Tuesday, March 22, 2022

What is the problem with Primary Care? The US health system!

What is wrong with primary care in the US? Shall I count the ways? Medscape details a number of them in its recent article, citing much of the data provided in the Commonwealth Fund report “Mirror, Mirror on the Wall” which I discussed in my last blog post, Our health system: Not equitable, not effective, and not even efficient. Bad business!, (March 4, 2022). The spoiler answer is: what is wrong with primary care in the US is the US health care system – how it is designed, how it is implemented, the purposes for which it is intended, and the intrinsic corruption of it. If the primary care portion of the US health care system is in particular disarray, it is because it is the (relatively) poor stepchild of a system that is all about making lots of money for corporations, particularly large health systems, insurance companies, and the vendors of drugs, devices, and equipment. The way our health system is currently structured is to feature those parts of it that generate this money, rather than those that maximize the people’s health, and under our current reimbursement system primary care is not in the game. Thus, it is unsurprising – if incredibly depressing – that our primary care sector performs poorly on the metrics assessed by Commonwealth (and reported on by Medscape), because they are looking at different markers, that is, how it meets the health needs of our people, and a robust and effective primary care capacity is critical to that. If only they would look at corporate profit they would see how well the health system, by neglecting primary care, is doing!

What is primary care and what are primary care doctors? They care for all the issues that a person has, not limited to disease, organ system, procedure, etc. They care for people with as-yet undiagnosed problems, with undifferentiated conditions. They provide care over time, and consider the physical, mental, and social conditions affecting a person. They provide care in the context of a person’s family and community. Any issue that is affecting a person’s health, or that they think is, is fair game to bring to a primary care doctor, who will try to diagnose and treat it, referring if necessary. In a coherent and effective health system, they continue to be involved with the person, even after referral or hospitalization. The characteristics of primary care, and the reasons for its benefit to people and to society are discussed most clearly by Barbara Starfield, MD, in many papers including this one. I like to think that while the relationship between primary care doctors and their patient is defined by the relationship, not the disease, or procedure involved. Family medicine, unlike even other specialties in primary care does not even limit its practice to certain age groups. But even these doctors are being relegated to practice only part of what they could; few deliver babies, most don’t do hospital work, and a large number do not care for children.

But few of us have seen such a physician lately, still less with a “full scope” practice. There are not enough family physicians or other primary care doctors in the US. There are not enough to meet the primary care needs of our people, nor to adequately perform the role that primary care should play in regard to specialists – that is, assessing a patient, determining if they can be treated by the primary care doctor, and if not referring. Otherwise subspecialists spend a lot of time caring for things that could have been done by a primary care physician. Or missing problems that are outside their specialty focus when people directly self-refer. And it is not only in the US; in parts of Canada, there are such shortages of primary care doctors (there they are virtually all family physicians) that consideration is being given to a new profession, possibly called associate physicians. In the US, much primary care is delivered by nurse practitioners and physician’s assistants. Some of them do excellent work, but they are also hampered by the same constraints as those primary care physicians face – excessive workload, assembly line production, (relative) underpayment, and a perverted reimbursement system.

To the extent that the move to non-physicians is driven by the fact that they cost less because they earn less money, any such effort is doomed. Nurse practitioners are increasingly being recruited by hospitals and subspecialty physician groups where they can earn, as do the doctors in those specialties, more money. This has overwhelmingly already happened in the case of physician assistants. The answer to the need for more primary care is simple: PAY MORE MONEY. Pay them as much as, or almost as much as (70% would probably do it) other specialists. There are a lot of students, residents, doctors, nurse practitioner and physician’s assistant trainees who would like to do primary care, and would be good at it, but are dissuaded because they can earn WAY more in another specialty. It is not that complicated; virtually all reimbursement for health care in the US is based on Medicare rates; private insurers pay some multiple of what Medicare pays. So all that has to happen is for Medicare to completely revise its reimbursement schedule so that primary care is paid a lot more, and interventive procedural specialty care less. Don’t increase the size of the pie; reallocate!

