"Direct primary care" not the answer for our health system. Beware "Project 2025"!

My last post (June 27, 2024) was about the shortage of primary care physicians (as well as NPs), and the reasons why. To save you the time of (re?)reading it, here is the bottom line: It’s the money, stupid! Primary care physicians – and NPs – get paid a lot less than those working in subspecialties, for what is indeed very hard work, encompassing breadth (everything), depth (everything), and time. I also suggested that there was a relatively simple way to address the income disparity between primary care and subspecialty practice: having Medicare revise the criteria for payment, which affects not just Medicare but also the rest of us as most insurance companies base their reimbursement rates on Medicare’s.

There have been other suggestions on how to “help” primary care. One of them, which has been seen in many places across the country for years, involves having people pay extra money (usually in an annual or monthly fee) to their primary care doctors to supplement their income and to make them more available to their patients. This phenomenon has many names -- “concierge care”, “boutique care”, “direct primary care” -- depending both on the way it is structured (and the amount of the additional fee) and how the user wants to spin it – are they portraying it as good or bad?

One place where it is portrayed as good is in the Project 2025 document issued in April by the Heritage Foundation and its allies, Project 2025 Mandate for Leadership: The Conservative Promise. This document outlines an ambitious, far-reaching, and horrifying vision for the future of the federal government once “conservatives” take the White House back. It systematically goes through every federal function, and many agencies, detailing what should be eliminated or scaled back (mostly) or expanded (rarely, mainly tax cuts for the rich). It manifests a vision of America where the corporations and the richest individuals are even richer and more powerful than they are now and the “poorest” (meaning not just the poor but working people and the majority of those who consider themselves “middle class”) are even worse off.

How does this relate to primary care? One of their (many) plans for healthcare in this country, discussed in the Health Justice Monitor, is to “Remove barriers to direct primary care”. That the Heritage Foundation is for it should in itself be a warning. They like it because it is “free enterprise” and comes from a libertarian approach that basically maintains that it is good to sell (to people who can afford it) those basic things that everyone should have as a right. Also, like most (all?) things endorsed by these “conservatives” (who mainly wish to conserve privilege) it ignores the negative impact on those folks who cannot afford to buy it.

This is not to say that everything about direct primary care as it exists currently is bad. I know many doctors who chose it because it allows them to make a living, yes, but mostly because it permits them to more fully and completely practice the kind of medicine that they trained to do because they wanted to do it, manifesting the 4 C’s of primary care – comprehensive (more or less), first contact, caring, and continuous over time. Most of them had previous jobs where they worked for big health systems (and, increasingly, private equity companies) in which they were continuously pressured to work faster, see more patients for fewer minutes, and generate more income for their employers – a concept” familiar to manufacturing jobs called “speed up” that comes from literally increasing the rate of speed of an assembly line. By charging a (modest, in many cases – this is not about true concierge care where the charges can be $10,000/year or more) fee, they are able, they believe, to take care of most of their patients’ problems, do it compassionately, see them for long enough to do so, and be available to them when they need it. These are all good things, and like most of the doctors I know who are doing this, most of the people I know who go to them as patients appreciate it and think it is beneficial.

So, what is the problem? Well, obviously, it is not available to everyone, to those who can’t afford an extra fee, and already have a problem with their insurance premiums, deductibles, and co-pays. Note that when Project 2025 says “DPC has faced many challenges from government policymakers, including overly exuberant attempts at regulation and misclassification,” the solution they propose is to ensure that the payments for it are not paid by insurance or health savings accounts. That many, most, people can’t afford DPC is the big objection to it, but there are also other problems. DPC hearkens back to the days of the old GP, where for a small fee (or a chicken) avuncular Marcus Welby could take care of all of your problems (of course, old Marcus somehow managed to stay in practice with only one patient a week). But medicine is not like that anymore. While I am a huge advocate for primary care, for family medicine, for comprehensive practice, providing all the benefits that modern medicine has available often requires more than the one primary care doctor can do. It may require specialists, both knowledge-based and surgical. It may require imaging (x-rays, CT, MRI, PET). It often requires laboratory tests and medicines. It requires other people and other resources.

