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Tag: Primary care doctor

  • Why it’s so hard to find a primary care doctor?

    Why it’s so hard to find a primary care doctor?

    With the medical profession becoming increasingly corporatized and physicians burdened by administrative ordeals and unable to treat patients as they think appropriate, fewer people are becoming physicians, particularly primary care physicians. A new report on the situation in Massachusetts by the Massachusetts Health Policy Commission explains why it’s so hard to find a primary care doctor.

    These days, you can wait a long time to see a primary care doctor, and you are too often forced to switch from one to another. Insurers do not treat continuity of care as a value and limit your coverage to their ever-changing and often restricted network of providers. It’s hard to get an annual check up without a long wait.

    Massachusetts is looking into the shortage of primary care doctors with the goal of increasing their numbers. You need a primary care doctor. The shortage will continue unless government acts.

    Three key reasons for the shortage:

    1. The bulk of primary care doctors in the US are older, averaging 55 years old, and retiring by the time they are 65. Others are just exhausted by their workload and administrative demands on them.
    2. New physicians are less likely to go into primary care because insurers pay little for preventive services; the provider money is in procedures and tests to treat conditions. Moreover, medical school can be very expensive and becoming a specialist allows physicians to pay off their debt more quickly.
    3. Those primary care doctors who continue to practice either end up doing new services to make money or going into concierge medicine, which gives them more time with patients and less administrative hassle.

    What is the value of having a primary care physician? Preventive services help identify diseases early or stop them altogether.

    What is to be done? We need to pay higher rates to primary care physicians and reduce their administrative burdens. As a society, we need to be investing in primary care.

    Here’s more from Just Care:

  • Portugal’s health care system focuses on primary care and public health

    Portugal’s health care system focuses on primary care and public health

    Portugal spends much less than the US on health care for its citizens, but it focuses on primary care. So, when it comes to health, the Portuguese live longer and fare better than Americans, reports Usha Lee McFarling for Stat News.

    The Portuguese health care system is not modern. You won’t see fancy hospitals with marble atria. But, the data show that the Portuguese on average live four years longer than people in the US. And, the country spends 80 percent less on health care per person than we do. Yep. It spends 20 percent of what we spend on health care per person with far superior health outcomes.

    The 2021 Global Security Index looks at a country’s ability to respond to a pandemic and provide its citizens access to affordable care. Portugal was at the very top of the list of 195 countries, ranking third. The United States was at the very bottom, ranking 183rd.

    Portugal’s national health care system gives every resident free or low-cost health care. Access to health care is not based on ability to pay. Everyone is guaranteed access, though there is a shortage of primary care doctors, as in the US, and people need to wait to get needed care.

    A million Portuguese do not have a designated primary care physician, but they are cared for. Portugal has primary care neighborhood clinics and regional public health systems. It can track sickness as well as  where people are not getting health care. New medical treatments are not always available, but the focus on prevention and primary care is keeping the people healthy at low cost.

    The Portuguese health care system uses data to monitor the population individually and collectively. The government also engages in “social prescribing,”  using home visits to learn about patients’ social issues that can undermine their health and finding community resources to assist them.

    In 2022, the US spent $4.5 trillion on health care or $13,500 a person. But, the US ranks 60th relative to other countries on life expectancy. Our average, life expectancy in the US is 78.5 years, on a par with Turkey and Ecuador, not other similarly wealthy nations. In Switzerland and Japan, life expectancy averages 84 years. Portugal spends about $2,700 a person on health care, and life expectancy averages 82.3 years.

    The US might innovate on the health front, but its health care system is dysfunctional. Portugal, Costa Rica and Thailand get better results through their investments in primary care and community health.

    Here’s more from Just Care:

  • Primary care in Medicare Advantage: A crapshoot

    Primary care in Medicare Advantage: A crapshoot

    Don’t join a Medicare Advantage plan because you believe it will offer good primary care. According to a new report by the Commonwealth Fund, primary care could be good and it could be bad in Medicare Advantage, depending upon the plan you are enrolled in and the primary care physician you use. What’s for sure is that if you get sick and need costly care, you are taking a huge gamble with your health in Medicare Advantage.

    For sure, some if not most insurers offering Medicare Advantage plans want you to see a primary care doctor. That’s how they can most easily add diagnoses codes to your medical records in order collect more money from the government for your care. But, it’s not clear whether seeing a primary care physician in Medicare Advantage will improve your health or not.

    We know very little about whether a particular Medicare Advantage plan will ensure a primary care doctor coordinates your care in ways that keep you healthy. The government pays Medicare Advantage plans upfront regardless of whether they coordinate care. So, they could advise their primary care doctors to spend little time with you or pay these physicians more if they don’t refer you for specialty care or refer you to specialists who cost less and provide lower quality care.

