Why You Can’t Find a Primary Care Physician
Have you had difficulty finding care with a primary care physician? If so, you’re not alone: it’s getting harder to connect with primary care across the country. This summer in the Upper Valley, after a million-dollar rebrand, Dartmouth Health announced that it was unable to accept new patients for primary care. Ninety-eight million Americans now live in an area with a shortage of primary care, often in rural regions.
Access to and continuity with high-quality primary care is the foundation of high-functioning health care systems. Primary care teams ensure immunization, screening for lead poisoning in children or cancer in adults, address health habits, mental health, and numerous conditions such as high blood pressure and diabetes, while coordinating care for an aging population. The National Academies of Sciences concluded that primary care is the only medical specialty in which the most practitioners improve the longevity, equity, and health of a population.
Comprehensive social solutions are required to remedy social determinants of health such as racism, inadequate housing, food insecurity, and the opioid epidemic. However, improving access to primary care is the sole responsibility of any effective medical system.
US adults are less likely than developed nations to have regular primary care. The Association of American Medical Colleges projects a shortfall of 55,000 primary care physicians in 10 years. Physician retirement has been accelerated by increased administrative burdens and overtime spent on unwieldy electronic medical records. US surveys report poor work-life balance, stress and burnout among primary care physicians, even before covid. Fewer doctors, nurse practitioners, and physician assistants are choosing to enter the field. Most other developed nations spend more on primary care services and work to integrate such services within communities. The US spends a diminishing 5-8% of total healthcare dollars on primary care, while other nations allocate 14%. Many other nations compensate generalists on par with subspecialists in hospitals, and their primary care physicians deal with a much lower administrative burden. Here, primary care/pediatrics career compensation is still half of what “proceduralists” earn. You get what you pay for: Primary care physicians make up 45% of practicing physicians in France and 26% in the UK, versus 12% in the US. The consequences are better health outcomes, reduced mortality amenable to medical attention and greater longevity.
There are many reasons why America’s primary care has become secondary. The AMA convenes a “Relative Value Scale Update Committee” (RUC) to establish reimbursement by specialty. The secret RUC has 32 voting members, of whom 27 represent medical specialties, and the RUC’s recommendations are implemented by the Centers for Medicare & Medicaid Services (CMS). The AMA is indebted to specialized societies, so conflicts of interest abound within the RUC.
In addition, health insurers can negotiate, behind closed doors, with the hospital’s multispecialty practices to establish payment for services. Established mega-hospital systems strive to increase the “market share” of “covered lives” in their regions, to demand higher payouts from insurers in such negotiations. (The higher costs of hospital service do not concern insurers – they make a profit from a percentage of the premiums they set, so when hospitals charge more, they simply increase premiums to cover costs, keeping a constant 20% for overhead and profit.) According to the Urban Institute, commercial insurance compensation for specialty services ranges from 10% to 330% more than Medicare rates, while rates for cognitive services through family medicine or psychiatry are just above Medicare rates.
Hospitals earn most of their revenue from elective surgical procedures. Hence all the ads for knee replacements. Hospital multi-specialty megaliths view primary care as a “loss leader” and may price primary care accordingly. “Non-material damage” as well as salary have affected American primary care. With the rise of HMOs in the 1990s, primary care physicians were placed in a professionally untenable role of “gatekeepers.” Group practices received a fixed annual reimbursement per patient from HMOs, so conflicts of interest arose to limit care or procedures. That has diminished, but now Medicare Accountable Care Organizations are being tested to be run by private equity, which will recreate such perverse incentives, but this time among patients who don’t even know they’re enrolled in a Medicare ACO. Health care organizations have also misapplied business principles to transform physicians into efficient producers of health care “product lines.” Highly trained physicians with fiduciary advocacy for their patients become “providers” ticking off checkboxes and diagnostic codes during abbreviated visits with increasingly older and complex patients.
Of interest, the word supplier is extracted from commerce. Its first medical use was in the 1965 Medicare legislation, referring to providers offering health-related products or services. “Supplier” does not refer to professionalism. Teachers and lawyers are not labeled as “providers” of knowledge or providers of legal expertise, 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, physicians became “suppliers” to support an engagement in a commercial transaction, rather than within a long-term, trustworthy therapeutic physician-patient relationship.
Other than Medicare for All, here are some options: Congress should legislate that CMS set rates based on the advice of transparent public agencies that meet the needs of society, rather than the needs of the AMA. This is recommended by the Government Accountability Office. Congress must close the revolving door on administrators leaving CMS to become lobbyists for the healthcare industry, as it has started for the defense industry. Insurance “middlemen” that market Medicare, Medicaid, employee-sponsored insurance, ACA, and other tax-backed “products” should develop uniform forms and policies to lessen the burden on practices and pay for community-integrated primary care teams instead of “service providers.” services.”
Tax-free hospital megaliths can be required to provide robust, high-quality primary care to meet the needs of the communities they serve. Incentives and tuition reimbursement for health professional students should be improved for those wishing to enter primary care, especially in rural areas. Finally, state chambers can learn from and emulate Maryland’s full payment system. This state-directed, transparent negotiation process establishes uniform payments for a particular hospital’s services from all types of insurance, such as Medicaid, Medicare, and private insurance intermediaries. Such negotiations occur with all hospitals, large or small, urban or rural, encourage Medicaid acceptance and reduce payer mix issues. We can ask our congressional and state representatives, as well as local hospital board members, to investigate such actions and strengthen primary care. Our health depends on it.
Dr. Ken Dolkart worked as a primary care physician and geriatrician in New Hampshire for nearly 40 years, retiring from Dartmouth-Hitchcock Medical Center in 2016. He now works part-time in primary care and geriatrics at Mt. Ascutney Hospital (an affiliate of Dartmouth) in Windsor, Vermont, and teaches at Dartmouth College’s Geisel School of Medicine.