Saturday, January 31, 2015

Primary Care Is So Over

There are close to a quarter million primary care physicians in the U.S., more than any other individual specialty, and about half the total number of all specialists combined. Yet, somehow, primary care seems to lack the power and social influence necessary to chart its own professional course. As the availability and granularity of specialist physicians increased, the value proposition of a generalist primary care doctor seems to have become unclear to those who pay for medical services and to physicians as well. As a result, primary care medicine was forced to price itself lower than specialized medicine, and now it is being forced to compete with a variety of other business models. Primary care seems to be experiencing an identity crisis, unable to decide if it is the cornerstone of medicine, or an antiquated service whose time has passed.

What is primary care?

The primary care name itself can be understood in two very different ways, depending on how you translate the word primary. It could be seen as the first step one needs to take when engaging with the medical system, a step followed by secondary care, tertiary care, etc. This is the gatekeeping view, where primary care doctors apply their knowledge to direct patients to appropriate specialized resources, if necessary. Since there could be multiple specialized resources, and since medicine is very complex, the gatekeeper doctor is also tasked with follow up, coordination and general supervision. In the business world, this job is known as project management, and it is usually filled by workers that need not be expert at anything other than management of tasks and resources.

Another way to look at primary care is to assert that it is the central and predominant type of medical care, or the way most medical care is provided. In this model, the primary care physician is expected to treat and resolve all but the most unusual medical problems, which may from time to time require a consult with a specialized resource. A consult is not the same as a transfer of care. This type of practice requires that the primary care physician has more knowledge and more understanding of the patient than all transient specialists put together. And this type of super doctor cannot be either underpaid or easily replaced. Unfortunately, short of some old timers here and there, nobody practices primary care quite this way anymore.

There are many reasons why medicine developed into an essentially fragmented model of care. The often touted explosion in medical knowledge, beyond what one human can accumulate and apply, is probably not as instrumental here as money and power seem to be. There are only a handful of diseases that make life miserable for most people, and eventually kill us all, and data shows that most medical resources are spent on a tiny percentage of people at any given time. It is difficult to reconcile these realities with the assertion that we need hundreds of thousands of highly specialized resources, because no one doctor can master the intricacies of a few run of the mill diseases occurring over and over across the board, and seriously affecting only a minority of patients. This, by the way, should not be confused with the obvious need for having a great variety of specialized research in academic and industry settings.

Whatever else it might be, primary care is a $100 billion per year industry in complete disarray. In addition to its own revenues, primary care as it stands today, heavily influences the flow of revenues in all other health care sectors. This should explain rather nicely why so many businesses are trying to be part of it, trying to reform it, reinvent it, flip it, control it, or just replace it. What practically all these innovations have in common is a tacit agreement to adopt the lighter definition of what primary care consists of, for the very simple reason of reducing barriers to entry into this potentially lucrative market.

Keeping People Healthy

In today’s complex environment, individuals cannot be trusted to care for themselves or their children, and rightfully so. The survival and prosperity of our society is predicated on passive consumption of massive quantities of goods and services. Our electronic way of life is designed based on the timeless axiom of “don’t make me think”, and an extra click of a button is considered undue burden on average consumers. We are expected to ingest billions of Big Macs to keep the economy chugging, and go through trillions of disposable trinkets sold on the Internet to keep WWIII from erupting. Even getting the news every morning has been replaced with news “feeds” to save you the long walk down the driveway to pick up the old newspaper. And turning pages, even on the Internet, is too much of an imposition. What makes us excellent consumers is also rendering us unfit to be trusted with our own health.