    The Commonwealth Fund examined whether primary care physicians treat Medicare Advantage patients in different ways from physicians who treat Traditional Medicare patients. They found that, overall, there were not many meaningful differences between the care primary care physicians provide patients in Traditional Medicare as compared with the care they provide patients in Medicare Advantage.

    Unfortunately, “overall,” is not really helpful in this analysis. It’s like saying that “overall” restaurants in NYC are fine. The question for people with Medicare is which are the good Medicare Advantage plans and which ones should be avoided. This Commonwealth Fund survey does not provide that information.

    In short, it seems not to be the case that insurers are making it easier for their primary care physicians in Medicare Advantage to manage and coordinate care than Traditional Medicare.

    Here’s more from Just Care:

  • Senator Sanders wants greater US investment in community health centers

    Senator Sanders wants greater US investment in community health centers

    Sen. Bernie Sanders, Chair of the Senate HELP Committee, is focused on expanding the number of primary care physicians in the US. His recent bill would put $100 billion into community health centers, sometimes called Federally Qualified Health Centers or “FQHCs” in the next five years to train physicians, nurses and other health professionals. If you do not have a primary care doctor or simply need good primary care, consider contacting your local FQHC.

    Today, millions of Americans cannot see a primary care doctor without a long wait. Not only can a long wait jeopardize their health, it can cost our health care system more. Without prompt primary care to treat a variety of conditions, people can end up needing costly emergency room or hospital care.

    No question that primary care doctors are in short supply. The Association of American Medical Colleges says that ten years from now we will face a shortage of as many as 48,000 primary care doctors.

    Kaiser Health News reports that as many as 100 million people live in areas where it can be hard to find a primary care physician. One physician who heads a center on primary care at Harvard Medical School reports that lack of access to PCPs can shorten your life expectancy by as much as a year.

    Around 70 million adults in the US–more than one in four adults–say they have no go-to doctor they can turn to when they need treatment or guidance with their health. They must use the emergency room at their hospital. In 2010, more people had primary care physicians than today, even though today more people have health insurance.

    For sure, some of the adults who don’t have primary care physicians arguably have not needed them. Many men in their 20s, for example, might have no reason to see a primary care physician if they are healthy. But, even if you take them out of the equation, 47 million adults have no primary care physician to see.

    People sometimes see nurse practitioners for primary care. If you include nurse practitioners in the mix of primary care providers, there is arguably less of a shortage than Senator Sanders claims, but the shortage is still meaningful in some parts of the country. The US needs to invest more in primary care.

    Here’s more from Just Care:

  • Traditional Medicare at risk with ACO REACH

    This month, the Biden administration is launching ACO REACH, a program that pits the financial interests of corporate health insurers, private equity firms, and the primary care doctors they employ against the health and well-being of their patients in Traditional Medicare. Is there any chance that REACH will deliver better quality care at lower cost, or even just lower costs without harming quality? More than two million people in Traditional Medicare are at risk.

    How does REACH work? The Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, is contracting with middlemen–insurers, private equity and other companies–which assume the risk of keeping health care costs down for people with Medicare. These companies engage primary care doctors (PCPs) to oversee patient care, with the goal of keeping them out of the hospital and away from costly specialty care. If they succeed, the companies can keep 25 percent or more of the savings.

    How do REACH entities keep costs down? They incentivize their primary care doctors financially to keep their patients from getting specialty care and other costly health care services. Best case scenario, they keep people from unnecessary hospitalizations and duplicate tests. Worst case scenario, they keep people from getting critical care they desperately need.

    How do people enroll in REACH? Generally, they do not. Rather, the Centers for Medicare and Medicaid Services involuntarily enrolls them in the program if their primary care doctors are employed by a REACH entity. If you are enrolled, you should receive a letter letting you know.

    How many people are enrolled in REACH? All told, the Biden administration is contracting with 132 health insurers, private equity firms and other entities to “coordinate” care for some 2.1 million people enrolled in Traditional Medicare.

    What do these REACH entities know about health care? The Medicare Innovation Center (CMMI), an arm of CMS, claims that it has vetted all the REACH entities to ensure that they understand health care and are invested in the initiative from a quality and cost perspective. At the same time, the Innovation Center’s director, under questioning about how the government protects enrollees from bad actors, said that CMMI could “not draw lines between good guys and bad guys.” Perhaps she misspoke. I hope it does not mean that entities that inappropriately keep people from getting needed care will be able to do so.

