THE DEATH OF PRIMARY CARE

In the 1970’s and 80’s, the medical profession made a concerted effort to increase the number and quality (competence) of primary care physicians, the focus being on Family Physicians.  State legislatures, medical societies, and the American Academy of Family Physicians worked together to provide the public with greater access to medical care by emphasizing the need and value of primary care physicians. Residency programs in Family Medicine popped up everywhere and increasing numbers of med school grads chose Family Medicine. It was a hey day for young physicians whose skills were sought by communities all over the country. 

Family physicians enjoyed prestige and respect from their patients and specialist colleagues, and earned a leadership role in the treatment milieu. Things were going well for Family Doctors, except that it took 7 years to train a family physician and the number of docs wasn’t increasing as fast as needed. Then, several bad things happened, and slowly the prominence and prestige Family physicians had earned began to erode. What follows is an explanation of the problems that negatively affected primary care: 

1. The Medicare Law was passed in 1965. In the ‘80’s and ‘90’s Medicare began dictating what physicians could charge patients and decided how much of that charge the physician was allowed to receive. As a requirement to be able to see patients “insured” by Medicare, the program mandated physicians accept only the amount Medicare said they were entitled to receive. If you didn’t agree, the doctor was not permitted to see Medicare patients and/or payment was denied. 
2. In the mid ‘90’s, Congress and Medicare devised a physician payment system that was widely touted to be the financial boost Family physicians needed to prevent financial ruin. Called the Resource-Based Relative Value System, RBRVS, it did nothing to improve physician payment and indeed had the opposite effect. A detailed explanation of RBRVS is found in the blogs “What are RVU’s and DRG’s? How physicians get paid,” and “2023 Medicare Conversion Factor Reduced.” From that moment on (for 27 years), Medicare payments to doctors decreased every year to the point that physicians now are paid less than 10% of their approved fee. 
3. To increase the workforce and to reduce Medicare expenditures, the government, and other forces, proposed the nurse practitioner and physician assistant concepts. These “professionals” were trained in a much shorter time, accepted an hourly pay rate, and multiplied like ants on sugar. Suddenly, NP’s and PA’s, were considered equal to FP’s, and performed most of the same services as Family physicians. The prestige Family doctors had earned was fading, and fully trained (7 years) physicians began feeling insignificant. Family physicians (MD’s) have far more comprehensive education than 2-year PA or NP students, but NP’s and PA’s were given status equal to MD’s. The importance of Family physicians has declined ever since.
4. The advent of hospital-based specialty and critical care physicians, called hospitalists and intensivists, has forced family physicians to stop making hospital rounds and attending patients in the hospital. Medicare would not pay Family physicians for this service. Hospital-based physicians have relegated Family doctors to care for outpatients, exclusively, and function as triage officers. Family physicians aren’t always informed their patients are in the hospital and don’t know why or how they’re being treated. Continuity of care is disrupted. Poor Communication with the Family doctor leaves him/her uninformed about the patient and erodes the importance of the primary care physician.
5. Annual decline in Medicare and insurance payments to Family physicians has resulted in financial insolvency and the closing of many practices, nationwide. Basic economics of increasing expenses (overhead) and decreasing income (reimbursements) forces practices to cut corners, eliminate services, lay off employees, and see a larger number of patients, to stay in business. Sometimes that’s impossible, though. Physicians respond by becoming an employee of a hospital or group or by retiring. 
6. Delay or denial of payment is more commonplace as Medicare is approaching financial insolvency. Congress gives billions to other countries, but skimps on payments to its own citizens.  
7. COVID-19 and the use of telemedicine. What a concept! Take care of a patient from a remote location? What a crock! Telemedicine told patients I’m just as scared of this virus as you are. You’re on your own to diagnose and treat it. I don’t want to get COVID. I don’t want to die! Since when are doctors afraid of a disease? What kind of message does that send? You gown, mask, and glove up just like physicians have done for over a century and take care of the patient like you always did. ER docs did it. Hospitalists did it. Nurses did it. What’s with the Family doc who refused to see sick patients in a live encounter? Besides that, Medicare denied payment for telemedicine visits and family doctors were denied access to personal protective equipment (PPE), testing materials, and were late to receive COVID-19 vaccines. The pandemic was overseen by the CDC, NIH, NIAID, and HHS, all agencies of the public health system. Most Family doctors are private practitioners and not part of the government-run public health system, and thus are way down on the priority list. 
8. In 2010, the government devised a system to incentivize doctors to adopt the use of Electronic Medical Records (EMR) systems. Called “meaningful use,” it added complexity, confusion, and inconvenience to the use of EMR and reduced the number of patients a doctor could see each day because it was cumbersome and not user friendly. I went from seeing 35 patients per day to 28 overnight, and thus, took in significantly less income. That was financially a huge strain on my practice. It was time to retire. 

These are just some of the reasons primary care is dying and Family physicians are becoming fewer in number. No one is doing anything about it, either—Not the AMA, not the AAFP, and especially not the federal government. I blame the death of primary care squarely on the Center for Medicare and Medicaid (CMS) and the U.S. Congress who reduce payments to physicians EVERY YEAR! 

Surveys of Family physicians over the past two years have revealed practitioners are growing weary of their situation, and the financial collapse of their practice is imminent. They are also losing control of the doctor-patient relationship. They feel “relational primary care” is disappearing. The personal-care family doctor, who is most readily available to his patients, is no longer appreciated by public health officials who prioritized ER’s, hospitals, and pharmacies during COVID-19. The primary care doctor, who patients call first, was left out of the team that was given the resources to care for COVID patients. Their significance was ignored. Despite patients’ loyalty to and reliance on their primary care doctor, public health entities gave preference and attention elsewhere.

Primary care is dying. NP’s and PA’s are assuming the role of the primary care physician. The public, insurance companies, and Medicare don’t seem to mind this because NP’s and PA’s are more numerous, more accessible, and can be trained and graduated in far less time than physicians. New, non-MD practitioners are entering private practice all the time. They work at the Minute Clinic or urgent care center, and fulfill the void left by the shortage of physicians. The biggest issue for Family physicians is the total lack of revenue sufficient to financially sustain a medical practice. Reimbursement is disgracefully inadequate and an insult to a respected and socially essential profession. The profession has been forced to accept only what the government says its services are worth. Every year that amount decreases, and it shows no indication of ever increasing (See “2023 Conversion Factor is Reduced”). 

Unless something of major proportion is done or someone with significant influence goes to bat for Family physicians, the specialty will fade out or be relegated to a triage officer role and become irrelevant. It seems that no one in authority has noticed what’s happening to Family medicine. If they have, they haven’t made any effort to stop it. The AAFP has lobbied legislators for years with no changes forthcoming. Only an influential group of congressmen and women who recognize the importance of Family medicine will be able to do anything that will keep Family medicine from dying. But we all know Congress finds it more important to spend tax revenues on things that don’t help Americans. The death of primary care definitely is bad for Americans.

Reference: Miller WL. The Impending Collapse of Primary Care: When is Someone Going to Notice? JABFM Nov-Dec 2022;35(6):1183-1186.