Not that long ago, urgent care centers did not exist. The hospital’s emergency department was used only for emergencies. Primary care doctors took calls after hours, seeing patients in their offices or in the emergency department when needed. Insurance played an insignificant role. When specialist care was needed urgently, primary care physicians called — yes, called — a surgical or medical colleague directly to get things done. It was a remarkably efficient system.
I’m a family physician, and this was the way our primary health care system functioned when I began practicing — but I represent a way of providing health care that is nearly extinct.
I was trained to provide acute care and adult disease management — as well as minor surgical, emergency, ob-gyn and pediatric care, and behavioral health management. My education provided ample hands-on experience and instilled a sense of obligation to the patient. I was taught: “Do what is right for the patient and you will be rewarded.”
In the 1980s, a sea change occurred — the HMO/managed care industry began a steady process of altering America’s medical system as insurance organizations assumed increasing control. I practiced through progressively more complicated fee-for-service diagnosis and procedure coding; this year’s Current Procedural Terminology (CPT) and International Classification of Diseases (ICD-10) code books alone have more than 2,000 pages. Between varying fee schedules and allowable payments, cumbersome credentialing, prior authorizations, ever-increasing paperwork and never-ending new regulations, there were so many major changes in the administrative climate and such an increase in overhead expenses that small primary care practices were forced to adapt or fail.
Many small group primary care practices consolidated into larger organizations that controlled health care delivery as well as financial management. Hospital care and nursing home care by primary care physicians stopped in order to generate more time for office services. Hospitals also consolidated and began to employ many physicians, with tight management that controlled and directed care. Responsibility for an individual’s health care was steadily taken away from providers and given to various bureaucracies in the system. The medical care that was “covered” and for which reimbursement was highest — not the care that was needed or desired — became the focus of medical decision-making.
There was an exodus of primary care physicians to work in subspecialties that paid more without the challenge of office administration. Medical students, saddled with student loans, became less inclined to pursue an underpaid career in primary care mired in ever-changing administrative work with little time to focus on patient care. As physician recruitment became more difficult, nurse practitioners and physician assistants began to fill the gap. There was marked growth in the utilization of urgent care centers and the emergency department for routine primary care services.
Information exchange worsened. Patient care was increasingly fragmented. Collegial lines of communication within our medical community all but disappeared. There were increasingly obvious delays in services and problems with the coordination of care, especially between inpatient/nursing homes and outpatient management.
Systems were put in place to control soaring health care costs: HMOs and managed care with various capitation arrangements, self-insured employers managing health care for employees, value-based systems with quality metrics, and guideline-based one-size-fits-all systems. Yet costs were not controlled.
To improve outcomes for patients and control costs, we must reposition the patient at the center of the decision-making process — as the medical system I remember at the beginning of my medical career did.
To disrupt and reinvent the current primary care system, policymakers should:
- Build a consensus with insurance, big health care systems and the government to consider primary care medical delivery outside of and in parallel to subspecialty health care delivery.
- Structure an environment unencumbered by insurance for the delivery of primary care and many of the diagnostic and therapeutic services it coordinates.
- Rather than traditional insurance coverage, make insurance/government payors pay individuals a risk-adjusted stipend for primary care services and for certain diagnostic and therapeutic services. Using their primary care stipend, individuals would purchase these services directly from primary care physicians and diagnostic and therapeutic vendors of their choice.
- Revamp the medical education system to establish a new self-employed primary care workforce working directly for the patient outside of the insurance umbrella.
Under such a system, an individual would be paid a flat yearly or monthly fee for primary care services by insurance/Medicare/Medicaid/TriCare, with risk adjustment not based on a coding system and not requiring primary care physician (PCP) risk documentation. Risk stratification would be negotiated between the payor and the individual, as it is for disability and life insurance determinations. The PCP would independently contract with each patient and not with insurance payors. Patients would select their PCP and pay for primary care services charged by their PCP, who would not be required to use specific procedure or diagnosis coding to determine charges. Charges might be a la carte or a flat fee.
Diagnostic and therapeutic services ordered by PCPs are often very expensive under the current insurance system, but cash alternatives have begun to lower costs. GoodRx and Mark Cuban’s CostPlus Drug Company are low-cost alternatives to insurance coverage for generic drugs. Lower-cost, high-quality hearing aids are now available without a prescription. Cash discounts for laboratory services and radiology imaging have started to appear for those without insurance. Introducing more cash-only competition into the complicated world of “certificate of need” dominated diagnostic services is long overdue.
Providing transparency in pricing and introducing more competition in a marketplace in which the patient is at the center of the process is needed not only in primary care but throughout other areas of medicine. Billions of dollars of third-party, middleman expenses can and should be eliminated.
A direct primary care physician-patient relationship that controls primary care services, with insurance only tangentially involved, is the only viable pathway to save and reinvent primary care.
David M. Smith, MD has been a practicing board certified family physician for 41 years. He is the founder of Access HealthCare, an independent primary care group practice in Central Virginia.