Chapter Nine. Primary Care Doldrums

This is chapter nine in my new book Health Reform in Perspective

Prologue: This is a brief chapter. Everybody knows primary care physicians are an endangered species. The reasons why are obvious, and so are the solutions – higher pay, more respect, and more trust in them as personal health advisors and guides to specialist care.

The Low Value of Primary Care Doctors in Eyes of Patients

Preface: Sometimes it is painful to discuss the obvious, especially when the obvious goes against your grain. But here goes. Primary care is in a bad way. Only 2% of medical students are picking primary care specialties. The number of primary care doctors is dropping. And over 90% of costs stem from specialty care. The reasons are obvious: low reimbursement, long work hours, and as Rodney Dangerfield, might say, “We get no respect.” This in face of the fact that policy types and payers, like IBM, are calling for a rejuvenation of primary care as the salvation of American medicine with its cost, coordination, care improvement, and efficiency problems.

It pains me to say this. But the deck is stacked against primary care. I won’t go into the reasons why, but, according to the following blog, one is the low value patients place on primary care physicians.

Chris Rangel, MD, a practicing internist, brilliantly explains this in his blog RangelMD.com. I recommend that you go to his blog and read his other posts and that you visit kevinmd.com, which features Rangel’s blog with 34 comments from patients and primary care doctors, mostly affirming what he says.


Why Patients Don’t Value Primary Care Doctors

“’Hey doc, all I need is this referral.’

I’ve been encountering more of this lately. A patient who has not been seen in the office for months to years (well beyond when they were supposed to come back for a follow up visit) walks in and requests a “referral” for a specialist visit but they can’t be bothered with actually being seen and evaluated in the office or to be compliant with their return appointments.

Or they do show up years after their last visit for no purpose other then that the specialist they recently saw after developing a serious illness and being hospitalized, told them that they needed to “go see their PCP to get a referral.”

Seriously? This entire concept of the “referral” system required by insurance companies was designed to contain health care costs by making the primary care provider a so-called “gatekeeper” who controls utilization by deciding who needs a referral and who does not.

In very few circumstances were the “gatekeepers” given incentives to avoid “unnecessary” referrals and more commonly, they were penalized financially for what the insurance company considered to be excessive utilization. Even worse, at least one study found no differences in utilization of referrals whether they were required or not. Hence, there remains no good evidence that this system works to reduce utilization or enhance primary care.

Currently, our health care is a system that emphasizes specialty and complex care over primary care and requires patients to get referrals from their PCPs but does not absolutely require them to be compliant with routine primary care visits and preventative care. As such, the importance and utilization of primary care has been marginalized even by patients who increasingly see it as a bureaucratic burden. Even for patients, primary care is little more than a paperwork hassle.

The irony is that primary care works!

In 2008, a Congressional Budget Office report found huge geographic variations in Medicare resource utilization (health care spending) and that areas with high spending also tended to have high relative populations of medical and surgical specialists (and hospital beds) and actually had worse quality outcomes than areas with lower spending rates and lower relative numbers of specialists.

But it’s not just the relative numbers of expensive specialty care that affects care quality. A 2005 review of the literature by Johns Hopkins University researchers found that primary care does indeed work to prevent and treat disease and health care quality and access is improved in areas that have higher relative numbers of primary care physicians.

But all of this favorable data was virtually ignored by Democrats and the Obama administration in the last – certain to be disastrous – “reform” of health care which didn’t even fix the always impending 21% Medicare physician pay cut.
Patients take their cues from the current system and insurance company and Medicare policy. Primary care providers are seen as little more than purposeless “gatekeepers”, especially when it comes to anything more serious than a cold or vaccines.

But maybe if these patients in question – all of whom had insurance with low co-pays – had been seen regularly then maybe this would have changed. Maybe if the patient noted above would have been seen much earlier when her symptoms first appeared, a simple blood test could have detected her condition at a stage where she could have been evaluated and treated as an out-patient before it became severe and life-threatening.

Avoiding expensive hospitalizations is something that primary care can improve and yet primary care is even marginalized by the insurance companies who end up paying for the hospitalizations and ER visits. Go figure.