There is a crisis in providing primary care in the United States. You know it because you only get 8–12 minutes with your primary care physician (PCP), who interrupts you within about 18 seconds and never fully listens to you. You are sent for tests, given a prescription, or referred to the specialist even though the PCP could — with more time — have figured out your problem without a test, prescription or referral. You are less than satisfied, yet the charge is high. Your doctor is no more satisfied and indeed is highly frustrated and feels like he or she is on a never-ending treadmill. This leads older PCPs to seek early retirement, mid-career PCPs to sell out to the local hospital, and medical students to shun primary care, each leading to a growing shortage of PCPs which will worsen as the population grows and ages.
PCPs need time to listen, time to think, time to give quality preventive care, time to manage chronic illnesses, and time to coordinate care for those who must see a specialist. In other words, they need time to practice at the top of their profession, which they currently cannot do thoroughly.
The crisis means that Americans do not get the level or quality of health care they deserve. This crisis is the major reason health care is so expensive and why costs keep rising.
The solution is not so complex. The reimbursement system needs to change so that more resources are placed into primary care so that many fewer resources are required in specialty care. It’s an easy answer but challenging to implement because of massive resistance by the insurance industry, the government, and by the conservative nature of physicians, and lack of knowledge by employers and by patients.
Before proceeding, it is essential to note that primary care is not just for the “simple stuff.” PCPs are trained and experienced in caring for complex chronic illnesses like diabetes and heart failure and only need to refer to specialists occasionally. But PCPs have too little time per patient, so the reflex is to refer, test, and prescribe, thus driving up healthcare costs. There is no time to address wellness and health and no time to develop and maintain a trusting relationship.
Don’t blame the PCPs. They are caught in a terrible conundrum. PCPs’ overheads (especially the need for added staff to deal with billing, preauthorizations, and government mandates) have risen much faster than revenues. The only remedy is to “make it up with volume,” i.e., more patients per day. But that is a non-sustainable business practice and certainly an unacceptable care model.
Of course, some activities must be done other than the patient visit. The typical PCP takes 24 phone calls daily, 17 emails, processes 12 prescription refills (above those handled during visits), and reviews 20 laboratory reports, 11 x-ray reports, and 14 specialist consult reports. These are all done outside of the visit and, obviously, take substantial time. In addition, they have needed substantial time to comply with electronic health record “meaningful use” and Medicare quality indicators.
PCPs report that they must see about twice as many patients as before in return for the same income, inflation-adjusted. It follows that if a PCP needs to see 24 to 30 patients daily, that amounts to mostly 15–20 minutes visits with actual “face time” of about one-half of that. This is long enough for a simple problem but much too short for someone with a complex issue or someone with multiple chronic diseases and taking multiple prescription medications. It is certainly not long enough for an older person with impaired vision, hearing, or cognition and not enough when the problem has an underlying anxiety.
There is inadequate time for compassion, to build trust, or do true healing. Since there is too little time, the tendency is to send the patient off to a specialist when a bit more time with the history would give the answer. There is not enough time to discuss lifestyle changes, so it is easier to just write a prescription. These steps are the principal cause of higher and higher medical care costs in America — unnecessary referrals (now double what it was a decade plus ago), unnecessary tests, unnecessary X-rays, and unnecessary prescriptions. And with it has come the loss of the close and trusting doctor-patient relationship and the lack of true healing.
Patients and PCPs must take charge and change the primary care paradigm. Patients need to demand the time they deserve. PCPs need to insist that they will give the time.
This means fewer patients per PCP; 500–800, rather than today’s 2500–3000. Fewer patients mean more time for each patient and much better access to the PCP. But, of course, this will need to be paid for by the patient directly (e.g., direct primary care, membership, retainer, concierge) unless employers, insurers, or government choose to do so.
Comprehensive primary care offers same or next-day appointments lasting as long as needed and 24/7 access via the PCP’s cell phone. Often it means generic medications at wholesale prices and reduced-cost laboratory and radiology testing. It means much-improved care quality, satisfaction, and lessened frustrations for patients and doctors alike.
Fewer patients means more time for the patient and doctor to interact. It means more time for listening, building trust, and healing. It means better diagnostics and improved treatment plans. It means fewer tests, X-rays, prescriptions, and specialist referrals. Combined with a much less expensive high deductible health insurance policy, the savings for patients are substantial, and the total costs of all care decline quite dramatically, as in these two reports. So putting more resources into primary care is definitely cost-effective.
When PCPs do have time, they can develop that trusting relationship. When they do have time, PCPs can treat the vast majority of issues brought to them by their patients without the need for specialist referrals or excessive testing. When PCPs do have the time, they can appreciate the underlying stress and anxieties that propel so many illnesses and trips to the doctor. When PCPs do have time, they can help preserve wellness, and give genuinely proactive preventive care by reaching out now rather than waiting for the patient to arrive with a problem. The result is better quality care, greater satisfaction for both doctor and patient, and much lower total costs.
Most Americans do not realize how vital and valuable comprehensive primary care can be to their health overall. A new paradigm is often difficult to embrace, especially when its purpose and logic are not appreciated. Most of us are skeptical of stepping away from what we know.
Look again at the first article in this series, the true story of Susan, who had a symptom that bothered her. Her PCP gave her the usual 12 minutes. But, instead of taking the time to understand the family stresses that underlaid it, she was sent from specialist to specialist, had multiple unnecessary tests and procedures, and had an unneeded operation — none of which revealed the cause of her issue. But it all cost about $18,000. That is a lot of money wasted without ever addressing the actual problem!! And please, don’t think this is not a common occurrence.
But if patients want to benefit from much better care, if they want a doctor that is not frustrated and can spend time with them listening, if they want their total costs of health care to decline rather than rise, then they will need to educate themselves and then advocate– to legislators, to insurers, to employers and especially to their doctors. Concerted patient action will force the issue and make change occur. It will be a win for everyone.
The alternative to transformation is the continued status quo — rushed visits, lack of a close doctor-patient relationship, an emphasis on specialty care, and excessive tests, procedures, and prescription medications, all leading to higher costs yet less quality, less satisfaction, and more frustration.
It behooves doctors and patients to agree and demand change; don’t wait for the bureaucrats because they will not deliver. Abraham Lincoln once said: “With public sentiment, nothing can fail. Without it, nothing can succeed.” So, we need to advocate for change and do it together.