How to repair the paradox of primary care – the health care blog

By Matthew Holt

If health policies believe something, it is because primary care is a good thing. In theory, we must all have solid relationships with our primary care physicians. They should navigate us in the health system and arrive at our doors like Marcus Welby MD if necessary. Wonks like me believe that if you introduce such a relationship, patients will receive preventive care, take the right drugs and take them, avoid the emergency room and have less admission to the hospital – as well as to cost much less. It is in large theory behind the HMO and their descendants of the last days, the care based on the value and the ACO

Of course, there are decent examples of systems based on primary care such as the United Kingdom NHS or even permanent Kaiser or Alaska Artic Native Health Association. But for most Americans, it’s a fantastic field. Instead, we have a system where primary care is the ugly step. It is slowly strangled and separate. Even Walmart’s wealth could not make it work.

There are at least 3 types of primary care that have emerged in recent decades. And none of them really succeeds in making the idea of ​​”primary care as a Lynchpin of the health of the population”.

The first is the primary care doctor purchased by and / or working for the large system. The purpose of these practices is to ensure that the references for costly things are entering the right hospital system. For a long time, these primary care physicians have lost money from their employer – Bob Kocher declared $ 150,000 per year per doctor in the late 2000s. So why are they maintained by the biggest systems? Because the patients they admit to the hospital are incredibly profitable. Consider this NC system which ended up continuing the great atrium of the hospital system because they only wanted the references. As you can expect that the benefits of “cost reduction” of primary care is difficult to find among these systems. (If you have time to watch Eric Bracker’s video on Atrium & Troyon / Mecklenberg)

The second is an urgent care. Urgent care has replaced primary care in a large part of America. The number of urgent care centers has doubled over the past decade. Although it has done some pressure on emergency rooms, urgent care has replaced primary care as it is practical and you can easily get appointments. But that does not make the health and management of population care. And often, urgent care centers are owned either by hospital systems that use them to generate references, or investment capital pirates that try to stimulate the costs that do not control them.

Thirdly, the telehealth, particularly attached to pharmacies, allowed many people to access the drugs in a cheaper and more practical way. Of course, these are not really complete primary care, but Hims and their own and their many competitors allow access to current antibiotics for urinary tract infections, contraceptive pills and also mental health drugs, as well as good pills and baldness.

This does not mean that there have been no attempts to build new types of primary care

Oak Street, Chenmed and Iora (who are now part of a medical) have been built with the idea of ​​increasing the primary care services given to the elderly in Medicare Advantage, with the idea that Kaiser and his competitors – they can take a financial risk for specialized and hospital care. Theory, as the founder of the Iora, Rushika Fernandopulle said, has always been “doubled primary care spending and reduce overall costs by 30%”. It is not too clear if they got there.

Of course, like all the rest of the American Health Care, Oak Street and Iora were rehearsals of previous efforts in Mullikin, Friendly Hills, Healthparters and many others to manage overall care costs by taking a capital risk of primary care. None of these experiences were left alone by the finance bros long enough to see what would have happened if they were playing. The stock market of the 1990s and the 2020s is full of cemeteries of granted primary care groups which all had very promising departures. If they had been left alone long enough to develop organically, it is possible that we saw a different future. We could even see that the future if there was health, transcarent and others manage to develop their offer of primary / TV / navigation / centers of excellence. But it will take a while

Overall, primary care on the risk remains a lonely business although it has been the solution of favorite policy since Sydney Garfield began to take prepayment of workers on the Grand Coulee dam in 1933

Of course, it’s in America, you can always get excellent primary care, it will just cost you.

The multimillionaires of Silicon Valley pay Jordan Shlain’s Private Medical 40ka Year Plus for White Glove Service. At the other end of the scale, a medical collected $ 80-200 per year with patients paying access to appointments the next day, NPs who actually respond to emails and a free remote channel for urgent care. Between the two there are a multitude of doctors who have withdrawn from the tactor of billing insurers and who charge between $ 500 and $ 5,000 per year for concierge care. Then, there are a ton of services based on primary care using remote charters, home visits and NP, often combined with on -site clinics on workplaces

This means that the number of those with a real Marcus Welby MD style primary care in the community continues to fall.

And it’s not too difficult to understand why. The average primary doctor is much less than their specialized counterparts.

Primary care costs are low. They are deliberately defined by the RUC (the update committee of the relative value scale) which is dominated by specialists and essentially establishes health insurance costs, which are then followed by most private insurers. Thus, most doctors tend to look at the upper end of this graph rather than the background, they choose their residence slots. American health care is expensive because we have too many specialists who care marginally useful, and too many hospitals (and pharmaceutical companies and devices) that make them the bank. And everything is linked to this graph.

There was a rather strange KFF count saying that almost 50% of American doctors were in primary care, but which had many doctors are “primary care” which do not provide traditional primary care. This is of course false, but it gives an index for the solution.

There are 340 million Americans. We can give everyone a PCP and put them in a panel of 600 people (as opposed to the PCP panel typical of 2 to 3,000. This number is what MDVIP and other concierge services offer.

So, if we convert all these PCPs currently under license and have added NP, we could give everyone in America, concierge style care. These doctors would be immediately available and would help their patients navigate the system.

His supporters believe that concierge medicine is not only better, but also tends to be much cheaper than regular care. MDVIP claims that he backup $ 2,500 per patient even after paying his doctors more, about 20% of health spending. My statement is that we could give each PCP $ 2,000 per patient (or $ 1.2 million per patient panel), which they could use (my assumption) $ 300,000 to manage their practice, and they could keep $ 700,000 to pay.

So, my proposal is that we give everyone very high -end primary care, let’s pay primary care documents very well and save money. And apparently, we have almost enough primary care documents to do so. For sure, if they were paid $ 700,000 a year, we would soon find it much more.

Matthew Holt is the editor of ThcB