Fixing primary care, Part 1
Fixing primary care, Part 1
Burnout, buyouts battering the physicians who are key to better health
Tried to find a new primary care physician lately? Insurers must provide you with a list of doctors, but you quickly discover that few are taking new patients. When you do find one, your first appointment is scheduled for two months out.
When the day finally arrives, the doctor seems nice, knowledgeable, but more than a bit frazzled. She spends most of the 13-minute visit entering data into a computer as you answer the same questions that were on the paper forms you filled out in the waiting room. You assure her you’ve been vaccinated for COVID-19 at a local pharmacy, but she has no record of it. You walk out without a referral for a long-overdue colonoscopy.
Dr. Sarah Mullins once ran a practice with similar flaws in Wilmington, Delaware. “Care was disjointed, unorganized, and there was a lack of communication,” she told me. But today, her practice, which employs four primary care physicians and five nurse practitioners for more than 10,000 patients, has been radically transformed.
Its doctors spend a half hour with every patient. The nurse practitioners leave part of their days unscheduled so the practice can offer same-day appointments to patients with pressing needs. They also act as care managers—reaching out to schedule wellness visits, vaccinations, and other preventive services. Patients’ electronic medical records incorporate data from hospitals, specialist referrals, urgent care clinics, and pharmacies, enabled by a comprehensive state health information network that didn’t exist a decade ago—and still doesn’t exist in many parts of the country.
“I spend less time searching for vital data,” Mullins said. “My staff is reaching out to schedule wellness visits while I have dedicated time to preventing illness and suffering. It’s a shift that’s changed our practice into one that helps people more and in a more organized fashion.”
This article originally appeared in November-December issue of The Washington Monthly.
It’s also far from the norm. In most of the U.S., primary care is in deep crisis. Family physicians are reporting high levels of stress and burnout, thanks to a reimbursement treadmill that requires many of them to see four patients every hour in order to make a living. Older physicians are retiring prematurely. Heavily indebted medical students are shying away from family medicine and pediatrics, which pay less than half the $500,000-plus salaries offered to surgeons, cardiologists, and other specialists. When surveyed, few newly minted doctors express interest in joining community-based practices, preferring the set salaries that come through employment with large institutions.
Family physicians are reporting high levels of stress and burnout, thanks to a reimbursement treadmill that requires many of them to see four patients every hour in order to make a living. As primary care has gotten worse, many patients with chronic illnesses have found themselves growing sicker and in need of expensive medical interventions.
The deteriorating state of primary care is undermining every effort to rein in America’s bloated health care budget. Family physicians, who are both the most trusted and lowest-paid doctors in the United States, provide routine and preventive care to patients with common but complex chronic conditions, like high blood pressure, diabetes, substance abuse, and mental health disorders. As primary care has gotten worse, many patients with these illnesses have found themselves growing sicker and in need of expensive medical interventions. This has driven up health care spending while driving down outcomes. Between 2014 and 2019, the share of U.S. GDP spent on health care rose even as life expectancies fell. (Life expectancies have fallen further since 2019, but later data is skewed by COVID-19.)
New models emerging
But as the transformation of Mullins’s Delaware practice shows, it doesn’t have to be this way. New models for reinvigorating primary care are emerging from both the public and private sectors. They have the potential to dramatically lower costs while improving the overall health of the American people. Yet expanding these isolated experiments into system-wide change will take major reforms of the federal policies that govern how we pay for care, and who we put in charge of our health.
Since the early 1970s, U.S. spending on health care has increased faster than both inflation and wages. We now devote nearly 18 percent of the economy to health—40 percent more than any other country—yet our population trails peer nations on every measure of public health, from longevity to infant mortality to incidence of chronic disease. The expensiveness and poor outcomes are causally connected. Growing health care costs have depressed wages, as employers redirect would-be raises into insurance plans. They have forced individuals to fork over growing shares of what income remains to insurers and providers. This has left a greater share of the population suffering from inadequate housing, food insecurity, and substance abuse, which in turn increases demand for the most costly health care services.
The only way to break this downward spiral is to invest more in primary care–led prevention and social services, which have declined from 7 percent to just 5 percent of total health care spending over the past several decades. But the obstacles to doing so are formidable.
