Commentology: Thoughts on the Death of Primary Care

Commentology: Thoughts on the Death of Primary Care

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Vance Harris MD writes:

We are our own worst enemies, as we have allowed insurance companies and Medicare to set the value of our services. Clearly those values they impose have nothing to do with our contribution to the health of our patients or the cost savings we bring about.

Case in point:

How many dozens of chest pain patients have I seen in the last month who I didn’t order an EKG, get a consult, set up nuclear imaging or send for a cath? Only I have the advantage of knowing just how anxious most of these patients are and that they have had the same symptoms time and again over the last 20 years. After a pointed history and exam, I am more than willing to make the call that 27 hours of chest pain is most likely not angina in nature. When I take the responsibility on my shoulders I am saving the system tens of thousands of dollars. Most of these patients present to my office directly and are worked into a busy day pushing me even deeper into that mire of tardiness for which I will be chastised by at least 6 patients before the end of the day. Most of those who scold me are retired and have more free time in a day than I get in a month. My reward for working these people in and making a call that puts me at some risk is at most $75 if I count the less than $25 I get paid for being able to read an EKG without sending it off to be interpreted by a cardiologist. My incentive pay for saving thousands of dollars on each patient for 1-2 days in the hospital, stress treadmill and cardiologist referral is $75. Now there is motivation on a busy day to not send someone to the ER.

How many times has an anxious patient come in, almost demanding an endoscopy, who I examined, after taking a good history, and then decided to treat for 3-4 weeks before making the referral? Few of these patients are happy with me after the visit, no matter how many times I explain that it is reasonable to treat their reflux symptoms for several weeks before considering endoscopy. This delay in referral has lead to many a tense moment in the last 20 years. Cost savings to the system is again thousands of dollars each and every time I do this. I am willing to make the call and go with the treatment first before getting the scope. My reward is about $55 from Medicare and the Big Blues.

How many low back pain patients have come to the office in agony knowing that there has to be something serious to cause this kind of pain? Again a good history and a directed exam allows me to reassure the patient that there is nothing we need to operate on and that the risk of missing anything in this setting is low. This takes a lot of time to explain as I teach them why they don’t need, and better yet, why they don’t want to get an MRI at this point. If someone else ordered the MRI guess who gets to explain the significance of bulging disks and narrowed foramen to an alarmed patient? Setting realistic expectations on recovery and avoiding needless imaging that rarely helps, in the acute setting of a normal exam, saves the system thousands of dollars again. My reward is another $55 if I am lucky.

How many times does a good shoulder exam allow me not to order an MRI giving the patient time to heal and recover before imaging racks up another couple of thousand dollars followed by orthopedic referral for a shoulder that doesn’t need surgery? Another $55 will shower down on me at the end of the day when I send off the bill for that exam.

How many basal cell and squamous cell cancers have I discovered while examining some ones shoulder or abdomen or even a sore throat? How many of those was I stupid enough to remove the same day, only to find out that I would be paid for only one procedure and it would always be the least expensive of the two? How many appeals have been successful to Medicare when I performed the service and was denied payment?

How many diabetics do I struggle with, trying to get them to take better care of themselves? How many hours have I spent with teenage diabetics who will not check their blood sugars and forget half of their insulin doses? I have spent hundreds of hours dealing with them and their families trying to effect changes that will someday allow them to get their disease under control. I do this because the only Endocrinologist in the county will not see pediatric diabetics. I can’t say that I blame him as the time spent seems like a total waste. That is, until one day they open their eyes and want to take care of themselves. My reward for years of struggle and years of 30 minute visits trying to get them to take responsibility for their health is a few hundred dollars at best. The savings to society for my hard work and never give up attitude is in the tens of thousands of dollars.

I continue on in my 22nd year giving advice and services to 30 plus patients each and every day. Having me in the system has resulted in savings in the hundreds of thousands of dollars each and every year. My financial incentive to hang in there and work hard is the following. Twenty years ago I made about twice as much as I do now. This year I will make less as it seems even more of the claims are being reviewed while payment sits in someone else’s account drawing interest.

