Decoding Health Care

Part 29: Primary care

Never once during medical school or my residency training did I consider being a primary care physician. This was probably mostly because the institutions where I trained (Washington University in St. Louis and the University of Pennsylvania) really didn’t consider training primary care doctors part of their mission; they were all about training physician scientists and the next generation of academic physicians. The University of Pennsylvania did have an outstanding Department of General Internal Medicine; in fact, I considered doing a fellowship in that discipline before I settled on hematology-oncology. But that department was all about health policy and public health, not toiling in the trenches of primary care practice.

My daughter, on the other hand, is very interested in primary care. She is completing her third year at a state medical school and they DO consider training primary care doctors a big part of their mission. Plus my daughter spent several years between college and medical school teaching high school science in a socio-economically depressed area, and she saw first hand how important good primary care was to her students. Her career choice will be influenced by her life experiences. I will confess that I have some anxiety about her practicing in a primary care field.

Why? Primary care doctors are the Rodney Dangerfields of American medicine: they get no respect. Primary care doctors routinely are near the bottom of the medical profession when it comes to income. And although they generally profess high job satisfaction, they are commonly near the top of the list for physician burn-out. The rock stars of American medicine are the specialists, especially those that do a “procedure” like a cardiac intervention. It’s those specialists that get to use the cool new high tech stuff. It’s those specialists that are credited with saving lives. It’s those specialists that make the most money. There is not a lot of glory in executing a perfect childhood vaccine schedule or keeping a type 2 diabetic’s HbA1c less than 7 by successful lifestyle counseling and judicious use of oral glucose lowering agents. As a close friend, colleague and retired primary care doctor told me, “As a primary doc you are rarely considered the ultimate answer on anything.”

And we need primary care doctors. Americans who regularly see primary care doctors have better health outcomes and cost the system less money (Using Primary Care’s Potential to Improve Health Outcomes < PBGH). These patients use the ER and hospital a lot less. But we do not have enough primary care doctors. About 30% of medical graduates pursue primary care as a career, but we lose some of them along the way. About 25% of practicing physicians do primary care. There just aren’t enough of them and they aren’t necessarily distributed where we need them.

There are national efforts to make primary care a more attractive career. Attempts have been made to increase compensation. As I discussed in the post covering physician compensation, doctor pay is based on relative value units (RVUs) that are assigned by a panel of physicians (nominated by their specialty societies and appointed by the AMA) and which should reflect the work needed to deliver the care. Historically, procedure based specialities get higher RVU scores and so make more money. There has been a conscious effort to change this equation, but progress has been slow. There is a lot of ground to make up.

Physician practices have turned to the use of advanced practice providers (APPs) to help reduce the burden on primary care doctors. In some cases, the relationship between primary care docs and their APPs is collaborative and in other cases the APPs work independently. In either scenario a little pressure is taken off the primary care physician.

It has long been felt that the debt burden students incur in getting a medical education heavily influences specialty training choice. Medical schools are looking at ways to reduce this debt. So tuition free medical schools have offered the ability to choose a career path without debt as a factor. These haven’t been around very long but unfortunately the preliminary results do not suggest a migration to primary care.

As far as I can tell, none of these efforts have produced a lot more primary care doctors and I think I know why. I think the real problem is that as practiced today, being a primary care physician can be a frustrating, thankless job. Unless you are mission driven, like you want to be the family doctor in the rural town you grew up in or the pediatrician in inner city urban America who really is solely focused on making a difference in your community, the positives associated with being a primary care doctor are overshadowed by the negatives.

Does it have to be this way? I think we should figure out what would make primary care a good job and decide how to evolve the field (including how to pay fairly for their services). Let’s start by listing the most important roles that a primary care physician fulfills.

Harold Miller is a health policy expert who is the CEO of the Center for Healthcare Quality and Payment Reform. He has focused on moving from traditional fee for service to a more patient focused payment model, both in primary care as well as in specialty care. In order to help define how to pay for primary care, he starts out by defining what it is that primary care doctors (should) do, and then assigning a reimbursement for these activities (Patient-Centered Payment).

In Miller’s model there are three major services provided by primary care:

1. Wellness Care: this includes vaccinations and cancer screenings but might involve other issues including dietary counseling. And addressing social determinants of health.

2. Chronic care management: this includes both the primary management as well as the coordination of care of patients with chronic medical illnesses.

3. Non-emergency acute care: this includes acute management of minor acute medical problems or appropriate triage of more serious ones.

He also includes a fourth domain involving behavioral health but for the sake of simplicity lets stick to the three major areas.

