Physicians

Why We Need Private Primary Care Doctors

Things have been busy in my absence.  A recent post on Kevin MD by Joseph Biundo, a rheumatologist, challenged my assertion that primary care doctors can save money:

(In reference to my claim) That may be true in theory, but I see patients in my rheumatology office every day who have been “worked up” by primary care physicians and come in with piles of lab tests, and x-ray and MRI reports but are diagnosed in my office by a simple history and physical exam.

Prior to that, an article in the NY times along with a post by Kevin Pho noted the fact that more solo practitioners are leaving private practice and joining hospital systems.  Why are they doing this?  Dr. Kevin suggests the following:

Lifestyle matters. More doctors are entering the workforce seeking part-time jobs in order to maintain a family balance. By removing the administrative hassles from their plate, they can go back to focusing solely on practicing medicine and coming home at a reasonable hour.

The NY Times article suggests possible benefits to patients:

In many ways, patients benefit from higher quality and better coordinated care, as doctors from various fields join a single organization. In such systems, patient records can pass seamlessly from doctor to specialist to hospital, helping avoid the kind of dangerous slip-ups that cost the lives of an estimated 100,000 people in this country each year.

So as a primary care doctor in private practice, am I soon to go the way of the dinosaur?  Is this simply a shift in the business model as demanded by the times, or should people be concerned?  Would the system function better with fewer primary care doctors or ones who are employed by large hospital systems?

Those who read my blog regularly (and those clever enough to read the title of this post) already know my answer: private primary care is essential for a healthy healthcare system.

Why Primary Care?

While I can’t disagree with Dr. Biundo on his point regarding the physical exam skills of PCP’s, I do disagree that this raises question of the cost-effectiveness of primary care.  In his case (the practice of rheumatology), there are few expensive procedures, the diseases are less common (compared to fields like cardiology and other high cost specialties), and the patients don’t spend a high number of days in the hospital.  One overnight stay for a cardiac catheterization will pay a large part of a rheumatologist’s salary for a year.

Like primary care, rheumatology is largely an outpatient practice, with success being measured by the ability of the practitioner to keep the patient out of the hospital and away from expensive procedures.  Lately, rheumatologists have started having biologic medications (like Enbrel) that are quite costly, but the number of people on this relative to the general public is still quite small.

Primary care, on the other hand, is the fountainhead of all healthcare costs.  A good PCP is also measured by patients staying out of the hospital and away from expensive procedures.  In general, a PCP is less likely to:

  • order an x-ray compared to an orthopedist
  • get an EKG compared to a cardiologist, or
  • order an endoscopy compared to a gastroenterologist.

There are some high-consuming primary care doctors, but much of the blame for this can be placed on the payment system that encourages expensive procedures and the ordering of tests.  For example, one of the PCP groups in our area has their own stress-testing equipment and CT scanner.  I am 100% sure that the physicians in this group order many more CT scans and stress tests when compared the physicians in my practice.  I am also sure that the care quality in my practice does not suffer from our lack of test-ordering.  Why?  Because the physicians are financially motivated to order these tests, making the appropriate business decision clash with the appropriate medical decision.  As long as it’s not harmful to order the test, the doctor can justify it.

Even these physicians, however, are not going to do any of these tests as much as a specialist, who depends on the presence of chronic disease to make a living.  The only specialists I have seen who are slow to order tests and procedures are those who don’t financially profit from their ordering: academic specialists.

Why Private Practice?

This brings me to my second point, which is the necessity of having primary care physicians who are in private practice.

Why do hospitals have an interest in hiring primary care physicians?  The answer is twofold: first, they allow them to negotiate contracts with the insurance companies in a position of strength.  Primary care is a must for most insurance contracts.  Patients will change insurance plans if their PCP is not on the plan, but they won’t do so nearly as much for specialists (with the possible exception of OB/GYN, which often act as PCP’s) or hospitals.  Plus, most insurance plans do their care management by requiring referrals, denying or accepting them being their means of cost control.  Primary care physicians are the referring physicians, and without them the hospital’s negotiating power is greatly diminished.

The second reason hospitals want PCP’s under their wing is that they generate business by ordering radiology tests, lab tests, and sending patients to specialists who will do expensive procedures in their facilities.  Primary care is a loss-leader to hospitals.  Hospitals make no money off of their PCP practices directly but make a huge amount from the referrals and procedures they generate.

This shifts the mission of the PCP.  The “success” of the PCP in the eye of the hospital system is not to avoid referrals or costly procedures, but to order them.  It’s not bad in the eye of the hospital that the PCP has higher hospitalization rates, it is better.

The Answer

The solution from an overall cost standpoint is to give primary care physicians incentive to do what they should be doing in the first place: keep people healthy and away from hospitals.  Any system that places too much value on procedures is going to fail at this, as the institutions and individuals who profit off of the procedures are going to fight for control of PCP’s.  Independent PCP’s who profit from keeping people well are the best thing for a system.

I have lived in both worlds: as a private PCP and as a salaried physician from a hospital.  I left the latter because it was clear that they had no interest at running my practice well and really just wanted me to be a turnstile into their money-making procedures.  It would be a big mistake to take away the one specialty that restrains cost.  We need to do the opposite, and encourage good primary care medicine.

