Comprehensiveness is Killing Primary Care

In most other human activities there are two speeds, fast and slow. Usually, one dominates. Think firefighting versus bridge design. Healthcare spans from one extreme to the other. Think Code Blue versus diabetes care.

Primary Care was once a place where you treated things like earaches and unexplained weight loss in appointments of different length with documentation of different complexity. By doing both in the same clinic over the lifespan of patients, an aggregate picture of each patient was created and curated.

A patient with an earache used to be in and out in less than five minutes. That doesn’t happen anymore. Not that doctors and clinics wouldn’t love to work that way, but we are severely penalized for providing quick access and focused care for our well established patients.

Why is that?

Our Quality mandates have ended up creating perverse roadblocks and disincentives for taking care of the simplest needs of our patients. Any time we don’t screen for depression, alcohol use, smoking and readiness to quit, obesity, immunization status, blood pressure control and so on, we lose brownie points and, increasingly, money.

This is happening near me:

The primary care practices of Maine Coast Memorial Hospital in Ellsworth Maine have lost many, if not most, of their providers in recent years after some belt tightening due to running the clinics at a loss. They are not able to see new patients for six months or more. BUT the hospital is actively promoting its walk-in urgent care center – and they don’t seem to have trouble staffing it, and don’t appear to be losing very much money on it.

Bangor, Maine, home of a small Catholic Hospital and a 400+ bed hospital with a level 2 trauma designation, cardiac surgery, neurosurgery and many other specialties, has a severe lack of primary care doctors in spite of having a Family Medicine residency. Yet, a private out-of-state company is building a brand new freestanding urgent care center a couple of blocks from the Catholic hospital.

Quick and easy acute care visits visits could generate revenue with positive cash flow for primary care practices, especially for Federally Qualified Health Centers with their flat rate reimbursement, but possibly for all practices if CMS’ new proposal to scrap differentiated Evaluation and Management codes becomes reality. But the requirement to weigh down the simplest visits with all those screening requirements eliminates the incentive to nimbly meet patients’ need for access.

The end result will be that primary care providers will become chronic care providers only, and care will be fragmented so that anything profitable will be siphoned off to freestanding entrepreneurs or hospital owned profit centers. Meanwhile primary care practices risk becoming more and more of a millstone around their hospital owners neck because all their patient visits are more complex and costly than the reimbursement scheme can support.

And more and more providers will be tempted to jump ship for the easier work and greater predictability of a Doc in a Box career.

The only solution is to acknowledge that Family Medicine and all primary care is meant to assess patients over the continuum of time. You don’t have to fix the whole person when all they ask for is some penicillin for their strep throat.

Sometimes you need to be quick and sometimes you need to be slow. Without the freedom to adapt, in a patient centered way, to the situation each patient presents with, primary care risks going under.

10 Responses to “Comprehensiveness is Killing Primary Care”

  1. 1 Philip Miller MD August 12, 2018 at 12:28 am

    Single payor would do a lot to eliminate the profit driven entrepreneurs I would think.

    • 2 meyati August 12, 2018 at 4:00 am

      It’s the NIH, Medicare, Medicaid, the US Surgeon General, and Congress. They get together and make these rules to meet population medicine and the practice of good medicine.

      High blood pressure leads to strokes, kidney destruction, and heart attacks-if you live in a state that has any of these problems-It’s a population medical problem. That requires are doctors to inquire if they think the BP is up, and Primary Doctors are required to inquire deeply, and try to get the patient to have a life style change-they are graded and paid for lifestyle change.

      I went in for my annual visit for hypothyroid visit to go over the TSH and get a new prescription for the year. I used to keep the TSH visit seperated from my annual oncology labs, scans, and oncological follow-ups. My BP always goes up. We call it scanaxiety.

      I tried to explain that my disabled vet son broke his arm, the roof is leaking, my grandson got caught in a Colorado mud slide, my Bluetick coonhound passed from a rare blood cancer, Comcast sent new modems-to get extra money by having techs plug them up-but I plugged it in. I spent 3 hours on a borrowed phone screaming and crying-finally a new tech said- Gee, we never entered your password. That did the trick for the modem but did nothing to bring my BP down.

      That’s why primary doctors don’t have time to examine your back after you fall off of a ladder or trip over a coonhound.

  2. 3 Mary Symmes August 12, 2018 at 1:28 am

    The situation you describe is insane. I wonder who is making money from it.

    • 4 meyati September 8, 2018 at 1:53 pm

      Pharmaceutical and insurance companies, in my opinion. Many people that go to Mexico, often stop taking many meds, and live a high quality life.

      For me, I’ve been offered BP meds-I still have the scars from the one time I took it-I fell on the 3rd day. Then, for the last 5 years, they’ve been pushing diabetes big time in my state.

      I’m almost grateful that I had cancer-it’s been gone for 5 years-but they do an annual BUN-CREATININE that shows my liver and kidneys are working perfectly-in the middle of the range.

      I have IBS-D, diagnosed about 1965-in the early 1990s, they came up with a med that actually helped me. 2015 winter Holiday time, they pulled the med from the shelf (it cost 45 cents a pill to make, and sold for a dollar to 2 dollars a pill most of the time), and replaced it with a take til you die med that cost $1,200 to $1,400 per month with a one of those pharmacy coupon groups.

      I surprised myself and my family by living through that-no I didn’t go to the ER- Why should I? They wouldn’t give me anything for pain when I had a rotator cuff injury, so why should I expect any help for a stomach problem? Only my GI understood what I meant, when I said that I was too sick to go to the ER with my orange 5 gallon bucket and a roll of toilet paper.

      These things are also-fads to build reputations-and to be a good follower-and not have the legal problems caused by being independent—

  1. 1 Comprehensiveness is Killing Primary Care | Health Advice and more Trackback on August 24, 2018 at 4:11 pm
  2. 2 Comprehensiveness is Killing Primary Care – Health Econ Bot Trackback on August 24, 2018 at 4:15 pm
  3. 3 Comprehensiveness is Killing Primary Care – BrighterLife Trackback on August 24, 2018 at 4:34 pm
  4. 4 Comprehensiveness is Killing Primary Care – Site Title Trackback on August 24, 2018 at 4:41 pm
  5. 5 Comprehensiveness is Killing Primary Care - Health Insurance Companion Trackback on August 24, 2018 at 4:41 pm
  6. 6 Comprehensiveness is Killing Primary Care – Health News Trackback on August 24, 2018 at 7:28 pm

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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