Moreover, as reported in (among many places) a succinct and accurately titled Medscape Medical News article, July 2, 2024, “Better Access for a Few Patients Disrupts Care for Many”. With so few doctors (and NPs) entering primary care, the impact of those entering DPC further decreases the number of providers for those who cannot afford it. Adam Leive, one of the authors of the article on which this report is based (“On resource allocation in health care: The case of concierge medicine” J Health Economics, July 2023) is quoted as saying “Concierge medicine potentially leads to disproportionately richer people being able to pay for the scarce resource of physician time and crowding out people who have lower incomes and are sicker". This is the key point. The Medscape article also adds that ‘Leive's research showed no decrease in mortality for concierge patients compared with similar patients who saw non-concierge physicians, suggesting concierge care may not notably improve some health outcomes.’

Let’s get this straight. The Heritage Foundation’s support for DPC, and indeed elite concierge care, is because they are right-wingers whose agenda is all about further privileging the privileged and ignoring the needy. The large insurance and private equity companies who sponsor versions of DPC are doing it to make money. The primary care doctors who are engaged in it are (mostly) trying to make a living and provide quality care in miserable healthcare system (although not yet as miserable as the one Project 2025 envisions). These doctors are basically engaged in a “work-around” that does help some people, if not everyone, to have better access if not health outcomes.

But we don’t need a “work around”. What we need is a well-designed, single payer, comprehensive, cover everything, no co-pay or deductible, no necessary services that are not covered, health system. Improved and expanded Medicare for All!

Lead poisoning of our children: then and now

Back in 2016 much of the country was shocked to learn about widespread lead poisoning among children in Flint, MI. The cause was lead leached from old lead pipes supplying water to people’s homes after the source was changed from Lake Huron to the more corrosive water of the Flint River (to save money, of course). The identification of this problem was largely due to the great work of a committed pediatrician, Dr. Mona Hanna-Attisha, about whom I wrote on Jan 24, 2016, “Flint, lead, medical heroes, O-rings and guns”. That piece also discusses the shameful – probably criminal – denial of both the problem and its cause by the then-governor of Michigan, Rick Snyder, and his politically appointed state health department, until the evidence became too overwhelming to deny. After all, poisoning children is one thing, but getting negative press is another!

Many of us probably assumed – or at least hoped – that this epidemic of lead poisoning of children, as horrible as it was, was an exception, an outlier, something that should not be happening in the 21^st century in the United States. We knew that it was related to the fact that Flint is a poor, largely minority, community, and if we are at all sentient we know that those are the people who suffer the worst from environmental degradation. In the case of lead poisoning, they live in houses that are more likely to have old lead paint, in neighborhoods built closer to heavy automobile and truck traffic areas where the soil (such as, for example, in the playgrounds) has high concentrations of lead. We might have even thought of lead pipes supplying water. But surely this was not something that was happening in many places around the country, even in poor communities?

 

But it was, and is. All over. More in very poor and minority communities.

A few years ago, [Sean] Ryan, now a Democratic state senator, learned that his constituents in Buffalo were sending bottled water to Flint, Mich., where widespread lead contamination in the water supply had drawn national attention. While respecting the gesture to help, he recalled from a Reuters investigation that there were 17 ZIP codes in Buffalo where the rate of children with high lead levels was at least double that of Flint. (Gabler, NY Times, below)

And it is still happening. And still not being addressed. Flint may have stood out because of the sudden increase in children with high lead levels identified by people like Dr. Hanna-Attisha after the change in water to a cheaper source leached lead from the old pipes, but chronic, ongoing lead poisoning of our children, primarily from lead paint in old houses, continues apace. And there is a lot of resistance to doing anything about it.

