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Column: Why you can’t find a primary care doc

  • Private equity is rapidly moving to reshape health care in America, coming off a banner year in 2021, when the deep-pocketed firms plowed $206 billion into more than 1,400 health care acquisitions, according to industry tracker PitchBook. (Juan Moyano/Dreamstime/TNS) Dreamstime/TNS — Juan Moyano

For the Valley News
Published: 11/21/2022 11:18:57 AM
Modified: 11/21/2022 11:18:49 AM

Have you had difficulty finding care with a primary care clinician? If so, you’re not alone — it’s become increasingly difficult to establish with primary care all across the country. This summer in the Upper Valley, Dartmouth Health announced it was temporarily unable to accept new patients for primary care. 98 million Americans now live in a primary care shortage area, often in rural regions.

Access and continuity with high-quality primary care is the bedrock of high-functioning health care systems. Primary care teams assure immunization, screenings for lead poisoning in children or cancer in adults, address health habits, mental health and numerous conditions like hypertension and diabetes, while coordinating care for an aging population. The National Academies of Sciences concluded that primary care is the only medical specialty of which more practitioners improves longevity, equity and the health of a population.

However, even well before the COVID pandemic, US adults were least likely among developed countries to have regular primary care or preventive visits. Although reforms in the ACA have eliminated many copays or deductibles for preventive services, Americans still see primary care less often than citizens of other industrialized nations. A declining workforce will further exacerbate difficulties with access. The Association of American Medical Colleges projects a shortfall of 55,000 primary care clinicians in 10 years.

Physician retirement accelerated in recent years due to rising administrative burdens and hours spent on often unwieldy electronic medical records, while fewer doctors, nurse practitioners and physician assistants are electing to enter the field. Surveys have demonstrated poor work/life balance, administrative demands and burnout among primary care doctors, for which novel adjustments are only now being trialed. Most other developed nations dedicate more expenditure on primary care services and work to integrate such services within communities. The US spends a declining 5-8% of total health dollars on primary care, while other nations allocate 14%. Many other countries compensate generalists on par with hospital-based subspecialists, and their primary care teams deal with much less insurance hassles. Here, career compensation for primary care/pediatrics remains half that earned by “proceduralists.” You get what you pay for: primary care docs constitute 45% of practicing physicians in France and 26% in the UK, versus 12% in the US. Better health outcomes, reduced mortality amenable to medical care and greater longevity are related consequences.

There are many reasons US primary care has become secondary. A “Relative Value Scale Update Committee” (RUC), convened by the AMA, meets without public disclosure to set specialty reimbursement. RUC has 32 voting members, of which 27 represent medical specialties, and the AMA lobby is beholden to specialist societies. Recommendations of the RUC are implemented by Centers for Medicare and Medicaid Services (CMS.) Importantly, health insurers also negotiate, behind closed-doors, with hospital-multi-specialty practices to set payment for services. Consolidated hospital systems strive to increase “market share” of “covered lives” in their regions to command higher payments from insurers. (Higher costs of hospital service do not trouble the insurers — they make profit off a percentage of the premiums they set, so, when hospitals charge more, they just raise premiums to cover the costs, keeping a steady 20% for overhead and profit.) According to the Urban Institute, commercial insurance compensation for specialty services range 10% to 330% higher than Medicare rates, whereas rates for cognitive services by family medicine or psychiatry are barely above the CMS-set rates. Hospitals make the most revenue from elective surgical procedures. Hence, all the ads for knee replacements. Some hospital-multi-specialty megaliths view primary care as a “loss leader” and may value primary care accordingly.

“Moral injury” as well as salary has set back American primary care. With the rise of HMOs in 1990s, primary care clinicians were positioned in a professionally untenable role of “gatekeepers.” Group practices received fixed yearly reimbursement per patient from HMOs, so professional conflict of interest arose to limit care or procedures. That has abated, but Medicare Accountable Care Organizations are now piloted to be run by private equity, which will recreate perverse incentives, but this time among patients who aren’t even aware they are enrolled in a Medicare ACO. Healthcare organizations have also misapplied business principles to transform doctors into efficient producers of healthcare “product lines.” Highly trained, caring clinicians with advocacy for their patients are morphed into “providers” clicking off check-boxes and diagnostic codes during abbreviated visits with increasingly older and complex patients.

Of interest, the word provider is extracted from commerce. It’s first medical usage was in 1965 Medicare legislation, referring to vendors delivering health-related products or services. “Provider’ makes no reference to professionalism. Teachers and lawyers aren’t labeled as knowledge or legal expertise providers, and we go to a barber, not a hair-shortening provider. A highly profitable medical-industrial complex aims to transform healthcare from a public good to a commodity. Does profit prefers “providers” that are engaged in a commercial transaction, or professionals sharing a trusted, long term, therapeutic doctor-patient relationship?

Short of Medicare for All, here’s some remedies: Congress should legislate that CMS set fees based on advice from transparent public agencies that meet societal needs, rather than needs of the AMA. So recommends the Government Accountability Office. Congress must shut the revolving door of administrators leaving CMS to become health industry lobbyists. Insurance “intermediaries” that market Medicare, Medicaid, employee-sponsored insurance, the ACA and other tax-supported “products” must develop uniform interactions and policies with hospitals and practices to lessen cost, and pay for community-integrated primary care teams rather than “providers delivering services.” All non-profit and non-taxed hospital-megaliths must reconsider approaches which have not yielded robust, equitable, high-quality primacy care and improved health outcomes for American communities. Incentives and tuition-reimbursement should be enhanced for clinicians who wish to enter primary care, especially in rural areas. Lastly, statehouses can learn from and emulate Maryland’s all-payer system. This transparent, state-wide negotiation sets uniform payments for hospital services from all types of insurances, such as Medicaid, Medicare and private insurance intermediaries, and involves all hospitals, big or small, urban or rural, within the state. We can ask our Congressional and state representatives, as well as local hospital board members, to research such actions, and fortify primary care — our health depends on it.

Dolkart, of Grantham, is a primary care internist and geriatrician who has practiced in New Hampshire and Vermont for 40 years. He is also a member of Granite State Physicians for a National Health Program.

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