    What’s the worst case scenario? Primary care doctors keep people from getting the care they need in order to help the REACH entity maximize its profits as well as to maximize their own income. We know from Medicare Advantage that insurers engage in all sorts of fraudulent and wasteful behaviors to maximize their profits. There’s every reason to believe that the REACH entities, including private equity firms and insurers, will engage in the same acts. They know that CMS does not have the resources or the tools or the political will to hold them accountable in a meaningful way for their bad acts.

    What can you do to protect yourself if you’re in traditional Medicare? CMS suggests that all the entities with which it has contracted to “coordinate” care will do their  jobs well. It also suggests that it will oversee them to make sure that “they don’t stint on care.” Don’t believe that. Question your primary care doctor. Make sure he or she is not part of a REACH entity. If so, make sure your PCP is ensuring you get the care you need. If you’re not sure, you have the right to opt out by leaving your primary care physician and moving to another one. Also, remember that you are still in traditional Medicare, and your care is covered from any doctor or hospital that takes Medicare.

    Make your voice heard: Go to protectmedicare.net and sign the petition to President Biden. He can end  REACH.

    Here’s more from Just Care:

  • Six reasons you need a primary care doctor in this age of specialization

    Six reasons you need a primary care doctor in this age of specialization

    As we age, most of us develop health issues. Along the way we may visit a specialist to handle each of these issues: for example, a cardiologist to treat hypertension and a gastroenterologist to treat acid reflux. However, it has become increasingly clear that in today’s era of specialization, you need a primary care doctor more than ever to coordinate your care, give you treatment appropriate for your age and gender, and prevent future health problems for the fullest quality of life.

    You may be surprised at how much of your treatment a primary care doctor can provide. Primary care doctors know your whole story, while specialists may not be in communication with each other or understand the range of your health care needs. Medicine has become increasingly specialized, and specialists can provide much needed targeted treatments for specific ailments or organ dysfunctions. But fragmented, uncoordinated care is the handmaiden of specialization.

    What is a primary care doctor?

    This term is generally restricted to internists (who have completed a 3 year residency in internal medicine, and treat adults) and family physicians (who have completed a 3 year residency and treat patients of all ages). Geriatricians are internists or family physicians with additional training in caring for the elderly, often in primary care. Within the healthcare system, these types of physicians are often called “PMDs”, for primary medical doctor or “PCP” for primary care provider.

    The word ‘primary’ care may imply simple or elementary medicine, but primary care is a highly complex practice. PMDs are prepared to diagnose and treat all common diseases, and many, if not most, of the less common ones too. Additionally, they are uniquely qualified to provide comprehensive and holistic care to patients with multiple simultaneous diseases. PMDs also try to prevent future health problems-– they don’t just treat what you have. PMDs keep up to date on the frequently changing recommendations on preventive medicine (e.g., vaccines, mammograms, colonoscopies). In all of their functions, PMDs strive to give care tailored specifically to each patient.

    Why do you need a primary care doctor?

    Above all, primary care is good for your health and will help you live longer. Multiple studies have demonstrated this. Here are six important reasons you need a primary care doctor now more than ever:

    1. A PMD can coordinate and oversee your care. The more complex and varied your health conditions are, the more important a PMD becomes. A PMD will give you guidance on how to integrate varied, complex, and sometimes contradictory recommendations that you may receive from multiple specialists.
    2. A PMD can save you from unnecessary or harmful treatments by taking the time to understand you as a person and know your history. The PMD has a 30,000-foot view of all your health problems. The PMD considers your age, gender and other factors to ask “is this really the right treatment for you?”
    3. A PMD can ensure that your medications are not hurting you. Some medications can be dangerous in older patients. A PMD might replace or stop medications that may do you more harm than good and detect drug interactions. It has been estimated that 265,000 adults (age 65 and older) each year go to the emergency room or are hospitalized because of an adverse drug effect. A PMD also can almost always shorten your medication list if it is too long for you; so, the PMD can end up saving you money.
    4. A PMD can offer a second opinion on whether a treatment recommended by another doctor is likely to be beneficial. For example, many treatments have been proven effective only in patients under 65 years old, and older patients may not derive the same benefit from them.
    5. A PMD works to prevent possible problems by offering vaccinations, screening tests and discussing lifestyle changes like weight loss, exercise and quitting smoking.
    6. A PMD can help you realize you’re developing health problems you hadn’t noticed yet. Problems with vision, strength and fall risk, urinary incontinence, depression or anxiety, and memory can sneak up on you over time without detection—even by doctors who don’t ask. These are things that you may not report, but PMDs are trained to look for.

    Click on the link to read the follow-up post: How can you know if your primary care doctor meets your needs?

