Our talks of retainer medicine became more general talks about primary care, which is a great segue. A classmate emailed me his own sentiments:

I think you’re underestimating how screwed primary care physicians are… Primary care is royally f’d, and I don’t think its fair to pretend that their problems will magically get fixed by universal heatlhcare. As a lot of primary care’s f’d-ness has come at the hand of specialists.

As others have said, priarmy care is in trouble in this country. And I agree. Some of it is due to the lack of reimbursement compared to specialists; some of it is due to the lifestyle–seeing 8 patients an hour, including documentation and all that’s required for a patient visit–and the inability to properly care for a very sick patient with multiple medical problems in 7 minutes. (I do not ever mean to give the impression that “universal healthcare” would magically fix all these problems, just that I would rather deal with the problems in a fairly logical, rational, planned-out system than the patchwork disaster we have today.)

I’m going to attempt to discuss some solutions to the problems–both for an individual physician and health care/society as a whole. (While when I’m working as a clinician, my goal is the best care for my patients, when I discuss health care reform, I think it makes no sense to ignore the ramifications of a change to society as a whole.) If you solution is “people need to take more responsibility for their health and behaviors,” that’s a sentiment I whole-heartedly support, but if you think that’s sound health policy, Do Not Pass Go, Do Not Collect $200.

1. Income. Perhaps the biggest issue for most is the lack of reimbursement when compared to other specialties. By having a system that so heavily reimburses procedures over primary care (I wish I could remember where I read about the history of the RVU, Medicare’s unit of measure for determining who gets paid what for everything they do), you by default inequalize the playing field, and Sutton’s rule applies. One decent tutorial is from The Happy Hospitalist, “That’s Less Than Burger King Pays”, minus one gaping error of ommission:
   

   Imagine for simplicity that an internist has an all Medicare practice that generates $360,000 a year in clinic revenue. Let’s imagine the overhead is 50%.

   (I assume by “overhead” HH means expenses.) Overhead is 50%? Why not try to take a piece of this pie back? Administrative costs are a fierce proportion of total health care spending, even if you don’t like the numbers proposed. You do, of course, realize that in other countries, solo physicians can literally be solo physicians because they submit one form for their services, and get paid, right? And they certainly jump through fewer hoops with HMOs getting follow-up colonoscopies approved, or writing letters to non-medically-educated administrators to get treatment approvals, right? All of those things cost money.

   So we could certainly get money back into everyone’s pockets if we simplified the billing and administrative systems in the US, but I also think the RVU system needs to reward primary care work more and reward some procedures less. This would encourage more people to go into primary care and keep more people in primary care as well.

2. Lifestyle. Two big parts to this (correct me if I’m missing more)–time and paperwork. Panda sums up the former pretty well, and how the lack of time contributes greatly to costs (although he doesn’t mention costs specifically):
   

   The typical elderly patient who needs anything more than a routine physical exam cannot have her problems addressed in a fifteen minute visit, much of which is taken up by compliance and admininistrative tasks. Consequently, there is a disturbing tendency to consult specialists for every medical problem that will take more than fifteen minutes to address (a tendency that is completely separate from the legal imperative to fend off the predatory plaintiff’s attorneys). The result of this is that you have three or four doctors doing the work that one could do with all of the lost time and inefficiency that this entails. Additionally, under the theory that to the man with a hammer everything is a nail, when you send a patient to a specialist they are going to use their signature procedures to the full extent allowed by reimbursment and ethics. In other words, the default position of a gastroenterologist is to perform the colonoscopy because short of this, he may be adding nothing of value to the patient’s care. Now, I’m not saying that there is no use for specialists, just that sending a patient to a specialist to confirm something you already know or to implement a treatment plan that you would start yourself is a waste of money…except that the economic realities of primary care make it impossible not to use them like this.

   Many specialists are used as nothing more than physician extenders, kind of like mid-level providers if you think about it, for busy primary care physicians who know what to do but don’t have the time.

   Time. I’ve commented on this before, but it seems silly to give specialists more time with patients than primary care docs. Sure, primary care-ists see more acuity and less chronic disease, but that’s becoming less and less the case. Taking a page from the retainer medicine book, what if new standards were set for a patient based on the patient’s comorbidities? The annual diabetic exam gets 30 minutes at a minimum. The seemingly-refractory hypertensive patient gets half an hour so you can figure out what’s really going on. (Probably compliance.)

   Paperwork. Documenting is important — and not just for medico-legal blah blah blah. The US health care system is confusing and complex (and could certainly be simplified by health care reforms), but say we started paying doctors for their time–all their time. And perhaps to incentivize primary care, we only pay primary care doctors for all of it. That people practicing primary care can get reimbursed for their time on the phone, the paperwork they fill out–all of that. (Yes yes, I know this would create other incentives to send more paperwork to the PMD, but I’m brainstorming here, people.) I will also quote a poll that I can’t find right now stating that two-thirds of physicians would be willing to take a 10% pay cut for a significant reduction in the amount of paperwork they have to complete.

Look, to all of those who think retainer medicine will fix primary care, think again. It will fix primary care for individual physicians, but not for society as a whole. I’ve run the numbers. We need something in-between: something that encourages providers to stay in (and go into) primary care with better lifestyle and reimbursement, but that still allows them to see more patients than in a retainer practice.

I welcome your comments and criticisms, but I’m brainstorming solutions that would help both individual physicians and society, not one or the other. Offer something constructive–it seems like most people are happy to poo-poo an idea and complain (maybe that’s what the blogosphere is good at), but not to offer up their own solutions.

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