The System is Collapsing!
None of this is a surprise to you, I’m sure. Like many areas, we have a serious problem in our large community and it feels like our healthcare system is in collapse.
In the past year, a lot of Primary Care doctors who prided themselves on caring for a large patient base have closed their practices to new patients or retired. In fact, this past month, we surveyed all of the Primary Care (Family Practice and Internal Medicine) practices and found they are simply not taking new patients anymore. Some of the doctors are “sort of” taking new patients, but the appointment times are so many months out that they are effectively closed to new patients.
We undertook this survey because my partner and I totally closed our practice to new patients almost a year ago. We did this because we have been overwhelmed by the workload. Over the past twenty years as an independent practice, we have often limited entry for new patients, but 2021 was the year we totally closed to EVERYONE not known to our practice. We did this with the knowledge that practice expenses are climbing rapidly. Like many, we had to provide huge salary increases to our staff. Doctors do not have the ability to increase their prices. We can only work harder. Yet, we are simply exhausted with the workload and are tolerating pay-cuts because we cannot work 24-7.
We are not getting younger and I see my peer group retiring or preparing for retirement. My goal is to practice for as long as my abilities allow. I like my job and I believe my presence makes a difference in the community. Yet, we are not meeting the demand. One third of the phone calls coming into our practice are not from our current patient base. These are calls from frantic people trying to find a doctor. In the past, we tried to offer names of doctors accepting patients. Now, there are simply no names to offer. People are really in need. When they are turned away by our staff, they try to get to me via social media. They track down my email and cell phone. I wish I could offer them options, but I have none.
We are seeing a lot of problems that are worsening the burden on the diminishing doctor capacity.
- NP’s and PA’s are being hired locally by both hospital systems and most practices to fill in the gap. This is having unexpected impacts. At first glance, it seems like the easiest option. In many cases, this works fairly well. Unfortunately, far too often, patients immediately recognize these providers have holes in their knowledge base and demand specialty referrals. Remember, specialists are also already overwhelmed. Often, traditional Internal Medicine problems are not handled and are, instead, simply triaged into a specialty referral. The more practices try to plug the gaps with PA’s and NP’s, the more demand for specialists simply increases.
- Meanwhile, specialty offices also use NP’s and PA’s heavily. Sometimes, this is helpful. Other times, the result is often care which is incomplete and poorly supervised, requiring urgent intervention. Certain specialties have only a narrow margin for error.
- Specialists in too many fields are no longer available in any timely manner. There is simply a shortage. This is far worse than the age-old local problem of unavailable Endocrinologists, ID doctors, Rheumatologists and Dermatologists. Now, this list includes Neurologists, Urologists, ENT docs and others. The Urology problem is particularly acute in our area (just ask a patient who has recently gotten a Foley in the ER). Even Orthopedics, a field which once had a local doctor surplus, has become a field of scarce availability, resulting in patients being sent out of town for care.
- Many practices have become office management messes, leaving patients and their doctors frustrated. It is difficult to find good staff and you have to constantly increase your pay scale to keep them. Remember, office fees pay these salaries and reimbursement has either stayed flat or gone down for MANY YEARS. Phone wait times measure 30 to 45 minutes on average. Such waits make patients give up.
- These issues in specialty care lead to a huge increase in the workload for the PCP’s who are contacted by patients who cannot navigate the system. Simply following the current practice of writing on discharge or ER instruction sheets: “See Dr. X of Urology or Orthopedics in 24 hours” does not make the appointment magically appear. The patient is still lost when they are later told such follow-ups are impossible. Patients will call their PCP for help.
But, the biggest and most acute problem is in the Primary Care field.
- The support staffing requirements for Primary Care grow higher every year, while reimbursement drops. Prior authorization demands are soaring out of control. If you do not have a staffed office to manage this, you will lose the doctors. Almost every radiology scan requires additional work. Almost every patient has a drug prior authorization issue. Even cheap drugs require insane prior authorization demands. Almost every $15 steroid cream gets denied by insurance. How is that helpful?
