Private Practice is DEAD: The Doctor Will See You in the ER.
The destruction of Private Practice and Primary care practice models via unsustainable government mandates, and unaffordable overhead costs.
Primary care, including private practice, is imperative for building a robust healthcare system that ensures positive health outcomes, effectiveness, efficiency, and health equity. It is the first contact in a healthcare system for individuals and is characterized by a longitudinal approach, comprehensiveness, and coordination. It provides individual, family-focused, and community-oriented care to prevent, cure, or alleviate common illnesses, disabilities and promotes health.
Many countries have embraced primary care using a variety of structures and models. Lessons from these countries could serve as case studies for the U.S. healthcare system, which currently faces an imbalance between specialty and primary care along with a significant shortage and inequitable distribution in the primary care workforce. Different types of indicators and tools have been developed to measure the function of primary care, the performance of providers and facilities, quality of care, and so forth, but the need for more indicators and more data remains. Patient-centered measurements are gradually replacing disease-specific measurements to yield a more accurate assessment of primary care.
In both developed and developing countries, primary care has been demonstrated to be associated with enhanced access to healthcare services, better health outcomes, a decrease in hospitalization, and the use of emergency department visits. Primary care can also help counteract the negative impact of poor economic conditions on health. Therefore, research suggests increasing the supply of primary care physicians in the United States of America. Further research is also needed to evaluate what models of primary care can produce the best health outcomes.
Many factors are determining the quality of care, such as ease of access including the availability of after-hours care, length of office wait time, travel time to an appointment, and flexibility in selecting a PCP, clinical quality, interpersonal aspects, continuity, the structure through which primary care is delivered, and insurance coverage. Although studies in international settings have compared the quality of care in primary care and specialty care settings, the results were mixed, and further research is needed to elucidate how system-level factors and specific policies may influence quality in the USA.
Additionally, research has indicated that countries and regions more oriented towards the primary care model have lower healthcare costs and better health outcomes, although further studies using formal cost-effectiveness methods need to be conducted. The Cost-effectiveness of primary care has been tentatively established through a few interventions conducted in primary care settings, and the adoption of health information systems in primary care settings may further yield financial gains.
Also, better primary care is correlated with more equitable distribution of health within a population and can mitigate the adverse effects of income inequality, which is especially important in the USA, where racial and ethnic minorities face greater difficulties accessing regular primary care. Therefore, CHCs (Community Health Centers) in the USA have a significant role in providing primary care services to vulnerable groups and reducing disparities. CHCs in the USA are primary care facilities that provide family-oriented services to meet medically underserved populations’ healthcare needs.
However, difficulties in recruiting primary care providers and maintaining financial viability are significant challenges to the sustainability of CHCs, which subsequently influence primary care services available and health outcomes for these underserved populations. Furthermore, research on health disparities in children and migrant workers is still lacking and needs further attention.
Healthcare reforms aimed at strengthening the primary care system have been implemented in several developed and developing countries and have improved the healthcare system. The Patient Protection and Affordable Care Act (ACA) also emphasizes primary care in the USA. Future assessments focusing on the ACA’s impact on primary care, health outcomes, healthcare costs, and health disparities should be conducted to serve as an empirical basis for policymaking in the future.
The pandemic reveals how critical it is to invest in redesigning our primary care system, especially for the most vulnerable among us. Policymakers can increase what we pay for primary care and how we pay for it, shifting from fee-for-service to models that reward value over volume, enabling providers to deliver holistic and high-quality care. Although these models are being implemented, they are ineffective and are a major cause of PCPs shying away from their practice. These policies are poorly thought out, and their creators seemingly lack the proper understanding of the office workflow. They have created arbitrary goals that a physician must meet to deliver quality care, but there is no evidence that such measures influence behavior change in the patient towards being more compliant. By directly tying these policies to reimbursement structure, physicians are not meeting these arbitrary quality goals, and patients are not getting any health benefits.
With expenses climbing and earnings constant, PCPs attempt to make up the difference by increasing the number of patients they see daily, typically upwards of 24–25 patients, if not much more. In order to see this amount of patients, the PCP has to sacrifice time spent with patients drastically. A typical visit with the doctor usually lasts between 10–15 minutes, and within that time, it is impossible to create that doctor-patient relationship or have a long discussion about the patient’s concerns and barriers to health. 10–15 minutes can be enough time to quickly assess the patient with a strep throat, blood pressure medication adjustment, or diabetes consultation, but when it comes to more complicated patients with multiple barriers to care, this amount of time is certainly not adequate. It is not enough time to explore family issues, personal stress, or anxiety that often leads to symptoms and sickness.
Patients with multiple barriers to care and multiple chronic illnesses require extra attention and diligence from the PCP. Illnesses like Diabetes, heart failure, chronic lung disease, kidney failure, or multiple sclerosis naturally are challenging to manage, persist for the patient’s lifetime, and are inherently expensive to treat. PCPs are well trained to perform these consultations and ensure that the patients are getting the care they need. Emergency Room physicians are not trained to deal with the long-term effects of Diabetes, for example, and only have a snapshot of the patient’s current health. PCPs, on the other hand, has complete knowledge of past and present including the social situation that patient is dealing with, which makes them better equipped to manage chronic diseases. Chronic illnesses consume about 75%–85% of the claims made to the insurance companies; therefore, having a PCP as the leading provider decreases the cost since the illness is better managed, and long-term health complications can potentially be avoided.
Policymakers could also develop payment models that reward spending time with patients and build long-standing, trusting relationships, which shows matter for effective primary care.
The U.S. also can increase the availability and supply of primary care, especially for low-income communities, through programs like the National Health Service Corps, which offers financial incentives to providers who practice in underserved areas. Finally, policymakers can help primary care providers develop telehealth infrastructure, assist them in effectively using these platforms, and offer fair reimbursement.
EMRs were thought to be the solution to streamline healthcare delivery and revolutionize medical practice, but it has not achieved these goals. These systems are costly, complicated, and have a steep learning curve for anyone trying to learn the system. Older physicians are leaving medical practices altogether due to the forced implementation of EMRs. Young physicians are less frustrated by the digitization of medical records but continue to experience excessive oversight and administrative burden brought upon them via EMRs. The non-standardization of EMRs leads to learning brand new systems each time a physician changes jobs. Medical errors have also been reported to be higher in EMRs as opposed to paper charts. Despite its shortcomings, EMRs significantly facilitate documentation and healthcare delivery. There needs to be a push to simplify the user interface to make it more intuitive and have physicians be involved in developing this software.
Administrative costs and micromanaging of physicians have also created a divide and power struggle between the administrators and physicians. Most hospitals have an administration monopolized by non-clinicians who seldom understand a physician’s duty and mainly focus on the bottom line. There need to be more physicians in administrative positions alongside non-clinicians, so they can make more informed decisions together leading to better hospital and resource management, driving higher patient and physician satisfaction rates.
A more robust and well-functioning primary care system matters now more than ever to save lives in an increasingly daunting health crisis.