By HANS DUVEFELT, MD
Dr. Hans Duvefelt
In most other human activities there are two speeds, fast and slow. Usually, one dominates. Think firefighting versus bridge design. Healthcare spans from one extreme to the other. Think Code Blue versus diabetes care.
Primary Care was once a place where you treated things like earaches and unexplained weight loss in appointments of different length with documentation of different complexity. By doing both in the same clinic over the lifespan of patients, an aggregate picture of each patient was created and curated.
A patient with an earache used to be in and out in less than five minutes. That doesn’t happen anymore. Not that doctors and clinics wouldn’t love to work that way, but we are severely penalized for providing quick access and focused care for our well-established patients.
Why is that?
Our Quality mandates have ended up creating perverse roadblocks and disincentives for taking care of the simplest needs of our patients. Any time we don’t screen for depression, alcohol use, smoking and readiness to quit, obesity, immunization status, blood pressure control and so on, we lose brownie points and, increasingly, money.
This is happening near me:
The primary care practices of Maine Coast Memorial Hospital in Ellsworth Maine have lost many, if not most, of their providers in recent years after some belt-tightening due to running the clinics at a loss. They are not able to see new patients for six months or more. BUT the hospital is actively promoting its walk-in urgent care center – and they don’t seem to have trouble staffing it, and don’t appear to be losing very much money on it.
Bangor, Maine, home of a small Catholic Hospital and a 400+ bed hospital with a level 2 trauma designation, cardiac surgery, neurosurgery and many other specialties, has a severe lack of primary care doctors in spite of having a Family Medicine residency. Yet, a private out-of-state company is building a brand new freestanding urgent care center a couple of blocks from the Catholic hospital.
Quick and easy acute care visits could generate revenue with positive cash flow for primary care practices, especially for Federally Qualified Health Centers with their flat rate reimbursement, but possibly for all practices, if CMS’ new proposal to scrap differentiated Evaluation and Management codes becomes reality. But the requirement to weigh down the simplest visits with all those screening requirements eliminates the incentive to nimbly meet patients’ need for access.
The end result will be that primary care providers will become chronic care providers only, and care will be fragmented so that anything profitable will be siphoned off to freestanding entrepreneurs or hospital-owned profit centers. Meanwhile, primary care practices risk becoming more and more of a millstone around their hospital owners neck because all their patient visits are more complex and costly than the reimbursement scheme can support.
And more and more providers will be tempted to jump ship for the easier work and greater predictability of a Doc in a Box career.
The only solution is to acknowledge that Family Medicine and all primary care is meant to assess patients over the continuum of time. You don’t have to fix the whole person when all they ask for is some penicillin for their strep throat.
Sometimes you need to be quick and sometimes you need to be slow. Without the freedom to adapt, in a patient-centered way, to the situation each patient presents with, primary care risks going under.
Hans Duvefelt, MD is a Swedish-born family physician in a small town in rural Maine. He blogs regularly at A Country Doctor Writes where this piece originally appeared.
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My one experience with a Minute Clinic was unsatisfactory. I had a wax buildup in my ears but the NP was unable to remove it. She sold me some Debrox to loosen it up and I saw my PCP who was able to remove it easily. Retail clinics are good for some minor things but I would only use them if my PCP was either closed at that time or fully booked for the next few days. Urgent care centers are probably a better option under those circumstances though they are more expensive.
“I saw 27 patients in my clinic yesterday during walk-in hours, and we would do more of that every day of the week if the comprehensiveness regs were lifted.”
Do you really want to use your extensive knowledge, experience and training to compete with drug store NPs diagnosing runny noses?
As I pointed out, urgent care is somehow freed from the millstone of being comprehensive in every single visit, even though they may only see a patient once. I saw 27 patients in my clinic yesterday during walk-in hours, and we would do more of that every day of the week if the comprehensiveness regs were lifted.
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I disagree. Even Maryland’s all-payer system pays academic medical centers like Johns Hopkins and University of Maryland more than it pays community hospitals and it pays community hospitals more than it pays ambulatory surgical centers. While large health systems may have the market power to negotiate better payment rates than smaller systems, insurers can push back against that with tiered copays just as they already does with drugs.
Once you allow disclosure of reimbursement rates you run into the monopsony conundrum even though there may not be a domonant purchaser: every time a payer needs to hire a new provider, it has to pay every additional employ AND every old employ the same new rate!
Thus is a dead weight loss to society.
The reason this happens is simple: an old employee, payee, etc. is going to say to himself: “shucks, I’m not being paid what thus new guy is getting…I’ll just quit and be re-hired!”
Your assumption is correct. Thanks.
While list prices are off the chart, especially hospital list prices, insurers’ contract reimbursement rates are within reason while providers claim Medicare and especially Medicaid rates don’t cover their full costs. Drug company rebates are mainly a problem for the uninsured and those with a high deductible insurance plan but that problem can be easily solved.
Give me litigation reform that includes safe harbor protection for doctors who follow evidence based guidelines and protocols where they exist, a more sensible approach to end of life care that allows doctors to apply common sense depending on circumstances without having to worry about being sued for not offering a full court press no matter how futile, and outlawing of confidentiality agreements between payers and providers that preclude disclosure of contract reimbursement rates and much of the cost problem will resolve itself.