Right now, the physician reimbursement system is effectively determined by the American Medical Association, which is dominated by specialists and systematically undervalues the time spent listening to patients, evaluating their needs, and recommending preventative measures. The AMA instead places the highest values on surgical interventions, or delivering complex treatment and chemotherapy regimens. While critics have forced the organization to narrow the reimbursement gap in recent years, the wide gulf between the salaries paid to primary care physicians and specialists remains.
Insurers and employers have exacerbated the imbalance by increasing the number of workers and their families in high-deductible plans. Requiring people, especially those in the bottom half of the income distribution, to pay up front for care incentivizes them to skip primary care and preventive services. Paying rent and keeping food on the table come first. And when people wait to show up for care until their bodies are breaking down, they quickly wind up in the hands of specialists, who cost far more. The poorer Americans who do go in for regular checkups often fail to fill prescriptions for the drugs that manage chronic conditions, which can lead to expensive hospitalizations.
The broken insurance reimbursement system has left many independent primary care practices looking for a way out. Many become willing sellers to larger health care companies. Between 2010 and 2016, the share of the nation’s 200,000-plus primary care physicians working for hospital chains surged from 28 to 44 percent, while the share of physicians working in primary care fell by two percentage points to 30 percent of all doctors between 2010 and 2018. Many other doctors’ groups have been gobbled up by private equity–backed corporate entities and insurers. It’s part of the broader consolidation movement within the medical industrial complex.
That consolidation has had grave consequences. When primary care doctors wind up working for a hospital instead of for themselves, they can come under pressure to put the hospital’s needs ahead of their patients’, including by not making referrals to competing hospitals that offer better-quality care. Similarly, when these physicians wind up working for health care plans, most of which still pay a fixed fee for each appointment, they can find themselves pressured not to recommend expensive treatments or spend much time with each patient.
Selling out
The pandemic accelerated primary care consolidation. In June of last year, for example, with hospitalizations and deaths from COVID mounting and routine demand for health services in free fall, Fairfax Family Practice and its 38 primary care physicians sold itself to Inova Health, the five-hospital system that dominates the northern Virginia market. Dr. Robert Phillips, a Fairfax physician, is well positioned to understand the pitfalls that practices face when they get acquired. He directs the Center for Professionalism and Value in Health Care at the American Board of Family Medicine Foundation and served as cochair for a recent National Academies of Sciences, Engineering, and Medicine report on primary care.
He told me that the practice’s decision to join forces with a hospital system beat its prior arrangement. Over the previous five years, the still-independent Fairfax and its 500 employees had been managed by Privia Health, which went public earlier this year after achieving profitability. Its major investors include Goldman Sachs and Anthem, one of the nation’s largest insurers. Privia, according to a spokesperson, takes 12 percent of practice revenue in exchange for providing electronic medical records, practice management, and billing software. But it did little to cushion Fairfax Family Practice when office visits declined during the 2020 COVID shutdown, causing revenue to collapse.
I asked Phillips why he thought joining Inova might achieve better results. He cited the hospital system management, which brought in a new CEO in 2018 and has professed a commitment to “patient-centered care.” “They had been going in the direction of tertiary, quaternary care. That’s not what a community hospital should do,” Phillips said. “Part of our deciding to join was faith in the new leadership [and] their realization that the community was their main mission.”
But there’s reason to suspect that Inova will still prioritize expensive specialty medicine. While well-heeled acquirers of physicians’ practices, like Inova, pay lip service to the value of primary care, acquired practices have structural conflicts of interest that inhibit family physicians from providing the consultation, care coordination, and social support services that could dramatically improve outcomes and lower overall costs. Hospital revenue depends on putting heads in beds, as industry jargon puts it, and controlling the physicians who make the referrals is a way to achieve that goal.
Insurers also have incentives that lead them to degrade primary care. To lower their immediate spending and increase short-term profits, many have started excluding higher-priced but higher-quality hospitals from their networks and exerting heavy-handed oversight of physician referral patterns. Controlling family physicians’ practices enables both tactics.
The focus on short-term profits becomes even more acute once investors get involved. Most of the Wall Street–oriented financiers in primary care have a three- to five-year exit strategy for getting a hefty return on their investments, either by flipping the practices to another firm or through an initial public offering. That leads many to pursue cost-cutting and revenue-enhancing tactics, like eliminating support staff or stepping up offices’ appointment pace. This, again, increases short-term profitability at the expense of overall patient health.
“They will double down on whatever business strategy raises their margins the fastest,” said Phillips. “It has no heart. It has no population health mission.”
Part 2 of Fixing Primary Care will appear here tomorrow.