Is primary care dying, and does it matter?
December 21, 2008
In my 30 years in family medicine I never expected that the future of my specialty would look so bleak. I love being a primary care physician. I love the idea of seeing new and different problems every day. I love the history of Kremmling’s Doc Ceriani who exemplified the idea of the country doctor so vividly. Most of all, I love the long-term relationships and being a part of my patients’ families when they need me most.
The potential loss of primary care is real and means more to our communities than nostalgia. Studies over the last 10 years have shown that the loss of primary care creates more emergency visits, long delays and more expensive care. Dr. Starfield has written extensively on health care around the world and has shown outcomes are tied to robust primary care systems and not to national or private health insurance. Countries with the best outcomes have a primary to specialty care ratio of 70/30. In the United States, we are the exact opposite. We all love our technology, but it is expensive and often there is no demonstrated improvement in outcomes, which explains much of our country’s lackluster health outcomes compared to the dollars we spend.
Primary care suffers because of the insane payment system that is forced on us by the insurance companies. Primary care doctors are paid for episodes of care; the “office visit.” Each visit must have a code that measures some level of care for some diagnosis. This system has nothing to do with keeping families healthy, since we are more than a list of codes and illness. Medicare does not pay for physical exams, or wellness. Further, every insurance company pays different rates for different codes and every patient has a different copay or deductible. Primary care is not a retail commodity based on units of care, but should be based on a continuum allowing relationships and to do what it takes to keep patients healthy. Now many physicians simply see more and more patients to make ends meet. This “hamster wheel” style of care benefits no one.
The process for getting paid is so complex, it is estimated that 16 percent of health care costs are gobbled up in arguing about who gets paid what.
We are suffering because reimbursement for each “visit” is shrinking at a time where costs continue to climb. Most insurance payment contracts are based on a socialized system based on a percentage of what Medicare pays. Since 2001, reimbursements have been heading lower, as Medicare reimbursements have declined. Currently, we are paid the same we were in 2001, despite practice costs increasing by more than 20 percent. If the outlook for Medicare going broke holds true, primary care could see a net 81 percent decrease in reimbursement. In some states 40 percent of the primary care docs expect to have unsustainable practices within the next three years.
Medical students now finish the eight years of college and medical school with hundreds of thousands of dollars of debt and simply cannot afford to become primary care docs. Over the past 10 years, there has been a 54 percent drop in graduates entering family medicine. As the entry point, and the least expensive way to receive 90 percent of needed care, this has the impact of accelerating the cost of health care.
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Few family docs I know encourage their children to follow them; I am one of the lucky ones. Recently, a survey of current family docs reported that 60 percent said if they could go back to training they would choose a different specialty.
The tragedy is that as we look for health care solutions; we are loosing the one group of docs that has been shown to decrease costs and improve outcomes. No system of health care reform will succeed without a solution to create a robust system of primary care. For those of us in the rural areas, this is even more important. The good news is some hope. Recently, the American Medical Association and others have begun lobbying for changes in reimbursement, training requirements and other measures to readjust the mix of health care manpower. I sincerely hope to see a day where primary care relationships regain the importance they deserve, and primary care is once again on a sound footing.
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