They’re Lying

Remember Joe Isuzu?

Back in the 80’s Isuzu, a Japanese car company, broke into the national consciousness with the introduction of Joe as its a new spokesman. In the commercial he would claim remarkable facts about various Isuzu models, such as:
• “It has more seats than the Astrodome!”
• Hi, I’m Joe Isuzu and I used my new Isuzu pickup truck to carry a 2,000-pound cheeseburger.”
• “Isuzu Trooper II, can hold the whole state of Texas!”
The subtitles in the ad would explain that Joe was lying and, in fact, the Trooper II could only hold 78.2 cubic feet of Texas.

It was a phenomenon. During a presidential debate, Michal Dukakis said of George, H W Bush, “If Bush keeps it up, he’s going to be the Joe Isuzu of American politics.”

Joe became the symbol of pathological liars.

Joe came to mind when I heard about a hospital system that was seriously pursuing the idea of opening direct primary care practices as part of their business strategy. Through my professional life I’ve seen many hospitals, insurance companies, and even venture capitalists claim a belief in and commitment to primary care medicine. They claim an understanding of the sacredness of the doctor/patient relationship, and a desire to “put people before profits.”

They’re lying.

Primary care medicine can never be the main business plan for any company wanting to make money because primary care simply doesn’t make enough money to keep their interest. Primary care is cheap to do, so unless you jack up the prices, you won’t see much in the way of profits. The average visit in my office involves me talking with a patient…and that’s all. It’s not costly to do, and we don’t charge all that much. In my practice, low overhead means I can be profitable and still charge only $60 per month on average. Fee-for-service practices like I used to run have significantly higher costs (around $200 per visit, give or take) because of their comparatively higher overhead. Besides the nursing staff, I had to employ a significantly large billing staff, have managers, and more office space because of the much higher volume of patients I’d see in a day.

But still, the costs…and the profits…are nothing compared to specialists doing procedures, radiology departments doing scans, and ER’s doing everything. That’s where the money is, not in primary care.

So why do hospitals, insurance companies, and others in the healthcare space even pretend to be interested in primary care? Because primary care doctors play a big role in determining who gets the big the money. We refer to one specialist or another. We send a patient to one hospital or another. We manage people well to avoid expensive problems, or we are careless and our patients become cash-cows to hospitals and specialists. We are the source of patients, and patients are the source of profits.

This is why hospital systems buy primary care practices. It’s not because they are profitable. The practices can lose money but still be hugely profitable for the hospital because of admissions, lab and radiology orders, or even referrals to orthopedist who does 40 hip replacements a year in the OR. Primary care is the source of those hips begging to be replaced.

There’s one more advantage in hospitals owning primary care docs: influence. They can “encourage” PCP’s to order more tests and do more referrals. There is no motivation to order tests efficiently, to avoid unnecessary referrals, to keep people healthy. In fact, those things are bad for business.

This is why I think primary care is best served alone. Why insure it if it’s not expensive? Why let hospitals run it when there is a huge conflict of interest in what’s best for patients versus profits. Why jaundice the judgement of a doctor whose goal should be preventing disease, reducing cost, keeping people away from hospitals and specialists whenever possible. Should we as PCP’s be playing defense against the rest of the healthcare system whenever possible? Shouldn’t our advice be untainted by what makes the shareholders happy?

So forgive me for my scowl when I hear of hospitals showing interest in direct primary care. Forgive me for the skepticism toward health systems advocating disease prevention. Forgive me for sneering when politicians propose huge bureaucracies to “control healthcare costs.” The real revolutions don’t happen in the treetops, they happen at the root. Doctors need time to give good care. Patients need doctors who spend time and listen to them. Doctors need to be free from motivations to drive up cost or lower care quality. Patients need someone they can believe in, someone they can trust.

Not more lies.

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