Saving Primary Care? It’s Not All About Money.

I read many healthcare blogs and of course follow healthcare news.  It is bewildering and stupefying the (seemingly) thousands of different directions it’s all going.  Honestly, our politicians and leaders really seem to be clueless.  Driven by so many “fingers” in the pot and ultimately they continue to make one fatal flaw.

Politicians are to busy telling people what they WANT to hear and not what they NEED to hear.  Where are the real leaders?  Alas, that is a different blog entry.

One common (albeit thin) thread is the reoccurring theme that primary care needs to be more of a central focus in healthcare.  It seems so obvious and is supported by many as the way to improve not only cost and efficiency but also the quality of healthcare.  The healthcare system was meant to be a pyramid with the majority of physicians as primary doctors at the base and supported by a much fewer specialist at the top.  Our system however, has turned this upside down and the pyramid is rapidly growing at the top while the primary care base dwindles.  I dare anyone to argue that this is not a calamity in the making.  The pyramid standing on it’s point will collapse.  Yet, our politicians continue to ignore this issue or throw small bones at it in passing that are laughable.

So, what does it take to reverse this trend and fix Primary care?  In one word, time.

Many have articulated this in so many different ways, my blog today seems redundant, but I think the point is still missed.  Most want and feel that primary care needs to be payed better.  I wont argue with that and it would certainly be a quick and efficient way to solve the problem.  However, in this economic and political climate that doesn’t seem feasible or likely (thus the growth of Direct practices where physicians have taken matters into their own hands.)  In a nonscientific survey of my colleagues, I think most primary care docs are actually happy with their income (mostly), but they are not happy with what they have to do and the liability they assume for that income.

So, let me make this clear.  We don’t have to focus on money as the only panacea to fix Primary care.  There is a whole other side to this equation that needs to be dealt with. Let us “fix” the job.  Do away with countless unfunded mandates and meaningless bureaucracies and suddenly, hours of wasted physician time can be used for…. dare I say it, actual care!  Not to mention the enormous amount of wasted staff time and expense that will disappear and… dare I say it, the practice will make more money.

So many of these “little task” have been invented and created with the sole purpose of “slowing” down physicians and to artificially lower cost.  Since most fall squarely on primary care they have completely missed the boat.  Primary care is not  the source of massive spending problems in healthcare.  So why do they still exist?

In an attempt to be constructive, I offer these suggestions.

1. Outlaw prior approvals.  How convenient for the insurance company, “of course we would pay your benefits, but YOUR doctor hasn’t done the prior approval.”    I’m not sure how these are legal in the first place.  Insurance is a contract between patients and the insurance company.  How does the Insurance company get away with “forcing” physicians to waste time and energy to complete this process without paying them for that time?  If insurance really thinks that need a “checks and balance” on doctors, then I suggest implementing a “second opinion requirement” for certain high dollar healthcare expenses.  If the insurance doesn’t want to pay for an MRI, fine, then require 2 different physicians agreeing that an MRI is needed before they will pay.  At least then, the insurance company would have to pay for 2 evaluations to get the professional consensus that they think they need.  that extra expense would be nothing for slowing actual “waste” but it would prevent the insurance from abusing the process.  I once was told to get a prior approval for atenolol.  Really?? Atenolol is about as cheap as it comes…

Another great example: Medical Necessity « Musings of a Dinosaur.

 

2. Require companies to pay physicians for FMLA, disability, and long term care forms.  yes, I know that physicians can charge patients for these forms but why do we need to drive even more of a wedge between patient and doctor when it is the companies that are benefiting from the bureaucracy of the forms?  Most docs don’t charge for the forms yet we should be paid for our time.  Companies create their own forms and then demand physicians to fill them out, often 4-5 pages long and filled with nonsense.  Simply, more wasted time and an attempt to prevent people from being able to get their benefits.  How convenient for the insurance company, “of course we would pay your benefits, but YOUR doctor hasn’t properly filled out the forms.”

 

3. Pay primary care doctors for time, not for encounters.  Current system encourages volume of patients and not quality.  Patient comes in with chest pain that looks, smells, and sounds like reflux, the PCP gets the same amount of money to write “consult to GI” in 5mins that they get paid to spend 45mins educating the patient and explaining why a trial of PPI is worthwhile.  Amazingly, the 5 minute “consult to GI” visit also has a lot less liability for the physician.  This McMedicine approach is a major reason for the chaos we have in medicine now.

 

4. Offer real malpractice reform (at least for primary care if the politicians can’t stomach it for all healthcare.)  Reality is that Primary care already has lower liability than most in healthcare, but that doesn’t stop us from having ridiculously high premiums.  I personally don’t know a single primary care doctor that honestly feels they don’t practice defensive medicine.  This often includes many of those 5 minute “consult to so and so” visits that I mentioned above.  Without the constant threat of liability, Primary care doctors wouldn’t be so crabby about their relatively low pay and they certainly would be less likely to order unnecessary consults and test.

Ultimately, we have to give PCPs more time to do their job, or we have to pay them better.  My Guess is the right answer is somewhere in the middle.

If we want a return to a high quality primary care centric model of medicine in this country, then we have to improve primary care.  More money helps, but it is not the only answer.  Simply making the job better would go a long way to improve attractiveness of primary care for young doctors.

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