The need to enhance the delivery of primary care is not a new dilemma, although there has been a renewed recognition of the necessity to do so in any current health care reform debate. As it now stands, the lack of a strong primary care infrastructure will only be exacerbated as the population ages and the need for up to 44,000 more primary care physicians by 2025 has been reported (http://www.sciencedaily.com/releases/2008/06/080617111826.htm).
The reason for the decline in medical students entering primary care has been debated for many years. Some of the causes are obvious, such as lower reimbursement. In fact, it has gotten so bad in some areas of the country that well known practices are no longer accepting Medicare reimbursement as they struggle to survive economically (http://www.bloomberg.com/apps/news?pid=20601202&sid=aHoYSI84VdL0), (http://www.foxnews.com/story/0,2933,306439,00.html. ). This does not even address the issue of Medicaid reimbursement a focal point for expanding coverage and reducing cost in congress.
One very often overlooked issue that contributes significantly to the strain on our primary care system is lifestyle and practice environment. Primary care physicians must see more and more patients with ever increasing chronic conditions and do so in less time than ever before (http://www.nejm.org/perspective/primary-care-video/). This phenomenon is often referred to by primary care doctors as running the “hamster wheel”.
Volume alone is a problem, but practice hassles exacerbate that ten fold. It is not uncommon for a diagnostic procedure or treatment plan that would be approved by an insurer if ordered by a specialist, be denied when ordered by a primary care physician. This then triggers the time consuming appeals process. Recently, a patient of mine was denied a prescription for her angiotensin receptor blocker (ARB). This was originally prescribed by her cardiologist, and I was simply refilling the prescription. It was denied. Despite the fact that I personally called and spoke with the pharmacist and explained why the patient needed the ARB as well as the fact that it was chosen by a cardiologist because it had been determined that given this patients condition that the patient would particularly benefit from this drug. When the cardiologist had his staff call, it was approved immediately.
I won’t continue with the laundry list of hassles (I haven’t even gotten to insurers telling my patients I coded their visit wrong and that is why they won’t cover it, the family medical leave act forms, and every other form that employers, schools, insurers, home health companies, durable medical equipment companies, and the like require that I fill out). I am sure you get the idea.
Despite all of these barriers which negatively impact patient care, primary care delivers a good return on investment. Starfield et al found that: “The contributions of primary care to improvements in many aspects of population and individual health are well documented. In addition to the health benefits, there are reductions in health system costs and reductions in disparities in health across population sub-groups. These findings are robust over time and across areas and health systems. International comparisons show that countries with health systems based on strong primary care have better health at lower costs” (http://www.jstor.org/stable/30045625?seq=1. ).
Imagine what a robust primary care workforce could provide to improvements in patient care.
-Randy Wexler, M.D.
Assistant Professor of Clinical Family Medicine