I have always served my fellowman out of a sense of love and compassion and for those reasons I went into medicine. I have been richly rewarded by my patients over the decades as they appreciate my judgment and skills. Isn’t it a shame that after all this time and with skills honed by decades of experience, I can barely afford to work as a physician? Taxes will be collected, no pass for the working physician, not like the Goldman Sacks guys and their buddies with the 9 billion in bonuses given last year after the 58 billion in funds we gave them.

My parting words next year will be good luck having PA’s provide the safety net with their 2 years of training. Good luck getting newly trained physicians to take over once they see my salary. Good luck having internists in your community with only 1% of medical students going into Internal Medicine. Good luck recruiting the primary care specialists when you are short 70,000 now and 1/3 plan on retirement within 3 years.

If there is any irony in this at all, it is that I will find myself in the same boat as I struggle to find a doctor to take care of me. Now that is ironic. Anyone know who is taking new patients in California?

Vance Harris, MD

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34 Comments on "Commentology: Thoughts on the Death of Primary Care"


Guest
Thomas Schwieterman MD
Aug 18, 2009

Vance,
Thanks for posting this. As a fourth generation family doc in rural Ohio, your message rings loud and true for me. Despite 115 years of successful healthcare delivery without lawsuits and a over-full patient population, we are now finding it very hard to make ends meet.
Your message is similar to the lead story in today’s USA Today. I fear that most people in the industry and in government are underestimating the consequences of a vastly underserved primary care foundation to handle our current and future healthcare burdens.
Death in our complicated patients often occurs not from one disease, but from a progressive series failures in multiple organ systems. The death of primary care is analogous with coincident failures in providing proper prestige, adequate salary, and rewards for the efforts you mentioned above. All three will need to be addressed before we can expect primary care to flourish.

Guest
Aug 18, 2009

Dr. Harris
I am one of the biggest fan of PCPs. I also believe that they can be used to cut cost and improve care if given right tools, right incentives, and protection.
I do know they are relatively underpaid but I am not sure I agree with your dedcription of poverty. I think we shall reduce the salaries of specialists as it is too high. And NO, I do not agree with CEOs salary also specially if they are unable to create a business model where there are no lay offs. Person with even a high school education can do their job….they have no money, they fire people and when they do have, they hire.
There is no brain involved…
I hope that the health reform, which seems to be already on wrong path, will give PCPs power to be health manager….and help cut cost.
rgds
ravi
blogs.biproinc.com/healthcare
http://www.biproinc.com

Guest
pcb
Aug 18, 2009

a priceless post. absolutely hit it out of the park.
ftw, as the young people say.
(for the win)

Guest
bev M.D.
Aug 18, 2009

A very powerful post, and most in the profession (even if not in primary care) can vouch for its accuracy. Thanks for helping illuminate the situation.

Guest
MD as HELL
Aug 18, 2009

The death of primary care can be attributed to the following:
1. No standing in court.
2. Failure to diagnose…
3. Standards of care being decided by juried of lay people who of course think the standard of care would have to be assuring the plaitiff had not died or suffered serious injury. Anything short of this is considered “neglegent”.
Hence the rise of specialists and the consumer movement usurping medical control of the dying patient and the management of the death of a patient from the patient’s doctor to the family who, quite naturally, do not want guilt heaped on them by the death of a loved one.
Hence the rise of PEG tubes and dialysis for all, mega workups ON DEMAND in the ED to show a patient is stable enough to go home.
Hence the rise of statin therapy for all.
Welcome the age of the specialist. The government initially neutered primary docs who were the cost drivers in the 1980’s. Now primary care is irrelevant to anything.
Primary docs used to deliver babies until the tort crisis made it economically untenable with huge premiums required to cover the unexpected outcomes that led to expensive care of surviving babies. Todays obstetrician is being crushed by the same forces. More and more OB-GYN docs are dropping obstetrics.
The missing ingredient in the futue of primary care is a relationship. Docs used to practice in a single community forever. It was rare one ever moved. Now primary docs move frequently to find a better life style, more money or less litigation.
I trained in family practice. The very next day I started working in an ED. I have been there ever since (same one, also rare.) I have watched my community’s medical staff deteriorate. The family docs no longer admit there own patients, because it is not economically feasable to do so. This is true for our general internists as well.
We now are having a huge pay for call discussion with our surgeons. This is a nationwide trend where the hospital has to pay the surgeon just to be available. We canot recruit new docs here if the lifestyle includes every third night call. Unassigned coverage for the ED is getting very shaky.
The only way out is for the patient to once again value a long term relationship with a doctor who will help them live well and long and then help them die without pain and without family guilt and without liability for being a good doc.

