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 thousand.
And, for big academic practices like UCSF’s and MGH, opening up new primary care practices involves substantial subsidies, which 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 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). (A percentage or two won’t help because the increases needed to change the dynamics are on the order of 20-40%.)
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 health care 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 forgo 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 insiders like medical school faculty members can’t find a regular doctor, though, 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.