The Long Awaited Crisis in Primary Care: It’s Heeere!

I recently heard from a UCSF physician who was flabbergasted when he sought an appointment in our general medicine practice and was told it was “closed.” Turns out we’re not alone: there are also no new PCP slots available at Mass General. The primary care crisis has truly arrived.

I’ve written about the roots of the problem previously, and won’t restate the sad tale of woe. But I hope you’ll take the time to listen to two very powerful NPR reports on the topic – the first, a WBUR special by healthcare journalist Rachel Gotbaum called “The Doctor Can’t See You Now,” is the best reporting on this looming disaster I’ve heard (here is the MP3 and the show’s website). The piece is long (50 minutes), so I’ll summarize a few of its moments that really hit home.

First, it is true – MGH is not accepting any new primary care patients. Like UCSF, therefore, getting “a regular doctor” at MGH now takes the combination of cajoling, pleading, and knowing somebody generally referred to as “working the system.” In other words, the process of finding a primary care doc is now like getting a great table in a trendy restaurant. Obviously, this is horrible for patients, but it is also no fun for doctors. For example, in the NPR special, MGH’s director of Emergency Medicine laments:

“If you really want to give me heartburn, you can say, excuse me but I know you work at Mass General and I would like a primary care physician please.”

As someone who gets requests like that about once a week, I can empathize. Of course, things are far worse for the patients. One woman described her efforts to find a primary care doc this way:

“Yeah, I asked people who had really good doctors that they would put a word in for me and it was almost like writing a personal ad: ‘Hi, interesting woman who’ll talk to you, gives good history…’  ‘Gives good history,’ that would be a really good thing to say!” [she laughs]

The report also makes clear that providing more “access” through expanded insurance coverage won’t do the trick. Massachusetts, you’ll recall, markedly expanded its coverage a couple of years ago (in legislation proposed by that ex-liberal, Mitt Romney). Scott Jasbon, a 47 year-old contractor/bartender, thought he was all set when he enrolled in one of Massachusetts’ subsidized health plans. He was wrong.

“I received a card with my doctor’s name on it and I was told that was my primary care physician. I called the office. They told me that they no longer took the insurance. So then I went through every list of doctors in Sandwich, in the book, called each doctor, and each doctor told me the new plan that I received, they, no one took the insurance… I knew that there was something wrong with me, and I was explaining to each doctor actually as I called them, ‘I’m having problems urinating.’ Hot flushes, I was hot all the time. I knew something was wrong, and I couldn’t get anybody to take care of me.”

Jaspon ended up in an ED, where he was diagnosed with diabetes and hypertension. The ED staff helpfully suggested that he should think about getting a PCP.

What’s happening is old news. The combination of 15 minute visits to see patients bearing both complex medical problems and 20 pages of internet printouts to discuss, the loneliness of a small group practitioner, the lack of prestige, the woefully low pay (the income of the average PCP is less than half of that of many specialties, including dermatology and radiology) in an era in which the average medical student finishes school more than $100,000 in debt, and the sensibilities of Generation Y trainees – who now are looking for reasonable “lifestyles” and incomes without the need for martyrdom – have combined to push all but the most unusual medical student and resident away from primary care careers. At Mass General, one out of the 50 graduating internal medicine residents last year was planning to become a PCP; at UCSF, our numbers are only slightly higher.

Some primary care educators used to say that the problem was that students didn’t have opportunities to see the real practice of primary care docs – if they did, they’d recognize the subtle satisfactions and be more inclined to enter the field. But an upcoming paper by UCSF’s Karen Hauer and others demonstrates that such exposure actually discourages trainees from choosing primary care. Primary care docs are frustrated and demoralized, and most of them are honest enough to share their angst with their students. In other words, It’s The Practice, Stupid.

The dwindling number of PCPs who remain in practice are being far more discriminating about the patients – and insurance payments – they will accept. With Medicare reimbursement tightening (Congress just overrode the Prez’s veto of a proposed 10% Medicare pay cut, but you can bet that the proposal will be back again next year), Medicaid reimbursement near Starbucks barista levels, and states proudly providing subsidized insurance at Medicaid-like reimbursement rates, the result is primary care “access” that sounds good in a press conference but is not real.

