Why We Need Private Primary Care Doctors

Things have been busy in my absence.  A recent post on Kevin MD by Joseph Biundo, a rheumatologist, challenged my assertion that primary care doctors can save money:

(In reference to my claim) That may be true in theory, but I see patients in my rheumatology office every day who have been “worked up” by primary care physicians and come in with piles of lab tests, and x-ray and MRI reports but are diagnosed in my office by a simple history and physical exam.

Prior to that, an article in the NY times along with a post by Kevin Pho noted the fact that more solo practitioners are leaving private practice and joining hospital systems.  Why are they doing this?  Dr. Kevin suggests the following:

Lifestyle matters. More doctors are entering the workforce seeking part-time jobs in order to maintain a family balance. By removing the administrative hassles from their plate, they can go back to focusing solely on practicing medicine and coming home at a reasonable hour.

The NY Times article suggests possible benefits to patients:

In many ways, patients benefit from higher quality and better coordinated care, as doctors from various fields join a single organization. In such systems, patient records can pass seamlessly from doctor to specialist to hospital, helping avoid the kind of dangerous slip-ups that cost the lives of an estimated 100,000 people in this country each year.

So as a primary care doctor in private practice, am I soon to go the way of the dinosaur?  Is this simply a shift in the business model as demanded by the times, or should people be concerned?  Would the system function better with fewer primary care doctors or ones who are employed by large hospital systems?

Those who read my blog regularly (and those clever enough to read the title of this post) already know my answer: private primary care is essential for a healthy healthcare system.

Why Primary Care?

While I can\’t disagree with Dr. Biundo on his point regarding the physical exam skills of PCP\’s, I do disagree that this raises question of the cost-effectiveness of primary care.  In his case (the practice of rheumatology), there are few expensive procedures, the diseases are less common (compared to fields like cardiology and other high cost specialties), and the patients don\’t spend a high number of days in the hospital.  One overnight stay for a cardiac catheterization will pay a large part of a rheumatologist\’s salary for a year.

Like primary care, rheumatology is largely an outpatient practice, with success being measured by the ability of the practitioner to keep the patient out of the hospital and away from expensive procedures.  Lately, rheumatologists have started having biologic medications (like Enbrel) that are quite costly, but the number of people on this relative to the general public is still quite small.

Primary care, on the other hand, is the fountainhead of all healthcare costs.  A good PCP is also measured by patients staying out of the hospital and away from expensive procedures.  In general, a PCP is less likely to:

  • order an x-ray compared to an orthopedist
  • get an EKG compared to a cardiologist, or
  • order an endoscopy compared to a gastroenterologist.

There are some high-consuming primary care doctors, but much of the blame for this can be placed on the payment system that encourages expensive procedures and the ordering of tests.  For example, one of the PCP groups in our area has their own stress-testing equipment and CT scanner.  I am 100% sure that the physicians in this group order many more CT scans and stress tests when compared the physicians in my practice.  I am also sure that the care quality in my practice does not suffer from our lack of test-ordering.  Why?  Because the physicians are financially motivated to order these tests, making the appropriate business decision clash with the appropriate medical decision.  As long as it\’s not harmful to order the test, the doctor can justify it.

Even these physicians, however, are not going to do any of these tests as much as a specialist, who depends on the presence of chronic disease to make a living.  The only specialists I have seen who are slow to order tests and procedures are those who don\’t financially profit from their ordering: academic specialists.

Why Private Practice?

This brings me to my second point, which is the necessity of having primary care physicians who are in private practice.

Why do hospitals have an interest in hiring primary care physicians?  The answer is twofold: first, they allow them to negotiate contracts with the insurance companies in a position of strength.  Primary care is a must for most insurance contracts.  Patients will change insurance plans if their PCP is not on the plan, but they won\’t do so nearly as much for specialists (with the possible exception of OB/GYN, which often act as PCP\’s) or hospitals.  Plus, most insurance plans do their care management by requiring referrals, denying or accepting them being their means of cost control.  Primary care physicians are the referring physicians, and without them the hospital\’s negotiating power is greatly diminished.

The second reason hospitals want PCP\’s under their wing is that they generate business by ordering radiology tests, lab tests, and sending patients to specialists who will do expensive procedures in their facilities.  Primary care is a loss-leader to hospitals.  Hospitals make no money off of their PCP practices directly but make a huge amount from the referrals and procedures they generate.

This shifts the mission of the PCP.  The \”success\” of the PCP in the eye of the hospital system is not to avoid referrals or costly procedures, but to order them.  It\’s not bad in the eye of the hospital that the PCP has higher hospitalization rates, it is better.

The Answer

The solution from an overall cost standpoint is to give primary care physicians incentive to do what they should be doing in the first place: keep people healthy and away from hospitals.  Any system that places too much value on procedures is going to fail at this, as the institutions and individuals who profit off of the procedures are going to fight for control of PCP\’s.  Independent PCP\’s who profit from keeping people well are the best thing for a system.

I have lived in both worlds: as a private PCP and as a salaried physician from a hospital.  I left the latter because it was clear that they had no interest at running my practice well and really just wanted me to be a turnstile into their money-making procedures.  It would be a big mistake to take away the one specialty that restrains cost.  We need to do the opposite, and encourage good primary care medicine.