    [N.B. This post was originally published on June 17, 2019.}

    Here’s more from Just Care:

  • Four questions to ask yourself about your primary care doctor

    Four questions to ask yourself about your primary care doctor

    I’ve explained the many reasons it’s important to have a good primary care doctor (PMD). Once you have one the next question is, how can you know if your PMD meets your needs?

    Most of us trust our doctors and believe they meet our needs. And, without medical expertise, it’s hard to judge whether a doctor is good beyond the doctor’s bedside manners. Do you like the doctor, and feel comfortable with the doctor? Of course, these things matter. Research confirms that patient health improves with better doctor communication skills. A doctor’s reputation, training, and certification are also important to review. The office location, and how smoothly the office functions are important factors.. However, there are other questions you should ask yourself about whether your primary care doctor meets your needs that are more subtle.

    Here are four questions to ask yourself:

    1. Does your PMD listen to you, know you, and share important decisions with you? Does your PMD practice ‘the art of medicine’? A good PMD will ask you questions about your view of your health, and health priorities before giving recommendations on important testing or treatments. For example, continuing routine mammogram screenings after the age of 75 is something for women to discuss with their doctors; the U.S. Preventive Services Task Force does not recommend it. But, the right decision is whatever is best for you. This discussion can also be important if you are considering a new drug or surgery. Age, kidney disease, diabetes, heart disease and gender may reduce (or increase) the effectiveness of some treatments, and you should know these factors before making a decision.
    1. Is your PMD comfortable discussing all of your medical problems? A good PMD will address any and all medical problems you raise, and doesn’t constantly refer you to specialists for every symptom.
    1. Is your PMD prepared to ‘be the quarterback for’ or ‘orchestrate’ the care from all your other doctors? All PMDs do want to coordinate care with your other doctors, but realistically may not have the time or resources to do this effectively. At the very least, does your PMD attempt to know what the other doctors are recommending for you?
    1. Do you have a PMD who tries to prevent new problems and not just treat existing ones? A good PMD will keep a ‘health maintenance’ list on you, or some similar file, that records your needs for screening tests, vaccines, and other preventive medicine items.

    You may be surprised to learn that some PMD behaviors may not reflect whether your PMD is meeting your needs:

    • A good PMD may often have a staff member relay his or her response to your phone calls. PMDs have to balance how to spend their time, and may decide that some of their responses can be safely and effectively delivered to you through their staff. This doesn’t mean they haven’t thought or care about you!
    • A good PMD might sometimes be rushed, and unable to discuss multiple concerns at every visit. A good doctor will always at a minimum identify and address your most urgent needs, acknowledge the others, and make a plan for additional visits.

    If you haven’t really thought about these questions, you’re not alone. It’s easier to assume your doctor is meeting your needs than to find another doctor. You might want to consider asking a family member or close friend to help you to answer these questions. If some of your answers are no, consider starting here at this Just Care link to find a new internist or family physician who better meets your needs.

    [This post was originally published on June 4, 2015.]

  • Amazon Care is shutting down

    Amazon Care is shutting down

    Surprise, surprise. HealthcareDive reports that Amazon is shutting down Amazon Care, its primary care business. By 2023, Amazon Care will be no more.

    Amazon Care started just three years ago. It began as a primary care service–both in person and virtual–for its workers in Seattle. In 2021, it expanded to meet the primary care needs of companies throughout the country.

    And, as recently as February of this year, Amazon announced that Whole Foods, Hilton and four other large companies were using Amazon Care for their workers.

    But, Amazon Care appears not to have offered Amazon’s enterprise customers enough. Amazon says that its corporate customers were not interested in Amazon Care. Perhaps they felt that the insurance coverage they provide did a good enough job of meeting the needs of their workers.

    The Washington Post reported that Amazon’s medical team was unhappy with Amazon Care’s inability to help people in crisis. The drive for Amazon Care to get bigger conflicted with struggles to meet patients’ needs. One telehealth nurse had nowhere to send a suicidal caller in crisis and had to hang up on the person.

    As I reported for Just Care last month, Amazon bought One Medical, a primary care company, for nearly $4 billion and planned to expand on its primary care business. But, it would have had to figure out how to make Amazon Care and One Medical work together, an apparently challenging feat.

    It’s not at all clear that the end of Amazon Care means the end of Amazon’s interest in offering health care services. It’s possible that Amazon decides it’s better off buying health care services than trying to build them.

    Here’s more from Just Care:

  • Requiring primary care coordination could cause patients needless harm

    Requiring primary care coordination could cause patients needless harm

    There is a government move afoot to have primary care doctors “manage” care for everyone with Medicare. The benefits of primary care coordination can be tremendous but must be balanced against the risks.  Given the shortage of primary care doctors, requiring primary care coordination could cause patients–particularly vulnerable patients needing urgent care–needless harm.