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.

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John DoeLouisofficeconciantPrimary Health Care CentersFaisal Qureshi Recent comment authors
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John Doe
Guest

Good work ! Keep us posting.

Louis
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Louis

I would like to know where an individual could search and find part time positions for PCP.
I know many PCP’s that have had it and have no faith in the government going forward regarding America’s health care system and they want OUT! They want quality of life and balance, NOT more $$$$$$ and Bureaucracy.

officeconciant
Guest

There is actually a vast revenue of primary care physicians, of whom 99% are in private practice, provide highly cost-efficient health care, and the usage of whom has been shown to reduce the need for more expensive interventions.

Primary Health Care Centers
Guest

I agree with you in this topic,and thanks for you, and i had information about Primary Health Care Centers
in King Abdulaziz Medical City
,I hope to like you

Faisal Qureshi
Guest

It’s amazing how few private PCPs realize their power. They are the routers for patients to the lucrative specialist cobweb.
Smart PCPs are build alliances with their specialty referral patterns all the while adhering to STARK.
Is a minor in business needed in med school for PCPs to survive?

lmj
Guest
lmj

I think it is important to define out need for primary care phsyicians. Our healthcare system needs to be more proactive, rather than reactive. The article mentions how PCPs try and keep patietns healthy and out of hospitals. While I respect the expertise of specialists, I often feel they order unneeded tests and this leads to increases in healthcare costs. For decades, the PCP treated all ailments the patient presented with. I do agree that incentives often drive behavior, and if we need to provide PCPs with incentives to keep patients healthy, then we must do so.

Rob
Guest

OK, sorry I am late to comment on comments. I actually would be just as reluctant to join with subspecialists – maybe that’s just my bias from my position, but the hospitals and specialists are on the consuming side of health care. In other words, they benefit from more procedures, more sick patients, and more care. Primary care (and specialties like rheumatology, endocrinology, and other non-hospital specialties) are the opposite. If I am paid more to profit my group most, then I am motivated to use medical resources more. Our system has to only encourage use of resources when appropriate.… Read more »

Avery Jenkins
Guest

There is actually a vast revenue of primary care physicians, of whom 99% are in private practice, provide highly cost-efficient health care, and the usage of whom has been shown to reduce the need for more expensive interventions.
I wrote about this in some detail at:
http://www.averyjenkins.com/?p=84

inchoate but earnest
Guest
inchoate but earnest

oh, and James, you actually think Matt has anyone moderating this carnival? Where on earth would he find time or energy to do that, after nomming down all of that Parisian snails & champagne?

inchoate but earnest
Guest
inchoate but earnest

Nate, what’s your take on Section 10104 of the new health law? Qliance seems to think it addresses your PCP capitation suggestion: “the Dept of HHS shall permit coverage in the exchange to be offered through a qualified direct primary care medical home plan.’’ This provision enables Americans who shop in the insurance exchanges to elect an alternative to traditional insurance plans in which patients and/or employers pay a flat monthly fee directly to a primary care provider for all primary and preventive care, chronic disease management and care coordination throughout the entire health care system. Also, I’ve never seen… Read more »

James
Guest
James

Has anyone looked at how Scott & White in Texas? As an integrated system, they somehow seem to make this all work. I note they also have a health plan, which might be a factor in their institutional self-discipline regarding highly effective care. Their Dartmouth scores are impressive (Central Texas is an island of low Medicare costs).
Also, to the admins, is there any way to implement a spam flagging system for the comments? There seem to be more of these “ads discuised as posts” lately.

Barry Carol
Guest
Barry Carol

Nate – Those are all good points. I’m not clear, though, on the definition of episodic care. I understand that a hip replacement, CABG or other surgeries are episodic. What about a screening colonoscopy or an MRI to try to diagnose or rule out a problem? Both could be considered part of sound medical management or they could be done to drive revenue, especially the MRI’s. It’s also interesting to note that in Massachusetts, investigators found that care delivered under capitated payments sometimes cost more than the same care would have cost if it were paid on a fee for… Read more »

DNA Activation
Guest

This is really interesting take on the concept. I never thought of it that way. I came across this site recently which I think will be of great use http://www.dnaperfection.com . Have a look!

Nate
Guest
Nate

While a large multi speciality IPO can work in large population centers what does the rest of the country do? When there is only 1-2 doctors in town is there still an advantage to partnering with other docs hundreds of miles away? What works for/in CA, NY etc isn’t going to work in Montana. Barry do you think capitated primary care is viewed the same way as capitated hospital care or speciality? Fee for servie works for care that is episodic. Primary care on the other hand is probably the only care that makes sense to capitate. A nice trial… Read more »

Improve patient satisfaction
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Improve patient satisfaction

Good post, we BTW use patientsurvey.com for keeping a tab on patient feedback. Works out well. Makes the staff also think twice about how they treat patients. Also, this is helping out to let go staff who are not doing a great job. What better way to document something than something that is provided to you by patients themselves. Plus, all staff wears a name tag just to make sure they know patients can see who the person is. Also, doctors are now reviewing these every month as well. They get positive and negative feedback about how patients feel about… Read more »