Expecting everything from primary care: reasonable?

In 2003, Kimberly Yarnall and colleagues from Duke University published an article in the American Journal of Public Health documenting that it would take 7.4 hours a day, essentially an entire workday, for a primary care physician to perform all the preventive services recommended by the US Preventive Services Task Force (USPSTF) on a typical population of 2500 patients.[i]  Six years later, they wrote a follow-up article in which they added the time it would take to also deliver care for the acute and chronic conditions that patients actually came to their doctor for, and it came to 21.7 hours of a 24-hour day![ii] One year after that, in What’s Keeping Us So Busy in Primary Care? A Snapshot from One Practice, Richard Baron wrote about a day in his practice, where, in addition to seeing an average of 18.1 patient visits per day (the one activity they were paid for), they also returned an average of 23.7 telephone calls, and 16.8 email messages. They refilled 12.1 prescriptions, reviewed 19.5 laboratory reports, 11.1 imaging reports and 13.9 consultation reports per day, and also filled out large amounts of paperwork that they do not report on because they are not captured by their electronic medical record, such as “…administrative forms (e.g., for physical examinations for work, camp, and school and Family Medical Leave Act forms), correspondence received from health plan (e.g., disease-management letters), and reports on home care and physical therapy.”[iii]

When I wrote about this, in Primary Care: What takes so much time? And how are we paying for it? (May 21, 2010), I discussed the incredible burden that this placed on primary care physicians, and how unrealistic it was to expect this of them. I addressed an article by David Margolius and Thomas Bodenheimer, Transforming Primary Care: From Past Practice To The Practice Of The Future,[iv] in which they envision the effective and efficient provision of primary care by well-designed teams. I also expressed some skepticism about how likely this would be to happen. So, now it is another 9+ years since the Baron article, and how far have we come? Not, as it turns out, all that far. The impetus in medicine, from health systems, payers, and primary care physicians’ own specialty colleagues, is for more and more work to be expected from primary care providers, both in terms of direct patient care (acute, chronic and preventive) and the kind of paperwork and form-filling-out described by Baron. This comes, unsurprisingly, with little additional financial reimbursement to the doctors or practice (or financial support from health systems for the kind of expanded teams envisioned by Margolius and Bodenheimer), and certainly without more hours in the day!

Why? For one thing, it’s easier. If you don’t know where something fits in the always-getting-more-complex-and-confusing health system, assign it to primary care providers. This is particularly attractive if you are a specialist and it’s something you don’t want to do. And, if you are a health system manager, if it is something that is poorly reimbursed. Think about it. The surgical subspecialist, for example, wants to operate on people. S/he wants, perhaps, to consult with patients about their particular problem, and maybe even their concerns about it, but mostly wants to operate, and to generate the income that comes from operating and not to fill their time up with additional paperwork, or blood pressure checks, or FMLA requests. When they do follow-up they mainly want to follow up the narrowly-defined surgical problem; if there are other complications that are acute, there are consultants for that; if there are longer-term issues that will need to be dealt with, there are primary care providers for that.

Similarly, the health system makes money from procedures being done, and wants their proceduralists, say this subspecialty surgeon, to generate the surgical procedures that make them money, not “waste their time” on more poorly reimbursed medical activities -- or certainly paperwork. When such work can be done by others – nurse practitioners or physician’s assistants, or scribes or nurses, or anyone who gets paid less, then it is financially efficient to fund those positions. In her New York Times article “The Business of Health Care Depends on Exploiting Doctors and Nurses” (June 8, 2019), Danielle Ofri, a physician at Bellevue Hospital in New York, makes a truly important point: that health care professionals actually care about their patients, and want to do the right thing, and will work hard even when that requires more hours than they have or are being paid for. In this sense, it is the health systems (individually) and the health system (writ large) that is profiting. But it is also true that the degree of exploitation (and payment) is not the same for all health professionals; it is not the same for nurses and doctors, and it is not the same for primary care doctors and many subspecialists.

Primary care physicians may inadvertently encourage this. As Ofri describes, they want to be professional and responsible, to know about everything that is going on with their patients. They want to be the physician for the patient, not the disease, to coordinate and manage all the care, to interpret for their patients what other doctors are telling them, especially when the messages that the patients are getting are mixed or unclear. This is what makes them good doctors. However, it is also what makes them really good candidates for being the “buck-stops-here” venue, the “take care of everything no one else can or wants to”, especially if these tasks, from the larger health system point of view, are not reimbursed or poorly reimbursed in themselves but are required by payers (private and government insurers) to be done in order for the system to get reimbursed for the high-ticket items (such as surgery) that they provide.

This is not irrational. It makes sense for people to do the work that only they can do, to, in the jargon, “work at the top of their license". But this requires changes in reimbursement. In particular, the concept that a single episode of treatment (e.g., surgery) is worth a lot more than the ongoing continuous lifelong management of a person’s health needs to be re-examined. But for this to work, adequate resources – especially human, like enough primary care doctors so that they don’t have the 2500 patients each, and enough support nurses and assistants and clerks and scribes to address the workload – have to be available.

Some primary care providers have moved into “direct primary care”, where, for a fee beyond insurance reimbursement, they provide (presumably) all the primary care needs of smaller group of patients. It has its pluses, but without adequate numbers of providers and without a national health insurance system covering everyone, it leaves too many people out; it becomes another “market niche” for those who can afford it, and this is not what health care should be.

I have heard it said that there are 3 entities that are always identified as likely places when something additional is suggested to be added to health care: primary care, nursing education, and black churches. Nursing education because, you know, nurses should know how to do that (whatever that is today). Black churches, you know, because they are important institutions in the community, with credibility, so if they urge people to healthier behaviors it may work better than when outside health professionals do. Could be a good idea. Maybe the nursing schools or black churches could hire people who could use the jobs to do this work.

But, as in primary care, rarely are these “good ideas” backed up with money, with sufficient funding to make it happen, to employ people, to support them. That money, of course, needs to go to for health systems, subspecialists, insurance companies, and mega-corporations.

Time for a change.

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[i] Yarnall KSH, Pollak KI, Østbye T, Krause KM, Michener JL, Primary Care: Is There Enough Time for Prevention?

MD Am J Public Health. 2003 April; 93(4): 635–641.PMCID: PMC1447803. PMID: 12660210

[ii] Yarnall KSH, Østbye T, Krause KM, Pollak KI, Gradison M, Michener JL, Family Physicians as Team Leaders: ‘Time’ to Share the Care, Prev Chronic Disease Apr2009;6(2):A59),

[iii] Baron R, What’s Keeping Us So Busy in Primary Care? A Snapshot from One Practice, New England Journal of Medicine, Apr29,2010;362(17):1632-6

[iv] Margolius D, Bodenheimer T, Transforming Primary Care: From Past Practice To The Practice Of The Future, Health Affairs May 2010, 29(5): 779–784.