Commentary: Why you can’t find a primary care clinician, and what you can do about it
Have you had difficulty finding care with a primary care clinician? If so, you’re not alone - it’s become increasingly difficult to establish with primary care all across the country. This summer in the Upper Valley, after a million-dollar rebranding, Dartmouth Health announced it was unable to accept new patients for primary care. Ninety-eight million now Americans live in a primary care shortage area, often in rural regions.
Access and continuity with high-quality primary care is the bedrock of high-functioning health care systems. Primary care teams assure immunization, screenings for lead poisoning in children or cancer in adults, address health habits, mental health and numerous conditions like hypertension and diabetes, while coordinating care for an aging population. The National Academies of Sciences concluded that primary care is the only medical specialty of which more practitioners improves longevity, equity and the health of a population.
Broad societal solutions are required to remedy such social determinants of health as racism, inadequate housing, food insecurity and the opioid epidemic. However, improving primary care access is the sole responsibility of any effective medical system.
U.S. adults are least likely among developed nations to have regular primary care. The Association of American Medical Colleges projects a shortfall of 55,000 primary care clinicians in 10 years. Physician retirement accelerated from rising administrative burdens and after-hours spent on unwieldy electronic medical records. U.S. surveys report poor work/life balance, stress and burnout among primary care doctors, even before covid. Fewer doctors, nurse practitioners and physician assistants are electing to enter the field. Most other developed nations dedicate more expenditure on primary care services and work to integrate such services within communities. The U.S. spends a declining 5-8% of total health dollars on primary care, while other nations allocate 14%. Many other nations compensate generalists on par with hospital-based subspecialists, and their primary care clinicians deal with much less administrative burden. Here, career compensation for primary care/pediatrics remains half that earned by “proceduralists.” You get what you pay for:primary care docs constitute 45% of practicing physicians in France and 26% in the UK, versus 12% in the U.S. Better health outcomes, reduced mortality amenable to medical care and greater longevity are the consequences.
There are many reasons U.S. primary care has become secondary. A “Relative Value Scale Update Committee” (RUC) is convened by the AMA to set specialty reimbursement. The secretive RUC has 32 voting members, of which 27 represent medical specialties, and recommendations of the RUC are implemented by Centers for Medicare and Medicaid Services (CMS.) The AMA is beholden to specialist societies so conflicts of interest are rife within RUC.
Also, health insurers are allowed to negotiate, behind closed-doors, with hospital-multi-specialty practices to set payment for services. The consolidated mega-hospital systems strive to increase “market share” of “covered lives” in their regions, so to command higher payments from insurers in such negotiations. (Higher costs of hospital service do not trouble the insurers - they make profit off a percentage of the premiums they set, so, when hospitals charge more, they just raise premiums to cover the costs, keeping a steady 20% for overhead and profit.) According to the Urban Institute, commercial insurance compensation for specialty services range 10% to 330% higher than Medicare rates, whereas rates for cognitive services via family medicine or psychiatry are barely above the Medicare rates.
Hospitals make the most revenue from elective surgical procedures. Hence, all the ads for knee replacements. The hospital-multi-specialty megaliths view primary care as a “loss leader” and may value primary care accordingly.“Moral injury” as well as salary has impacted American primary care. With the rise of HMOs in 1990s, primary care docs were positioned in a professionally untenable role of “gatekeepers.” Group practices received fixed yearly reimbursement per patient from HMOs, so conflict of interest arose to limit care or procedures. That has abated, but now Medicare Accountable Care Organizations are piloted to be managed by private equity, which will recreate such perverse incentives, but this time among patients who aren’t even aware they are enrolled in a Medicare ACO. Healthcare organizations have also misapplied business principles to transform doctors into efficient producers of health-care “product lines.” Highly trained clinicians with fiduciary advocacy for their patients are morphed into “providers” clicking off check-boxes and diagnostic codes during abbreviated visits with increasingly older and complex patients.
Of interest, the word provider is extracted from commerce. It’s first medical usage was in 1965 Medicare legislation, referring to vendors delivering health-related products or services. “Provider’ makes no reference to professionalism. Teachers and lawyers aren’t labeled as knowledge “providers” nor legal expertise providers, and we go to a barber, not a hair-shortening provider. The highly profitable medical-industrial complex aims to transform healthcare from a public good to a commodity. In doing so, doctors became “providers” to support an engagement in a commercial transaction, rather than within a trusted, longterm, therapeutic doctor-patient relationship.
Short of Medicare for All, here’s some options: Congress should legislate that CMS set fees based on advice from transparent public agencies that meet societal needs, rather than needs of the AMA. So recommends the Government Accountability Office. Congress must shut the revolving door of administrators leaving CMS to become health industry lobbyists, as it has initiated in the defense industry. Insurance “intermediaries” that market Medicare, Medicaid, employee-sponsored insurance, ACA and other tax-supported “products” must develop uniform forms and policies to lessen burden on practices, and pay for community-integrated primary care teams rather than “providers delivering services.”
Untaxed hospital-megaliths can be mandated to provide robust, high-quality primacy care to meet the needs of the communities they serve. Incentives and tuition-reimbursement for health professional students should be enhanced for those who wish to enter primary care, especially in rural areas. Lastly, statehouses can learn from and emulate Maryland’s all-payer system. This transparent, state-led negotiation process sets uniform payments for a particular hospital’s services from all types of insurances, such as Medicaid, Medicare and private insurance intermediaries. Such negotiations occur with all hospitals, big or small, urban or rural, encourages acceptance of Medicaid and reduces issues with payer-mix. We can ask our congressional and state representatives, as well as local hospital board members, to research such actions, and fortify primary care. Our health depends on it.
Dr. Ken Dolkart worked as a primary care clinician and geriatrician practicing in New Hampshire for almost 40 years, retiring from Dartmouth-Hitchcock Medical Center in 2016. He now works part-time in primary care and geriatrics at at Mt. Ascutney Hospital (a Dartmouth affiliate) in Windsor, Vermont, and teaches at Dartmouth College's Geisel School of Medicine.
This article originally appeared on Portsmouth Herald: Commentary: Why you can’t find a primary care clinician