- Getting patients situated with the appropriate specialist eats a lot of phone time.
- Urgent Care is not the same as Primary Care. The model of Patient First and others, which want to be your PCP and your Urgent Care doctor is a disaster. As the problems grow in complexity, the providers in these models basically “give up” and tell you to “find a good Internist.” Great advice, but there is no such option!
- PA’s and NP’s can fill in some gaps, but you need an adequate supply of physicians to supervise the complicated care of people hitting Medicare.
- Recently, some very busy PCP’s have retired, leaving a huge number of patients trying to find new doctors. As the doctor gets older, their patients also get older and more complicated. They are finding the region is saturated with patients and no one wants them. Almost daily, my cell phone rings after hours as total strangers have tracked me down, begging me to be their doctor. When one of our patients dies, we literally get calls from people within hours: “I know you have an open slot now! Can I have it?” It sounds too tragic or comical to be real, but it is indeed happening.
- Hiring and training staff is a continued struggle. Every insurance company and pharmacy plan has its own byzantine requirements for radiology studies and drugs. Even Medicare equipment like oxygen requires extensive computer work, something most hospitals fail to accomplish at patient discharge. Thus, it becomes the task of the PCP. Even referring a patient to a practice like GI or Pulmonary now requires a computer interface that takes time to learn and execute. The result is delayed care and patients often fall through the cracks. Increasingly, patients are discharged from the hospital with many loose ends and unaddressed problems. Again, simply writing: “See Neurology in ten days” on the discharge sheet will not make such an appointment magically appear (…and trust me, it will require A LOT OF MAGIC).
- When you agree to be the Primary Care Physician for a patient, it is a lifelong commitment to the patient. You are saying, “I will be here when you need help. I will be here when your specialist does not return your calls. I will respond to you day or night until one of us dies or I retire.” This means just one elderly new patient can significantly increase the practice’s workload.
My personal goal is to try and bring in a Family Practice or Internal Medicine Doctor to our practice in the coming year. Our patient load is huge. Yet, the finances of such growth keep me awake at night.
The national solutions are easy, in theory, but impossible in reality:
- At least index physician reimbursement to inflation. Instead, every year, doctor reimbursement drops.
- Stop crazy prior authorization demands. Even such models as Concierge or Direct Primary Care are stopped cold when prior authorization halts a prescription or scan.
- Stop insurance mandates for chart copy requests. The administrative burden is huge for this.
We believe we have a mission to “improve the health of the people in the communities we serve.” Unfortunately, we still have to pay employees and feed our families and this gets more impossible every year.
The system is crumbling around us and stabilizing our little piece will soon no longer matter.
i would hope that someone sent this en masse to every Congressperson currently seated….
I retired 2 years ago as it was too tiring to do office, take call and do hospital work. Plus being recently widowed and having a mentally handicapped son to care for. Never took vacations as my son was so unpredictable so they money was saved. Son improved, was planning on a vacation but wife got ill and died in 3 months. Was easy for me to retire and not look back.
Practice I worked for still does the classical call, office and hospital work. Wonder how many docs left since I retired? Office only with no call is pretty enticing.
Insurers and PBMs are posting record profits.
The system is working perfectly to achieve its intended goal.
This piece effectively catalogues so much of what has gone wrong, but it declines to name a major culprit. Sure, these prior authorizations are a major problem, forced on us by Big Insurance and government. Who put them in charge?
Yes, reimbursements decline yearly – never mind inflation! – as both government and Big Insurance pay less while expecting the same amount and quality of work. Who put them in charge? Who made it necessary to hire LELT’s to make up on volume?
Costs go up as the regulatory burden increases, mad mandatory by the colluding parties of government and Big Insurance, delightfully abetted by Big Hospital. Who put them in charge?
Compassionate, helpful malpractice lawyers still prowl the medical sea, waiting to bite on any bad outcome, real or perceived. Who gave them such power?
