Here are the existing realities of primary care
We can ’ t afford to just see you for something quick . Our quality indicators , which more and more will determine how we get paid , will go down if we don ’ t screen you at every visit and offer interventions for depression , smoking , alcohol misuse , hypertension , weight management , immunization needs and much more .
We won ’ t refer you without seeing you , and we often hesitate giving you medical advice over the phone . Our providers are not scheduled for anything else besides seeing patients , because the rules of how we are paid still emphasize face-to-face visits over “ population management .” So our providers are busy all day long seeing patients for visits that could have been simple but are loaded up with mandatory screenings and interventions and our medical assistants , besides being busy with all our screening questionnaires , are discouraged from giving medical advice they aren ’ t formally trained to provide .
Is there a doctor shortage ?
We are said to have a doctor shortage . We have an aging population with more and more chronic diseases , like diabetes and heart disease . The need for skilled and experienced medical providers is continually increasing .
We have no public health system to speak of in this country , so the government , through Medicare and Medicaid , has mandated that health care providers do the things the public health system does in other countries .
This is , plain and simple , what is clogging up the works in health care today : Too much non-doctor work is crammed into each patient visit , and we can ’ t charge for giving advice or directing care except in a face-to-face visit .
You don ’ t need to go to medical school to give immunizations , tell people smoking is bad for you , explain that “ low fat ” foods cause obesity , or promote regular exercise . You don ’ t even need to be a doctor , PA or NP to screen for high blood pressure – only to
treat it . ( Some pundits , in utter desperation , have suggested we send pharmacists to school to learn how to treat hypertension , but there are of course plenty of licensed medical providers who are able and willing to do that if we get freed up from the lessskilled tasks I just listed above .)
Patients and doctors have no control
Now , why are we doing all those things we do if they are so inefficient ? Quite simply , whoever pays us has the power to define our work . We call that “ health insurance ,” but that is not exactly what we are dealing with . Insurance , for home , auto or employer liability , has nothing to do with predictable events or minor issues . Your car insurance doesn ’ t pay for oil changes or tire wear , not even for a minor paint scratch . But somehow that is what we expect health insurance to cover for our bodies . In terms of auto insurance , most people probably figure an insurance job carries an inflated price tag and lots of paperwork . The same is true for health care , which should not be a surprise to anyone .
For example , years ago the overhead cost of insurance billing for each primary care doctor was reported to be $ 80,000 . That , put very plainly , is money that patients and employers are ultimately paying through
“ This is , plain and simple , what is clogging up the works in health care today : Too much non-doctor work is crammed into each patient visit , we can ’ t charge for giving advice or directing care except in a faceto-face visit .”
Hans Duvefelt , MD
premiums and deductibles . And all the mandated screenings are there because Medicare , in particular , has the right to micromanage doctors ’ work because they are paying for health care visits , which could be quicker and less costly if patients had control over their health care spending .
How could we do better ?
We do three things in primary care , each with its own workflow and , really , each with its own economics .
1 . We could do our part of public health more effectively . Allow us to promote immunizations and other primary preventions outside our already crammed fifteen-minute visits . Pay us a per patient per year stipend to reach out to target populations through mail , phone , web or , when appropriate , in person about general health issues . Stop imagining we can do all of it and still treat diseases , acute and chronic , in our measly fifteen minutes . Right now , that is just clicking boxes with little actual substance . Use some of the government money that should have been spent on a working public health system ...
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