You might ask, won’t the existing PCPs need to accept even these low insurance payments? After all, they need to see some patients to generate an income. Well, as it turns out, no. The remaining PCPs are in such demand (not only because so few people are entering the field, but because so many are leaving it – an ABIM study found that 10 years after initial board certification, approximately 21% of general internists were no longer in the practice of general medicine [vs. 5% of subspecialists leaving their field]) that they can afford to limit their practice to patients with better paying commercial insurance. A few, of course, are limiting their practices even further – to well-heeled patients willing to provide an up-front stipend of several thou.

And, for big academic practices like UCSF’s and MGH, opening up new primary care practices involves substantial subsidies – subsidies that most academic medical centers are increasingly unwilling to provide. The 1990s theory that you needed a big primary care base to feed your neurosurgery and liver transplant programs has not materialized – many academic hospitals (including ours) are packed to the gills; with managed care de-fanged, most patients can get to us without necessarily receiving primary care in our system. The result: more “Closed To New Patients” signs.

Won’t the market and the political process work this problem out? Not so much. Even though everybody recognizes the crisis at hand, bumping Medicare’s primary care reimbursement presently involves changing the formula used to calculate reimbursements to all physicians. This is handled by a Secret Society known as the “RUC”: the RBRVS Update Committee. In a 2007 JAMA article, Harvard’s John Goodson described the RUC’s membership:

“The RUC has 30 members (the chair only votes in case of a tie) with 23 of its members appointed by ‘national medical specialty societies.’ Meetings are closed to outside observation except by invitation of the chair. Only 3 of the seats rotate on a 2-year basis. Other members have no term limits. Seventeen of the permanent seats on the RUC are assigned to a variety of AMA-recognized specialty societies, including those that account for a very small portion of all professional Medicare billing, such as neurosurgery, plastic surgery, pathology, and otolaryngology.”

In other words, representation on the RUC is like the Senate rather than the House, and in this case Montana isn’t very excited about turning its money over to California. And since the dollars available for physician payments are capped (at best), bumping primary care reimbursement significantly (a percentage or two won’t help – the increases needed to change the dynamics are on the order of 20-40%) can only be accomplished if dollars are freed up through lower payments to radiologists, plastic surgeons, and other specialists (and guess who has the better lobbyists). For more details on the RUC, check out Roy Poses’ blog, which has made a cause out of exposing the committee’s biases and secrecy, and Maggie Mahar’s terrific description of the RUC’s history and inner workings.

The state of primary care is not only sad, it is incredibly stupid. Mountains of research have demonstrated that primary care-based care is less expensive – without access to primary care doctors, patients get their basic care in emergency rooms, or from subspecialists, or not at all. In any case, care is fragmented, technology over-intensive, and wickedly expensive.

The second NPR report I liked described primary care in the Netherlands, where the cost of healthcare is far less than that of the U.S… and the doctors make house calls! How do dey do dat? Easy. They’ve determined that providing superb access to primary care, even in patients’ homes, is not only humane and effective, but probably saves money by preventing unnecessary ED visits and hospitalizations. Just one more reminder of how dumb our present system is.

The forces of inertia getting in the way of solving the primary care crisis are so strong that only a very powerful implosion will create the political wherewithal to overcome them. Specialists don’t want to forego income, medical students will continue to vote with their feet, existing primary care docs have resigned themselves to more of the same and are hunkering down for retirement, and many patients are perfectly happy bypassing primary care docs to get their care from hordes of subspecialists. The patients who take the biggest hit, of course, are poor and middle class folks with chronic diseases – even those with insurance – who can’t find a PCP and can’t afford a VIP doctor, and who therefore live in perpetual fear of the next crisis.

When even insiders like medical school faculty members can’t find a regular doctor, you know that this dysfunctional and unsustainable situation is now coming to a head. Once gas prices and the mortgage meltdown begin receding from the headlines, expect that the primary care crisis will become a Page One issue.

