Fixing health care starts with primary care

John Christian Kryder: ©New Era Medical Operations

Hospitals should not be at the center of the health care system. This problem has been building for fifty years. Patients and their doctors are at peak frustration. It’s time to rebuild the patient-doctor relationship.

Let’s be clear: hospitals deliver some miracles every day, but these companies - whether for-profit or not-for-profit - make their money from providing volumes of expensive, transactional procedures. Hospital business models are now in serious jeopardy. The noisy Steward bankruptcy is certainly dramatic, but the financial problems are hardly unique. Look no further than negative operating margins and falling hospital bond ratings as leading indicators of the impending crisis.

How did we get here? Community-based primary care has been hollowed out over the past 25 years, starting with the advent of electronic health records. Doctors did not have the money to implement EHRs alone, so hospital systems bought up and centralized these financially strapped medical practices. Until recently, hospitals could afford to lose money in primary care because they obtained control of referrals for high-margin ultra-specialized solutions. No longer.

We’ve tolerated these fee-for-service payment inefficiencies and associated crazy costs because of the third-party payment system which insulates consumers (and taxpayers and employers) from actual costs. What’s different today? Access is poor. It really is bad out there. Try calling one of the big hospital systems in Boston or San Francisco and ask for a primary care appointment.

The fix for U.S. health care won’t come from giant regional non-profit hospital systems, or from private equity-backed companies, or from drug store chains or corporations like Walmart or Amazon, or from for-profit insurers. These top-down companies are too big and bureaucratic, and cannot deliver customer service at the local level. Physicians in these corporate cookie-cutter models are unhappy cogs in the wheel.

The center of the health care system must move, rather quickly now, to a true community-based system, where hospitals are the last stop for really sick people, not the first stop for accessing care.

Our foremost health policy goal must be to immediately improve access to independent physicians. Physician-owned primary care (aka ‘private practice’) delivers much higher-touch patient care. Whether addressing obesity or sore throat or a clogged artery needing repair, direct non-emergency decision-making among patients and their primary care providers requires a very personal connection. Given proper incentives from insurers -- to focus upon preventive services and coordination of complex care -- community-based physicians can deliver ‘concierge-like’ care at a far lower price point. These services include tele-medical (text, voice, video) engagement. Primary care physicians know their patients, and offer truly personal care, thoughtful ordering of diagnostic testing, smarter referrals, and tighter connections with their highest value specialty colleagues. Derivative benefits include smarter management of unpreventable diseases, prevention of unnecessary acute care, and reduction in low- or no-value procedures. In short, they improve quality, and patient satisfaction, while reducing wasteful spending. And, when patients become very sick, they act to accelerate access to great hospitals which deliver the necessary miracles.

PCPs and their patients need help, right now. Assistance needs to come from policymakers and regional non-profit insurers. Policymakers need to demand alternative payment models and approve alternative (telemedicine) service modes. Insurers need to improve payments to primary care.

Change of course is very hard. U.S. health care, employing nearly 25% of the entire US workforce, and with more than $4 trillion in annual spending, is the largest industry in the history of the world! With vested interest piled upon vested interest, over 50 years, the resistance to change is gigantic.

If we don’t act quickly, more hospitals will certainly fail, and angry voices will demand that the government take full control of care delivery. We can then expect legislative action to prohibit the private practice of medicine. Perhaps the citizenry will become so exasperated that they will accept the authority of government decision-making in the delivery of this most intimate of personal affairs, along with the taxation required to support such a plan. (Of course, proponents will need to explain why other state-controlled systems around the world have not grown greener grass).

As a PCP and former Massachusetts Health Policy Commissioner, I don’t think we are ready for that option. U.S. society in not interested in going down the wholly government-controlled health care highway. The right solution to improve access and reduce wasteful spending is to jump quickly from talking about the virtues of primary care to political and economic actions which support independent physicians who are frustrated and burning out.

John Christian Kryder, M.D., MBA, is a primary care physician and Boston-based health care information technology entrepreneur. He is the founder and CEO of New Era Medical Operations. Contact him at info@docNEMO.com.