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A Glimpse of a Bleak Future for Primary Care Access

August 17, 2014

First, we are all so thankful that our family physician colleague Kent Brantly seems to be recovering from his Ebola infection. When his family left Liberia, they had to leave all of their possessions behind, which should have been burned by now. If you would like to donate to help him rebuild his personal effects (clothes, computers, everything), the JPS Foundation has created a mechanism where all donations can be earmarked for this purpose. Go to www.givetojps.org. You can donate to the fund by clicking on the “Give a Gift” button, where a drop down menu allows you to choose “Dr. Kent Brantly and Family” as the designation of your donation.

Now back to trying to fix this mess of a non-healthcare system. Below is a letter I emailed to some local HR professionals in the DFW area. If you have observed similar changes in your community, feel free to use whatever portion of this message you find helpful and start a conversation with your local business community.


HR professionals,

Many of you came to our disrupting healthcare conferences at SMU and BNSF where we talked about increasing healthcare costs and its impact on businesses, job growth, and wage growth.  It was clear that many attendees understood these realities, but there has been little collaborative action between the large DFW employers as far as we can tell.

Unfortunately, we have a preview in DFW and other communities of the failed policies of the federal government (Medicare and Medicaid specifically), state government, and insurance companies related to how they value medical services, and how the poorly supported first-contact primary care system in the U.S. is further degrading into a farce.

I’m sure many of you have seen these freestanding emergency rooms popping up all over DFW like mushrooms after a hard rain. Ask yourself this: if you were thinking about opening a healthcare business and you could get paid $1500 in one facility or $100 in another for the same product, which facility would you invest in? This is not a facetious question. It’s exactly the dynamic that is driving the growth of these freestanding ERs, and the urgent care centers before them. And, many of these facilities are out of network (and can and do charge higher rates). A recent article in the Star-Telegram about one of the freestanding ER companies stated that the average revenue per visit is $1500, which is completely believable. Another source I know in the ER business told me that it only takes 8 patients per day for these things to break even.

A shortage of primary care physicians has been talked about for decades, but no one in the public or private sector has taken any action to reverse this, except for inadequate gestures such as loan repayment programs. Practically all U.S. payers use the highly flawed CMS payment system, which is founded on the limited AMA coding system (CPT codes). A full explanation of why this system is so bad for family medicine is more than I wanted to cover today. In short, these billing and coding systems work sort of well if the doctor only takes care of one body part or one disease per visit. The system completely falls apart when a patient seeks care with a family physician, and expects that physician to manage more than one or two concerns in an office visit (or phone visits or email visits).

This is fundamentally why these freestanding ERs and urgent care centers make their money. They skim off of the patient visit the easy acute symptoms (“What is your emergency?” “We can only see you for one problem.”) and leave the more difficult acute and chronic disease care to the “PCPs.” They over-order unnecessary tests and treatments and hand out narcotics like candy. They figured out that this approach increased their patient satisfaction scores. The flawed fee structure used by all major payers encourages this.

Another reality you must understand is that very few actual emergencies show up in these ERs. In fact, a colleague who works in one of these facilities says that when a true emergency shows up at their doorstep (such as a heart attack or septic shock), they just call 911 to take the patient to a real ER. Most of the patients have urgencies at the worst and many don’t have that bad a situation. The vast majority of these patients could be cared for by well-supported family physicians’ offices: coughs, cuts, rashes, fevers, vomiting, sprains, strains, pains, etc. You might respond that their offices aren’t open in evenings and weekends, which is often true. There simply aren’t enough of them around to provide this level of accessibility.

With these market forces in place we can already get a glimpse of where primary care will be in 20 years. Nationwide there is a predicted shortage of about 50,000 primary care physicians over the next few decades. This will be exacerbated in one to two decades because there will be massive retirement of family physicians and internists who opened their practices prior to the declining interest in primary care among American medical students.

Some primary care physicians who care for well-insured patient populations are moving to a direct primary care model, some people might call this concierge medicine, where a basket of primary care services are offered for a monthly fee. $70 PMPM it is a probably a midrange estimate of where many physicians are setting this price. Qliance in Seattle and AtlasMD in Kansas are two examples of companies using this model. I personally don’t think this is the ideal model, but Qliance in particular has presented data at conferences showing that they have lowered their patients’ insurance costs by 10%. They do it with long visits with family physicians, and none of the baggage of the NCQA-driven Patient-Centered Medical Home model. (And BTW, the Texas Academy of Family Physicians should announce a better PCMH model soon.) The doctors who work at Qliance seem to love working there for two primary reasons: 1) they feel like they are paid to be good doctors and spend adequate time caring for their patients, and 2) they have completely unshackled themselves from the CMS/private insurance medical record documentation, coding, and billing system.

