Primary Care Shortage is Due to a Lack of Imagination

In light of how "effective" we've been at devastating primary care, it's understandable that people have concerns that new models might further undermine primary care. After all, there's no well-functioning healthcare system in the world that operates without a strong primary care foundation. As I pointed out in a chapter in my last book, the opioid crisis isn't an anomaly. Rather, it's the logical (and tragic) byproduct of a catastrophically dysfunctional healthcare system with undermined primary care being one of the core facets of the dysfunction.

Nothing created more fertile ground for the opioid (and rising benzos) crisis than a badly undermined primary care system.

I'll confess I find it odd that people are tacitly endorsing the wildly under-performing status quo healthcare system when they think next generation primary care models such as value-based primary care (e.g., Direct Primary Care) will somehow worsen the status quo. It's almost impossible to imagine it getting worse.

Why is there a shortage? Primary care appointments are often less than 10 minutes, there are long waits to get an appointment, severe abuse of primary care docs has been leading to burnout and docs regularly spend two hours on insurance bureaucracy for every hour of patient time. These are hardly things to defend. In contrast, in a well-functioning primary care model, over 90% of the issues people enter the healthcare system for can be fully addressed in a proper primary care setting. That's relatively rare in the U.S. but common outside the U.S. when there's functioning primary care.

To those who are concerned that new models such as Direct Primary Care may lead to patients being "abandoned" I say we've long since abandoned patients via the severely flawed primary care model that is too often little more than a referral and prescription machine fueling health system and pharma profits, not proper patient care.

When we rationalize primary care, there are countless resources that get freed up and inefficiencies that go away. Even without looking at the details in the graphics, it's clear how badly we've botched primary care in the volume-centric, fee-for-service primary care model.

The following are some of the band-aids and manifestations of badly undermined primary care:

• Urgent care and retail clinics largely wouldn't need to exist. Studies have shown they don't even reduce visits as anything beyond simple conditions often leads to a patient still going on to schedule another appointment.
• Telehealth for primary care. In a proper primary care model where the distortion of forcing a face-to-face encounter for the doc to get paid is removed, telehealth is a feature of a value-based primary care model. It shouldn't be an entire separate category.
• Carriers having care management programs often staffed by nurses. While well-meaning, for the most part, who wants to have a primary care relationship with an insurance company? Not many people. Largely, these exist because the status quo system is extremely silo'ed with little coordination between various provider organizations. It's how you get Russian Roulette Medicine.
• The majority of unnecessary emergency room visits are people who have insurance but can't get into their primary care doctor in a timely manner. It's common for there to be a one month wait to get in. How can that be called primary care?!
• The Patient centered medical home (PCMH) concept is full of great ideas and laudable goals. However, the reason why the impact of PCMHs has been very modest is because it is layered on top of a fundamentally flawed model. It's like putting a Tesla body and dashboard on an AMC Pacer. It doesn't change the fact that the underlying engine is still an AMC Pacer. While the PCMH concept obviously didn't create the opioid crisis, the rise in PCMH mirrored the rise in the opioid crisis.
• The good intent of the PCMH wasn't enough to overcome the fact that the opioid crisis is a microcosm of the larger healthcare dysfunction -- and the undermining of primary care, in particular. The undermined primary care model made us much more vulnerable to the tactics of the drug makers aggressively pushing their opioid drugs. I'd argue a "pure" PCMH is one free of insurance bureaucracy and misaligned incentives due to health system ownership in a fee-for-service environment.

There are a variety of ways that everyone can get proper primary care -- far better than more band-aids. As with most problems, there's no single silver bullet. Note: There is one area where the shortage of primary care physicians is most acute -- rural communities. That is a tougher challenge but can be addressed with some creativity as outlined below.