Congrats on letter published in the WSJ today Aug. 28 re the need for price transparency. (Assume you are the Barry Carol published).
If nearly one fifth of the GDP is spent on car repair, everyone would be spending a fortune on every little thing like valve stem repair, glove box liners and winter wiper fluid. We’ve allowed the stakeholders to gain too much power and income. Time for a physician union or a stronger voice somehow.
Believe it or not, pharmacies generally make more gross profit dollars on a generic script than they do on a brand name script even though the generic is significantly cheaper. Pharmacy margins on brand name drugs are MUCH lower than on generics. Moreover, pharmacists can and generally will provide a generic drug in place of a brand name drug as long as the doctor didn’t check the dispense as written (DAW) box on the prescription form. Close to 90% of all prescriptions are generics now.
As for giving urgent care centers a higher reimbursement rate than primary care doctors receive for the same consult, it probably has to do with a long history of reimbursing for costs. Urgent care centers are open more hours per week than the typical primary care practice which accounts for their higher costs but the insurers see them as a significantly lower cost alternative to an ER visit.
The 33% higher payment is based on EOBs my patients share with me.
The 50% higher use of scripts, especially brand-name, is anecdotal – 3 months of reviewing progress notes from urgent care compared to my progress notes – treatment for URIs, sinusitis, and bronchitis.
It’s not malpractice. It’s part of the incredibly complicated feedback between urgent cares, pharmacy chains, PBMs, and insurers.
It’s sickening – don’t defend it.
I think the minute clinics and telemedicine models are more useful than most people think. Doctors should definetely utilize them more in after hours visits or during regular hours on certain conditions.
“Patients are 50% more likely to get a script for a brand-name antibiotic at the urgent care – the pharmacy chain that owns them needs to get their cut.”
I’m not sure how you can prove that statement, but if that’s happening then I would consider that malpractice, both for over use of antibiotic and for insider trading so to speak.
How/why is the insurance company authorizing brand name over generic?
Res, the notion that insurance companies and pharmacies can run ersatz primary care clinics is a scary one. Makes the doctor and the patient relegated to third and fourth fiddle.
The major insurer in our area pays the local urgent care 33% more than they pay me for a level three visit. Patients are 50% more likely to get a script for a brand-name antibiotic at the urgent care – the pharmacy chain that owns them needs to get their cut.
I guess we save money on volume?
Peter, I disagree. Minute clinics are not the way to save money. My point with this post is: Allow us to do quick visits with people we know by liberating us from screening for this, that and the other EVERY SINGLE TIME. We know these folks. We are in the best position to have a quick visit and still spot the weird stuff, like the sinusitis patient with slower than usual mentation who actually has a brain abscess.
“A patient with an earache used to be in and out in less than five minutes.”
In my youth my mother treated most non-life threatening aliments, but that skill does not seem to exist any more. So now we have CVS Minute Clinics for, “the little stuff”.
I firmly believe in the primary care model and that they should be compensated for their skill and hopefully comprehensive coordinated patient care, which does not include things like ear aches, just so the bottom line can show some good margins.
If you believe we are spending too much on health care then minute clinics save us money.
Now two years ago, I finally closed our small group, private Primary Healthcare office after 41 years. Our inability to find and fund affordable EMR that supported our ability to manage comprehensive care plans finally “shut-us” down after 41 years. Admittedly, it occurred with the relief of my family. So, I continue my avocation that started ten years ago.
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I have chased the conundrum represented by the cost and quality problems of our nation’s healthcare with only a modicum of improved insight. Two observations may represent the fundamental underlying issues. Our nation’s health spending will eventually bankrupt our Federal government, AND the most representative attribute for its overall quality issues is the worsening incidence of our nation’s maternal mortality. It needs to be reduced by 70% for our nation to rank among the 10 lowest (best) of the other 34 OECD nations. There are probably at least 500 women who die annually as a result of a pregnancy just because they lived in the wrong nation at the start of their pregnancy. This number has worsened for “25” years in a row.
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We will need a comprehensive strategy to assure that enhanced Primary Healthcare is equitably available, ecologically accessible, justly efficient and reliably effective for each community’s citizens. This must be sponsored by several national policies, especially for the funding of advanced Primary Health Care, AND locally coordinated along with each community’s local efforts to ameliorate its own sociodemographic determinants of diminished social mobility. Currently, healthcare reform is burdened by its institutional codependency, its wide-spread cognitive dissonance and its inability to finance the nationally uniform, enhancement of Primary Healthcare that is uniformly available by each citizen.
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By promoting an engaged caring relationship with a Primary Physician and their Healthcare Team for each citizen, the basis for for coordinating Complex Healthcare Needs becomes more resilient. To understand the underlying attributes, I offer an expanded definition:
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..a social interaction between two persons,
..occurring with an evolving purpose, synergy and permanence,
..that both person’s understand as representing a beneficent intent
..to enhance each other’s autonomy by communicating in harmony
..with warmth, non-critical acceptance, honesty and empathy.