If the existing market forces don’t change, here is where we are headed: Primary care physicians will mostly abandon traditional family medicine. Many of the weaker family physicians will work in these urgent care centers or freestanding ERs because the pay is better and the cases are simpler: one “emergency” is much easier to manage than the patient who wants to discuss five concerns. Family physicians who have a broader range of skills who care for patient populations in the higher income strata will go to direct primary care or concierge models, whichever you want to call it. Other family physicians who want to have some long-term continuity with their patients will go to work for places like THR and Baylor (whose exorbitant facility fees also markedly drive up the cost of basic ambulatory care, little of which goes to the physician). But when they sign their contracts, these physicians enter a professional setting where they are constantly under pressure to feed the beast. The hospital-based systems want them to generate referrals to ologists who will then over-test and over-treat patients with more hospital-based services.

These forces will literally leave low- to middle-income patient populations with nowhere to seek care other than the urgent care centers and freestanding ERs. Oh, and they will also have access to mid-level providers at Wal-Marts and other retail shops for simple algorithmic problems like bladder infections and straightforward cases of high blood pressure. But these facilities have no capacity to care for patients in long-term continuous relationships or complex situations, which is where family medicine delivers its best care at the lowest cost. Imagine an endless string of more complex patient needs going to Wal-Mart nurse-in-a-box clinics only to be told to then call an ambulance to take them to the freestanding ER down the street, which then calls another ambulance to take the patient to a hospital ER, where they will then commonly be over-tested and over-treated at each step along the way.

Because of the high-deductible health insurance plans common in today’s corporate benefit packages, local stories are already being told of families going to one of these ER three times per benefit year and then spending out their entire deductible of $5000. Most of their concerns could have been handled in a well-supported primary care center for a fraction of the cost (and the care is better), but there simply is not enough primary care capacity in the area to accommodate this population. To the degree there is some capacity left in the community, many of your employees can be poor utilizers of the healthcare system and sometimes make wasteful choices. But driving by 4 ERs on the way to work doesn’t help this situation.

This situation will correct itself when the payers say “I’m mad as hell and I’m not taking it anymore.” You are the payers. The insurance companies have no vested interest in promoting an efficient primary care system. They make more money when care costs more and more billing paperwork gets shuffled around.

When other countries notice their medical students drifting away from choosing primary care fields, they increase support for primary care to right the ship. The best the U.S. government and private insurance companies have come up with is an insulting pittance, which is why interest in family medicine among U.S. medical students has been stagnant for 15 years, actually more like 30-40 if we discount the brief managed care era blip. All payers say there is a problem with primary care supply, but they point their fingers at someone else saying, “It’s not my responsibility to fix this.”

You, your shareholders/owners, and your employees are paying for this healthcare systemic waste and inefficiency. Please stand together and make it stop. Be bold and support a local army of comprehensive family physicians who can deliver to you and your employees better health at a lower cost. Here are a few suggestions to achieve this aim:

  •          Talk to your employees and HR colleagues to gauge their recent experiences on adult primary care access and their experiences with out-of-pocket costs when they seek care for a new or acute health concern.
  •          Ask your insurance company to run a report on recent trends of costs incurred in emergency rooms. And ask if they can break out the costs of the free-standing vs. traditional ERs. (But if you receive a report, discuss with your employees about its accuracy. ER visits by employees with high-deductible plans may or may not be counted if the employee does not meet the annual deductible).
  •          If you discover that your employees’ experiences are similar to what I stated, then let’s get together again and discuss strategies to reverse these trends. I am working on a thorough assessment of all primary care capacity in Tarrant County, which I hope to conclude in a month or so.

Thanks for your time and consideration,

Richard Young, MD

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One Response to A Glimpse of a Bleak Future for Primary Care Access

  1. Peter on August 19, 2014 at 7:39 pm

    The health care market is completely out of control and corrupted by CMS/Medicare payment schemes, allowing for skewed incentives and a fractured “non-system” of care. The pressure to sub-sub-specialize is enormous and very expensive.

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