Top Three Obstacles to Better Primary Care :: Obstacle #1

You may not know that I am married to a health insurance expert.  My husband Alex founded a company called Bernard Health which specializes in helping individuals, families and businesses with health insurance needs.  Recently, Alex has begun writing for a few publications including The Tennessean offering his thoughts and opinions on everything from Medicare to primary care and healthcare reform.

A nurse practitioner myself, our interest in healthcare is mutual leading to some downright nerdy conversations.  Yesterday over a particularly academic dinner discussion, Alex mentioned his most recent article, Top Three Obstacles to Better Primary Care. I checked it out and was impressed with the content (for the record, I’m always impressed by what he writes, but this article was exceptionally interesting).

Personally, I have worked in primary care clinics witnessing the broken system for myself.  In fact, the frustrations of our primary care system and obstacles to providing effective patient care ultimately led to me quitting my job opting for specialty practice.  I have never been able to pinpoint the exact reasons for the stresses, frustrations surrounding primary care.  It all just seems like such a mess.

Alex’s article does an excellent job of identifying, simplifying and explaining major problems in our primary care system.  With his permission, I decided to share them with you this week (and maybe next) in a three part series.  So, here is goes!

Top Three Obstacles to Primary Care

By Alex Tolbert for Bernard Health 

Fee-for-service is the wrong business model for primary care.  Why?  Because it bases payment too much on activities that are measurable, when the role calls for excellence in areas that are very difficult to measure.

For example, if you have been diagnosed with Stage 4 ovarian cancer, what is it worth to discuss options, likely outcomes and get advice from your personal physician who you have known for years, who you like, and who you know cares about you and your family?  It’s tough to put an exacat price on that, but it’s worth far more than what Medicare reimburses for an office visit.

So if fee-for-service is wrong, then what is the right business model?  The job of a primary care physician calls for an ongoing relationship, ideally with an ongoing health “accountability partner” component, a chronic care management component, and an acute advisory componenet all wrapped up in a strong, mutually beneficial relationship.  The right model for that kind of ongoing, long-term relationship is a subscription-based business model.

And please don’t take my word for it.  Clayton Christensen, often referred to as the father of disruptive innovation, calls for it in his book The Innovator’s Prescription.  Qliance, backed by founder Jeff Bezos, is already doing it in Seattle.  There are other examples of it around the country, too- check out MedLion out of Las Vegas for one.  An industry term has even developed for it: Direct Primary Care.

What is Direct Primary Care?  There are different flavors, but the bottom line is that it’s kind of like concierge medicine for the masses.  Doctors who practice it generally don’t take insurance, and the patients or their employers pay an ongoing, monthly fee for the kind of primary care doctor relationship that most people say is what they want.  Sound expensive?  Qliance charges between $54 and $94 per month, depending on the patient’s age.

So we have experts saying we need this new business model for primary care. We have some practices already doing it.  We have proven visionaries like Bezos backing it financially.  Three obstacles remain that prevent it from spreading as rapidly as it should.

Obstacle 1: The Expectation Primary Care Should be Paid by Insurance

Having insurance companies pay for primary care doesn’t work.  How do we know?  We’ve tried it all and failed.

When it comes to primary care, patients want an involved, comprehensive relationship with their doctor.  They want someone they trust implicitly.  If they end up with a chronic ailment, they want their doctor involved and helping them sort out what to do.  When tough decisions need to be made in acute settings, they want to be able to rely on their doctor for advice.  Not the specialist that they met five minutes ago.  They want the doctor who has known them for years.

Insurance has a hard time figuring out how to reimburse for that.  Insurance reimbursement emphasizes measurable activities, in part simply because they are easier to measure.  It’s too hard to measure the value of “Long, caring conversation around Stage 4 ovarian cancer options with patient who the doctor has built a relationship with over 30 years”.

As health care consumers, we are more than capable enough to put a value on having that kind of relationship with our primary care doctor.  We are closer to the problem than the insurance company or Medicare, and can be better judges of whether the primary care doctor is going to do a good job.

The problem is that, historically, we’ve thought everything should just be “paid for” by insurance.  We’re disappointed that insurance reimburses for office visits, not relationships.

Bottom line: If we want a relationship with our doctor, we need to expect to pay for it.

My Thoughts as a Medical Provider

As a nurse practitioner, I completely agree with the sentiment of this first obstacle to better primary care.  How many times have we as NP’s, PA’s and MD’s rushed patients through their medical histories, incompletely explained treatment options and hurried through physical exams.  It can be hard to complete your allotted number of patient visits working in primary care without interrupting patients and seeming rude.

However, we are pushed by ourselves and our employers to see more and more patients in a shorter amount of time.  Insurance pays for visits, procedures and imaging studies not conversation.  Employed by a company that pays on a RVU-based system, my paycheck reflects how much I bill.  This system encourages quick, incomplete conversations and expedited care which is almost never to the benefit of my patients.

While solving this problem seems nearly impossible as it would require a massive overhaul of the healthcare system including how medical providers are paid, Alex’s mention of Direct Primary Care offers a practical solution for many patients. Maybe one day, this system will become the new norm leading to better primary care for patients and providers.

What do you think?  Is the expectation that primary care should be paid by insurance companies a major obstacle to providing better primary care?  How should we fix this?


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