 

This is covered in depth in a recent (Mar 29, 2022) article in the NY Times by Ellen Gabler, ”How 2 Industries Stymied Justice for Young Lead Paint Victims”. This exposé documents the ongoing and continuing poisoning of America’s children (particularly those of poor and minority people) by lead paint in houses (“about 500,000 children under 6 have elevated blood lead levels in the United States and are at risk of harm”). One of the two industries is the housing industry, which both lies about whether there is lead paint in the homes that they are renting, and, if they are large enough, obstruct those people from finding some sort of (generally financial) justice by hiding the ownership in a web of companies, and fighting culpability.

 

Without insurance, there is little chance of recovering money for a child when a landlord has few resources. Property owners who do have substantial holdings have found ways to legally distance themselves from problem rentals, increasingly using L.L.C.s to hide assets and identities.

 

And the other industry? That would be the insurance industry itself, which places clauses in its homeowner’s policy excluding lead. Why? Well, you see, it would cost the insurance company a lot of money if they had to pay for the mitigation of lead paint in these old houses. So they don’t insure the owners, and the owners are either unable to afford to do the mitigation or are large and wealthy enough that they could afford it but choose not to. In fairness, the quote above about property owners legally distancing themselves from “problem rentals” applies to many “problems” (virtually all of which are the owners’ responsibility), not just lead. Property owners want to collect rent but not maintain the property; insurance companies want to collect premiums but not pay out when there is a problem. What could be more American?

 

Another recent article, in Medscape, documents how most current adults had elevated lead levels as children, and how, as stated in its title, Half of Adults Lost IQ Points to Lead Toxicity. The culprit in this case is primarily lead in gasoline. Added to gasoline beginning in the early 1920s, lead’s phaseout was accelerated by the advent of catalytic converters, which require unleaded gas, in 1975, but it was probably an additional 20 years before it was gone from most gasoline sold.  And, of course, the residual lead in the soil (including places where children play) remains even today. This graphic from the article demonstrates how ubiquitous high lead levels were when today’s adults were children, what age ranges are most affected, and of course how minority children (and today’s adults) were affected with levels far higher than whites (which were bad enough).

 

 

So we have a situation where the majority of today’s adults, at lead those over the age of 30, probably had high lead levels when they were children, and have lost IQ points as a result, and where poor and minority children then (now adults) had far higher levels than whites. And we have another situation in which children continue to have high lead levels, and to suffer not “just” a loss of a few IQ points but serious brain damage, because of ongoing lead exposure, now primarily in lead paint that still exists, unmitigated, in many houses. And, of course, these children are disproportionately poor and minority. (Some things, sadly, do not change.) When I was a young physician, working at Cook County Hospital in Chicago, we would not infrequently have to treat (often as inpatients) children with high lead levels. I thought, like measles and chicken pox and rheumatic fever and infections from Hemophilus influenza that this was pretty much history, stories of the “old days” that I could tell medical students and young doctors. I am aghast to discover how common it continues to be.

 

But there is another part of the story. It is that lead could be cleaned up. Houses with lead paint could have that lead mitigated. If it were, children would no longer be exposed to it and suffer the kind of brain damage described in the Times article. But it isn’t happening, because of the stonewalling, opposition, and outright blockage by the landlord and insurance industries, and their enablers in Congress and state legislatures. Their profits, of course, are more important than the brains of developing children, especially poor and minority children.

 

You can’t have it both ways — be a big company when it benefits you to generate revenue and business, and then hide behind an L.L.C. when you are sued in an attempt to escape accountability

 

says the attorney for “JJ”, a South Bend, IN, child with brain damage from lead paint in his home.

 

But they do have it both ways – this is how the US treats companies compared to children. And as a result we have the article’s final quote from JJ’s mother:

 

“We know it damaged his brain,” she said. “We know it is irreversible. And we know it is a lifelong thing. No doctor can tell you, ‘This is what is going to be.’”

 

Somehow, this does not make me proud.

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.