Is Primary Care Dying?

More patients are choosing to visit NPs or PAs

The days of long waits at the doctor’s office have been replaced by a completely opposite, but perhaps even more troubling problem.

A ‘revolving door’ mentality has led patients to feel as though their problems aren’t being properly addressed by their primary care provider. Combined with costs, it’s one explanation for recent data from the Health Care Cost Institute that states office visits to primary care providers dropped 18 percent between 2012 and 2016, while visits to NPs and PAs jumped 129 percent in that same time frame.

Of course, there’s something to be said for the cost savings, so why the focus on getting patients back in to see their primary care provider? Because these physicians are uniquely qualified to treat potential problems early, avoiding even costlier visits to specialists and potential procedures down the line.

Dave Chase is the co-founder of Health Rosetta, which promotes reform within the U.S. healthcare system. Chase, the author of multiple books on fixing various business models, shared some of his thoughts with ADVANCE on how to restore primary care’s position in our system.

Chase’s most recent book is entitled The Opioid Crisis Wake-Up Call: Health Care Is Stealing the American Dream. Here’s How We Take It Back. He emphasizes the mention of primary care over 150 times in this book. “That’s how central it is to the opioid crisis, which is a microcosm of the larger dysfunction,” he explains. “But it’s also the solution, our redemption.”

“I’m not aware of a single properly functioning healthcare system in the world that isn’t built on a healthy primary care foundation,” said Chase. “[Ignoring primary care] leads to people putting off having their health issues addressed, and people getting care in inappropriate places such as the emergency department.”

Chase likes to compare primary care in today’s healthcare system to the fact that milk—perhaps the most essential product at a grocery store—is often located at the rear of the building, causing customers to walk past numerous other products to reach their desired destination. “Milk is low margin,” he explained, “so you walk past all these high-margin products. Similarly, in healthcare, without proper primary care everything is rushed, and not only are they failing to address real issues, but they’re also moving you along to the expensive things—the tests, the prescriptions, procedures.”

For example, lower back pain is the second leading driver of patients’ entry into the healthcare system. But in these short ‘drive-by’ appointments, time is limited in which to address the root cause of said pain. “So what happens, most commonly, is people are prescribed a painkiller—an opioid—even though there’s really no evidence that (the opioid) will get to the cause.”

Aside from its standing as the number two reason for doctor’s visits, low back pain is also the number-one cause of disability and the number-one reason for opioid prescriptions.

“It can be extremely expensive when things aren’t addressed in a primary care setting,” explained Chase. “And we all pay for that.”
Chase maintains that any patient behavior—fewer visits to primary care, increased visits to NPs/PAs—are a response to the healthcare system, not a conscious choice by patients to avoid primary care. “Primary care can be very difficult to access,” he said. “Distortions such as doctors only getting paid if they ‘see the whites of your eyes’—what ends up happening is the waiting rooms are clogged with people who don’t really need to be there, thus preventing people who do need to be there from making an appointment.

The end result? Data suggests the average time it takes between setting an appointment and seeing the primary care doctors is about 24 days. Not surprisingly, there is also a breakdown of behavior by age groups—older adults are still likely to see the primary care doctor at all costs, but statistics from Becker’s Hospital Review say that over 50 percent of millennials avoid seeing the primary care doctor in order to cut costs. Are we headed towards a future where primary care becomes a ‘last resort’?

“I think we need to meet them on their terms,” says Chase. “What we’re seeing is that in the newer practices, doctors are available via phone, text, in real time or otherwise. They don’t have a dictate to get you into the office, refer you out—prospectively, they’ll get paid per member, per month. Their job is to keep you healthy, not referring you out.

“I’ve heard figures of anywhere from $5 million–$10 million in referral value that a primary care clinician can have in a hospital setting. That’s why (hospitals) buy these practices up.”

Whether it’s direct or virtual primary care, doctors are becoming more accessible. As Chase explained, if you can access your financial services, entertainment, and social media via your phone or iPad, why should healthcare be any different?

“Sure, sometimes the doctor will need to see you, need to lay hands on you,” he allowed. “But the vast majority of the time, it’s unnecessary, particularly if they have an existing relationship with you.”

“So how do you fix it? You make these services available. And it’s attractive to the physicians too—the employers I’ve written about over the past 25 years, these are some of the employers with some of the best benefits packages available, and they’re spending anywhere from 20 percent to 50 percent less per capita because they’ve gotten it right.”

When you care for the care team, it leads to the improvement of the patient experiences, creating a partnership that leads to better outcomes. Chase emphasizes that those health care practitioners who find themselves frustrated with the status quo are finding an increasing number of organizational options who focus on the Quadruple Aim, which means focusing on the care team first.

“In a fully actualized primary care setting, everybody’s practicing at the top of their license—from the dietician to the physical therapists to the physicians. It’s a team-based model. I’m in a model like that, as are my parents and my entire family. It’s amazing how happy the clinicians are in those settings, and it leads to high satisfaction for the patients.

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