Family physicians and the fight against the health system

Editor’s Note: The following is adapted from “Searching for the Family Doctor: Primary Care on the Brink” by Timothy J. Hoff. Copyright 2022. Published with permission of Johns Hopkins University Press.

Poor soil for growing generalists

When I worked in primary care as an administrator back in the late 1980s, I heard the same complaint from the family doctors with whom I worked as I do now from those that I interview for my research—primary care medicine is not paid for in the United States anywhere commensurate with its value to patients. When I helped to run an insurance billing department for a primary care office thirty years ago, I saw firsthand how much lower the payments were for services meant to keep people from getting sick compared to payment for services that relied on waiting for people to get sick. Not much has changed in 2021. There is the rhetoric that primary care and prevention matter much more now to insurance companies, hospitals, and doctors’ offices. Sure, maybe in a few areas like chronic disease management where primary care medicine and family doctors have been asked to do more for patients. But that has not created a financial windfall for primary care, and what it asks of family doctors is very much responsible for how joyless some of their patient care work has become. For the most part, high-cost specialty medicine still dominates the health care system and still receives the bulk of the insurance payments. It is responsible for keeping hospitals profitable and specialist doctors well paid and in control.

The specialty of family medicine has always existed within the context of an unsupportive American health care system that underemphasizes primary care, where service is fragmented and procedural medicine is favored, and that waits until people get sick to interact with them and is ever more corporatized. It is a care delivery system long built on capitalist ideals. One defined by a supply side which pushes the prevailing narrative that health care is not a fundamental individual right, but rather a market in which buyers and sellers come together to transact business that benefits both sides. Despite the advent of Medicare and Medicaid in the 1960s, and the Affordable Care Act in 2010, health care in America since the 1970s has been mostly about providing big ticket items to an unhealthy, largely uninformed group of patients. That is where the money has always been for hospitals and specialists. This profit motive has produced a care delivery system in which monopolistic behavior and service fragmentation abound, politicians serve powerful industry stakeholders in biased ways, growth is valued above all else, and patients are left mostly out of the equation.

To create such a cold-blooded system takes time. It has not happened overnight. Neither will it be fixed overnight. Such a system is no friend to either family medicine or primary care. In fact, such a system views primary care as an attractive nuisance, useful for capturing patients in more expensive systems of care and getting them efficiently to higher-cost services. A loss leader to get patients to the expensive stuff. The American health care system has for decades been less enthusiastic to the idea of a generalist doctor managing patients’ care holistically and with a high level of relational excellence. It has financially undervalued primary care in all its forms. It has allowed the job of a family doctor to become saddled with administrative chores and bureaucratic requirements. It has made family doctors buy into one new initiative after another, overpromising how these initiatives would help primary care while under delivering. In many ways, it has treated family doctors like the generalists of old they replaced — as lower-valued and lower-paid parts of American medicine.

The financial undervaluing of primary care

All things hostile to family medicine in the American health care system start with reimbursement. And reimbursement has not been kind to family medicine and primary care delivery over the years. In terms of receiving adequate payment for its services, primary care medicine has always been the ugly stepchild of American health care. In other countries like Canada and the United Kingdom, primary care medicine and its doctors remain the centerpiece of care delivery and receive a significant bulk of the resources, but in the United States it has not been that way since World War II. Continued advances in medical technology, the rise of hospitals and specialists, and an ambivalent public have been steady negative influences on primary care’s viability.

Aiding these developments beginning in post-World War II America was the increased availability of private insurance for many Americans, usually paid by employers. Before insurance, generalist doctors dealt in a cash-only business, charging patients fixed fees for different types of services. Their system of billing was perhaps less egalitarian in giving everyone the chance to obtain their services, but it was within physicians’ control and fully transparent. Patients knew how much a service would cost, and they could assess whether it was worth the cost to have it performed, at least from their personal perspective. Doctors, almost all of whom owned their practices, could in theory better manage their revenue and expenses, altering their prices in relation to how much time and other resources were put into the service provided. Such a payment system helped to keep generalist medicine an economically viable endeavor in which a single doctor could be involved as an owner. One might not get wealthy, but you could earn a good living, control the economics of your practice, and do the kind of medicine that you wanted with your patients.

Then insurance came along. Private insurance separated patients from the costs of various forms of care, making specialty medicine an attractive option with fewer financial risks associated with it. While other countries like Canada and the United Kingdom insured most of their populations through government-run programs that had spending caps and placed primary care medicine at the center of care delivery, the United States pursued its insurance expansion in a different way, focused for decades on fee-for-service reimbursement and providing “usual and customary” payments to doctors based largely on what the latter wanted to charge for their services.

Insurance in American health care undercut the economic rewards of primary care medicine for family doctors because it biased payments toward procedures and specialists. It prevented patients from understanding “value” when it came to diagnosis or treatment and many no longer needed to worry about how much a health service cost. The fee-for-service payment system over time paid out more bills at a higher rate for specialists than for primary care doctors, because the usual and customary fees were set by specialists themselves, with little questioning of how they came up with their fees.

Good primary care medicine is slower to do than most procedural work. It does not align well with procedural medicine that can be done in an assembly-line fashion, generating a higher volume of overall fees in the process. Family medicine or primary care involves something called “evaluation and management services,” which in essence is time the family doctor spends on interviewing the patient, asking questions, getting to know patients, and managing a wide swath of clinical complaints and treatments for some. Attempting to be someone’s “comprehensive doctor” and “care manager” means a lot of these types of tasks and activities.

Whereas specialists are niche providers focused on treating single diagnoses and body parts, family doctors in theory are practicing medicine focused on prevention, disease management, behavioral health, and family care. They rely on getting to know their patients’ preferences, needs, and wants to deliver this type of medicine effectively. They must get patients to trust and listen to them. Primary care medicine takes more time as a result. It also has a longer trajectory to seeing the end results because it is more uncertain and complicated for many patients, involves a lot of cognitive work on the part of the doctor, and often has delayed time frames for seeing good outcomes. Many tasks and activities of primary care medicine simply have not been as highly valued dollar-wise by insurers. But they are critical to a close-knit doctor-patient relationship.

Timothy Hoff, Ph.D., is professor of management, health care systems, and health policy at Northeastern University in Boston; a visiting associate fellow at the University of Oxford, and author of “Next in Line: Lowered Care Expectations in the Age of Retail- and Value-Based Health.”