff." But PCPs are trained to manage complex chronic conditions such as heart failure and diabetes — the illnesses that cost about 70 to 80 percent of the health care dollar. This takes time and requires listening and thinking. This is especially true with a geriatric patient with multiple chronic illnesses, taking five or more prescription medications and having difficulty with hearing, vision or perhaps cognition. It also takes time to develop a real relationship between doctor and patient, the type of relationship that allows and encourages trust, empathy and healing.
What can be done to assure comprehensive primary care? There are multiple innovative approaches that can work. Each allows the PCP to see fewer patients for longer periods yet earn a similar income. Here are a few innovations, mostly selected from in Maryland.
Some PCPs are forgoing all insurance billing and reducing the size of their practice from the usual 2,500 to 3,000 or more to about 500 to 800. They can then offer same or next day appointments — reducing the need for E.R. or urgent care visits. The appointments are much longer, allowing for clinical problem solving, as opposed to the PCP serving as a referral engine to specialists. Some offer generic drugs at wholesale prices and reduced-fee laboratory and radiology testing. These services are offered for a fixed fee, with no co-pays or deductibles. Called direct primary care (DPC), membership or retainer based, it can be quite affordable or "blue collar." Patients with a high deductible find this offers excellent quality at a cost less than traditional fee for service.
Qliance, MDVIP (there are Maryland PCPs associated with MDVIP) and Iora Health follow a similar approach. Primary care utilization is higher, but the end result is total medical costs are substantially reduced due to fewer specialist referrals, fewer hospitalizations, fewer E.R. visits and so on, yet quality indicators are up and satisfaction for patient and doctor are greatly improved. A few insurers such as CareFirst are seeing the value of more time with the patient and are adjusting their fee for service reimbursements accordingly in return for a written care plan and more time with prevention and chronic illness care coordination.
Catonsville-based Erickson Living retirement communities set the ratio of residents/patients to PCP at just 400. This assures the close relationship and quality care that older people need, including a focus on prevention and chronic illnesses. The result is better care and many fewer hospitalizations, E.R. visits and unplanned returns to the hospital.
Medicaid-covered individuals often get limited care; AbsoluteCARE has taken the opposite approach. They place intense resources into primary care — one PCP and team to each 300 patients, whose prior year total costs usually exceeded $60,000. There are social workers, nutritionists and mental health practitioners on site along with an in-house pharmacy, laboratory and basic radiology, and a van to pick up and return patients for visits. The result is greatly improved health yet reduced total costs of care: In 2015, six months after enrollment, patients had a 42 percent decrease in hospital admissions and 39 percent drop in E.R. visits. Patients feel like they are getting real medical care, which they are.
The message is clear. Comprehensive primary care through reducing the patient-to-PCP ratio and offering the patient more time per visit leads to much better health, more satisfied doctors and patients, and substantially reduced total costs of care.
Dr. Stephen C. Schimpff (firstname.lastname@example.org) is senior adviser to Sage Growth Partners, a quasi-retired internist, professor of medicine and public policy, and former CEO of the University of Maryland Medical Center. He is also the author of "Fixing the Primary Care Crisis — Reclaiming The Doctor Patient Relationship and Returning Healthcare Decisions to You and Your Doctor" from which this is adapted.