Saving Primary Care:
How to Keep America Healthy
by Alex Lickerman, MD
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.1 While this is a welcome development, it poses a significant problem for the healthcare system: not only is there already a shortage of primary care physicians to care for those currently insured2 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.3 When we also consider that the rate at which medical students are choosing to enter primary care has plummeted to a mere 2%,4 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. will be short between 14,900 and 35,6000 primary care physicians5 by 2025 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 2025.6 Little doubt exists that access to primary care is about to become significantly more restricted than it already is.
This is a problem not just because restricted access to primary care is associated with patient dissatisfaction7 but also because restricted access to primary care is also associated with a decrease in the quality of care8 and an increase in the cost of care.9 Inadequate primary care, in other words, lies at the heart of the three most pressing problems facing healthcare today.
Just how hard is it to get access to primary care in America? According to a study conducted by Merritt-Hawkins in 2017 in multiple cities across the U.S., the average wait time for an appointment with a primary care physician is approximately 24.1 days.10 This represents a 30% increase from 2014. 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 21-40 minutes11 to be seen. What’s more, the average length of time primary care appointments last is only 15.7 minutes.12
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 real time to address important topics that require extended dialogue (for instance, end-of-life care in terminal cases). Further, 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. By some estimates, almost 1 million people die each year (Table 2)13 in the U.S. due to complications from medical interventions. Certainly these interventions 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.
Health insurance premium growth is driven by two main things: 1) the rising cost of the healthcare services themselves and 2) the rate of healthcare utilization by beneficiaries (the more that patients see physicians, have tests done and interventions performed, the higher premiums will rise). Given also that starting in 2020 the ACA will impose a 40% excise tax14 on any plan with annual premiums exceeding $10,200 for individuals and $27,500 for a family, reducing unnecessary healthcare utilization will have a significant impact not just on the quality of healthcare but also its cost.
How great an impact? In 2010, $29.7 billion15 was spent in hospitalizing patients for potentially preventable complications of conditions like diabetes, congestive heart failure, and osteoarthritis. Better managing—or even preventing—these complications, therefore, could dramatically reduce the cost of caring for patients with these diseases.
In a very real sense, many of the changes in healthcare in the last several decades have been 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.16 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 deficiencies in access, quality, and cost of healthcare?
Because in direct primary care, or concierge medicine, panel sizes remain far lower (typically no more than 600 patients) than in traditional fee-for-service primary care practices (in which patient panel sizes run anywhere from 1,500 to 4,000 patients per physician), patients are able 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, virtually guaranteeing that all patient concerns will be adequately addressed.
Further, other than during vacation periods, after-hours coverage is typically 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, resulting, in most cases, in a greater than 86% chance that calls will be answered by physicians who the patient doesn’t know).
The improvement in access, then, holds the key to improvement in quality. First, blocking appointments at hour-long intervals or greater 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. Second, whether in the middle of the night or during regular business hours, when patients have immediate and direct access to their own primary care physician who knows them and their medical history intimately the results are more appropriate testing, reduced use of ancillary services (ER and specialty care), fewer administrative hurdles, 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 access17 are not only healthier but are also, in fact, more likely to live longer.18 There are believed 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: Studies19 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 intense upfront primary care is good at preventing. In one study, researchers evaluated the cost-benefit of the largest direct primary care, or concierge medicine, 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.20 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 a patient is unlucky enough to develop leukemia, he or she will 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.
Despite its increased upfront cost, direct primary care, or concierge medicine, has 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).
Data21 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:
- 59% decrease in ER visits
- 30% decrease in number of days admitted to the hospital
- 62% decrease in specialty referrals
- 65% decrease in radiology exams
- 80% fewer surgeries
- 115% increase in primary care visits
—yielding a $1,486 savings per patient per year compared to traditional fee-for-service practices.
Finally, according to a Gallup poll,22 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), 30% 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 both increases healthcare quality and reduces healthcare cost.
Objections to Direct Primary Care
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. Primary care physician patient panel sizes haven’t risen to their current levels of 1,500-4,000 patients because primary care physicians believe that these sizes are optimal for patient care. They’ve risen to these levels 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. This has resulted not only in poorer access to care, poorer quality of care, and increased healthcare costs, but also in dramatically increased primary care physician dissatisfaction—and increased primary care physician dissatisfaction is the real driver of the primary care physician shortage. 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, as the nation’s healthcare bill decreases 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.
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 26th23 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.