It’s about time.

10 Responses to “The Long Awaited Crisis in Primary Care: It’s Heeere!”

  1. Brad F July 21, 2008 at 10:54 am #

    Nice post Bob.

    Along the lines of primary care and efficiency, one issue which I have not seen addressed are the findings of the latest version of the Dartmouth Atlas. Unlike prior iterations which demonstrated across the board value in primary care, ie, regardless of where primary care docs practiced, their clustering/presence led to lower costs or better outcomes. This go around, primary care practices in high cost areas also had commensurate “decreased efficiency” along with their other non-primary care colleagues.

    It certainly does not mitigate against the case for primary care, our system is failing, but this finding deserves attention and requires another look at how to approach the problem. The clippings, press, medical literature keep sounding the same theme and we need to change the tune. It is the regions and culture that may matter just as much as primary care presence.

    Again, surprising this finding has not been bantered about a bit more.

    Brad

  2. tholt July 22, 2008 at 1:15 am #

    Thank you for addressing this crisis.

    When I left primary care for hospital medicine I was surprised to here of the severe shortage of hospitalists. I was aware of the crisis in primary care. I suspect it is more acute in rural America than at UCSF or MGH. The primary care shortage is a true crisis. I think most hospitals want more hospitalists, but most communities in the United States need more primary care physicians, particularly physicians to manage complex patients with chronic disease.

    There are tremendous rewards for those who choose the role of personal or family physician. That keeps many of my colleagues going despite the other negatives listed in Bob’s comments. These rewards are not likely sufficient to attract enough medical students to choose primary care.

    In my experience, academic medical centers and hospitalists have contributed to this crisis by their attitudes about primary care. The breadth of knowledge needed to do primary care is daunting. In hospitals this knowledge is shared by a variety of specialists. The primary physician attempts to manage complex patients with limited time, money and technology. Because of this they live with more diagnostic uncertainty. Then the patient ends up in the hospital where an army of hospitalists and specialists with more time and specialized knowledge apply the latest technology at great expense. It is easy to see how the work of the primary care physician pales in comparison.

    I think the solution will be found in an integrated health system where a system is responsible for all the care of a population including primary care and intensive care. In such a system there could be rational allocation of resources. (Sounds like an HMO.)

  3. chris johnson July 22, 2008 at 2:35 pm #

    Bob:

    An outstanding summary post! I hope it is read (and linked) widely. I recently had to do exactly what you describe. I’m a physician and we moved to a new city a couple of years ago. I had to twist arms and call in favors to get myself and my wife PCPs–and we have “good” insurance and no significant health problems (yet). So folks like us should be all gravy to PCPs, yet we had difficulty in finding ones to take us. If I didn’t know how to work the system I doubt we could have gotten doctors at all.

  4. Joe Hospitalist July 23, 2008 at 6:10 am #

    I don’t know anyone who wrote “I love to read x-rays in a dark room for the rest of my life” in their personal essay for their medical school application. So how do we explain the sudden increase in the applications for radiology, dermatology, pathology, and anesthesia and the major decrease in the number of residents going into primary care?

    I’d love to think it’s a very complex problem but as a recent medical school and residency graduate I know better:

    “ITS THE MONEY, STUPID!”

    and until the folks in washington get THAT, they can change whatever elase the want. It won’t have any effect WHATSOREVER!!!

  5. MikeP-QMD July 31, 2008 at 3:40 pm #

    Great summary and discussion. Stunning how dramatically the costs and risks of being a PCP have increased while the pay and stature have declined. Has any profession ever experienced this in such a deliberate fashion?

    I worked with the National Health Service (NHS) in England from 1999-2004 and observed the gradual and awkward but necessary and appropriate rise of Primary Care over there.