Guest
rbar
Aug 18, 2009

Most of the described problems don’t have much to do with the problem of specialist vs. primary care, but rather with a culture of immediate satisfaction and desire for health care technology/gadgets that IMHO is particularly strong in the US.
I am a nonsurgical specialist. For many problems, watchful waiting is very reasonable, and it is actually my specialty training and experience that make me comfortable suggesting that (as opposed to a PCP who may not feel comfortable with observation). The problem is: very many, if not most patients want tests (pictures, labs) +/- “specific” therapy (prescription drugs) and think that they miss out on something.
And the other side is the threat of litigation, as MD as HELL already explained.
It can’t be said often enough: for physicians, there is barely a reason NOT to order any (noninvasive) test, but multiple motivations to order many, even worthless ones.

Guest
jd
Aug 18, 2009

What a fantastic argument for no longer paying physicians on a fee for service basis.

Guest
MD as HELL
Aug 18, 2009

No fee no service.

Guest
dwhite
Aug 18, 2009

WOW! How eloquent. You have written exactly what I was feeling a year ago when I left general internal medicine for hospital medicine. Primary care is a sinking ship with CMS and malpractice lawyers making direct hits broadside.

Guest
Claudia B Rutherford PhD
Aug 19, 2009

You make such good points and I empathize with your plight! I am a clinical psychologist and I couldn’t help but notice as I read your post that many of the people you mentioned who came in with physical symptoms, you seemed to suspect were actually having anxiety or depression. Our whole healthcare system discourages prevention and it also discourages mental health treatment. Just as primary care doctors are grossly underpaid, so are psychologists and social workers. The current system discourages us from working collaboratively with other providers (for example, calling the primary care doctor to talk about what contribution mental health issues may have or may not have in a particular patient’s symptoms). It discourages us from trying to solve anything without immediately suggesting psychiatric medication, which certainly has its place in some situations but not all and is not a panacea. It is so frustrating how far the existing healthcare system is from actual provision of care to patients and our ability to manage financially as providers.

Guest
Economics 101
Aug 19, 2009

I am a family physician. My twenty-something daughter graduated from an ivy league school with a BS in computer science. She now works for a well-known tech company. Salary + bonus + stock options = more than $200K/yr and great benefits to boot. Her future is bright with boundless upward mobility. Cohorts who are going to medical school? 4 years undergrad + 4 years med school + 4 years residency + lost opportunity in the workplace = a whole lot less than $200K if they go into primary care and not a lot of upward mobility. Why don’t we have enough primary care physicians? Young people are better at math than we think.

Guest
DrWonderful
Aug 22, 2009

There will be no health insurance reform until the health insurance industry is no longer allowed to collude and price fix. Repeal their anti-trust exemption and see how quickly they behave.

Guest
Jim Bertsch
Aug 22, 2009

Primary care physicians are victims of the current health care system. Especially those who are interested in caring for their patients. Those that have adapted to the system realize that they are not dealing with patients but customers. They need to wring every last dollar from them to line everyone’s pocket. It is the primary role of the doctor to generate revenue for the system. If he happens to help a few customers feel better that is a good thing, but not required.

Guest
DrWonderful
Aug 22, 2009

There will be no substantive changes in health care until the health insurance industry loses it’s anti-trust exemption. As it stands now they can collude and price fix thereby making sure there is no free market competition. They basically lay dormant and rivers of money passively flow to them. That is not good for America and it’s been bad for doctors and patients for quite some time. Repeal the anti-trust exemption for health insurance companies. Their run is over. We’re not selling tires here, folks.

Guest
propensity
Aug 22, 2009

Vance,
You forgot to mention the forms, the PBMs, the inane letters reminding you how long a patient should be treated, and the demands of insurance carriers for records to enable a clerk to determine how well you care for your patients.