In this age of patient empowerment and freedom from paternalistic physicians, it seems that primary care doctors are being put in charge of keeping us healthy. It only seems that way though, because nobody needs a doctor’s education and expertise, not to mention expense, to figure out what every good grandma, and every single one of us, knows already. Besides, going to see a doctor does not fit with our tried and true, instantly gratifying, passive consumption paradigm. In our new way of so called life, primary care becomes an electronic assistant that uses, and is used by, every consumer, every day. Note that the modern term “primary care provider” is specifically geared to this low level function. Nobody uses the term cardiology provider, or surgery provider, or even pediatrics provider, to refer to a medical doctor. Primary care is different.
  • Primary care monitors your food intake and level of exercise, reminding you to eat your veggies (or no dessert) and take your constitutional regularly
  • Primary care reminds you, or schedules for you, health screenings and preventive care services as recommended by your government
  • Primary care monitors your vital signs and lets you know if normal parameters are exceeded
  • Primary care answers your questions if you feel under the weather, or just concerned that you might be
  • Primary care treats minor illness and injuries, such as mosquito bites and nail fungus
  • Primary care is available 24x7 from the comfort of your iPhone, or in extreme cases next to the bakery counter at your favorite discount store
  • Primary care is provided by Siri and augmented by certified technicians with impeccable customer service credentials
If you have a sudden urge to kick me in the shins right now, remember that primary care is not your profession. You are credentialed in Family Medicine, Internal Medicine or Pediatric Medicine, keyword here being Medicine. Yes, you may be providing some of these services for some of your patients, mostly for free, but is this really what you want to do all day, every day? Yes, having people come see you when they are healthy, better equips you to care for them when they are sick, but this seems a luxury few can afford today. The new primary care has as much to do with practicing medicine, as fixing traffic tickets has to do with practicing law. It is a piece of your old practice that has been successfully carved out by competing businesses that can and will be providing these, and many more, services to your patients. And if you’re not careful, specialists will take whatever is left on your plate.

Healing the Sick

When primary care was defined by Barbara Starfield as high quality, compassionate, comprehensive general medicine, it was an honor to be called a primary care physician. Today, the term is becoming essentially oxymoronic. Physicians, contemplating the plucking of low hanging fruit from their scope of practice, are usually concerned with being forced to juggle a schedule full of complex patients, with no cognitive respite throughout the day. This, however, is highly unlikely. If you subtract the healthy and easy patients from your schedule, they are not going to be magically replaced by an equal number of very sick individuals. Instead of 25 to 30 spurts of quick encounters, you are more likely to experience 12 to 15 long visits per day. Is that so bad?

It is very bad if your pay rate stays the same. It is spectacularly good if it doubles and triples. Whereas primary care physicians of the past are trapped in high-volume hamster wheel races, the new family docs, internists and pediatricians will be providing real value to their patients. Since the pundits are screaming from every rooftop that we should be transitioning from volume to value, this seems like a perfect arrangement for all stakeholders. Value, of course, needs to be valued, so paying, say, $300 for a doctor visit (not to be confused with primary care) sounds pretty respectable to me.

Corner drugstores are full of medicines and gadgets that used to be exclusively available from doctors. There is nothing new in transitioning tests and therapies into the hands of the lay public. You don’t have a microscope and a rabbit in your office, do you? Quit worrying about nurses and retail stores and the Internet stealing your lunch. You didn’t go to medical school to coach poor people on their sinful lifestyles and their need to be righteous and deserving of charity. You wanted to heal the sick, so have at it. If you want to fight for something, don’t fight for volume. Fight for value. Your value.


  1. "Another way to look at primary care is to assert that it is the central and predominant type of medical care, or the way most medical care is provided. In this model, the primary care physician is expected to treat and resolve all but the most unusual medical problems, which may from time to time require a consult with a specialized resource. A consult is not the same as a transfer of care. This type of practice requires that the primary care physician has more knowledge and more understanding of the patient than all transient specialists put together. And this type of super doctor cannot be either underpaid or easily replaced. Unfortunately, short of some old timers here and there, nobody practices primary care quite this way anymore."

    My new Primary often seems like a PA to me. His knee-jerk response is mostly "I don't know," and he then writes me for a specialist.

    1. Which really begs the question of why bother at all.... Of course going to a specialist to start with, based on your own assessment may still be a crap shoot for most people at this point, but I suspect not for much longer seeing the explosion of online and mobile tools and resources.
      Considering how much we pay specialists, and how they usually practice, this is shaping up to be a most expensive exercise in penny wise and pound foolish, unless they disallow independent access to specialty care. I think they already have a model where you must go to primary care just so you can get patched through for a brief telehealth session with a remote specialist....geared for the poor to start with....

    2. Here's what I wrote on my blog recently:

      I am effectively without a Primary these days. After I retired from the REC, sold the house in Vegas in September 2013, and moved over to Contra Costa County, I ended up in the Muir system. My new doc there is a nice young Internal Med D.O. whose answer to everything is to refer me to a specialist -- even to get a dad-gumbed scrip refilled!...

      t's Tramadol 50 mg. I have some bulging disks and pinched nerves ("cervical and lumbar spondylosis with myelopathy"), in part the upshot of too many years of getting the crap knocked out of me while pursuing my absurd decades-long full-court Hoop Dreams, (I have the attestational eyebrow suture scars, and torn meniscal and MCL vestiges), followed by too many recent years of too much sitting, reading, and blogging for hours and days on end.

