Family doctors and the fight against the health system

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Nowhere in the United States is paid for primary care medicine commensurate with its value to patients

Editor’s Note: The following is adapted from “Searching for the Family Doctor: Primary Care on the Brink” by Timothy J. Hoff. Copyright 2022. Published with permission from Johns Hopkins University Press.

Poor soil for growing generalists

When I worked in primary care as an administrator in the late 1980s, I heard the same complaint from the family physicians I worked with as I do now from those I interview for my research—Primary care medicine is not paid anywhere in the United States commensurate with its value to patients. When I was involved in running an insurance billing service for a primary care office thirty years ago, I saw how much lower payments were for services intended to prevent people from getting sick versus paying for services that relied on the expectation that people would get sick. . Not much has changed in 2021. There’s the rhetoric that primary care and prevention matter a lot more now to insurance companies, hospitals and medical practices. Sure, maybe in a few areas like chronic disease management where primary care medicine and family physicians have been asked to do more for patients. But it hasn’t created a financial windfall for primary care, and what it asks of family physicians is a big part of why some of their patient care is miserable. For the most part, high-cost specialty medicine still dominates the health care system and continues to receive the bulk of insurance payments. He is responsible for keeping hospitals profitable and medical specialists well paid and in check.

The specialty of family medicine has always existed in the context of an unsupportive American health care system that undervalues ​​primary care, where the service is fragmented and procedural medicine is privileged, and which waits for people to get sick to interact with them and is increasingly corporatized. It is a care delivery system that has long been built on capitalist ideals. One defined by a supply side that pushes the dominant narrative that health care is not a basic individual right, but rather a marketplace in which buyers and sellers come together to transact that benefit people. two parts. Despite the advent of Medicare and Medicaid in the 1960s and the Affordable Care Act in 2010, health care in America since the 1970s has largely consisted of providing big ticket items to a group of patients in poor health and largely misinformed. This is where the money has always been for hospitals and specialists. This profit motive has produced a system of care delivery in which monopolistic behaviors and service fragmentation abound, politicians serve powerful industry players in biased ways, growth is valued above all else, and patients are mostly left out of the equation.

Creating such a cool system takes time. It didn’t happen overnight. Nor will it be fixed overnight. Such a system is not a friend of family medicine or primary care. In fact, such a system sees primary care as an attractive nuisance, useful for capturing patients in more expensive care systems and moving them efficiently to more expensive services. A loss leader to bring patients to expensive things. The American healthcare system has for decades been less enthusiastic about the idea of ​​a general practitioner managing patient care holistically and with a high level of relational excellence. It financially undervalued primary care in all its forms. This has allowed the work of a family physician to be burdened with paperwork and bureaucratic demands. This prompted family physicians to sign on to one new initiative after another, over-promising how these initiatives would help primary care while under-delivering. In many ways, he treated family physicians like the erstwhile generalists they replaced—as less valued and less well-paid parts of American medicine.

The financial undervaluation of primary care

Everything hostile to family medicine in the American health care system starts with reimbursement. And reimbursement has not been good for family medicine and the delivery of primary care over the years. In terms of adequate compensation for its services, primary care medicine has always been the ugly grandson of American health care. In other countries such as Canada and the United Kingdom, primary care medicine and its physicians remain the centerpiece of care delivery and receive a large share of the resources, but in the United States there is none. not been like this since World War II. Continuing advances in medical technology, the rise of hospitals and specialists, and an ambivalent public have had consistent negative influences on the sustainability of primary care.

The increased availability of private insurance for many Americans, usually paid for by employers, contributed to these developments from post-World War II America. Before insurance, GPs operated on a cash-only basis, charging patients fixed fees for different types of services. Their billing system was perhaps less egalitarian in giving everyone the chance to get their services, but it was physician-controlled and completely transparent. Patients knew how much a service would cost and they could assess whether it was worth it, at least from their personal perspective. Physicians, who almost all owned their practices, could in theory better manage their income and expenses, changing their prices according to the time and other resources spent on the service provided. Such a payment system helped make general practice an economically viable business in which only one doctor could be involved as the owner. You might not get rich, but you could make a good living, control the economy of your practice, and do the kind of medicine you wanted with your patients.

Then the insurance came. Private insurance has separated patients from the costs of various forms of care, making specialty medicine an attractive option with less associated financial risk. While other countries like Canada and the United Kingdom provided for most of their populations through government programs that capped spending and placed primary care medicine at the center of care delivery, the United States continued their expansion of insurance in a different way, focusing for decades on fee-for-service reimbursement and offering “usual and customary” payments to physicians based largely on what physicians wanted to charge for their services.

Insurance in American health care has reduced the economic benefits of primary care medicine for family physicians because it has skewed payments toward procedures and specialists. This prevented patients from understanding the “value” in terms of diagnosis or treatment and many no longer had to worry about the cost of a health service. Over time, the fee-for-service system paid more bills at a higher rate for specialists than for primary care physicians because usual and customary fees were set by the specialists themselves, without wondering how they had established their fees.

Good primary care medicine is slower to do than most procedural work. This does not mesh well with procedural medicine which can be practiced on an assembly line, generating a higher volume of overall expense in the process. Family medicine or primary care involves what are called “assessment and management services”, which is basically the time the family physician spends interviewing the patient, asking questions, getting to know the patients and manage a wide range of clinical complaints and treatments for some. Trying to be someone’s ‘general practitioner’ and ‘care manager’ means many of these types of tasks and activities.

While specialists are niche providers focused on treating unique diagnoses and body parts, family physicians theoretically practice medicine focused on prevention, disease management, behavioral health, and family care. They rely on knowing the preferences, needs, and desires of their patients to effectively deliver this type of medicine. They must put patients in trust and listen to them. Primary care therefore takes longer. It also has a longer trajectory to see final results because it is more uncertain and complicated for many patients, involves a lot of cognitive work on the part of the doctor, and often has delayed times to see good results. Many tasks and activities of primary care medicine simply have not been valued so financially by insurers. But they are essential to a close doctor-patient relationship.

Timothy Hoff, Ph.D., is a professor of management, health care systems, and health policy at Northeastern University in Boston; Visiting Research Fellow at Oxford University and author of “Next in Line: Lowered Care Expectations in the Age of Retail- and Value-Based Health”.

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