As Congress and the new president consider the next steps with healthcare reform, they would do well to begin their deliberations around primary care.
There is a primary care crisis in the United States. We know it because patients only get 8-12 minutes with their primary care physician (PCP) who interrupts them within about 18 seconds and never fully listens to them. Patients are sent for tests, given a prescription or referred to the specialist even though the PCP could—with more time—have figured out the problem without a test, prescription or referral.
Hot topic: Top 10 challenges facing physicians in 2017
Patients are less than satisfied, yet the charge is high. Doctors are no more satisfied and are highly frustrated, feeling like he or she is on a never-ending treadmill. This leads older PCPs to seek early retirement, mid-career PCPs to sell out to the local hospital and medical students to shun primary care—each leading to a growing shortage of PCPs, which will get worse as the population grows and ages.
This means that Americans don’t get the quality of healthcare that they need and deserve, that healthcare is expensive and that the cost will keep rising.
The solution isn’t difficult. The reimbursement system needs to change, shifting more resources into primary care and out of specialty care. It’s an easy answer but difficult to implement.
It is important to note that primary care is not just for the “simple stuff.” PCPs are trained and experienced to care for complex chronic illnesses like diabetes and heart failure. They need to refer to specialists only occasionally. But PCPs have too little time per patient, so the reflex is to refer, test and prescribe, thus driving up health care costs. There is little time to address wellness, health and lifestyle changes and no time to develop and maintain a trusting relationship.
Where does the time go? The typical PCP takes 24 phone calls per day, reads 17 emails, processes 12 prescription refills (above those handled during visits) and reviews more than 40 laboratory, X-ray and specialist consult reports. In addition, PCPs need substantial added time with electronic health records and to complete Medicare quality indicators records.
But the major time problem is that primary care providers are caught in a terrible conundrum. Overhead costs (especially the need for added staff to deal with billing, preauthorizations and government mandates) have risen much more quickly than revenue. The only remedy is to “make it up with volume,” i.e., more patients per day. But that’s not a sustainable business practice and certainly not an acceptable care model.
PCPs report that they must see about twice as many patients as a few decades ago in return for the same income. If a PCP needs to see 24 to 30 patients per day, then a patient has a 15-20 minute visit with actual face time of about one half of that. This is long enough for a simple problem, but much too short for someone with a complex issue, or someone with multiple chronic diseases and taking multiple prescription medications. It is certainly not long enough for an elderly person with impaired vision, hearing or cognition and not enough when the problem has an underlying anxiety.