    The shortage of primary care doctors could mean dangerous delays for people who need care urgently and are required to see a primary care doctor before seeing a specialist. It could also mean additional copays and trips to the doctor, which could impede access to care. When primary care doctors work for insurers or private equity firms, as they increasingly do, financial incentives also could pose risks to patients who need specialty care.

    The Centers for Medicare and Medicaid Services, CMS, is on a mission to have everyone with Medicare in what it calls an “Accountable Care Organization” or “ACO” by 2030. With ACOs, the government pays entities–sometimes hospitals and sometimes private equity firms or insurers–an upfront fixed fee to treat patients. It’s up to the entity to decide what care to cover and when. They maximize profits when they provide less care.

    What could be wrong with an ACO? For now, ACOs are accountable in name only. They are largely unaccountable for the care they provide. The limited oversight of their performance coupled with their large financial incentive to withhold care–they profit more–suggests huge cause for concern, especially when Wall Street entities, private equity firms and insurers are calling the shots.

    Accountable Care Organizations, like Medicare Advantage HMOs, can leave patients waiting a very long time to see a primary care doctor. If people need to see a primary care physician in order to get specialty treatment, their conditions can worsen when care is delayed. Stories abound about that happening to people in Medicare Advantage HMOs.

    Pre-pandemic, Kevin MD reports that fewer than one in five physicians were taking new patients. More than eight in ten had no ability to see new patients. We are likely to be short 48,000 primary care physicians in the near future.

    Of course, the shortage of PCPs would not be as pronounced if doctors spent less time on administrative functions. One study found that about half of a physician’s time is spent on administrative work. Less administrative work would make it far easier for doctors to see more patients. Right now, the US fares poorly relative to other countries in ensuring people see primary care doctors in a timely fashion.

    We need to invest more in primary care before insurers and ACOs are allowed to require people–particularly vulnerable older adults and people with disabilities–to see a primary care doctor in order to see a specialist. Kevin MD reports that a lot of unnecessary medical treatment stems from the fact that primary care physicians do not have the time to oversee patient care. A lot of inappropriate delays and denials of care also result from a weak primary care infrastructure and financial disincentives for insurers to provide appropriate care.

    Here’s more from Just Care:

  • Amazon moves into primary care

    Amazon moves into primary care

    Amazon plans to buy One Medical, a large group of primary care doctors, for $3,9 billion. What does that mean for the future of health care in the US? Stat News reports.

    Amazon already owns a pharmacy business, health clinics and telehealth services. With the purchase of One Medical, it will own 180 medical facilities and business from a number of companies that use One Medical to care for their workers. One Medical says that it currently provides care to about 800,000 people.

    Once it acquires One Medical, Amazon will offer both in-person and virtual services through Amazon Care. It will offer primary care, lab services, vaccinations, preventive care, urgent care and an online pharmacy. Most likely, Whole Foods will offer some medical services on sit. Amazon Care also sends nurses to patient homes in some instances.

    Presumably, Amazon will generate revenues from big corporate health insurers and Medicare. One Medical has been contracting with Medicare on both the Medicare Advantage side as well as now in traditional Medicare as a direct contracting entity–an entity that is paid a flat rate by the government to “manage” care for people in traditional Medicare.

    Currently, employers and others pay One Medical an annual fee of $199 a person plus care costs to provide their workers and others primary care.

    Amazon intends to offer primary care services throughout the nation. The question remains as to whether Amazon will improve quality and lower costs. And, can it turn a profit? One Medical charges high costs for its primary care services.

    Primary care has never been a profitable business. Doing it well takes time. So, Amazon might be thinking it will use this primary care business as a tool to generate more revenue from its other businesses.

    And, how will Amazon address the care needs of people with costly and complex conditions? Older adults and people with disabilities who need a lot of care have always been a population corporate health plans have sought to avoid, for fear of losing money.

    I have always assumed that Amazon or Facebook or Google or Apple would take over our health care system. They continue to take over large tranches of the economy. It’s easy to imagine that these companies would not use their power to the good of patients. They need to generate profits. But, the current system is anti-competitive and completely broken. Could a world with Amazon Care be worse?

    What should you do? Choose your primary care doctor carefully. You need a good one for many reasons,, even if you’re healthy. You want one who puts your health care needs first and will direct you to the best specialists should you develop a complex condition. You want to avoid primary care doctors driven by financial incentives to delay or deny you care.

    Here’s more from Just Care: