What is the main cause of the primary care crisis?

 | POLICY |

Primary care physicians (PCPs) have too little time per patient which means too many referrals to specialists, too little time listening and thinking, no time to delve into the stress or emotional causes of many symptoms and substantial frustration by PCP and patient alike.

Previously in this continuing series on primary care and concierge medicine, I described a patient with a straight forward if unusual symptom who was bounced from specialist to specialist at great expense, with no one offering a diagnosis, with no resolution of her symptoms and with no physician ever exploring the actual underlying causes of her symptom – guilt related to a long ago family issue. Why did this happen? Because the PCP had only 15 minutes, not enough time to listen and to think and from there delve into her psyche.

Why so little time? The short answer is the insurance system, attempting to manage costs through price controls. Medicare has for years set a low reimbursement rate for regular office visits to the primary care physician. Commercial insurance always follows Medicare’s lead and has done likewise. Reimbursement rates have remained fairly steady for a decade or more (Medicare has very recently begun to raise rates a bit as a result of the Affordable Care Act) but office costs have risen each year. Overhead includes not just the nurse and receptionist but also the billing and coding people, accounting and legal needs, malpractice and disability insurance, health care insurance for the staff, supplies and rent and utilities for the office.

With costs rising and income steady, the PCP tries to “make it up with volume.” This means seeing more patients per day, usually about 24-25, often even more. In order to see that many, the PCP has generally stopped seeing his or her patients in the hospital or ER and has shortened the time per visit — most visits being about 10-12 minutes of actual “face time” with the patient.

This is enough time for a strep throat, a quick blood pressure medication check or possibly to diagnose and treat Lyme disease. But it is not enough time to deal with a more subtle problem like the patient described in the last post experienced. It is not time to explore family issues, personal stress or anxiety that so often lead to or accompany symptoms and sickness. This lady had a straight forward issue that primary care physicians encounter frequently and those that are experienced know well what it implies. But it still requires time — time to carefully listen to the patient’s story, time to put it into the context of the patient’s life situation, time to do an examination and then some time to think about how to proceed. And once the management decision is made, it takes time to talk to the patient, reassure her and yet explain that she should call should are any further concerns arise — and to come back soon for a further follow-up and attention to the underlying issues.

The situation is compounded when the PCP has a patient with multiple chronic illnesses who is taking multiple prescription medications. Chronic illnesses like diabetes, heart failure, chronic lung disease, kidney failure or multiple sclerosis by their nature are difficult to manage, persist for the patient’s lifetime (some cancers excepted) and are inherently expensive to treat. These patients need very close attention and often need the benefit of a team approach to care. The diabetic patient for example will need an endocrine consult at some point, a podiatrist, an ophthalmologist, a nutritionist and an exercise physiologist, to say the least.

But any team needs a quarterback and this is or should be the primary care physician. But here again, care coordination by the PCP requires time, the one thing the PCP most lacks in today’s reimbursement environment. The result is fragmented chronic illness care, disjointed care and care that is much more expensive than it needs to be. From a total healthcare system perspective, this is critical because chronic illnesses consume 75 – 85% of all claims paid by insurers.

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About Concierge Medicine Journal

Concierge Medicine Journal (CMJ) curates breaking concierge medicine news, and editorial opinion on a wide variety of topics relevant to the practice of Concierge Medicine.

One Response to “What is the main cause of the primary care crisis?”

  1. I think that this is a good example of where nurses can fill a void, so to speak. The nurses at the clinic that I work at have their own schedule with their own patients. If a provider feels that a patient requires more education or more support, they can schedule them a 60 minute visit with an RN (since the billing is different for us, it’s not a problem for us to spend a greater amount of time with patients). It’s entirely within the nurse’s scope of practice to explore psychosocial issues of a patient, and to provide appropriate interventions. In our case, we often provide further information about medication/pathology/nutrition, help with mastering coping and self-management skills, and provide information about outside resources like support groups, food banks, and employment agencies. In a primary care model, I think that RNs are often underutilized, and can be valuable members of any care team.

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