In his payment model, primary care physicians get paid a monthly fee to provide wellness care and chronic disease management as well as a specific episode fee for an acute problem. These fees replace traditional transactional fee for service billing. In addition, the practice receives an “overhead fee”. So a primary care physician’s compensation is based on the sum of tasks in these three categories. Patients will need to be “assigned” or attributed to a particular primary care doctor. Specific quality measures can be designed for each care activity, and this can be used to reward high quality clinical work.

Note that the monthly fee is paid whether the patient is seen or not. And the “provider” doesn’t need to be the primary care physician, it could easily be an advanced practice provider. Plus the model incentivizes remote care including telehealth, responding to patient texts or electronic patient symptom reports, or speaking to the patient or caregiver on the phone.

This might sound like capitation but it is most certainly not. The primary care physician is not directly responsible for the cost of care and does not face downside risk. The model can be built to reward financial performance (choosing high performing consultants, lower cost settings for testing, better performing hospitals and rehab centers). But that is not the major reason to move primary care in this direction. The major reason is to re-energize primary care and make the payment for primary care services more logical.

In today’s health care system, primary care doctors are asked to do too many things and cannot focus on the important stuff. And there is all that paper work. Arguably the most important role for a primary care doctor is chronic care management. Think about the diabetic population. Most of them do not need to see an endocrinologist. But even the straightforward diabetic patients need their care coordinated. They need an eye exam. They need dietary counseling. If their HbA1c starts to climb they might need a referral. Plus they need their general wellness care and they need a primary doctor available should they get bronchitis because if they get an infection their diabetes is going to get out of whack and the emergency room is a terrible place.

Then take the example of the really complicated insulin dependent diabetic. They probably do need to see an endocrinologist. They also need the eye exam and dietary counseling. They may also need at some point to see a neurologist, cardiologist, and nephrologist. And somebody needs to keep track of all this stuff. Somebody needs to take the specialist recommendations and synthesize them into a plan, and to make sure the specialists are talking to one another. I hate to say it, but all too often this doesn’t happen in today’s world.

I am not exaggerating. Recent data from Medicare is revealing (Trends in Outpatient Care for Medicare Beneficiaries and Implications for Primary Care, 2000–19 - PMC). The average Medicare beneficiary sees their primary care physician twice a year, and they have four specialist visits a year. But 30% of Medicare beneficiaries see more than 5 specialists a year. Today there is no payment for coordinating that care.

In Miller’s model, a primary care doctor can focus on what they are interested in. They might hire advance practice providers to do the wellness care and acute visits. The key to making this work is paying the primary care doctor enough.

I do not envision a return to the HMO world of the 1990’s in which primary care doctors were “gatekeepers”. In that world, patients needed a referral to see a specialist. Patients hated it and so did doctors. Clearly patient consumerism will need to be monitored and some check points may need to be installed. There are many ways to do this that we are already accustomed to: higher copays for specialists with primary care visits free. Enriching the life of primary care doctors will be good for everyone.

There are other potential benefits to reviving primary care. Expanding the role of primary care doctors will also help reduce the manpower shortage burden on some specialties. Let’s examine the potential impact in an area I am familiar with, medical oncology.

Oncology has long been identified as facing big manpower challenges ahead (https://blog.finder.doximity.info/the-oncology-shortage-is-here-what-recruiters-should-know-part-1). When I was in practice, my schedule was always full. Many of those office visits were with patients who had completed treatment and were on follow-up. Those patients really didn’t need to see me for the most part. And in many cases, I was exactly the wrong doctor for them. I wasn’t very good at the non-cancer aspects of their care . Many times the patient thought that anything that had to do with cancer of any type was my job, not the primary care doctor’s responsibility, and that includes screening for cancers other than the one I was treating the patient for. And as for cancer “survivorship” care, I can definitely state the care was not standardized (sometimes it was evidence based and sometimes not). But I will say that after those “well baby” visits both the patient and I felt better.

Cancer survivorship care probably should be the domain of the primary care doctor. They have a better longitudinal view of the patient’s medical needs and are much better at coordinating care. But although there isn’t a ton of evidence that patients suffer adverse health outcomes if the survivorship care is administered by the primary care physician, there is a lot of evidence that primary care doctors feel ill-equipped to take the lead (https://link.springer.com/article/10.1007/s11764-023-01397-y). There is also significant skepticism among patients. Better education of patients should solve this as well as formalization of a co-management model with improved oncologist-primary care physician communication, especially for the first few years after diagnosis. There is no doubt that most low risk breast cancer patients have a much higher risk of dying from heart disease than from their original breast cancer.

I believe it is possible to not only have primary care survive. It can and should again be one of the best jobs you can have. Patients will definitely benefit. This is one area where artificial intelligence isn’t going to replace doctors, at least not anytime soon.

In my next post I am going to change directions and will write about my experiences with the health care system from a different perspective, that of the patient. It all started when my knee started hurting and it ultimately ended up with a knee replacement.