Sadly, the reallocation (under both Republican and Democratic administrations) has been instead to increase the privatization of Medicare, effectively enhancing corporate profits rather than quality health care. The Medicare Advantage program, while it can be good for some seniors, is being touted as the greatest thing since sliced bread by many in Congress, although it is heavily subsidized and saps funds from Traditional Medicare (TM). MedPac (not a “political action committee”, but the official group convened by Congress to make recommendations on Medicare) has raised serious concerns about the program, which essentially cherry picks healthy seniors, gives them low cost benefits, and eschews sick people while getting more money from Medicare. As I have written before (Direct Contracting Entities: Scamming Medicare and you and bad for your health!, Feb 7, 2022), a program called Direct Contracting Entities (DCEs) was developed to push even those who have chosen TM into corporate controlled profit centers. And now, after DCEs have received criticism in Congress, they haven’t been abandoned, but re-branded as REACH, essentially the same model.

The problems with primary care are not with the clinicians. The problem is with the corporate model that seeks to limit the practices of the clinicians and speed up their work so they cannot provide the benefits of primary care. The key part here is being the core person who knows about you and your family and manages directly or in conjunction with others all your care. It cannot effectively happen if you are seeing different doctors in every setting, and no one is responsible for YOU. This is much different from being the person who orders the tests or prior authorizations. Family physicians and other primary care doctors and clinicians need to have the time to spend with the patients, getting to know them, getting to know them well enough that they are trusted by their patients, who may then reveal the Pandora’s box of complicated, difficult-or-impossible to solve problems that physicians dread to hear about and corporate employers hate to pay for. You can’t get to these, not to mention begin to solve them, in 15 minute visits. Often you can’t really begin to solve them at all, since they are based in the overall circumstances of life that people find themselves in, what are often referred to as the "social determinants of health" -- their income, jobs, education, housing, food, safety, and discrimination for starters. But they need to be revealed.

This is scary to corporate types, who want to continue to do what they do – generate big bucks by hiring procedural specialists to care for well-insured or rich people for big reimbursement.

Friday, March 4, 2022

Our health system: Not equitable, not effective, and not even efficient. Bad business!

Over a year ago, deep in the pandemic, a close friend felt she had a bladder infection. She went to the local Urgent Care (run by the large hospital system that also runs our University Medical Center) to be sure; they did a test on her urine, verified it was a bladder infection, and gave her a prescription for an antibiotic. It got better.

Not long ago she began getting dunning notices for the bill for this visit. She was surprised, as her primary insurer (Medicare) and her Medicare Supplement policy should have covered it all. Hours on the phone, with the health system and insurers, she determined it was because the system had not submitted the bill on time. Note that they have a year to submit a bill to Medicare. She talked it out, and thought that it was resolved. More recently, she received another dunning notice, followed by more phone calls. The billing department did not have her insurance information on file. She was surprised, she noted, as the Urgent Care clinic had taken photocopies. “Oh,” she was told, “that’s the clinic. We’re the billing department. We don’t have access to those.” Wait, you’re the billing department for the Urgent Care, but you don’t have access to the photocopies of the insurance cards that they took solely for the purpose of billing? What kind of an operation are you running here?

Sadly, and perhaps surprisingly, an operation of health care in the US, and perhaps business in the US altogether. Not efficient, not effective, poorly designed, and, of course, set up to make the victim – in this case the patient or the client – take the blame. Spoiler alert: It is their fault, not yours!

Every few years the Commonwealth Fund assesses the performance of health systems in 11 high income countries around the world. Since 2014 it has been called “Mirror, Mirror on the Wall”, and each time it comes out the US ranks last in overall performance, and also last or near last in most sub-areas (Healthy Lives, Quality,  Access,  Efficiency, Equity). It is worth looking over the whole report from 2021, but I am going to focus on Efficiency. When I first looked at the 2006 and 2008 reports (then called “Dimensions of a High-Performance Health System”) I was a bit surprised that the US’ worst score was on efficiency. Access, yes, I could understand. Equity, yes, of course not. Even Quality, depressed as it would be by the lack of access and equity. But efficiency? I thought of the waste that came from so many private systems which had (especially in those days before Electronic Health Records,  EHRs) so ability to share information. So you got a lab test or x-ray at one place, maybe an ER, but the next place couldn’t access it, so they did it again. Inefficient, and costly. And not good for you.