    A few years ago, the NHS GP (General Practitioner) Contract was renegotiated in a way that paid GPs a lot more than they used to be paid. On top of that, the NHS’ Pay for Performance model (called Payment by Results) was launched with an assumption that GP baseline performance levels against metrics were poor. After a year, the Department of Health found out–much to their chagrin–that their asssumptions about GP performance were way off. The subsequent payout to GPs for their performance, literally, almost bankrupt the NHS. So their big contract and their performance pay has put GPs in the most glaring and scrutinous spotlight imaginable. In fact, GPs have just endured a very high profile performance review by the Chief Medical Officer of the NHS, Sir Liam Donaldson, who was responding to a sentiment that GP productivity has actually decreased since the major investment in Primary Care. So that’s been the British experience with raising the stature and importance of Primary Care.

    More positively, GPs now run what are called Practice-Based Commissions. These are made up of 5-7 GPs, who are empowered to decide where and how to deploy resources to meet local health needs. How sensible! But this power shift has created great cultural tension between GPs and specialists, who are used to being the Belle of the Ball.

    The moral of this story comes from the Spiderman movies: With great power comes great responsibility.

  6. exodus August 1, 2008 at 5:46 pm #

    It is high time primary care docs stopped narrating their tale of woe and took indvidual action to change their lot. This may involve giving Botox injections, dropping Medicare, getting an MBA, joining a concierge practice or joining industry. Only when existing practitioners vote with their feet is when the establishment will get the message

  7. Jim Naughton August 1, 2008 at 8:08 pm #

    Great summary of the primary care crisis, the best I’ve seen. One area not covered however is the role of academic medical centers in the evolution of the problem. The number of specialty fellowship training positions historically has much more to do with the ambitions of department and subspecialy section chiefs and their empire building than with any public health need. The fact that entire “graduating” residency cohorts can all be absorbed into specialty tracks speaks for itself. If you build it, they will come and if you pay them more, they’ll definitely come. The “supply driven” overutilization so well documented by Wennberg et al in part begins with the supply of specialists and that begins at the academic medical center.
    And if you think the RUC is tough to deal with, how about the average academic senate??

    Jim

  8. MattFine August 4, 2008 at 10:39 pm #

    Bob,

    What a sad story about the demise of a noble speciality. Many of us working in the field saw it coming years ago. In 1990,when I was president of our local county Medical Society, I had to write an article for our monthly newsletter. In October I reviewed the proposal for the new RBRVS which had been published in the NEJM. I felt this proposal would be terrible for primary care and wrote “I don’t believe this type of schedule will encourage young physicians to go into primary care…” Obviously this was a major understatement.

    The “Medical Home” has been espoused as a way to make primary care practices financially viable. A proposed payment scenario was recently reivewed in the June AMA News. It shows that Tier 3 (the highest, requiring the most extra services and reporting) would pay an extra $161,871 for a panel of 250 patients. That comes to to $53.96/pt/mos which is barely enough to cover two or three extra phone calls. It’s hard to see how this will have any chance at all to fix the problem.

    Thanks for bringing these important, interesting topics to us in your Blog.

    Matt

  9. maj September 7, 2008 at 7:34 am #

    as a former PCP ( 10 years) and now a strict Hospitalist (3 years), I can say that practicing traditional office Internal Medicine is more labor intensive and less financially rewarding than Hospitalist work. In the real world of loan debt and raising children, Hospitalist Internal Medicine practice provides a significant income boost while having more time to be a dad, spouse, coach…etc….

    One un anticipated benefit of my hospitalist work is that I monthly attend 4 afternoon sessions per month in our local charity clinic..and I love every moment of it. While I was doing traditional Internal medicine i was too busy to do any charity work at all (although I always wanted to.)

    Despite the above benefits I still really miss the long term continuity I had with my office patients, so I might try some hybrid model of Hospitalist work ( 75 % Hospitalist ) and have a tiny micro practice where I can have a small panel of patients of my own.

  10. Todd January 25, 2010 at 5:49 pm #

    I think it is all about the money.  Every ‘fake’ university from New York to California has two week medical degree that will guarantee them 50k in the following year!  Many people believe it their right to receive medical care because this is America, land of the free, home of the brave.  Times are changing and health care must adjust.  Currently I am in between contract sas a project manager for various health operations and I have major issues just acquiring insurance.  People must compromise for us to succeed.  

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