The need for more primary care never goes away

When are we finally going to make progress on improving access and availability to high-quality, comprehensive primary care for all the citizens of the US? I have been a family physician for almost 40 years and the drumbeat for action has been the same across all those years. It has waxed and waned but has always been present.

“We don’t have enough primary care physicians for the population,” it goes. “There is a maldistribution of physicians with significant shortages in rural and under-served areas, and payment inequities for primary care make it hard to provide the comprehensive services needed in these communities and to recruit talented new physicians into a primary care specialty because of the lower pay and the huge medical school education debt they often face.”

L. Allen Dobson, MD, FAAFP

In response, we have been purposefully redesigning and changing primary care for a decade now. Have we made progress?

It is time to evaluate whether any of these changes have made a difference. In writing about this topic, I thought it best to get the views of some primary care colleagues across the country. Although this isn’t a scientific survey, it does capture sentiments that seem important, and I think worth a deeper dive over the coming months.

Some details on who I talked to: I spoke with 11 physicians from five states, most of them mid-career family physicians, though I did speak with one pediatrician and internal medicine physician. Two of the physicians were younger and new to practice. The quotes presented in this column are not verbatim; they were edited for clarity.

Electronic Health Records:

“We all made the painful transition to EHRs. It has not helped me see patients as promised and has actually made my life worse.”

“It makes reading notes from other physicians and the hospital impossible, and you have to dig through lots of useless information just to find what you need.”

“It is nice to be able to see my patients’ studies and images and who they have seen, but I work in a big system where we are all on the same EHR. That makes it easier.”

“Maybe if they had just made data such as labs, medicines and imaging studies available it would have worked better. It makes me think this was all about judging our coding and billing and not about clinical care.”

Patient-centered medical homes and certification:

“We went all in on PCMH certification with the promise we would get recognition and a new enhanced payment after we re-engineered our offices and proved our worth. What did we get? NOTHING!”

“I am still proud we got certified but it doesn’t make financial sense to pay for certification anymore. It is like it was a passing fad.”

ACOs and value-based care:

“It is incredibly complex and if you are a small practice, good luck! It is forcing us to join up with a hospital or for-profit group just to be able to participate.”

“Seems it is all about playing the coding game in order to make money”

“There is a lot of work to do in hopes you will get rewarded in a year or so”

“We have done well and gotten bonus checks which has been nice. The reality is that the computer systems and enhanced services that help us hit the targets don’t belong to us but belong to our for-profit company partner.”

General comments:

“I am concerned about the loss of professionalism in medicine. It is nowall about the money and business.”

“I feel a great loss of respect for what we do. Everyone thinks that they can do primary care.”

“I worry about the increasing number of NPs and PAs staffing primary care offices, urgent cares and now specialist offices.”

“We now have telemedicine companies and other venture capital-backed companies trying to take our patients but not serving the entire community.”

“It is like our physician training and role has been devalued in the healthcare system. The public no longer knows who is seeing them.”

“According to studies, for every dollar you spend on primary care, you save $13 dollars to the health care system as a whole. Therefore, the way to reduce US health care costs is to pay family physicians and other primary care providers more. This is not rocket science.”

Workforce:

“During COVID-19, I have been reminded of the importance of what we do. So many of my patients have been very grateful to be able to come talk to me about Covid, the vaccine and their concerns. It renews my passion for the profession. I just worry as I get closer to retirement, there won’t be anyone to follow me.”

“It seems I am asked now for more recommendations to PA or NP school than to medical School. That concerns me.”

“I still see such passion for family medicine in our graduates. Unfortunately, they think their only option is to join a hospital system. They aren’t looking to small towns or rural areas because the job opportunities don’t seem to be there even if the need exists.”

“I think the move to team-based care and adding more resources to the primary care team has made care better and practice more enjoyable.”

“We need more primary care physicians. Where are they?”

“Despite all the administrative hassles, I still love what I do as a physician. Taking care of patients is rewarding.”

Closing thoughts

So now for my own thoughts: There is no disagreement about the need for primary care in this country. We need a national strategy on primary care and the funding and plan to execute it. Primary care is an investment in the health of our citizens. Let’s quit judging how much to pay for it based solely on saving money or profits.

L. Allen Dobson Jr., MD, FAAFP, is a family physician and Editor-in-Chief of Medical Economics®.