By MATTHEW HOLT
A few weeks back I wrote an article on what’s wrong with primary care and how we should fix it. The tl:dr version was to give every American a concierge primary care physician paid for by the government. We would give everyone a $2k voucher (on average, dependent on age, medical status, location, etc) and have an average panel of 600 people per PCP.
My argument was that a) this would be cheaper than health care now – due to cutting back on Emergency Department visits and inpatient admissions and that b) it would enable us to pay PCPs the same as specialists (roughly $500K a year). This would mean that many current ED docs, internists, hospitalists etc would convert to being PCPs. I also think that we could and would make better use of the now 400,000 nurse practitioners in the US. We would only need about 600,000 PCPs to make this work. Although it would double spending on primary care, it would reduce health care costs overall. (OK there’s some debate about this but the Milliman study linked above and common sense suggests it would save money).
There are obviously two huge issues with my proposal. First we would have to go through the conversion process. Second, we would have to do something big with the three major players who are sucking at the teat of health care $$ right now—those being big hospital systems and their associated specialists, health insurers, and pharma and device companies.
I don’t think that there will be any problem selling this to most doctors or to the American people.
The doctors know that they are trapped in the current system. This would free them to practice as they want to practice, and to remember why they got into medicine in the first place—to care for their patients holistically.
People know all too well that accessing primary care is both good for them and also very difficult. Wait lists are way too long. In this system primary care would be abundant. And I and many others have only horror stories of how big hospital systems, insurers and big pharma treat them badly. They would much rather have an empowered PCP on their side.
The only concern about primary care for patients is if the PCP is incented to not refer them to needed specialty care. In my system there would be no global capitation or risk to the PCP, and thus no incentive not to refer out. But no reason to refer out unnecessarily. They would do the right thing because it is the right thing. (It has taken Jeff Goldsmith 30 years to convince me of this). So there would be no need for insurance companies to manage primary care at all. No claims, no bills, no utilization management. Instead we should have 600,000 primary care docs paid well and able to manage their practices to do the right thing.
And this would probably involve a ton of variation. There would be PCPs who work in groups. There would be solo. There would be those specializing in specific types of patients (think kids or people with serious diseases or geriatricians). They would all make the same amount of salary but their practice’s revenue and number of patients would be adjusted in a similar way to how we do risk adjustment for Medicare Advantage now, but without the games, and with no profit motive.
This system would create a lot of innovation. PCPs would be responsible for those with chronic conditions. They would have budget from the $2,000 per head (of which they would get roughly $800 as income) to build remote monitoring programs, to use AI, to build teams of assistants and nurses et al.
So can it be done in the US? Yes it already has. I urge you to take the time to read this ingenious ChatGPT summary of the Nuka system in Alaska. (I believe created by Steve Schutzer MD). Nuka went from being a hidebound bureaucratic expensive system–that its patients hated–to being a system with culturally appropriate care that its “consumer-owners” love today. And its costs are lower and outcomes better. There are lots of other examples of similar approaches across the US. Just ask Dave Chase. They just haven’t scaled because the current incumbents have killed them. (One great example is this case in Texas where a hospital chain bought and killed a big primary care group led by Scott Conard because it was costing them $100m a year in reduced hospital FFS admissions).
What we need is to set up the incentives, prod doctors and patients hard to get into these arrangements and let American ingenuity and medical professionalism go at it.
The other side of the equation is the need to reign in the costs of specialty and hospital care. How this would happen is up for debate.
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