• Part of the reason there is lack of time and access to primary care physicians is they are spending two hours on insurance bureaucracy for every hour of patient time. Remove that bureaucracy and a tremendous amount of primary care capacity is freed up.
• In a modern primary care practice, every healthcare professional practices at the top of their license. As important as physicians are, they are just one part of the primary care team. For example, where my family goes (btw, it's less costly than the status quo), the care team consists of not only the doctor but nurses, social workers, health coaches, nutritionists and more. Health coaches, in particular, have proven to be very effective at reversing lifestyle-driven conditions that doctors often don't have the time, empathy or training to address. Pharmacists are vital for helping patients with multiple prescriptions -- common for people with multiple conditions.
• Many physicians trained as primary care oriented physicians such as those who studied internal medicine expecting to spend their career in primary care type settings but as primary care became miserable (professionally and financially compared to many specialties), they left primary care. As primary care becomes more appealing again, these internal medicine docs return to primary care as there are many joys to it when insurance bureaucracy is left behind. I've even heard of cardiologists and surgeons continuing their medical career by specializing in primary care at the later stages of their career. In many cases, cardiologists have become quasi primary care physicians as they deal with long-term chronic conditions the way a great primary care practice does. The ones who value relationships over procedures are particularly drawn to primary care.
• An emergent model is care is called Virtual Primary Care. Unlike telehealth, there is an ongoing relationship with a care team versus the transactional nature of telehealth models. These are particular good for the 50% of the population that only consume 3% of the dollars, yet those patients can often clog a traditional primary care waiting room. Paraphrasing Dr. Don Berwick, primary care waiting rooms are clogged with people who don't need to be there keeping those who have more urgent and face-to-face demanding conditions from getting in. This causes more urgent conditions to get worse and more time-consuming for their care team. Docs regularly tell me that two-thirds of the their face-to-face appointments don't require a face-to-face interaction but that's the only way they get paid. Who can blame them? Remove that distortion and more time is freed up.
• We know that only ~20% of health outcomes are driven by access to clinical care. Investments in community health workers and health coaches have proven themselves to improve health outcomes and can be one piece of the puzzle in addressing issues such as vaccinations that have traditionally been addressed in a primary care setting. Barbers are helping reduce blood pressure, postal workers are checking on frail elderly and meals-on-wheels workers are reducing hospitalizations in COPD patients are just a few examples of creative thinking addressing some primary care needs.
• A variety of other health professionals such as nurse practitioners, physician assistants, community paramedicine (paramedics who visit homes between calls to check on frail elderly and others who need ongoing attention is being adopted in rural settings) and so on can help meet primary care type needs.
• As various technologies for remote monitoring and care management programs prove themselves, they become another piece of the puzzle. We've already seen various organizations use hybrid technology and health coach solutions implement programs such as the Diabetes Prevention Program that are proving highly effective at reversing conditions. There's a tremendous amount of investment in these areas that will chip away at these conditions. A modern primary care practice would embrace coordinating care with these condition-specific programs that have a strong incentive to coordinate with primary care but have been brushed off in the past.
• In the Health Rosetta community, there are many rural situations where there are no physicians, let alone primary care. Rather than throw up their hands, they bring in a DPC doc X days per week/month depending on the number of individuals served. A primary care relationship is established and since the majority of primary care can be done remotely, they can have primary care access all the time even if the PCP isn't local 100% of the time. 
• If all of the above items doesn't solve the issue, there are an enormous number of international doctors who would like to practice primary care in America. Ask any chapter of the American Academy of Family Physicians about the huge number of requests they receive from international doctors who'd like to practice in America -- many who are already in the U.S. but unable to get re-licensed to practice medicine. It's simply a matter of will to make this happen -- it doesn't require the long-term fix of training more PCPs from scratch. With enough political will and the shortage could be solved just with this tactic.

Collectively, it's the mix of the items above and American ingenuity that make me optimistic that we can address the range of primary care needs. It won't be doubling down on the flawed status quo primary/cattle care that will get us out of the disastrous status quo. It will be creative solutions such as Direct Primary Care and the items listed above that will get us out of our current predicament. Let's put our energy there rather than perpetuating the status quo or criticizing those tackling problems that have gone unsolved for decades.

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Dave Chase is the co-founder of the Health Rosetta Institute (a LEED-like organization for healthcare) and author of the book, “CEO's Guide to Restoring the American Dream - How to deliver world class healthcare to your employees at half the cost.” Follow the link to the book below for a free download of the book. Chase's TEDx talk was entitled "Healthcare stole the American Dream -- here's how we take it back." See the Health Rosetta Institute website for how to get involved, resources and how to join others to support its mission.