The oft-heard refrain “talk to your doctor …” is a joke. It is virtually impossible to reach one’s primary care doctor even if we have one. Established practitioners are leaving in droves, either for retirement or, if they have prominence, concierge practice. Curiously, the collapse of primary care medicine has received scant public attention. Unlike health insurance coverage, access to physicians is nothing to rally for or protest against.
Of equal concern is the Faustian bargain made by physicians to give up control of their practices in exchange for working fewer hours. As a result, primary care physicians are not available to see their patients with acute symptoms on nights or weekends. Even if the doctor’s office is open, “the next available appointment,” is often weeks away. Thus, a person with a fever, earache, rash, vomiting, or painful urination, or the parents of a 4-month-old with a high fever, have the choice of visiting an urgent care facility, a crowded hospital emergency room, or “waiting it out.”
Though many social, political and economic factors have contributed to the situation we find ourselves in, the overriding reason is the takeover of most components of health care, including hospitals, physician practices and pharmacies by large corporations. Medical care has been transformed from a service to be provided to a “commodity” to be “delivered.” Patients are called “consumers,” and health care workers “providers.” (I have never heard a patient refer to him or herself as a “consumer.”)
My own wonderful internist started practice 25 years ago in a small group and ended up employed by a large corporation. Decisions about his compensation were outsourced to a national firm. High marks were gained by “productivity” (volume of patients seen) and “customer satisfaction.” The latter was ascertained from the ubiquitous emailed post-visit surveys. My doctor was known by colleagues for his wealth of clinical experience and listening skills. He regularly visited his patients in nursing homes. Unsurprisingly, these attributes brought down his scores and his salary. He virtually skipped out of his office on the first day he was eligible for retirement. A host of experienced primary care physicians have followed suit.
Most hospitals and physician practices in Seattle are owned by a very few organizations: Providence-Swedish, Kaiser Permanente, Virginia Mason-Franciscan, UW Medicine and United Healthcare. Providence is one of the largest systems in the country. On May 25, 2020, The New York Times reported that the Providence system had hedge fund investments and venture capital accounts of over $12 billion, and that CEO Dr. Rod Hochman’s annual salary was more than $10 million.
Are primary care medical services going to improve? No, they will continue to get worse. First, because the seriousness of the problem is not appreciated by the public or political leaders. And second, because similar to the atmosphere that existed in the “robber-baron” era of the late 1800s, there are no constraints inhibiting the health corporations from earning profits by curtailing access. Primary care physicians will not return to “taking calls” on nights and weekends. Concierge practices, which offer patients a personal physician on retainer, will continue to proliferate. And boutique hospital wings, catering to the same “consumers,” will surely emerge.
There are several measures that might bring some relief:
∙ Greatly increasing the number of nurses at all levels, such as nurse practitioners with prescribing authority, registered nurses in a variety of specialized areas, and nursing assistants who can function in hospitals, clinics, nursing homes and in public health care. For this to occur, the pay of nurses must be substantially improved. In addition, health and educational institutions, especially community colleges, must partner to facilitate clinical training.
∙ Deploying more National Health Service Corps (NHSC) physicians. The Corps, created in 1972 by legislation sponsored by the late Sen. Warren Magnuson, assigns primary care doctors to practice in “underserved” rural and urban areas sites. The inducement in addition to idealism? Practitioners who make a two-year commitment can get their student loan debts erased. And medical students who make a similar commitment can get their educational expenses covered.
It will be interesting to behold how Americans respond when we recognize that our traditional system of providing personal health services has collapsed.