The sad fact is that PATIENTS are responsible for a great deal of this. Yes, they were ill-served by a greedy, cowardly medical community that failed to provide counsel and leadership, that should have refused to play along. That horse was out of the barn and long gone by the 1980’s, but that doesn’t alleviate our guilt.
Patients – or consumers, if you like – thought that health care should be plentiful, low (or no-) cost, and perfect. Patients were duped into trusting smiling insurance companies rather than their own physicians. In their envy, greed, and fear, they threw away their half of the relationship. It was patients that thought it so terrible to pay $35 cash for an office visit, yet would happily let their insurance promise – and often fail – to pay a delayed $60 for the same service.
Patients and their vengeful family members chose to expand a system of appropriate redress and compensation into a legal lotto, adding untold billions every year in defensive medical costs, and making doctors fee resentful, targeted, and fearful.
Patients – NOT customers, in this context – voted for the fantasy that the elderly could receive great, unlimited government-provided care forever, buying into the voodoo that the nebulous goal of “dignity” would rationalize any cost. Despite this leading to shortages, rationing, and turning our economic future into a national mausoleum, no serious reform was allowed. These same voters decided to bestow “free” care for the poor out of the taxpayer’s largess, with no care for the erosive effects on the work force, the inflationary effects on the insurance “market”, corrupt though it is, or the generational recruitment of massive welfare systems.
Yes, physicians, government, corporate interests and the cronyism with which they meshed with government, ALL deserve much blame. But who allowed them their abuses? Put more ably by Ayn Rand: ” “There are no evil thoughts except one; the refusal to think.”
Now that such a refusal has been institutionalized, we are all going to be pulled further down with no one able to understand why.
Primary Care was dead in the 90’s. It’s dust and bones now.
DPC is the only hope
Undiagnosed diseases are incurable. The failure of American medicine is undiagnosed. Like end-stage firearm disease, a set of unrelated band-aids are placed on the problem.
Great article. Can’t argue against a single point. Primary Care is dying (for physicians anyway) because the system has been killing it for decades. Mid-levels are the future. I am not anti-midlevels, I’ve worked with several good ones, but their teaching leads them to refer out early and order a lot of tests. That makes them very valuable to hospital systems that make money from tests, procedures, surgeries and employing specialists.
That’s not a sustainable model though. In business you try not to assign tasks to employees that could be handled by someone at a lower level, Medicine seems to be trending the opposite direction – sending simple problems to the most highly paid specialists, spending money on unnecessary testing and having highly trained nurses sit on the phone all day doing prior auths. For all the talk about hospitals and practices being rewarded for efficiency the actual effect has been the opposite.
I am anti midlevel. They should not exist.
Medicine, especially Internal Medicine, speaks this language. The basis is the adaptability of normal physiology, and its impairment by disease. As organ systems suffer in their ability to respond to new conditions, this is called “failure.” Adaptability fails long before end-stage disease occurs, when the system cannot do its job.
As a wild hand-wave generalization, organ systems exhibit signs of catastrophe when they are about 25% functional. It’s a good model for renal and cardiac failure.
The fix/ignore cycle is seen frequently in failures where the cause is not appreciated. Bring ’em to the ER when they fall apart, when pop’s turning blue. They give him oxygen and steroids, and send him home. “See your primary care provider!” is the helpful note scribbled on the bottom of the page. The family accepts the fix/ignore cycle. It’s a bad car what has no brakes. That is where we’re at.
Deterioration progresses, and the cycle continues.
PS: There’s an oldie but goodie behind the paywall in Scientific American on when systems stray into a state of catastrophe.
Although specialists are not allowed to complain . We have found out most of the Academic Universities get paid triple for the same service because of bargaining clout.
I have seen my reimbursement for my most common major surgery drop over 50% while my expenses have triped in the last 30 years .
Tricare, Medicaid, Medicare, and Obamacare all pay less than my overhead costs.
Meanwhile I compete against NPs with no training doing the most lucrative part of my practice.