So did it get better with EHRs? Well, not per the 2014 report, in which the US ranks 11 out of 11 in Efficiency (as well as in Equity and Overall). Maybe it takes time, but the 2021 report shows that the US is – still dead last, now presented with 3-digit scores rather than simple ranking. Even though our health system’s corporations are, as I have often said, about making money for themselves rather than taking care of your health, their business systems are poorly designed, inefficient, and cause you no end of grief even if you are insured and not too sick. Of course, woe to you if you are uninsured and very ill! THEN you really suffer!



I once sat on the Billing Steering Committee of a large practice plan, and one of the issues that kept coming up was people not paying their bills. As a patient there, I suggested that it was hard when you got a bill for, say, your doctor visit, paid it, and then a few days later got the bill for the lab test or x-ray or something else. Since one of the purposes of creating the practice plan was to have a unified bill, I asked why they didn’t send out a monthly bill, so people could pay everything at one time. We do, they said, but only after we send out the individual ones. Gee, I noted, one monthly bill works for credit card companies. Can you imagine if you got individual bills all month for all your MasterCard or VISA charges that indicated that you had to pay them then, rather than one monthly bill? T What, I thought, if you got a bill today for a lunch you had 3 days ago, and tomorrow for the shirt you bought last week, and a few days later for the vacuum cleaner you’d ordered? And each indicated you were to pay it today? What would be the point of a credit card? What is the point of integrated practice billing? he concept of not sending out each individual bill was not only foreign to them, but incomprehensible.

They remained unconvinced, and it was dropped. The reason that they remained unconvinced is it wasn’t how they did things. And management of health systems (and, to a large extent, US business) is doing things how they do things. And congratulating themselves on how well they do. And rewarding  themselves handsomely for it. And blaming someone else (usually the client or patient) when it doesn’t work. They are wrong, they are fooling themselves, the data is in, but they persist. Because they have the power.

After World War II, a statistician named W. Edwards Deming developed systems for enhancing quality in business and manufacturing, a data-driven approach that became known as Continuous Quality Improvement, CQI (there are a number of good books by and about Deming and his methods, some very easy to read). It caught fire in a Japan trying to rebuild after the war, but was ignored in the US because, in the 1950s and early 1960s, US businesses were doing great. The reason, of course, was that the manufacturing capability of every other developed country had been decimated by the war, so US business had essentially no competition. It could have been run by monkeys and would have done well. But the monkey-impersonators who were actually running it convinced themselves that it was because they were so good! Then, of course, by the late 1960s Japan and Germany were outperforming the US in terms of quality, and profit. US industry was still not that concerned about quality, but they did want profit, and many CQI models were adopted (famously at Ford, but also at other large companies).

But progress, as those who study history or at least are old enough to have lived through a fair portion of it know, is not linear. Traditional bad practices are hard to erase, and without continuous reinforcement of better ones continue to recur. Especially difficult to control are those which can be (and are) interpreted by the management (who like to call themselves “leaders” though that is rarely what they are) as showing how good and smart (and deserving of high pay) they are. So, they do recur. These attitudes, that things are best when Wise Managers are in charge, has permeated not only for-profit business but even non-profits and membership organization, not always to the good. In “Good to Great for the Social Sector” business guru Jim Collins has observed that while non-profits are often urged to operate “like a business”, since most businesses are poorly run and operate poorly this is not always a good idea!

Very recently I learned of a health system which contracted for the services of a doctor from a government agency. Since the doctor was not their employee, the system couldn’t bill for the doctor’s services. So, they assigned a nurse practitioner who was their employee to accompany the doctor and bill under the NP and health system’s name. Except the doctor worried that this would be Medicare fraud, and consulted the attorneys for their actual employer, who agreed. This surprised the health system; they worked – as almost all of them do – under the assumption that the whole thing is a game, to maximize their income and profit. Heck, they upcode all the time to get more money from Medicare and other insurers!

So, what is the upshot? Health systems (and US businesses in general) have a total focus on making money, even when they are pretty inefficient at it. This sometimes clouds their attention to obeying the law. It certainly is more important than the quality of your care, or your financial health. As always, while it affects everyone, the most disadvantaged – the poorest, worst insured, least educated, and least empowered suffer the most. So what can we do?

For starters, we need a universal health insurance system, like improved an enhanced Medicare for All (HR 1976 this year). This will not by itself bring us up to par with the other nations, but it is a necessary start.


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