Bleak Future of Primary Care Access

Richard Young, MD

Published 9/22/14 in The Ft. Worth Star Telegram

Note from Brian: Richard Young, a primary care physician at John Peter Smith, a safety net health system in Ft. Worth, TX, has been an articulate and tireless explainer of the deeper health care dynamics that have undermined primary care and good health care for us all. See below.

Unfortunately, we have a preview in Dallas-Fort Worth and other communities of the effects of failed policies of Medicare/Medicaid, state government and insurance companies in how they value medical services and how they poorly support the first-contact primary care system.

Freestanding emergency rooms are popping up all over DFW like mushrooms after a hard rain.

If you were thinking about opening a healthcare business and you could get paid $1,500 in one facility or $100 in another for the same service, which facility would you invest in?

This is exactly the dynamic that is driving the growth of these freestanding ERs, and urgent care centers before them.

A shortage of primary care physicians has been talked about for decades, but no one in the public or private sector has taken any action to reverse this, except for inadequate gestures such as loan repayment programs.

Practically all U.S. payers use the highly flawed Medicare billing and coding system, which works sort of well if the doctor only takes care of one body part or one disease per visit.

The system completely falls apart when a patient seeks care with a family physician and expects that physician to manage more than one or two concerns in an office visit (or phone visits or email visits).

Freestanding ERs work by skimming off the easy acute symptoms and leaving the more difficult acute and chronic disease care to primary care physicians.

They order unnecessary tests and treatments and often hand out narcotics like candy. They figured out that this largesse increases their patient satisfaction scores.

Very few emergencies show up in these ERs. In fact, a colleague who works in one of these facilities says that when a true emergency shows up at their doorstep (such as a heart attack or septic shock), they call 911 to take the patient to a real ER.

If the regulated disincentives don’t change, primary care physicians will mostly abandon traditional family medicine.

Many of the weaker primary care physicians will work in these urgent care centers or freestanding ERs because the pay is better and the cases are simpler. One “emergency” is much easier to manage than the patient who wants to discuss five concerns.

Family physicians who have a broader range of skills and who care for patient populations in the higher-income strata will charge monthly retainer fees of $75 to $150 just for basic primary care services.

Other family physicians who want to have some long-term continuity with their patients will go to work for large hospital systems. places like THR and Baylor (whose exorbitant facility fees also markedly drive up the cost of basic ambulatory care, little of which goes to the physician).

These forces will leave low- to middle-income patients with nowhere to seek care other than the urgent care centers, freestanding ERs and Wal-Marts, where mid-levels treat simple algorithmic problems like bladder infections and high blood pressure.

But these facilities have no capacity or interest to provide comprehensive care to complex patients.

This situation will correct itself when the actual payers, the local employers who pay most of the cost of their employees’ health insurance, say “I’m mad as hell and I’m not taking it anymore,” and demand real change in the way healthcare services are valued and paid for.

Dr. Richard Young is a family physician in Fort Worth.