11 thoughts on “Why We Need Private Primary Care Doctors”

  1. The title and summary of your article is exactly right. It would be important to note that as Primary Care practices are bought up by hospitals – referrals to Private Outpatient Specialists that model their practices to keep patients out of hospitals – are dwindling. Our neurology practice (that orders diagnostic testing when clinically necessary) has watched our top referring PCP's sell their practice to the large hospital system out of financial necessity and then get their hand slapped when attempting to continue referring to us. Doesn't matter that our MRI's are one-fourth the charge of the hospital or that the hospital neurologist is booked out for 2 months when we can see them tomorrow!
    Our senior neurologist posted a blog about the ethical side phenomenon titled Does Hospitals Ownership Of Primary Care Practices Create A Dual Agency Problem? http://bit.ly/d6j2Um
    As specialist in private practice, we're rooting for primary care to stay independent of the hospitals so that we can continue providing cost efficient care. Unfortunately, the hospitals in their negotiating with insurance companies have driven down PCP's reimbursement for all. Reform should focus on getting hospitals out of the business of ALL outpatient care.

  2. Spot on! I hope that more policymakers and physicians can be convinced of this, especially the point about the importance of *private practice* primary care. It's disheartening to see a never-ending commentariat of politicians and academic physicians explaining how we should all just trust hospitals with the entire medical care enterprise, even as minimizing hospitalizations is supposed to be a key part of reducing medical expenditures. It boggles my mind that physician-owned hospitals are verboten, whereas hospital ownership of medical practices is somehow considered free of harmful conflicts of interest. Coordination of care doesn't require consolidation, but this point is almost always overlooked.

    The worst part is that large numbers of the medical students of my generation will probably never give a serious thought to private practice. Between the inordinate complexity and, dare I say, work that's medical business ownership entails, the lack of training or exposure to business skills in medical school or beforehand, and the fact that there's this growing sense that “everything should be integrated with hospitals,” I don't know that the future will bring that many physicians willing to be anything more than someone else's employee. (Not that there's anything categorically wrong with that at an individual level, but when _everyone_ does it, there's a problem)

  3. I 100% agree with you that we need private doctors instead of those sold-out to hospitals. The private practice rheumatologist that I saw said that there were tests that could help pinpoint my diagnosis, but those tests are expensive and wouldn't change the treatment plan (so no point in doing them). When I switched to a rheumy employed by a hospital, she ordered $1862.80 worth of labwork to reach the exact same mistified conclusion that the private practice doc had.

    My PCP has a private practice. When he writes a referral, I know he's sending me to the person he thinks is best for my situation. In contrast, my rheumy is part of a hospital system and can't do that. Once she wrote a referral, and I asked, “Can I see ___ instead (since my son's already seen him and I know that I like him)?” She said that she wasn't allowed to refer outside the hospital system. That makes me trust those referrals less because she's not making a decision based on competence; she's just picking a name off a list.

    Lately, rheumatologists have started having biologic medications (like Enbrel) that are quite costly, but the number of people on this relative to the general public is still quite small.
    Are you referring to the cost, or the newness? Enbrel hasn't been around as long as aspirin, but it was approved 11/2/98. Yes, it – and the newer biologics – are expensive. So are the MRIs and EMGs that rheumatologists order. And the labs.

    Given a choice between equally qualified doctors, I will choose the one in private practice. I think I'll get better care (and it'll cost less).

  4. Enbrel is about $1000 per month, which is far more than one spends on the MRI and EMG's overall (since it is a recurring cost). The biologicals are incredibly expensive (and good medications), but their cost is absorbed by our system since they are used by a small fraction of the population (when compared to things like blood pressure or diabetes medications).

  5. The receipt lists the retail value of my Enbrel at $1,812.99 for a four-week supply. Multiply by thirteen for the annual cost. Definitely more than MRI & EMG.

  6. . Disclaimer: I am a employed physician by such an organiztaion. I had no choice, that's how the practice voted in 1992
    Two things about PHO's.
    1. As a PCP in a mostly rural area, in order to contract with any major insurer, we needed to be part of a network. Our area is small enough that an IPA was not enough. They may need us, we definitely needed them . They do need us, but the relationship is like they are running a non-profit sideline . I am almost willing to work a few more years just to see the tables turn , but not a whole lot more years .
    2. I don't get home any earlier , in fact quite a bit later. My manager is employed by the hospital and she gets salary increases based on lowering costs (personnel and services) . I am now just a turnstile to the high dollar specialists–a cost. In private practice we paid someone to sort and open the voluminous mail, not because we were too good to do it but because it was better to pay someone $15/hour to do that along with other tasks , like taking them across the street to the mailbox (the letter that they don't read gets there 2 days earlier ) than to limit patient care time . Most of this just gets shifted to lunch hours and weekends, but a lot has to be done in real time , e.g. 8-5 M-F when we should be seeing patients.
    We aren't allowed to work part time. So I have been in a work slowdown, a second decile rather than a top decile RVU machine, since I realized that the 800 of Ibuprofen QID for back pain was why I had new hypertension. Its not like there are people lined up to take my job.

  7. I also was a salaried physician who was promoted to private practice. While I agree that specialists like me do not practice cost effectively, I believe that my primary care colleagues need improvement here also. I am sure you are correct that internists and FPs take care of abdominal pain, rashes, chest pain, etc, in a much more fiscally responsible manner and without any quality sacrifice. Keep in mind, however, that most specialists grab hold of patients only when primary care physician ask us to do so. This is most evident in the hospital when primary care physicians routinely consult a bevy of specialist, often within hours of admission, or before even seeing the patient. In this case, it is the primary care physician who has lit the fuse. Thanks for your post.

  8. Heh, things must be changing as the definition of a specialist used to be someone who could think of more tests to order than you could. This was especially true in rheumatology.

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