Saving Primary Care

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In the twenty years I’ve been a primary care physician at the University of Chicago I’ve had the opportunity to do many challenging and interesting things. I ran primary care for seven years, led the implementation of an enterprise-wide electronic medical record system for six years, and served as the assistant vice president for Student Health and Counseling Services for four years. Nowhere else but in academic medicine could a primary care doctor find the opportunity to reinvent himself so often and so dramatically without having to change employers. But since the beginning of 2015 I’ve felt a strong desire to return to my roots—to become a full-time clinician again—so in July I announced that I’d be leaving the university to take care of patients full-time. Almost immediately I found myself filled with a renewed vigor, a remembered sense of purpose—but also with a feeling of dread, because practicing full-time primary care even in the protected environment of academic medicine has, in my view, become untenable.

A Broken Healthcare System

The healthcare landscape in the U.S. seems to have changed more rapidly in the last two years than it has in the last two decades. The Affordable Care Act (ACA) has mandated health insurance for all Americans and made it possible for approximately 30 million more of them to obtain it. While this is a welcome development, it poses a significant problem: not only is there already a shortage of primary care physicians to care for those currently insured, but also according to a survey conducted by the Urban Institute in 2012, 30% of primary care physicians between the ages of 35-49 and 53% of primary care physicians over the age of 50 want to quit medicine altogether. When we also consider that the rate at which medical students are choosing to enter primary care has plummeted to a mere 2%, we’re forced to conclude that the shortage of primary care physicians isn’t a looming crisis—it’s a crisis that’s already here.

Indeed, estimates show that the U.S. is 29,800 primary care physicians short of what it needs right now. What’s more, after taking into consideration the insurance expansion expected from the passage of the ACA, this deficit is expected to grow to 45,400 by 2020, and by 2025 it’s estimated that the U.S. will require nearly 52,000 additional primary care physicians to absorb an expected increase in the number of office visits, which are predicted to rise from the 462 million in 2008 to 565 million in 2025.

This is a problem not just because restricted access to primary care is associated with patient dissatisfaction, but also because it’s associated with a decrease in the quality of care and an increase in the cost of care. Inadequate primary care, in other words, lies at the heart of the three most pressing problems facing medicine today.

Just how hard is it to get access to primary care in America? According to a study conducted by Merritt-Hawkins in 2013 in multiple cities across the U.S., the average wait time for an appointment with a primary care physician is approximately 20 days. Also, according to Becker’s Hospital Review, even in Urgent Care centers (specifically designed to get patients in to see providers quickly) once patients arrive at their appointments almost 30% have to wait up to 40 minutes to be seen. What’s more, the average length of time primary care appointments last is only 15.7 minutes.

For simple issues like ankle sprains or back pain, this might be enough. But for patients with multiple, complex issues it’s completely inadequate—and further leaves no time to address important topics that require extended dialogue, like end-of-life care in terminal cases. What’s more, dealing effectively with important emotional issues (stress, anxiety, depression, and so on) in such a timeframe is nearly impossible, as are meaningful and effective discussions surrounding preventive care.

Clearly, reduced access to care impinges on the quality of care. But paradoxically too much access—that is, too much care—does as well. Every test and every intervention, from a routine blood draw to major surgery, carries with it a set of predictable risks. And though these risks are usually acceptably low at the level of the individual (or at the very least outweighed by the benefits), when viewed at the level of whole populations their impact becomes considerable. In December 1999, for example, the Institute of Medicine reported that medical errors cause up to 98,000 deaths each year in the United States. Yet as startling as the rates of death are from medical error, they pale in comparison to the rates of death from tests and procedures themselves: approximately 686,000 people die each year (Table 1) as a result of undergoing medical tests and procedures even when no error occurs. We think these tests and procedures save far more lives than they take (otherwise we wouldn’t perform them), but the take home point is clear: tests and procedures that are unnecessary, and which therefore expose patients to unjustified risk, must be avoided at all costs.

This is precisely what good primary care should do—protect patients from unjustified risk. But in the current environment when primary care practices are overflowing with anywhere from 1,500 to 4,000 patients per physician, there often isn’t adequate time to gather detailed medical histories, perform complete physical exams, think through challenging diagnostic dilemmas, or search the medical literature in search of answers when answers aren’t immediately obvious. As a result, primary care physicians themselves are frequently responsible for the overutilization of healthcare resources. Unnecessary ER visits, tests, and specialty referrals have become commonplace because primary care physicians often don’t have the availability or capacity to work through problems themselves. It’s not that they don’t want to practice better medicine. It’s that they often don’t have time.

