It’s time to address the needs of primary care

Conrad L. Flick, MD

As we move into 2024 and another potential change in the leadership of our nation, I wonder how it will affect health care. Having practiced front line primary care now for more than three decades, I have seen, but mostly heard about how we can and will build a better system.

We have had leaders lay out plans that never materialized, leaders institute plans that failed to fully deliver and leaders say they had great plans that were never disclosed. There are many facets to addressing issues that include changes in payment, improved technology, funding of medical education and training programs and others which also have not been addressed as they should.

But whatever direction we may take along the way, primary care physicians continue to serve as the backbone for a system that seems to do all that it can to promise and not deliver, underfund and overburden us, and expect better returns with fewer providers. Unlike every other industrialized nation, which have built their systems on primary care, we continue to build and fund a system of what some call specialty care: physicians who focus on a single organ system or problem, providers who take care of single conditions that people have.

Primary care takes care of people with physical and behavioral health problems, along with a host of issues related to the social determinants of health, and all at the same time. We do not have the luxury of ignoring their diabetes while addressing their heart failure or their gastroesophageal reflux while treating their arthritis or their poverty while dealing with their depression. They are one and the same, all tied to the biopsychosocial model all medical students are taught and that is the whole of a patient.

In the newest iteration of health care, over the last dozen years or so we have been moving to “value-based” care. In the simplest terms, it means trying to take some of the waste out of what we do, saving money by choosing cheaper alternatives for the same medication or service, not doing unnecessary or redundant labs or procedures, treating people at less expensive sites of service, such as outpatient offices rather than emergency departments, whenever possible.

Primary care has always done this and the only reason we may have stopped was a system that has consistently added stress to us without rewarding what we have to offer and do—keeping people healthy, managing their chronic conditions, coordinating their care and being there when needed for acute issues.

With the explosion of chronic diseases like diabetes, our days are filled with patients who now have an average of six to eight problems per visit, and a system requiring thousands of clicks per day in electronic health records that were supposed to save us time, not require us to spend hours after our clinics close finishing paperwork while missing time with family and friends.

Fixing the health care system will take a widespread and coordinated effort and will likely require a major transformation, whether one believes a single payer or our current free market system is the solution or that health care is a right rather than a privilege. There are plenty of other countries who do it better (by many measures or standards), and without question for less money than we do.

But how do we manage a system that wants value, but does not value its primary care workforce? Primary care is the lowest paid among the specialties yet is looked to to lead the effort to save the health care system money, often to the point of putting us “at risk” if we cost the system to much. Years of underpaying primary care doctors has led to severe shortages in many areas and a situation where a significant percentage of us are over 50 and will be retiring soon without anyone to take our place.

Medicare and commercial insurers have known for decades that to attract more people to primary care the payment system would need to change, yet nothing has changed. You cannot run an office or hire employees or invest in new technology on the promise of shared savings. You need a reliable front-end revenue stream to accomplish those things.

Medicare and commercial payers want us to practice evidence-based medicine. They expect us to keep sugars and blood pressures controlled to avoid complications and to immunize children and vulnerable populations to keep them well and out of hospitals. Yet they ignore the worldwide evidence that a health care system based on a strong foundation of primary care, with an adequate work force, is less costly and better for its citizens.

I think the biggest challenge is in the differing time perspectives we bring to the problem. Medicare and commercial insurers operate on budget cycles. They want to keep their annual spending less than what they have budgeted for a given year. For commercial plans, “under budget” means profits and happy investors.

Those who make laws and regulations in our state capitals and in Congress operate on election cycles. They need to answer less to the voters, but more to those who fund their political campaigns, which are often now big corporations who like things the way they are. They are less interested in an individual health care story unless it helps them get re-elected. Sweeping changes are hard to accomplish in the political arena because even what is right down the road may not be popular now.

But those of us on the front line of health care deal in life cycles. Our job is to make sure the newborn infant has every chance to live a long and prosperous life, not just make it to next year. Our jobs are to help the adolescent struggling with anxiety and learning issues overcome those challenges and become productive adults. Our jobs are to help the patient with diabetes who is developing complications better control their disease and continue working rather than going on disability.

Our jobs are to catch cancers early so they can be cured, rather than potentially costing the health care system millions of dollars and robbing the patient of their health and viability. Our jobs are about life cycles, and until Medicare and commercial payers and politicians start looking at our health care system this way, it will always be a struggle to do what is best for the people of our nation and we will see the continued decline of primary care. It is not a system that will easily be rebuilt once we reach a critical point—one we are rapidly approaching.

Conrad L. Flick, MD, FAAFP is a physician with Family Medical Associates of Raleigh, N.C.