      I usually took one Tramadol a day, in the early morning upon arising (even though the scrip said 'one every 4-6 hours as needed'). On bad days, I'd drop a 2nd one mid-day. They helped. Materially.

      Given that DEA recently "rescheduled" Tramadol, I can't help but wonder whether my young doc wants to keep his fingerprints off the Rx. I'd given him my entire longitudinal Hx from my Vegas Primary, dumped from the EHR. I fail to see the point of doing an expensive encounter with yet another physician -- one who doesn't know me, and who will have to redundantly (and expensively) read the chart, listen to (or blow off) my CC Subjective, and either bless or deny the simple Rx request.

      I note on the EOB that Muir charged me and my BC/BS $436 for each primary care visit (Cheryl and I are now on high-deductible HSA). I dutifully underwent the PT regimen he wrote me for (it helped a bit). I dutifully do my exercises. My cut of the nearly $3k for that was just shy of $1,200. My paid OOP for 2014 came to about $3,600 (welcome to the ACA). For a lot of people, that might be extremely painful in its own right.

      Knowing that I would have another annual visit coming up, I went into Muir's portal to schedule it and request a lab draw order (blood and UA panels) to avoid another $436 charge for a pleasant (MU-compliant) 30 minute 99213 chat just to essentially pick up a lab slip and incur yet another charge for the f/up.

      He refused. Had some Muir employee call me the following week with the news. Didn't respond (for the record?) to my portal email.

      I told the caller to just cancel my appointment request.

      Maybe Doctor on Demand won't be able to help me. The cost of finding out will be nil. I'll pay by credit card.

      Had I the right iPhone apps (suitably QC vetted, of course, for clinical accuracy and precision), I'd prick my finger, pee in a cup, and run the specimens for my own labwork. Maybe most patients aren't competent to evaluate them. That is not the case with me. I know what to look for, what safely seems negligible, and what needs MD attention...

    3. Oh wow! We are so being taken for a ride.... by everybody, the systems piling up unnecessary stuff as long as you can pay, and the innovators peddling little pieces of DYI plastic medicine for whatever loose change you still have in your pocket. It's nauseating....

  2. My primary care doctor couldn't even diagnosis my hemochromatosis. He sent me straight to a specialist who was able to properly diagnosis it and start me on a regimen of bloodletting to bring my high iron count down. My primary care scheduled a follow/up which I immediately cancelled. I told the front desk clerk that if the primary care wanted to know what was going on or had any concerns, he could talk to the specialist. Otherwise, silence is golden.

    Yes, we are being taken for a ride. Primary Care has turned into a bunch of middle-men who deserve to be squeezed out. No way am I paying >$300 just to get referred and then another >$300 just to sit and chat about it later.


  3. Hm. Although I've shifted my own practice to geriatric consultation and no longer do primary care, I think we will absolutely need primary care doctors to partner with people with chronic illness. Esp when it comes to seniors with multiple chronic problems. Basically once you have multiple chronic conditions in an older person, patients and families need a clinician to help them navigate and manage. The specialists generally can't do it because the work requires thinking outside the specialty/organ, plus helping patients pick a course that's a good fit with their preferences, situation, and values.

    Whether the current crop of PCPs can do this is another question. I think under the right working conditions they could.

    1. Absolutely. However, I think the definition of "primary care" needs to evolve away from stuff that healthy people can get at CVS or online from a semi-reliable source. In my opinion, and sadly it seems that this is solely my opinion, a visit with a senior with multiple chronic conditions should be paid at triple the rate of what it is paid now.
      I do agree that specialists can't do it and wholeheartedly agree that that PCPs can do it, if they are freed from the current model of hurry-up-and-get-to-the-next-patient.
      A while ago I suggested that people should start calling themselves Comprehensivists and leave the mundane colds, cuts and bruises to someone else....
      It is a chicken and egg sort of thing though, because it's hard to switch models before payments are changed and it's difficult to modify payments before comprehensive care is actually practiced.