This is why the idea of going back into full-time practice filled me with dread: in a standard fee-for-service primary care practice, physicians simply don’t have enough time to give their patients the care they actually need. There isn’t enough time to pay attention to all the problems patients bring, to think about them without worrying about getting behind; to do literature searches when facing puzzling diagnostic dilemmas; to learn about patients’ lives to be able to tailor advice to their values; to talk with them about their stress; to design lifestyle interventions to help them lose weight, begin an exercise program, quit smoking, get adequate sleep, or achieve a better work-life balance; to curate the overwhelming amount of health information constantly bombarding them into concise, relevant, bite-sized pieces that can be digested easily and in so doing help motivate them to make substantive positive changes in their lives. In short, in traditional fee-for-service practices, there isn’t time to practice medicine as it should be practiced.

Why have primary care physician rosters grown so large? It’s not because the healthcare industry has decided that taking care of 1,500 to 4,000 patients is optimal for patient care. Rather, it’s because insurance reimbursement for primary care has steadily declined and primary care physicians have been forced to increase the number of patients they see to survive financially. As a result, they’re able to spend less time with patients than they need, which often leads, as we’ve seen, not to too little care but rather to too much.

Too much care—that is, unnecessary care—doesn’t, of course, just impact healthcare quality. It also impacts healthcare cost. For example, in 2010 $29.7 billion was spent in hospitalizing patients for potentially preventable complications of diseases like diabetes, congestive heart failure, and osteoarthritis. These are all conditions typically managed by primary care physicians—conditions that, when managed well, should rarely result in hospitalization. Unnecessary hospitalization also drives a large portion of the year-over-year increase in health insurance premiums (the more that patients see physicians, have tests performed and interventions made, the higher premiums rise). Unfortunately, the rate of this rise is about to increase sharply: starting in 2018 the ACA will impose a 40% excise tax on any plan with annual premiums that exceed $10,200 for individuals and $27,500 for a family. As a result, unnecessary healthcare utilization is about to have an even greater impact on cost of healthcare.

The Direct Primary Care Model

In a very real sense, many of the changes in healthcare in the last several decades have been made as attempts to solve a single problem: the primary care physician shortage. This includes the introduction of physician extenders (physician assistants and advanced practice nurses), the appearance of acute care centers and minute clinics, and the emergence of the medical home model (where primary care physician responsibilities are divided up among many different types of healthcare workers like nutritionists, educators, case workers, and social workers). None of these solutions, however, has been shown to be as effective at increasing access, improving quality, and decreasing cost as the direct primary care, or concierge medicine, model.

In direct primary care, or concierge medicine, physicians charge a monthly or annual retainer fee to patients directly. Though some practices employ a hybrid model where they also bill insurance companies on a traditional fee-for-service basis, this adds complexity to office administration, as by some estimates nearly 33% of a primary care physician practice’s overhead is devoted to insurance billing. It’s important to note, however, even in practices that only charge retainer fees and don’t bill insurance for anything, patients still require health insurance for lab, radiology, and other tests, as well as for specialty appointments, hospitalizations, and surgeries.

How, then, does direct primary care, or concierge medicine, address the problems of access, quality, and cost of healthcare? The answer is simple: in direct primary care, or concierge medicine, physicians typically care for no more than 500-600 patients, compared to traditional fee-for-service primary care practices in which patient panel sizes run anywhere from 1,500 to 4,000 patients per physician. A reduced panel size enables patients to enjoy 24/7 access to their primary care physician and same-day or next-day appointments. Instead of the average of 15.7 minutes spent with each patient in traditional fee-for-service primary care practices, in direct primary care, or concierge medicine, patient appointments can be blocked at hour-long intervals—or greater.

Further, other than during vacation periods, after-hours coverage is often provided by each patient’s own physician (in contrast to fee-for-service practices where after-hours coverage for the entire practice is divided up among all participating physicians—often seven or more—resulting in a greater than 86% chance that calls will be answered by physicians the patient doesn’t know).

This improvement in access, then, results in improvement in quality. First, blocking appointments at hour-long intervals ensures that physicians will have more than enough time to take comprehensive patient histories, perform thorough, focused exams, read through the relevant medical literature, and think critically. (More than anything this is what attracts me—and many primary care physicians I know—to the direct primary care, or concierge medicine, model. There’s almost nothing a physician hates more than feeling at the end of a clinic session that he or she provided suboptimal care.) Second, whether in the middle of the night or during regular business hours, having immediate and direct access to your own primary care physician who knows you and your medical history intimately results in more appropriate testing, reduced use of ancillary services (ER and specialty care), fewer administrative hurdles for patients, greater diagnostic accuracy, and streamlined follow-up. Multiple studies confirm that this kind of intense, upfront primary care does indeed translate into an improved quality of care, that patients who receive care from primary care physicians who are able to provide timely and thorough access to their patients are not only healthier but are also, in fact, more likely to live longer.

There are thought to be four reasons for this:

  • Focus on prevention: Compared to subspecialists, primary care physicians have better training–and focus more–on the prevention of disease. And preventing disease has a more significant impact on health and the risk of death than does treating disease after it occurs.
  • Reduced harm: Studies suggest that each year in the U.S. approximately 7.5 million medical and surgical procedures are performed unnecessarily and that 8.9 million patients are hospitalized unnecessarily, thereby dramatically increasing the incidence of iatrogenic (medically caused) harm. Yet this kind of overutilization of healthcare is precisely what direct primary care is intended to prevent. In one study, researchers evaluated the cost-benefit of the largest direct primary care practice in the U.S. (MDVIP). In 2010 (the most recent year of the study), MDVIP patients experienced 83% fewer elective admissions, 56% fewer non-elective admissions, 49% fewer avoidable admissions, and 63% fewer non-avoidable admissions when compared to patients in traditional fee-for-service practices. Additionally, members of MDVIP were readmitted 97%, 95%, and 91% less frequently for acute myocardial infarction, congestive heart failure, and pneumonia, respectively.
  • Early management: Improved access to primary care increases the likelihood that diseases will be identified and treated early, decreasing both the frequency and burden of complications.
  • Better quality: Primary care physicians have better training in treating common diseases that have the greatest impact on health, such as diabetes, asthma, and hypertension. Certainly, if you’re unlucky enough to develop leukemia, you’ll need an oncologist. But far more people are likely to suffer complications and even premature death due to common diseases that primary care physicians spend their entire careers managing.

Effect on Cost

Despite the increased upfront cost of direct primary care, or concierge medicine, it’s actually been shown to reduce overall healthcare costs by reducing unnecessary healthcare utilization. In the MDVIP study, for states in which sufficient patient information was available (New York, Florida, Virginia, Arizona, and Nevada), decreases in preventable hospital use resulted in $119.4 million in savings in 2010 alone. On a per capita basis, these savings ($2,551 per patient) were greater than the payment for membership in the medical practices (generally $1,500-$1,800 per patient per year).

Data from Qliance, the second largest direct primary care, or concierge medicine, practice in the U.S. shows that, compared to patients in standard fee-for-service primary care practices, their patients had:

  • 14% decrease in ER visits
  • 60% decrease in number of days admitted to the hospital
  • 14% decrease in specialty referrals
  • 29% decrease in radiology exams
  • 58% increase in primary care visits

—yielding a $679 savings per patient per year compared to traditional fee-for-service practices.

Finally, according to a 2014 survey conducted by the Associated Press-NORC Center for Public Affairs Research, as more employers move to high deductible health insurance plans to reduce premium costs (offloading health care expenses to their employees via higher out-of-pocket costs), 20% of patients are refusing to visit their primary care doctor when they’re sick due to worry about out-of-pocket costs. This risks increased healthcare utilization (delays in addressing medical issues often result in increased complication rates, ER visits, and specialist referrals), which risks a greater rise in insurance premiums. A direct primary care, or concierge medicine, model where retainer fees are known in advance makes the cost of primary care far more predictable, thus reducing barriers to patients seeking help for medical problems early in the course of disease. This reduces the likelihood of healthcare overutilization, which, as discussed above, both increases healthcare quality and reduces healthcare cost.

Critics have argued that widespread adoption of the direct primary care, or concierge medicine, model will only exacerbate the primary care physician shortage because by necessity it will significantly reduce the number of patients each physician sees. In the short run, this might prove true. However, unless a viable solution is found to reverse primary care physician dissatisfaction, a critical shortage is already inevitable. What’s required is a new model that attracts physicians into primary care so we can reduce the number of primary care physicians who want to leave the profession and induce more medical students to enter it.

Other critics have argued that charging patients directly will only increase healthcare disparities between socioeconomic classes. While this could also prove true, if the nation’s healthcare bill does indeed decrease as a result of the widespread adoption of the direct primary care, or concierge medicine, model, savings to government programs like Medicaid and Medicare could be redirected as subsidies for the poor to enable them to enter into direct primary care, or concierge medicine, medical practices. Qliance, in fact, is already experimenting with this model and finding success, having added 14,000 new Medicaid patients in 2014.

Primary care—and with it, all of healthcare—is in crisis. Access to care is limited, the quality of care, while good, could be better (despite spending more per capita on healthcare than any other country in the world, the life expectancy of U.S. citizens ranks only 26th out of the 36 member countries of the Organization for Economic Cooperation and Development), and costs are spiraling out of control. Though many view the new model of direct primary care, or concierge medicine, with skepticism, derision, and even fear, new models that ultimately prove successful are often initially greeted that way (think cable television). But if we can challenge our fear, changing to a direct primary care, or concierge medicine, model might just prove itself to be the single most effective solution for the most significant problems facing American healthcare today. And for this reason more than any other, I’ve decided to give it a try myself.

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